I will present first, and then my colleague will present after me.
First of all, I want to acknowledge you, Mr. Chair, and the members of the committee. Thank you for providing us with this important opportunity to be here to speak about Bill , which responds to last year's unanimous decision of the Supreme Court of Canada in Carter v. Canada and introduces a federal framework around medical assistance in dying.
Medical assistance in dying, as you said, Mr. Chair, is a complex and deeply personal issue. Every jurisdiction in the world that permits it or has debated it has carefully considered the wide range of interests at stake. In Canada, we work within a distinct legal and constitutional framework, which includes a division of powers between provincial, territorial, and federal governments, and the Charter of Rights and Freedoms, all of which inform the government's choices as reflected in this bill.
Bill would establish criminal law rules regarding medical assistance in dying that address eligibility, procedural safeguards, and the framework for a monitoring system. The proposed legislation would re-enact sections 14 and section 241, paragraph (b), of the Criminal Code, so that it would continue to be a crime to assist another person to die or to cause another person's death with their consent, except if either of these actions were done in accordance with the rules for medical assistance in dying as set out in this bill.
Bill would exempt physicians and authorized nurse practitioners from criminal liability if they provide medical assistance in dying to an eligible person in accordance with the procedural safeguards in the legislation. It would also exempt others who might be involved in this process, such as pharmacists who fill the prescription for medication.
Importantly, the bill includes a parliamentary review five years after coming into force. The government is also committed to further studying the complex issues of medical assistance in dying in the context of advance requests, mature minors, and where a mental illness is the sole underlying medical condition, none of which were before the court in Carter.
The government chose this approach after thoroughly considering the full range of potential options for a medical-assistance-in-dying regime. As noted in our legislative background paper, which I tabled at second reading, this included analyzing and comparing regimes in other jurisdictions, including Quebec's legislation, certain American states, several European countries, the country of Colombia, and others.
The government also relied on consultations conducted in this country, including the work of the special joint committee, the external panel, the provincial-territorial expert advisory group, and Quebec's multi-year study that informed the development of that province's own legislation. We also engaged and consulted with a wide array of stakeholders.
With the benefit of all this evidence and knowledge, which exceeds even the detailed record that was before the Supreme Court of Canada in the Carter case, the government has thoughtfully addressed this issue. Bill would allow for greater flexibility than the laws that exist in the United States, which are limited to terminally ill patients. At the same time, it does not go as far as some of the more permissive regimes in European countries. As the court noted in its Carter decision, “Complex regulatory regimes”—such as this—“are better created by Parliament than by the courts.”
Bill is fair and practical, and presents a balanced approach.
In terms of eligibility. I'm aware the requirement that a person's natural death be “reasonably foreseeable” has received some attention, including in terms of how it relates to the Carter decision. I would like to address these concerns.
The bill was deliberately drafted to respond to the circumstances that were the focus of the Carter case, where the court only heard evidence about people with late-stage incurable illnesses who were in physical decline and whose natural deaths were approaching. The court said the complete prohibition on assisted dying was a violation of charter rights for persons in these circumstances. In this way, the eligibility criteria in Bill comply with the Carter decision. They focus on the entirety of the person's medical circumstances and not on the specific list of approved conditions or illnesses.
By defining the term “grievous and irremediable medical condition”, the bill would ensure that all competent adults who are in an irreversible decline while on a path toward their death would be able to choose a peaceful, medically assisted death, whether or not they suffer from a fatal or terminal condition.
A person can be approaching a natural death based on medical circumstances that are not directly related to a serious, incurable illness, for example. As well, eligibility does not depend on a person's having a given amount of time remaining, such as a certain number of weeks or months to live, as in the United States. Reasonable foreseeability of death is ultimately a medical decision, and not a legal one, to be made by taking into account all of the person's medical circumstances, including the types and number of medical conditions, frailty, age, etc.
The vice-president of the Canadian Medical Association has confirmed that reasonable foreseeability of death is a standard that provides sufficient guidance to physicians and nurse practitioners by taking out a lot of the subjectivity that was left by the court's undefined concept of a grievous condition, while allowing those with the necessary medical knowledge and expertise to make the decisions based on the individual circumstances of each case.
There are other compelling reasons for there to be a requirement that the person's natural death be reasonably foreseeable. First, it provides a fair way to restrict eligibility without making assisted dying available to almost everyone. Second, restricting eligibility in this way is necessary to protect the vulnerable.
Other approaches to eligibility that were proposed and suggested would be arbitrary. For example, it would be arbitrary to permit people with degenerative but non-fatal conditions to have access to medical assistance in dying before their deaths have become reasonably foreseeable, while excluding individuals with mental illness alone, or those born with a physical disability, or those suffering physically or psychologically for any other reason. These are not viable options, in our opinion, as they discriminate on the basis of a person's medical condition from the outset rather than allowing the medical practitioner to consider all of the person's circumstances.
Others have suggested that the government should grant access liberally, based on the subjective experience of suffering of each individual and the right to choose when life ceases to have meaning, with little in the way of objective parameters related to their condition or safeguards. Our government firmly believes that medical assistance in dying should not be available for any and all types of suffering. If that were the case, the risk to vulnerable people would be greatly increased and, frankly, would be unacceptable. Such an approach could contribute to the stigmatization of persons with disabilities; it could undermine suicide prevention; and it could lead marginalized or lonely individuals to seek medical assistance to end their lives prematurely.
As the court noted in Carter, when crafting legislation, Parliament must balance and weigh the perspective of those who might be at risk in a permissive regime. Our government respects the Supreme Court of Canada, and believes that in legislating in this incredibly complex and personal area, we must be concerned with protecting the dignity of these Canadians' lives.
This is why the criteria in the bill address the full range of medical circumstances that can make a person's death reasonably foreseeable. In doing so, the law sends a clear message about the intended purpose of medical assistance in dying: to give competent adults who are in a path toward their natural death the choice of a peaceful passing. It also provides maximum flexibility for medical assessment to health care providers, both in terms of the circumstances that led a person to be on a trajectory toward death and in terms of the time during which they can seek medically assisted death.
I want to emphasize the importance of having a legislative response in place before June 6, 2016, when the court's declaration of invalidity expires. Without a new law, on June 6 the parameters of the Carter decision would come into effect.
The scope of the decision is uncertain in several respects and, as a result, there would be uncertainty as to how it would be applied in practice. Assuming for a moment that the Carter decision read down in section 14 and section 241, paragraph (b), of the Criminal Code so that except for medical assistance in dying these criminal laws would be in force, sufficient uncertainty would still remain.
First, given that in the medical community there is no common understanding of a “grievous and irremediable” condition, it would become difficult for a patient who would be eligible under Bill to gain access to medical assistance in dying. Without a clear law in place, some physicians who may otherwise be willing to provide it could refuse to do so because they are not clear on who properly qualifies.
As well, failing to define the Carter parameters with federal legislation could lead to a wide variation on how eligibility is applied, not only between provinces or regions, but within them. Access in remote and rural areas would be negatively affected, not only because physicians may be unwilling to provide medical assistance in dying in such an uncertain legal environment, but also because, under the Carter decision, nurse practitioners are not able to provide assistance.
Second, the current interim court approval process will end on June 6. Therefore, outside of Quebec, there would be no legally binding framework to govern medical assistance in dying in Canada. In other words, there would be no mandatory procedural safeguards to prevent abuses and protect vulnerable persons.
Guidelines published by medical regulators are not binding, nor are they uniform, which further risks creating a patchwork across Canada. This can pose very serious public safety risks. For instance, a patient could both request and receive medical assistance in dying on the same day. Without going through an exhaustive list of risks, needless to say, it would be irresponsible to let June 6 come and go without a federal law in place.
As the court made clear in paragraph 117 of Carter, “the risks associated with physician-assisted death can be limited through a carefully designed and monitored system of safeguards”. Bill provides a responsible and balanced framework that limits those risks and puts in place those safeguards.
I certainly welcome the opportunity to discuss this bill and contribute to your study of the proposed legislation. The approach in Bill responds to the Carter decision with what I believe is sensitivity in all of the issues that were before the court in this case and creates a responsible and fair legal framework to permit medical assistance in dying in Canada for the first time in our country's history.
Now, with your permission, Mr. Chair, I would like to turn it over to Minister .
I will be making a few comments in French as well, for those who need the earphones.
Mr. Chair and honourable committee members, thank you for the opportunity to appear before you this afternoon. I am very pleased to be here with my colleague to discuss this important subject of medical assistance in dying.
I think that each of us around this table would not deny the monumental nature of the piece of legislation with which we are involved. This speaks to the profound and solemn nature of our responsibility as representatives of the people of Canada to make wise decisions, and I thank you for sharing with us in this process and look forward to your comments and questions.
Conversations about the end of life can be incredibly challenging. I can say that from personal experience, and I know that all of you have had similar experiences and have your own personal stories about end-of-life conversations, yet it's a vital conversation that we need to participate in as individuals, as members of Parliament, and as a society.
They are difficult conversations for health care providers as well. Health care providers may not have had an education that has adequately prepared them for discussing this, let alone providing the supports that patients need at the end of life. As we strive to meet the needs of Canadians at the end of life, we also encounter a system that can often frustrate the attempts of people to live out their personal autonomy.
We all want a system where respect for personal autonomy is a cornerstone of all policies. We also want a system where the rights of the most vulnerable are respected and protected. This legislation is one important piece of the puzzle when it comes to ensuring that Canadians have access to not only a good life, but also a good death.
It's about empowering patients to take control of their own narrative and ensuring that Canadians can receive compassionate care as they approach the end of life.
As you well know, we listened to what Canadians and stakeholders had to say before we developed this legislation. We reviewed it closely to ensure consistency with the charter. We looked closely at the Carter decision to ensure that individuals in similar circumstances would have access to care that would alleviate suffering, including the option for medical assistance in dying.
In the course of this debate and since the introduction of this bill, we have heard from several parliamentarians and many stakeholders. Some have had concerns that the legislation goes too far, and we acknowledge that for many the new reality in the post-Carter era is an unfamiliar one and will heighten anxieties about how we protect the most vulnerable in society.
I want to assure those Canadians that we acknowledge their concerns, and we believe that the safeguards in place in this bill will ensure that we protect the rights of those most at risk.
We've also heard from others who feel that the proposed legislation does not go far enough and who would like to see expanded eligibility in certain areas, and we would also like to thank these Canadians for speaking up on behalf of those who are suffering.
Our commitment as a government was to respond to the Carter decision. This necessitates changes to the Criminal Code that will protect health care professionals as they support patients in their decision-making. At the same time, we are committed to taking time to address additional questions that are more complex and where more time and study are needed.
For instance, the proposed legislation sets the minimum eligible age for decision-making at 18—the age of majority in most provinces and territories. We believe this is appropriate, given the unique and irreversible nature of this decision. We know that the capacity to make health care decisions is not tied strictly to age and that depending on the province, children as young as 14 have had the right to refuse or consent to medical treatment.
Given the divergence of opinion on this issue among Canadians and stakeholders, the special joint committee, as you know, called for further study and broad-based consultations on the issue surrounding the concept of mature minors. Our proposed legislation reflects that guidance and the need to tread carefully; however, we acknowledge the difficult situations that mature minors and their families face at the end of life, and we commit to taking the necessary time to study this matter in the months to come.
We faced similar challenges in considering the issue of advance directives. The Supreme Court did not deal with this issue in Carter, and the views of Canadians and stakeholders, as you know, are divided. I understand the hardship for those Canadians who fear that after being diagnosed with a disease such as dementia they may experience a decline that could compromise their dignity. This has led to pleas to allow people to make requests for medical assistance in dying well in advance of the time when the person is no longer competent to make or reaffirm a desire to accelerate their own death.
I had the opportunity to meet with a group called Dying With Dignity recently to understand their perspective and the thoughtfulness with which they presented their case.
After 30 years of practising medicine, I am well aware of the concerns of Canadians who endure suffering at the end of life, and understand why some would contemplate using advance requests to seek medical assistance in dying. However, we must consider the complex policy and medical practice issues raised by advance requests.
By their very nature, advance requests are made before they're needed. Even if reviewed regularly, they would be an enacted only when a person has lost competence or is no longer able to communicate. This means that the final consent, a key requirement in most assisted-dying regimes around the world, could not be verified by a health care provider or anyone else.
Health care stakeholder groups have cautioned that advance directives for other forms of medical treatment can be very difficult to respect in practice, and the implications would be more significant in the case of assisted dying.
As June 6 approaches, we have limited time to better understand how advance directives would work in practice. Determining how they would be carried out would require extensive consultations with Canadians, stakeholders, medical professionals, regulatory bodies, provinces, and territories. In light of these circumstances, we are proposing to explore this issue with further study.
The proposed legislation also does not permit eligibility solely on the basis of suffering from mental illness. There's no denying that mental illness can cause profound suffering, but illnesses such as chronic depression, cognitive disorders, and schizophrenia raise particular concerns with respect to informed decision making.
We've consulted with numerous stakeholders on this issue and have concluded that the nuances are not sufficiently understood at this time to allow safe and appropriate legislation to be crafted.
To that end, the government is making a commitment to mandate one or more independent studies on the questions of requests by mature minors, advance requests, or requests for mental illness as the sole underlying medical condition.
Bill also includes a clause that requires Parliament to conduct a review of the legislation five years after royal assent. This will allow for a parliamentary review of the complex issues, as well as the evolving experience of Canadians in implementing medical assistance in dying.
Finally, one cannot discuss this legislation without a reaffirmation of the importance of improving access to high-quality palliative care for all Canadians. Our government is firmly committed to investing in this area, and I look forward to working with provinces and territories to ensure equitable access to all options for care at the end of life.
In closing, we believe this proposed legislation values the personal autonomy of Canadians, in line with the Supreme Court's decision in Carter, while ensuring the protection of vulnerable Canadians and the conscience rights of providers.
I want to thank all of you and others who have engaged thoughtfully and respectfully on this challenging issue. I know this committee is going to hear a range of views and opinions in the coming days and weeks.
I thank you for your consideration. I look forward to your responses.
I welcome any questions you may have.
Good evening. Thank you, honourable members of the committee, for giving the Canadian Psychological Association the opportunity to speak to you this evening about Bill .
The CPA has two specific concerns with the bill.
The first concerns the role of health providers in end-of-life decision-making. The second concerns the assessment of a person’s capacity to give consent to end his or her life, particularly when a psychological or cognitive disorder is concomitant with a grievous and irremediable physical one. Accordingly, we have three recommendations that we're asking you to consider.
Proposed subsection 241(1) notes that it is an offence to counsel a person to die by suicide and to aid a person to die by suicide. Proposed subsections 241(2) and 241(3) appear to exempt practitioners from the provisions of proposed subsection 241(1) if they provide medical assistance in dying or aid a practitioner in providing medical assistance in dying.
The CPA's concern is that the exemptions articulated in proposed subsections 241(2) and 241(3) appear relevant to aiding a person in dying but not to counselling a person about an end-of-life decision. While proposed subsections 241(2) and 241(3) appear to exempt practitioners for involvement in the act of dying itself, regulated health providers will reasonably be involved in decision-making before any end-of-life act is carried out. Psychologists would be among the health providers who might assess a person’s capacity to give consent to medically assisted death. Psychologists would also be among the providers to whom persons with irremediable conditions might bring their end-of-life concerns.
It is important that persons who are considering hastening death have the opportunity to bring their concerns to a trusted regulated health provider if they so wish. It is equally important that a regulated health provider who enters into an end-of-life discussion or consultation with a patient also be exempt from proposed subsection 241(1).
Our first recommendation is for an additional exemption that stipulates that no regulated health practitioner commits an offence if they assess a person’s capacity to give consent to an end-of-life decision and/or provide counselling regarding end-of-life decision-making issues at the request of a person with a grievous and irremediable condition, or if they aid a health practitioner in the assessment of a person’s capacity to give consent to an end-of-life decision and/or in the discussion of an end-of-life decision for a person with a grievous and irremediable condition.
We also want to note that the word “counsel” in English, as used in proposed paragraph 241(1)(a), has both legal and profession-specific meaning. Mental health providers such as psychologists can be said to regularly provide counselling to their patients. In this sense, “counsel” has a very different meaning than the one intended by proposed paragraph 241(1)(a).
Our second recommendation is that proposed paragraph 241(1)(a) be revised such that “counsels” is replaced by “persuades or encourages”. It would then read “persuades or encourages a person to die by suicide or abets a person in dying by suicide”.
Finally, the CPA was also concerned that the bill is silent on how capacity to give consent should be assessed. While in many instances it may be straightforward to ascertain that informed consent can and has been given, there may be times when it may not be. Examples might be when a patient has a cognitive or psychological disorder concomitant with a grievous and irremediable physical one. The concomitance of a cognitive or psychological disorder with a physical one occurs commonly.
The CPA's submission to the expert panel that reported to the parliamentary panel made the following point, which I quote:
...the global experience of suffering, including suffering due to physical symptoms, is much more pervasive among terminally ill patients who are depressed than among those who are not depressed.... In the Netherlands, Dees [and his colleagues] have reported that only patients with a comorbid diagnosis of a mental disorder suffer unbearably all the time. Hence, it is likely to be a common scenario for depressed terminally ill patients to make requests for assistance in ending their lives. To prepare for this, legislation should be informed by certain clinical realities.... A mere diagnosis of a depressive disorder does not necessarily mean that someone is incompetent to make critical health decisions. Especially severe depression, however, may result in negative attitudinal biases that distort rational decision making around medical aid in dying....
The assessment of a person’s capacity to give informed consent, particularly when that person has a concomitant psychological or cognitive disorder, must be left to those regulated health providers with the training and expertise to undertake these kinds of complex assessments.
It is CPA's view that psychologists, along with physician specialists such as psychiatrists and neurologists, have the necessary training and expertise.
Our third and final recommendation is that a new provision be added under “Safeguards” as subparagraph 241.2(3)(i), as follows:
ensure that when a person presents with a grievous and irremediable medical condition concomitant with a cognitive and/or psychological one, the person's capacity to give consent be assessed by a regulated health provider whose scope of practice includes the assessment of cognitive and/or psychological conditions.
On behalf of the CPA, I thank you for your important work in the interests of the Canadian public. I'd be glad to answer any questions about our submission.
The College of Family Physicians of Canada is the national body responsible for establishing the standards for the training, certification, and lifelong education of family physicians. In this regard, we do welcome Bill , an act to amend the Criminal Code and to make related amendments to other acts.
We're pleased that the bill represents a prudent first step. We believe that the medical community is being given a reasonable opportunity to familiarize itself with the new changes and accommodate accordingly. It has been noted that medical assistance in dying has not been a reality for nearly every physician currently practising in our country, but will be a feature of our health care system starting in June.
As family practice is frequently the point of first contact with the public in our health care system, family doctors are often the first to witness how medical decisions that have legal implications can affect patient care decisions. Further clarification is required regarding the eligibility criteria for accessing assisted death, particularly the requirements for eligible patients who are facing a natural death that is reasonably foreseeable. For example, a progressive multiple sclerosis patient might fit the criteria of having an incurable disease and being in a state of irreversible decline and suffering, but the timing of foreseeable death might be difficult to determine. Some specificity around this criterion is needed.
There are also questions regarding the subjective interpretation of what could be considered physical or psychological suffering that is intolerable. As family doctors we witness every day in our practices that there are varying degrees of what is considered intolerable pain or suffering. Depending on the patient's threshold, tolerance can vary greatly.
Complex health issues such as physician-assisted dying and abortion require a level of protection for the privacy of not only the patient but also the health professionals providing these procedures. To ensure a level of security for the provider, names or information about those assisting in the procedures should not be released to the public or the media. Physicians and other care providers, such as nurse practitioners, should feel safe and secure when they care for patients.
In providing medical aid in dying to a patient with a long-standing relationship, a provider should not feel under pressure to do so for other patients under the same or other circumstances. Every case should be considered on its own merits.
The CFPC would also like to see further clarifications regarding the criteria for consent. What occurs if a patient provides a voluntary request for medical aid in dying, and during the defined waiting period of at least 15 clear days, their mental capacity deteriorates unexpectedly to a point where they're no longer able to reaffirm the request for assistance? Clearer guidelines on how to assist a patient without abandoning their needs should be outlined.
Clarity of process and resource availability will be crucial for physicians and their patients, as well as an understanding of criteria, when providing physician-assisted dying. There need to be assurances that a physician's conscientious objection will be considered and balanced with both the rights of the provider and the necessity of ensuring that patients are not abandoned when they are most vulnerable.
Regardless of any legislation created, physicians must be cognizant of the scope of their responsibility in providing care to a patient. The CFPC maintains that family physicians should, above all, remain committed to their relationships with patients and their patients' loved ones during this last chapter of their lives. Recognizing that those who have serious illness or disabilities and those who are dying are among their most vulnerable patients, family doctors are health advocates on behalf of such patients.
We also place great value on palliative care. The college will continue its work in fostering high-quality palliative care within the scope of comprehensive continuous care provided by family doctors, including those with enhanced skills in this area. We believe that Bill would benefit from having the support of a national palliative care strategy. Although a small percentage of Canadians may request medical aid in dying , everyone in Canada will likely need to access palliative care. No matter where one lives in the country, one should have access to high-quality palliative care towards the end of life.
My colleagues who helped me prepare this brief suggested that at this point I provide a real-life story.
I'm often asked whether any of my patients have asked me for medical aid in dying. The reality is that no one, to this point, has asked. I believe part of the reason is that they did not know it was going to become a reality.
The only person who asked me is my own mother, in May of 2013. She was a “super senior”, to quote Mr. Housefather. She was 94 years of age, with terrible mixed arterial and venous insufficiency in her legs, ulcers, and terrible pain, which morphine treated by making her a zombie and for which anything less did not do the job. At that time my mother asked me whether she could get medical aid in dying, and at that time she would have met the criteria for medical aid in dying.
We fast-forward three years, and this diagnostic test that she had, an arteriogram, in fact was therapeutic. Her ulcers are now healed, but she has declined cognitively. She's quite limited. She really is a frail elderly person, and I'm not sure that today she could articulate those kinds of wishes, although it could be said that she has a degree of existential suffering.
If we were to ask her today, she probably would accept that Mother Nature should run its course. I think that as we move forward with this legislation, we need to accept that three years ago we might have done assisted dying based on the conditions my mother had at that time and she might have died, even though we know that she is now alive. I think we need to feel comfortable with that. In the same way, we need to feel comfortable thinking of my mother today at 97 as a frail elderly person who's prepared to wait for Mother Nature to run its course without necessarily making the same request. Even though the quality of her life, by some standards, could be viewed as not the best, by her own standards it's probably okay. We need to think about all these things as we think about this legislation.
We look forward to continuing to offer our advice and perspective as the legislation takes shape.
Thank you very much.
Thank you very much, Mr. Chair, and also the committee, for inviting us to speak today.
First I'd like to acknowledge the difficult task you have before you. The final legislation must strike a balance between the needs of patients, the right to access, and ensuring that health care providers are fully equipped to deliver quality care regardless of the setting.
This is a very complicated and emotional issue for many, and one that has dominated much of the profession's discussions over the last year. Very early on in our discussions within the profession, it was clear there was an important role for pharmacists as the dispensers of the lethal dose of medication for assisted dying. Over the past year, we've worked with our members to understand the impact of the court's ruling and their views on the issue. We did this through an extensive survey of pharmacists and through the development of guiding principles, which we released in February.
Pharmacists are keenly aware of their role as a primary health care provider. They are consistently rated as one of the most trusted professions and they are often the first point of contact within our health care system.
We're already hearing stories of community pharmacists being asked questions about assisted dying. As a profession, we've been very encouraged to see the conversation around assisted dying expand from what was solely seen as physician-assisted dying to what is now called medical assistance in dying. This acknowledges that, like any other health care service or procedure, assisted dying involves a much larger team of health care professionals.
However, we must also appreciate that Bill is only one component of Canada's legislative response to the Supreme Court's decision and that many important practical considerations will be left up to the provinces and territories to address. This will require additional practice guidelines and regulations.
Generally speaking, as it is drafted now, we believe that Bill appropriately recognizes the role of pharmacists and protects those pharmacists who choose to participate from any criminal liability that could result from dispensing a lethal dose of medication.
I'd like to make some comments on some of the specific provisions in the bill.
First, it is important to note that under proposed section 241.1, medical assistance in dying is permitted in two instances: it can be administered directly by a physician or nurse, or it can be self-administered. This has significant implications for the role that pharmacists might have to play in assisted dying. In particular, in the case of self-administration, we see a far greater role for pharmacists, who may have to dispense the drugs directly to the patients. It's conceivable that this could be the last interaction between the patient and a health care professional prior to death, so we are pleased to see that proposed subsection 241(4) of Bill specifically exempts pharmacists from criminal liability if they dispense a substance to a person other than a medical practitioner or nurse practitioner.
We are also very supportive of proposed subsection 241.2(8), which requires that the medical practitioner or nurse practitioner who prescribes the substance inform the pharmacist that the substance is intended for that purpose. This is something we specifically called for, and we are pleased to see it reflected in legislation.
In addition to the specific provisions we've highlighted, we also want to draw your attention to two key elements that are not provided for in legislation but that we feel are equally important. Although we are not proposing any amendments to the legislation, we are hopeful that the federal government will work with its provincial and territorial counterparts, as well as stakeholders, to address these issues in the coming months.
On the issue of conscience, we strongly believe that pharmacists and other health care professionals should not be compelled to participate in assisted dying if it is counter to their personal beliefs. The legislation does not set out whether or how health care professionals can refuse a request. This leaves protection of conscience for health care professionals, including pharmacists, up to the provinces and to professional regulators. In addition, and to ensure that freedom of conscience is respected, pharmacists should not be compelled to refer the patient directly to another pharmacist who will fulfill the patient's request. This is an important consideration for pharmacists who view referral as morally equivalent to personally assisting a patient to die.
To provide equal protection of a pharmacist's right to conscientious objection and a patient's right to access, CPhA recommends the creation of an independent information body with the capacity to refer to a participating pharmacist, and we urge the federal government to work with the provinces and territories to create and implement such a system.
The second issue that is particularly relevant to pharmacists in their day-to-day practice is the question of drug access.
There is no single medication or drug that exists to end someone's life. Rather, it can be a cocktail of medications that could be administered by someone or self-administered. Depending on how it's administered, different drugs could be used.
Of great concern to pharmacists, who are all too familiar with issues of drug availability and accessibility, is that the drugs in question are in some cases not readily available in Canada. There is still some work to be done to understand which drugs might be most effective in assisted dying. Evidence shows that high doses of barbiturates are usually effective for death when self-administered, while a combination of barbiturates and a neuromuscular blocking agent is more appropriate for physician- or nurse-administered injection.
To give you an example, in Oregon, where drugs for assisted dying are solely self-administered, one of two barbiturates is used, neither of which is currently available in Canada. It is critical for Health Canada, as the regulator of drugs, to ensure that whatever drugs are recommended be available and accessible to patients and their health teams. We welcome the opportunity to work with them to address this issue.
In conclusion, we urge that this legislation be passed quickly in order to ensure that there is a framework in place by the June 6 deadline and to allow the provinces and territories an opportunity to develop appropriate practice guidelines and regulations. Over the coming months, our provincial pharmacy associations will continue to work with their respective regulators to ensure that appropriate practice guidelines are in place.
We thank you again for the opportunity to appear and we look forward to answering your questions.
I thank the committee for inviting us.
At the outset, I want to say that we welcome this legislative initiative, which responds to the requirements of the Supreme Court in the Carter ruling. Generally speaking, we feel that this is positive. However, I would like to share some of the reservations we have about the bill with committee members. I will highlight four points, and Mr. Ménard will provide more detail on them; then we will answer your questions.
The first reservation we have concerns the offence of counselling someone to cause their own death. There is an exemption in the bill for helping someone to die, but providing advice in that regard is not exempted. We think the bill should explicitly say that when a doctor explains all of the care available to a patient, including medical assistance in dying, that does not constitute an offence. In short, the bill should specify that for a physician to counsel a person on assistance in dying is not an offence. This has to be made very clear. Physicians or other health care professionals should not be charged with an offence if they provide information that could be interpreted as advice.
The second element is that in the bill the definition of medical assistance in dying also includes, for physicians, prescribing or providing a substance that will cause death, although the person will himself ingest the substance in question. This concerns us. One can easily imagine a situation that could arise if the health professional is not present at the time the person ingests the substance that will cause death. How can we know that that is really what caused the person's death? Moreover, there are ethical and legislative issues which may place health professionals in dilemmas or conflicts with their own standards and their own regulations. We think that the legislation should prepare for and include those situations. One cannot simply give someone a substance that can cause death without some kind of follow-up. We are concerned about that.
Also, with regard to the principle in the Carter ruling, the bill is somewhat too restrictive in our opinion. In order to obtain medical assistance in dying, it has to be shown that the medical condition of the person who is asking for this is one of advanced and irreversible decline in capacity, and that the natural death of that person has become reasonably foreseeable, in light of his overall medical condition, without necessarily having a prognosis on life expectancy. We feel that those criteria are not in the Carter ruling, and we think that the legislation has to be based on principles and statements that are in the Carter decision, and that they should frame this exercise. There is a clear risk that the bill will be challenged. Mr. Ménard will in fact go into this aspect more in depth.
The last point, which I will address quickly, concerns the new requirements regarding the documents physicians will have to complete. They must fill out forms. Even though the bill states that this must be done deliberately for an offence to be committed, it is somewhat excessive, in our opinion, to criminalize the fact of not having filled out a form properly. The provincial laws and regulations that regulate the medical profession should normally suffice for this type of information.
I will now yield the floor to Mr. Ménard.
Ladies and gentlemen, members of the committee, good evening.
The Barreau du Québec is the first intervenor from a province where legislation already exists on medical assistance in dying. The law has been in effect since December 10, 2015. There have already been dozens of cases, and certain issues have begun to arise in applying the law in some situations. To contribute to your debate, we are going to share some of the difficulties we have observed here and there, so that you may avoid encountering the same issues with the federal act. They are not major ones, but we have to be aware of them.
As Mr. Battista said, our first comment concerns the issue of assisting someone to commit suicide. The Quebec legislation does not provide for assisting suicide. We must not forget that the Quebec law is very comprehensive. It covers all of the medical assistance in dying practices that are under provincial jurisdiction. We decided not to include assisting suicide because at the time it was seen as an aspect that was essentially criminal, and the province had no jurisdiction in the matter. The provincial act is an act on care, it is not criminal legislation. Consequently, assisting suicide was not included. However, this will now be made accessible through medical assistance in dying.
We think it is important to think about measures to regulate this that are not contained in the Quebec legislation or any other provincial law. As Mr. Battista pointed out, one of the difficulties comes from the fact that the physician has no control over what happens once he has provided the medication to the patient. He cannot even certify that the patient really did pass away because of that process, nor can he determine when the death occurred. To the extent that the federal law permits assisting suicide, we think it should contain more obligations, such as requiring from those who assist the person that they immediately notify authorities, either the physician or a public authority, that the person has passed away in this manner, so that the proper management of the process may be monitored.
As Mr. Battista pointed out, there is an issue regarding physicians' ethical obligations. There is, for instance, the obligation of following one's patient and not abandoning him. For some physicians, giving a patient a pill and allowing him or her to take it himself is seen as a kind of abandonment. It can also be difficult for a physician to get involved in such a process.
Let's talk about compatibility with the Carter ruling. We should be aware that the impact of the law will in future be measured in light of section 7 of the Canadian Charter of Rights and Freedoms, which is broader in scope than what the bill is proposing. If we adopt more restrictive criteria than what is now allowed under section 7 of the Canadian Charter of Rights and Freedoms, clearly we will be opening the door to legal challenges. The Barreau du Québec feels that it is not desirable that people who could have access to medical assistance in dying under the criteria in the Carter decision, no longer have this access because of Bill . We have seen what happens in Quebec when a more restrictive standard is applied. For instance, some people have stopped eating in order to become eligible under the law. This type of situation, which occurs because of a more restrictive criterion, is not a desirable development. This is important and that is why we made that recommendation.
Moreover, we think that the criterion of reasonably foreseeable death is too vague, too uncertain. It is important for the Barreau du Québec that citizens be able to count on a legal standard that is as clear as possible. The fact that this is highly subject to interpretation, because of the wording, may deprive certain Canadians of the constitutional right to obtain assistance in dying. If we want such a criterion to be present, it is important to develop it more. However, since this criterion does not exist in the Carter ruling, we think that leaving it in the bill will open the door to legal debates. That is why we recommend the pure and simple elimination of paragraph 241.2(2)(d) proposed in the bill.
I'd like to discuss a few more technical situations regarding the safeguards, among others the characteristics of the witnesses. The standards being imposed are so strict that it will be difficult even for the person concerned to find a witness to sign the form. Members of the family and many other people are excluded. We should remember that the witness only attests the signature, nothing more. In any case, the physician is going to have to verify that the patient gave his or her consent freely. I think that too much is being imposed on the witnesses. These criteria would be more appropriate if we were asking for consent on behalf of someone else. But in the case of a simple witness, we think that these measures are far too rigid.
Let's move on to the declaration. Our brief was written from the perspective that a very detailed provincial law exists, and we are adding a federal law. In order to avoid a multiplication of forms and reports, I think it would be important that there be an exception in the bill; when the government is satisfied with the provincial declarations that are required, there should be an exemption in the bill so that physicians do not have to make a host of declarations. An overabundance of paperwork will also discourage a certain number of physicians from doing these things.
In Quebec, the reporting process is already very elaborate. Why should there be an additional report? I think that this will only make the process more cumbersome, unnecessarily. However, nothing prevents federal authorities from requiring that the province provide the information collected through its own monitoring measures. In Quebec, the province monitors medical assistance in dying. We have created an organization specifically for that purpose, the Commission sur les soins de fin de vie, the end of life care board, in addition to the monitoring done by the Collège des médecins and the Conseil des médecins, dentistes et pharmaciens. And so the creation of a new level of monitoring seems superfluous to us. We think you should consider less onerous monitoring measures in the provinces where a law already exists.
Thank you for having me here. My name is Nino Sekopet, and I am a psychotherapist retained by End of Life Planning Canada to support people who want a safe place to talk about dying. For four years before this, I played the same role with Dying With Dignity Canada.
I deal every day with the complex and profound topic of the end of life. I see it as a continuum that, unfortunately, consists of two emotionally charged and polarized extremes. We have people who support physician-assisted dying and we have people who oppose it. There is also a vast space in between. Looking through a purely psychological lens, I believe that when we as individuals or as a society stand in either one of those polarizing extremes, deserting the vast in-between space, we miss something very important. We miss the very thing that gives the charge to those polarizing extremes. We fail to recognize the impact on the end of life. We fail to recognize the impact of the fear and insecurity that drives the emotional charge at both extremes.
I believe that if we are able to correctly address the impact of fear and insecurity, and if we do it to the degree that is necessary, those polarizing extremes will lose some of their charge. We will become less polarized. As individuals and as a society, we will become healthier and more willing to consider and accept our differences. We will become more inclusive rather than exclusive. We will become more tolerant.
What I've learned through my work with people approaching death is that clarity is the best way to contain fear and create a space where these patients can feel more secure. Clarity provides a psychological frame within which individuals can rest safely, knowing that they are secure, recognized, and validated. This applies to everyone at the end of life, to all of us. It applies equally to health care professionals, to patients, and to their families.
In my professional opinion, the reasonably foreseeable natural death criterion proposed in Bill provides little security, little frame of reference. Because of its openness to interpretation, it encourages fear and insecurity, rather than creating space for safety. Removing that criterion from the proposed legislation will restore clarity in line with the Supreme Court's Carter decision. It will benefit everyone engaged in the end-of-life territory, patients as well as health care professionals. It will ultimately benefit all of us as individuals and as a society.
I would like to invite you to step into the vast in-between space and contain the fear of all individuals engaged in end-of-life territory by removing the reasonably foreseeable natural death criterion from the proposed legislation. I invite you to trust the individual who is suffering terribly, and that person's physician, to know when their time has come. By doing that, you will make us all feel safer, regardless of our place on the end-of-life spectrum.
I want to step in now and address the second point in our brief, which is advance requests for medical aid to die.
Bill ignores recommendation 7 of the special joint committee, which would permit advance requests for someone diagnosed with a condition likely to cause loss of competence—for example, Alzheimer's disease. The government is proposing instead an independent study of advance requests, and it may revisit the issue in five years when the bill is reviewed.
Here is our view.
Dementing diseases such as Alzheimer's are terminal. They kill vital brain cells slowly and cruelly. The course of the disease can last up to 20 years after a diagnosis. In the late stages of dementing diseases, the body is alive but the brain is compromised beyond repair. The person has become a shell, living in an advanced state of irreversible decline in capability. It is a pitiable state to be in.
The idea of being demented deeply scares me. I would rather be dead than live the final stages of dementia. We've all heard someone say “Just shoot me” as they imagine themselves severely demented. We foresee the loss of quality in their future life. They foresee the quality of life in their future life, and they beg to be allowed to receive assistance to die if they have by then lost the capacity to make the request. We believe that a valid advance request that includes a specific, independently verifiable description of a future state so devoid of quality that life itself would be intolerable to the individual should survive its author's loss of capacity to request assistance to die.
Some will say this can't work because that person might change their mind, but we posit that when you lose the capacity to make an informed choice about your own body, then you also lose the capacity to change your mind, and your advance request should stand as the last expressed wishes of your competent self.
If my validly written and witnessed advance request describes a state of being so lacking in quality that it would be intolerable to me, and if my description of that state is sufficiently clear that my legal substitute decision-maker and two independent medical professionals can verify that my debilitation has reached the point that I so clearly described, then my advance request should satisfy legal requirements to allow me to receive assistance to die.
Our overall view comes down to this. Bill must put forward clear rules about who is eligible for assistance to die, but it must do this in a way that respects the autonomy of the individual, in consultation with medical professionals, to decide when suffering has become so intolerable that death is preferable. This can be done in real time, or it can be done in advance through a clear and valid advance request. We beg you not to abandon to a pitiable fate those Canadians who would take the time to draft an advance request for assistance to die should they at some point in the future lose the capacity to make an advance contemporaneous request.
Trust the people who elected you to represent them, and trust the medical profession.
Thank you very much, Chair and members of the committee. It's an honour to be here today.
I am a family physician with 35 years of experience. I deliver babies. I look after people who are at the palliative end of life. I look after people with disabilities who are nowhere near dying. I am perhaps the only person at this table who has conducted capability assessments—about a hundred of them, in fact—with a lot riding on a legal medical assessment of whether the person was capable.
It was with some great relief that I saw that Bill at first reading, as drafted, took a very careful approach. Far from trying to be groundbreaking or in the van of the entire world in its daring nature, it took a very responsible approach to the many issues in front of us.
I'd like to take a minute to tell you a story about Uncle Matt.
Uncle Matt was a strong older man who was on a hunting trip in northern B.C. He spent two weeks traipsing through the bush, but on the way home, near Chilliwack, he began to suffer weakness on one side of his body. He was having a stroke. He eventually was transferred to Surrey Memorial Hospital and came to my attention 10 days after a feeding tube had been pulled out. His niece contacted me because she was able to discern that he wanted to live. He was able to say “hungry“, “thirsty“, and the niece asked Uncle Matt's daughter, “Why are you not putting that tube back down? We think he wants to live.” Her reply, in part, was “I've been tallying things up, and he wasn't a very nice man.”
The niece and another nephew kidnapped him from Surrey Memorial Hospital and took him to Vancouver General Hospital. The nurse there, although he was able to croak out the word “thirsty“, was aware they did not hold powers of attorney and put him in an ambulance and sent him back to Surrey Memorial. He died.
He died during an emergency hearing that I helped arrange, during which a judge actually issued an order that the feeding tube be put back down, that he be rehydrated, and that his true wishes discerned.
Now, this is not to say that the people who've come to Nino or who have come in front of Françoise are like Uncle Matt, because the people who have self-selected to approach people who are involved with end-of-life planning and that organization have already self-selected to be highly motivated. This is to simply demonstrate that the medical system, as it now stands, consisted for Uncle Matt of doctors who would not listen to the possibility that he wanted to live and was being intentionally dehydrated to death—he had several million dollars' worth of real estate—and that the hospital risk management, such as it was, was more concerned about the hospital not being sued than it was about Uncle Matt's wishes being respected.
This takes me to the point that this bill, although it might be assumed, nowhere specifies that doctors must actually examine the patient, the extent to which they must do so, or the extent that doctors must inquire into the internal and external factors that create vulnerability for the patient. I refer you here to the vulnerable person standard, which is being published now and which contains four key elements that should be reflected in this legislation.
This lack of requirement for the two doctors—and I use doctors to mean doctors and nurse practitioners—to deeply engage with the patient begins with the acceptance by the doctors of a written request, which can be created before two witnesses by someone representing the patient who purports to understand the nature of the request. The doctors do not have to meet, nor do they have to assess the motives of the representative. The patient representative and two witnesses must be physically together at some point in time, but a doctor does not have to be present at that time.
The two witnesses are not required to have any understanding of the situation, other than that a request is being signed and dated. The witnesses are not expected to have any knowledge of the patient's decision-making capability or the representatives' motives. Under the draft act, any number of physicians may be canvassed by anyone to find two who approve of death in any given situation.
The factors that are enumerated in the safeguard section of the bill in proposed section 241.2 are in many ways moot. Therefore, I would propose the first amendment of four that I'm interested in proposing, and it is that there needs to be some form of prior review by a third party, such as an independent, objective judge, or some sort of process in which the facts that brought this person to the point of being proposed for assisted suicide or euthanasia could be reviewed.
I can tell you that it is extremely difficult to make these determinations, and I have done it many times. I think that to expect that any two doctors in the medical system could do that is to invite wrongful death. I am sure that in 20 years, as the members of this committee must understand, many deaths will have occurred under the auspices of Bill . I'm sure the members of the committee will want to think that if there are wrongful deaths emanating from this legislation, you did your best to plug the gaps, to fill in the holes, and to make sure that vulnerable people were truly protected. As it stands, the two-doctor standard for assessing consent and capacity, I would suggest, is insufficient, and I think I've been echoed in that concern by others.
My second point is that it seems that Mr. Rankin has the deepest understanding of the fact that a long period of time may happen between the dispensing of the medication and the death of the patient. In that period of time, there is room for abuse, sadly. In Oregon, once the dose is dispensed from a pharmacy, it goes out into the wild blue yonder and is never accounted for again. If the patient struggled and was actually given the dose by someone else, one would never know.
Although Mr. Rankin's insistent questioning on this matter may be designed to lay the groundwork for advance consent to be put in place, I think there's another interpretation that could be taken from his acute observation, and that is on the wording of proposed paragraph 241.2(3)(h), under safeguards, that the physician must
immediately before providing the medical assistance in dying, give the person an opportunity to withdraw their request
I would suggest that this wording really should be “at the time of”. Furthermore, why is it not possible for the lethal dose to be dispensed not from a pharmacist to the patient but from a pharmacist to the doctor, so that the doctor could ensure that at the time the lethal dose was used, the elements of consent were there and the capacity was there? This would address the concerns of Mr. Emberley from the pharmaceutical association as well as some of Francine Lemire's concerns.
We have heard four times, I think, from Minister that nothing in this act compels anyone to become involved in assisted suicide and euthanasia. That, I think, suggests that the time may be right for those words to actually appear in this bill: “nothing in this act compels”. That could appear in the preamble. That could appear in another section. I think it would go a long way toward giving that central direction to conscience protection and the protection of professional judgment that is so desirable.
There is another question, of course, and that is the issue of whether we could actually make a simple wording change in the eligibility section of this bill, which would in some ways answer three of the four areas that I've talked about so far. We could actually.... I'm sorry. It's in proposed section 227, a proposed new section of the Criminal Code that deals with exemptions from criminal prosecution for doctors and others who provide assistance in dying to someone who qualifies under the eligibility criteria.
Under proposed subsection 241(2), it is stated that:
No medical practitioner or nurse practitioner commits an offence
There, we could easily say “no specially licensed medical practitioner or nurse practitioner”. This would address several concerns at once. One is that in the eligibility criteria, it is nowhere specified that the person has to have received the services or an offer of services of a multidisciplinary team that could try to address the symptoms that gave rise to the request for death. A specially licensed physician or specially licensed nurse practitioner could be charged with making sure that this had happened.
I think that's worth commenting on further. I've heard it said several times that it was unconscionable that this be left to two physicians who are not charged with making sure that alternatives have been offered, and that could easily be fitted into the eligibility criteria.
I look forward to your questions.
Thank you to the witnesses for being here.
I'm sure most of us in this room have experienced saying goodbye to a loved one or a friend. In my 66 years, I've said goodbye to my parents and my in-laws. Whether it's at a young age like my mother, at 47, suddenly in her sleep, or most recently my mother-in-law, it hurts.
My mother-in-law had dementia. She was never in a pitiful state. She lived a very wonderful life of love. We loved her. She was dignified. She was dignified because we gave her that dignity. She was never in a pitiful state. I heard in testimony today that it could be defined as a pitiful state, and in special committee I heard that it's not sensible for somebody to be in an adult diaper in the last year of their life in bed with dementia, but we loved her and we miss her.
We went to say goodbye to her. We were told by her family physician that she had two to five days to live. We asked what sense there was in giving her her meds, her glaucoma drops, her dementia medicine, and whatnot. As a family we said to just stop the medicine and let her go. After three days of staying with her—she was in California—my wife said goodbye. It was a wonderful experience. When we came back, we phoned the rest home: Is she gone? No. The next day: Is she gone? No. When we called the third day, they said somebody wanted to talk to us.
She came back. We had another wonderful year. It was one of the best years we had.
I tell you, we don't know what we're playing with here. We don't know if somebody's going. She missed Dad and she wanted to go. She would have qualified. But she came back, and we had that wonderful year.
Dr. Johnston, regarding putting “nothing compels a physician to” in the preamble, preambles are not usually seen by the court as the guiding principles as they would be if they were actually in the bill. I think all of us have heard from witnesses that the number one issue—and we're hearing it over and over again—is to protect the conscience rights of physicians, nurses, pharmacists, medical practitioners. We need to get it right when we protect vulnerable Canadians and we need to protect conscience rights. The Supreme Court in the Carter decision highlighted that.
The legislation that's proposed in Bill at this point is silent on that. It's been explained by the minister and the department that it does not say that anyone is forced to participate in this, but it is silent on it. Would it help, instead of having it in a preamble, to actually state in the bill that it would be a criminal offence to force, intimidate, or coerce a physician or health care practitioner, nurse practitioner, or pharmacist to participate against their will?
What we have in the Carter decision is that it was legal to commit suicide, but it was illegal to assist somebody. Carter has said that under certain criteria, you can assist somebody. The pendulum has swung to where the special committee has said you must refer, but the Canadians that I'm hearing from want conscience protected.
My question to you is this: if Bill were amended to make it a criminal offence to coerce, intimidate, or force a physician, do you think that would deal with the issue as far as conscience protection is concerned?
There may actually be all sorts of reasons, moral or other, to think otherwise, but from a strictly legal standpoint, the bill as it is worded creates a very real problem. I am a practising lawyer and I have clients, including groups of disabled individuals. Some of those groups have asked us to consider this scenario. In such a fundamental bill, it is important to generate some legal certainty for Canadians. The standards and the rules of the game must be clear for everyone.
This bill proposes a standard to enable access to medical assistance in dying, but the issue, with all due respect, is that this is not the standard from section 7 of the Canadian Charter of Rights and Freedoms as set out by the Supreme Court in the Carter decision. When a more narrow standard is adopted to cover end of life and similar issues, the problem lies in the fact that a void is being created. In fact, those individuals who do not meet the end-of-life conditions included in Bill , but who do meet the conditions related to grievous and irremediable illness from the Carter decision, want to have the right to access medical assistance in dying. The Supreme Court decision truly applied to those individuals.
The Supreme Court did base its decision on end-of-life criteria. It did not wonder whether the individuals were really at the end of their life. That is not a factor the court considered. It talks about people suffering from grievous and irremediable conditions, some of which may lead to a sooner end of life. When the court gave section 7 all its scope, it did so consciously, I believe, in order to ensure a broader reach than that ensured by the bill.
The problem is that, by setting limits as has been done in this case, there is a risk of overlooking some of the people who have the constitutional right to access medical assistance in dying. This bill will take away that right or force those who want to exercise it to start from scratch again before the courts, so that the Supreme Court would once again fill that void. Two, three or four years down the road, the House of Commons—Parliament—will have to amend its legislation again.
The Barreau du Québec does not feel that this is desirable, especially when it comes to individuals with a grievous and irremediable medical condition who would have to engage in a legal battle again. That is not what we should aim for as a society.
We can agree or disagree. The Supreme Court may have gone too far, but we are talking about the Supreme Court and the law of the land. We cannot ignore this for the sake of other principles.
As for the criterion whereby death must be reasonably foreseeable, we have a similar problem in Quebec, as well. In fact, the criterion whereby the individual must be at the end of their life is also being debated. We are in the process of applying the legislation, and there are issues with this. As the criterion can sometimes be too nebulous, the position may vary from one physician to the next. Some are saying that, to be considered at the end of life, people have to be dying, terminally ill, while others are talking about three or six months. It is clear that reasonably foreseeable death is an excessively vague criterion. For Canadians, it is important that legal standards be clear, applicable and easy to understand for everyone.
We have held a long debate in Quebec to decide whether it was desirable to establish a time frame—such as six months or three months. The issue is that medical science is unable to predict whether the time frame will be three months or six months, depending on the individual. Therefore, we have decided that it would be preferable to give physicians an opportunity to use their discretion.
However, the problem is that, with nebulous criteria, Canadians' rights become more or less elastic, and that leads to problems. Taking into account those problems, as well as the scope of the Carter decision, we have recommended that this criterion simply be removed from the legislation.
Ultimately, the Quebec legislation is based on two premises.
Here is the first one. Don't we all want to cross the threshold of death calmly, to let go without fear of suffering, without suffering? Is that not what we would wish for others?
The other premise is the following. We harm an individual's dignity by harming their self-determination; it's not a matter of diapers. The other principle is self-determination. The law considers this principle during our life, while we are healthy. So why would that self-determination principle be taken away in a moment as intimate as our own death? My neighbour won't be dying in my place or wanting to do so.
Those two principles give rise to the Quebec piece of legislation titled An Act respecting end-of-life care, which did not cover assisted suicide. The reason I am stressing that fact this afternoon is that there is a problem with conceptual confusion between euthanasia and physician-assisted death during the final stage of life. Whether we are talking about six months or a year, the fact remains that the process toward death is irreversible. We are then no longer talking about healing, but rather about the right to die and about palliative care. The request to die always emerges during palliative care, and rarely before.
The court is now asking us to provide a framework for assisted suicide. The criterion in question is that of natural death. There has been a lot of talk today about reasonably foreseeable death, but there is an even more nebulous term—reasonably foreseeable natural death. But is death in palliative care natural? To my knowledge, a patient in palliative care dies from whatever they are given to manage the pain. One last dose, even if it is not lethal, will end up stopping the heart. In that case, can we talk about natural death?
I could talk about this for a long time, but I want to ask some questions.
The Quebec legislation does not provide a time frame. In this case, we have talked about a time frame of 15 days. For all sorts of reasons, I feel like this is a dubiously drafted version of the Quebec legislation. Would you be open to adding an equivalency clause, as Professor Hogg was suggesting?
If this piece of legislation was adopted as is, it would lead to peculiar situations for Quebec. For example, the Quebec legislation does not talk about nurse practitioners or other health professionals. Would you agree with adding an equivalency clause to the legislation? That way, if the federal minister was convinced that a province or a territory has implemented the necessary guarantees equivalent in substance to the federal guarantees, the federal legislation would not apply. Would it not make more sense to do that?