Source: http://eol.law.dal.ca/?page_id=236
Timestamp: 2019-04-25 01:02:40+00:00

Document:
Medical assistance in dying (MAiD) is legal in Canada.
The most recent official data on MAiD in Canada can be found here.
The most recent official data on MAiD in Quebec can be found here.
A summary of the most recent official and unofficial data can be found here.
(b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death.
MAiD is legal under the Criminal Code of Canada if the eligibility criteria are met and the procedural safeguards are followed.
(d) their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.
(i) if the person has difficulty communicating, take all necessary measures to provide a reliable means by which the person may understand the information that is provided to them and communicate their decision.
Additional procedural details are set out in the legislation.
Quebec is unique within Canada in that MAiD in Quebec is subject to the federal Criminal Code but also to the provincial An Act Respecting End of Life Care.
“medical aid in dying” means care consisting in the administration by a physician of medications or substances to an end-of-life patient, at the patient’s request, in order to relieve their suffering by hastening death.
MAiD is legal under the Quebec legislation if the eligibility criteria are met and the procedural safeguards are followed.
(6) experience constant and unbearable physical or psychological suffering which cannot be relieved in a manner the patient deems tolerable.
26. […] The patient must request medical aid in dying themselves, in a free and informed manner, by means of the form prescribed by the Minister. The form must be dated and signed by the patient.
The form must be signed in the presence of and countersigned by a health or social services professional; if the professional is not the attending physician, the signed form is to be given by the professional to the attending physician.
27. If the patient requesting medical aid in dying cannot date and sign the form referred to in section 26 because the patient cannot write or is physically incapable of doing so, a third person may do so in the patient’s presence. The third person may not be a member of the team responsible for caring for the patient, a minor or a person of full age incapable of giving consent.
28. A patient may, at any time and by any means, withdraw their request for medical aid in dying.
A patient may also, at any time and by any means, request that the administration of medical aid in dying be put off.
(3) obtain the opinion of a second physician confirming that the criteria set out in section 26 have been met.
The physician consulted must be independent of both the patient requesting medical aid in dying and the physician seeking the second medical opinion. The physician consulted must consult the patient’s record, examine the patient and provide the opinion in writing.
30. If a physician determines, subsequent to the application of section 29, that medical aid in dying may be administered to a patient requesting it, the physician must administer such aid personally and take care of and stay with the patient until death ensues.
If the physician determines that medical aid in dying cannot be administered, the physician must inform the patient of the reasons for that decision.
It remains to be seen how the inconsistencies between the federal Criminal Code and the Quebec legislation will be resolved. Quebec’s legislation is more restrictive and that may be resolved by the Quebec National Assembly amending its legislation to make is consistent with the federal Criminal Code or by a court ruling that the Quebec National Assembly does not have the authority to restrict access to MAiD as it has. See Recent Developments for more information.
How is MAiD Being Implemented Across Canada?
The New Brunswick Department of Health has yet to provide information to the public regarding medical assistance in dying.
The Newfoundland and Labrador Department of Health and Community Services has yet to provide information to the public regarding medical assistance in dying.
The Nunavut Department of Health has yet to provide information to the public on medical assistance in dying.
Yukon Health and Social Services: Medical Assistance in Dying.
As well, health professional regulatory bodies have developed guidelines and standards to further regulate practice in relation to MAiD.
On June 15, 2012, Justice Lynn Smith struck down the Criminal Code prohibition of assisted suicide (Carter v Canada (Attorney General), 2012 BCSC 886). She found that it violated sections 7 and 15 of the Canadian Charter of Rights and Freedoms. Her declaration of invalidity of s.241(b) of the Criminal Code was suspended for twelve months to give the government time to fix the law. The government appealed and Justice Smith’s decision was overturned by the British Columbia Court of Appeal in 2013 (Carter v Canada (Attorney General)). The majority (2:1) allowed the appeal on the grounds of stare decisis (that the issue had been decided by the Supreme Court of Canada in Rodriguez v British Columbia (Attorney General) in 1993). The Supreme Court of Canada heard the appeal on this case in October 2014 and released its decision on February 6, 2015 (Carter v Canada (Attorney General)). The Supreme Court (unanimously and with a decision authored by “The Court”) found that the prohibition on assisted suicide violates section 7 of the Canadian Charter of Rights and Freedoms when it prohibits access for “a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition” (irremediable, the Court said, means that the condition cannot be alleviated by means acceptable to the person).
Re HS, 2016 ABQB 121.
A.B. v. Canada (Attorney General), 2016 ONSC 1571.
A.B. v. Canada (Attorney General), 2016 ONSC 1912.
A.A. (Re), 2016 BCSC 511.
A.A. (Re), 2016 BCSC 570.
Patient v. Attorney General of Canada et al, 2016 MBQB 63.
W.V. v. Attorney General of Canada, Attorney General of Ontario and Dr. C. Doe, 2016 ONSC 2087.
W.V. v. Attorney General of Canada, 2016 ONSC 2302.
A.B. v. Ontario (Attorney General), 2016 ONSC 2188.
X.Y. v. Canada (Attorney General), 2016 ONSC 2371.
X.Y. v. Canada (Attorney General), 2016 ONSC 2585.
C.D. v. Canada (Attorney General), 2016 ONSC 2431.
W.B.B. (Re), 2016 BCSC 1005.
Tuckwell, Re, 2016 ABQB 302.
E.F. v. Canada (Attorney General), 2016 ONSC 2790.
Patient 0518 v. RHA 0518, 2016 SKQB 175.
G.H. v. Attorney General of Canada, 2016 ONSC 2873.
Canada (Attorney General) v. E.F., 2016 ABCA 155.
I.J. v. Canada (Attorney General), 2016 ONSC 3380.
H.H. (Re), 2016 BCSC 971.
O.P. v. Canada (Attorney General), 2016 ONSC 3956.
One case was decided after the Supreme Court of Canada’s decision in Carter v. Canada (Attorney General) came into effect in June 2016 – i.e., when the prohibitions under the Criminal Code were no longer in effect. In this case, Justice Perrell of the Ontario Superior Court concluded that individuals would still need to seek court orders until federal legislation came into force. Given the introduction of the legislation shortly thereafter, this decision is not being appealed.
In August 2015, a Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying was created by provincial-territorial governments across Canada. Its mandate was “to provide non-binding advice to participating Provincial-Territorial Ministers of Health and Justice on issues related to physician-assisted dying. The advice is meant to assist provinces and territories in deciding what policies and procedures should be implemented within their jurisdictions in response to the Supreme Court’s decision in Carter.” The Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying delivered its final report on November 30, 2015. It made 43 recommendations for how federal, provincial, territorial governments (and other relevant actors) should implement a regulatory framework for physician-assisted dying in Canada.
In December 2015, a Special Joint Committee on Physician-Assisted Dying was appointed by Parliament. Its mandate was “to review the report of the External Panel on Options for a Legislative Response to Carter v. Canada and other recent relevant consultation activities and studies, to consult with Canadians, experts and stakeholders, and make recommendations on the framework of a federal response on physician-assisted dying that respects the Constitution, the Charter of Rights and Freedoms, and the priorities of Canadians.” The Special Joint Committee delivered its final report on February 25, 2016. It made 21 recommendations for a regulatory framework for medical assistance in dying and related initiatives.
On April 14, 2016, the federal Minister of Justice introduced Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying).
On May 12, the Bill was reported back to the House with amendments.
On May 17, the Senate tabled a pre-study report on Bill C-14 and made a set of recommendations for amendment to the Bill.
On May 31, the House passed the Bill.
On June 15, the Senate sent the Bill with amendments to the House.
On June 16, the House considered the Senate’s amendments, made more amendments itself, and sent it back to the Senate.
On June 17, the Senate considered the House’s amendments and passed the Bill. The Bill then received Royal Assent.
Bill C-14 was subjected to extraordinary debate in both the House and the Senate. Links to the speeches made in the House and the Senate are here.
Is MAiD legal elsewhere in the world?
Yes. Click on a country or state below for a description of its permissive stance re: MAiD. Wherever possible, we have excerpted the description from an authoritative source (e.g., Justice Smith’s decision in Carter v Canada (Attorney General) or the Royal Society of Canada Expert Panel on End-of-Life Decision Making) as these descriptions are the result of evidence being presented by experts and tested in a court of law (Justice Smith) or reviewed by a panel of experts appointed by a neutral body (Royal Society of Canada Panel). We have also included links to official government sources for legislation and data.
Note that although suicide is not mentioned in the legislation, the Act has been interpreted to include suicide.
Switzerland does not have legislation that decriminalizes MAiD. Rather, Article 115 of Switzerland’s Penal Code, SR 311.0 states that “any person who for selfish motives incites or assists another to commit or attempt to commit suicide is, if that other person thereafter commits or attempts to commit suicide, liable to a custodial sentence not exceeding five years or to a monetary penalty”. Therefore, assisted suicide is not a criminal offence where the assister lacks a selfish motive.
See page 55 of the Penal Code.
Does legalization of MAiD have a negative impact on availability or quality of palliative care?
In answering this question, we present the findings of Justice Smith in Carter v Canada (Attorney General) and the National Assembly of Quebec Select Committee on Dying with Dignity as these findings are the result of evidence being presented by experts and tested in a court of law (Justice Smith) or presented by experts in Canada and in the Permissive jurisdictions to an all-party committee of parliamentarians (Quebec Committee).
Reliable evidence does not support the claim that legalization of MAiD has a negative impact on either availability or quality of palliative care. The evidence does not demonstrate a reduction in availability or quality of palliative care post-legalization. Furthermore, availability and quality of palliative care are better in some countries that permit MAiD than in others that prohibit MAiD. For example, Belgium and the Netherlands rank higher than Canada for quality end-of-life care.
My review of the evidence regarding Oregon, the Netherlands and Belgium suggests that in those jurisdictions, legalization of assisted death has not undermined palliative care; on the contrary, palliative care provision has improved since legalization by some measures.
Few conclusions, however, can be reached about the possible impact on palliative care from a change in Canadian law regarding physician-assisted death.
First, as Canada points out, palliative care is a developing field; it may be assumed that it is improving not only in permissive jurisdictions but also in jurisdictions that continue to prohibit physician-assisted death.
Second, there are differences in the history, culture and modes of medical practice among the jurisdictions.
Third, further improvements in palliative care in Canada would require commitment of public resources, since health care in Canada is largely delivered through a public system. Some of the debate in the United States has raised the question whether health insurers would refuse to fund palliative care when assisted death was available; no evidence was provided to show that that fear has become reality in Oregon or Washington. It is difficult to imagine that Canadian politicians, public officials or health care providers, if physician-assisted death were legal, would reduce resources for palliative care services for that reason.
In summary, having reviewed the evidence and the submissions on this point, I conclude that while a change in the law to permit physician-assisted death could affect the palliative care system, predictions as to how would be speculative. I find that the evidence establishes that the effects would not necessarily be negative.
For Justice Smith’s full discussion of evidence on the impact of legalizing assisted suicide upon the quality of and access to palliative care, click here.
Legitimate as this fear may be, this has not yet happened in the European countries where euthanasia has been legalized. Perhaps surprisingly, the exact opposite has occurred. The legalization of euthanasia has boosted the development of palliative care. the social consensus was to openly accept this practice as long as palliative care was accessible to more patients. Consequently, Belgium and the Netherlands have quality palliative care, much of which is offered at home.
a 2010 report produced by the Economist Intelligence unit offers an overall ranking of the quality of end-of-life care across forty countries. Belgium and the Netherlands respectively ranked higher than Canada in the report’s overall ranking of end-of-life care services. This report was updated in 2015 and is available here.
a 2011 report authored by the European Association for Palliative Care for the United Kingdom Commission on Assisted Dying, investigates the impact that legalizing assisted suicide and/or euthanasia has had upon the development of palliative care in Belgium, the Netherlands and Switzerland, where assisted suicide and/or euthanasia has been legalized. Based on an analysis of available data, this report suggests that palliative care appears to be developing within the Netherlands, Belgium and Switzerland at a rate comparable to that of other European countries where assisted suicide and euthanasia are not legal. From a review of relevant scientific literature, the report also suggests that the quality of palliative care within the Netherlands and Belgium after the legalization of assisted suicide and euthanasia has remained comparable to the quality of palliative care available within European countries where assisted suicide and euthanasia remain illegal.
Does legalization of MAiD put vulnerable people at heightened risk of non-voluntary or involuntary euthanasia?
In answering this question, we present the findings of Justice Smith in Carter v Canada (Attorney General), the National Assembly of Quebec Select Committee on Dying with Dignity, and the Royal Society of Canada Expert Panel on End-of-Life Decision Making as these findings are the result of evidence being presented by experts in a court of law (Justice Smith), presented by experts in Canada and in the permissive jurisdictions to an all-party committee of parliamentarians (Quebec Committee), or reviewed by a panel of experts appointed by a neutral body (Royal Society of Canada Panel).
For a full discussion from Justice Smith on the issue of whether legalizing MAiD puts vulnerable people at risk, click here.
 The trial judge found that the prohibition violates the s.7 rights of competent adults who are suffering intolerably as a result of a grievous and irremediable medical condition. She concluded that this infringement is not justified under s. 1 of the Charter. We agree. The trial judge’s findings were based on an exhaustive review of the extensive record before her. The evidence supports her conclusion that the violation of the right to life, liberty and security of the person guaranteed by s. 7 of the Charter is severe. It also supports her finding that a properly administered regulatory regime is capable of protecting the vulnerable from abuse or error.
The SCC also highlighted the success of jurisdictions with permissive regimes: Oregon, Colombia, Montana, Washington, Switzerland, Luxembourg, Belgium and the Netherlands. The court noted that “Together, these regimes have produced a body of evidence about the practical and legal workings of physician-assisted death and the efficacy of safeguards for the vulnerable” (at 8).
After assessing evidence from the Netherlands and Belgium on the issue of whether a more permissive stance toward assisted dying would lead to abuse, the National Assembly of Quebec’s Select Committee on Dying with Dignity stated that: “these risks can be eliminated by defining clear and strict guidelines” (National Assembly of Quebec Select Committee Report Dying with Dignity, Report (2012) at 74).
For the Select Committee’s full discussion on this point, click here.
In sum, there is no evidence from the Netherlands supporting the concern that society’s vulnerable would be at increased risk of abuse if a more permissive regime were implemented in Canada.
To view an excerpt of the full discussion of the issue of whether legalization of MAiD puts vulnerable people at risk from Royal Society of Canada Expert Panel on End-of-Life Decision Making, click here.
A “meta-analysis” of peer-reviewed studies containing original data on the prevalence of euthanasia and assisted suicide among vulnerable patients revealed that, “most studies included in the review found that euthanasia was performed less often among the elderly, women, less-educated individuals and unmarried patients…” (see: Judith A.C. Rietjens et al., “Medical end-of-life decisions: Does its use differ in vulnerable patient groups? A systemic review and meta-analysis” (2012) 74 Social Science and Medicine 1282 at 1286). In other words, that legalizing MAiD does not appear to result in an increase of instances of euthanasia among vulnerable patients.

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