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Senate Debate on Senator Eaton’s Motion to include provisions for palliative care in Bill C-14 (Medical Assistance in Dying)

You Honour, colleagues, I rise today to speak in respect of our study of Bill C-14 regarding provisions enabling medical assistance in dying.

As we do so, it is timely to recall the words of Cicero, a Roman senator, a great philosopher, constitutionalist and orator, who is credited with uttering the now famous axiom, "While there's life there's hope."

While many of the voices enjoined in the debate on this matter might say otherwise, I believe this notion to be the absolute truth.

While there is life there is indeed hope: hope for a mitigation of pain and suffering at the end of life, hope for clarity of thought in decisions around life or death, hope for the very best in all aspects of care for patients and their loved ones.

Hope can spring eternal, yet Cicero was equally wise when he said, "Freedom is a possession of inestimable value."

Herein lies the crux of this issue. The space and diversity of intent between these two phrases is representative of the magnitude of the challenge we have before us.

Unlike perhaps never before, we now encounter a perfect storm around this legislation: a head-on collision of morals, values, faith, ethics, conscience and rights, each competing to be the nexus of the law's provisions.

We have heard a lot of opinions from various quarters on this proposed legislation, its compliance with the Canadian Charter of Rights and Freedoms and its ethics.

Yet with each further argument heard, I am struck with the reality that we are dealing with much more than lofty ethical consideration of a profound intellectual construct.

Colleagues, this legislation's purpose really is a matter of life and death.

As parliamentarians, we have been called upon by the highest court in the country to give advice on the development of legislation to responsibly guide and direct the practice of medical assistance in dying.

And so in this chamber of sober second thought we now study, debate and recommend either acceptance or improvement of the required legislation.

Therefore, how this law can achieve the balance between life through hope while respecting the freedoms of those with irremediable conditions is, I believe, the task before us. We have heard the arguments of our honourable colleagues regarding having the law mirror the broader perspectives around medical assistance in dying. They would have us match the proposals outlined in the special joint parliamentary committee's report deposited earlier this year and spoken to in this chamber by Senators Ogilvie and Cowan.

But I must caution colleagues that we must not by design or default allow or enable medical assistance in dying to become part of the norm of how Canadians die. It must only be employed in exceptional circumstances and as a very last resort for those who clearly qualify for its application.

Today I want to speak to the need in this legislation to ensure that all options are available to improve quality of life and to mitigate pain and suffering before the decision to end one's life is made. Let's face it, there is no dress rehearsal for death; there is no off-ramp on the road to eternity. This is particularly true in our modern disposable society in which things designed to become obsolete are consigned to the rubbish heap at the first hint of difficulty. We owe to society and to our younger generation to not present alternatives endorsing the false notion that suffering and hardship are not de facto reality of our lives.

Perhaps the most fundamental factor of eligibility for patients is ensuring that Canadians contemplating medical assistance in dying have access to high-quality palliative care.

We've heard much about palliative care in the debate around this issue, but my research has taught me that few truly understand the real nature of palliative care and its benefits. The World Health Organization defines palliative care as:

. . . an approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

Far from being the fast track to end of life many consider it to be, palliative care can actually intend neither to hasten nor postpone death. Its aim is to enhance the quality of life. It affirms life and regards dying as a normal process. It integrates the psychological and spiritual aspects of patient care and uses a team approach to address the needs of patients and their families.

Dr. Ignazio La Delfa is Medical Director of the Palliative Care Unit at Toronto's St. Michael's Hospital. It's his conviction that if there is to be medical assistance in dying there must also be education of doctors, nurses, health practitioners and specialists.

In his opinion, palliative care does not result in death. The purpose of palliative care is to provide all the care required so that patients can live out their final days without any unnecessary suffering.

It really is about death with dignity with a reduction in suffering and mitigation of other symptoms. This enables a feeling that the patient is in control of their situation.

Another thing Dr. La Delfa shared was that out of the literally thousands of patients he has treated over the years, remarkably few, less than 10, have called for medical assistance in dying. What is more, this number decreases even further after his patients receive a palliative care consultation.

Despite these realities, Dr. La Delfa maintains that people, including many health practitioners, fear palliative care because it's misunderstood. In fact, he commented to us that up until a decade ago palliative care was not taught in any formal way in under- or post-graduate health care institutions and medical schools. As a consequence, there are now two generations of doctors and medical professionals who know little about palliative care. They can forecast the onset of terminal illness but know little of how to render the care it takes for dealing with the suffering and its impacts until the condition claims its victim.

The Canadian Medical Association's vice-president of medical professionalism, Dr. Jeff Blackmer, would appear to concur with Dr. La Delfa's position. In a report in this week's Hill Times, Dr. Blackmer is quoted as saying, "as a profession, physicians need better training on palliative care for more patients than those with just one week left to live. There are patients with many different conditions that could benefit." He added that "they'd never want a situation where someone requests an assisted death because they couldn't receive palliative care."

Dr. Blackmer and the CMA research shows that between 1 and 3 per cent of Canadians will be the ones to pursue medically assisted deaths while the other 90 per cent could benefit from better palliative care. He added that the Canadian Medical Association will be advocating for the reinstitution of Canada's Health Secretariat on Palliative and End-of-Life Care and standardized national guidelines.

According to Dr. La Delfa, it is only recently that it is gradually becoming okay for society to talk about palliative care, to discuss how things can get better in the management of patients' conditions, to talk about improving conditions around patients' length of time on earth and to not merely prepare for their deaths.

This speaks to the real values of palliative care, and we should embrace its inclusions in this legislation and understand that its provisions can directly reduce the number of cases of requests for medical assistance in dying.

In short, palliative care can render hope, which can improve and positively prolong life, even in the face of irremediable illness. While there is life there is hope, and palliative care can deliver both.

Then, honourable senators, if palliative care is of such benefit, what has been done in Parliament to make its provision an integral component of health care in Canada?

Back in June 1995, the Special Senate Committee on Euthanasia and Assisted Suicide released its report Of Life and Death. It called for governments to make palliative care programs a top priority in the restructuring of the health care system.

The Hon. the Speaker: Honourable senators, it now being six o'clock, pursuant to rule 3-3(1) I am required to leave the chair until eight p.m. when we will resume, unless it is your wish not to see the clock. Is it your wish not to see the clock?

Hon. Senators: Agreed.

The Hon. the Speaker: Agreed.

Senator Eaton: In June 2000, the subcommittee of the Standing Senate Committee on Social Affairs, Science and Technology released its final report updating Of Life and Death, entitled Quality End-of-life Care: The Right of Every Canadian.

It recommended that quality end-of-life care become an entrenched core value of Canada's health care system. The report stated that each person is entitled to die in relative comfort, as free as possible from physical, emotional, psychosocial, and spiritual distress.

In 2005, five years later, the Honourable Senator Carstairs released a report, Still Not There, Quality End-of-Life Care: A Progress Report. It contained a series of new recommendations aimed at bringing the efforts of the 1995 and 2000 endeavours to fruition. Add to this the efforts of the Special Senate Committee on Aging, which was in place over the 2007-08 period, and you can see that myriad efforts have been under way in respect of embracing palliative care as a pillar in Canada's health care.

In the other place, another key step in this journey was the unanimous adoption in 2013 of NDP MP Charlie Angus' motion M-456. This motion called for the establishment of a pan- Canadian palliative and end-of-life strategy in conjunction with the provinces and territories. Yet, in the 21 years since this plethora of parliamentary endeavour began, we are no further ahead in ensuring Canadians benefit from high-quality palliative care. That's not to say that the debate around palliative care is not bereft of good intentions — far from it. During the meeting of the Senate Committee on Legal and Constitutional Affairs in early May, which Health Minister Philpott attended to defend this bill, she was emphatic about palliative care:

Canadians have resoundingly told us they want to receive care at home, and we have listened and are prepared to make significant investments in the order of $3 billion over the course of our mandate to help deliver better home care for Canadians, including palliative care.

She then stated:

I have already contacted my provincial and territorial colleagues to discuss the necessary changes to our health care system so as to allow home care, including palliative care, which is a shared priority.

When Minister Philpott appeared last week before us in the Committee of the Whole, she went on even further in promoting the critical importance of palliative care. She said:

. . . studies show that less than 30 per cent — some studies show only 10 to 15 per cent — of Canadians have access to high-quality palliative care. That is not acceptable to me. So we have to do much more. I, as the Minister of Health, am firmly committed to that.

As you know, though, the delivery of care is within the jurisdiction of the provinces and territories. I look forward to working with them. "We are prepared to make significant investments to make that possible, to find ways to scale up the programs that are working well across the country. . . .

I hope that I will have your support in finding ways in which we can make sure that we do better by Canadians.

While I am heartened by such comments, there needs to be balance between the rhetoric and the reality. The Liberal government's federal budget delivered in March of this year contained no funding for palliative care, and neither do the Department of Finance 2016-2017 Supplementary Estimates (A), currently under study by the Standing Senate Committee on National Finance.

So while the government is all fired up to see Bill C-14 immediately passed, it certainly seems to be much less compelled to entrench funding for critical matters that underpin managing the pain and suffering of those covered under the bill's provisions.

Colleagues, we can change this. This is our chance to give credence to the tireless efforts of our colleague, former Senator Sharon Carstairs, whose 2005 report, as I mentioned earlier, Still Not There, Quality End-of-Life Care: A Progress Report rings as true today as it did a decade ago.

The Hon. the Speaker: Senator Eaton, your time has expired. Are you asking for five more minutes?

Senator Eaton: May I have five more minutes?

Hon. Senators: Agreed.

Senator Eaton: By including measures of palliative care in the body of the bill, we can insist that a component of providing fully informed consent for patients seeking medical assistance in dying would require them to you undertake a palliative care assessment. Through this, patients would be assured of being informed of treatment, technology, or support options available to relieve their suffering. I know that there are some who believe that inclusion of palliative care in this legislation is not practical, and is a panacea in end of life care. On the contrary, insisting that the government act in this regard is part of our role and mandate. Should we not aspire to compel the government to act? Indeed, we must. It is our job to do so.

Honourable senators, this very simple, albeit very important, measure will help put palliative care at the centre of the bill and thus bring it greater certainty.

Seeding such measures into this legislation can help make its provisions more evolving than final in nature, treading softly and gingerly into these matters, as suggested last week in this chamber by some of my colleagues. While choosing this path does not necessarily reflect my personal belief, I must err on the side of pragmatism in this matter of such final consequence.

Colleagues, poet Robert Frost wrote, "Nothing can make injustice just but mercy." Enabling the delivery of palliative care at end of life through this legislation is a merciful means to an unjust end for those whose suffering is exceptional.

Hon. Nicole Eaton: Therefore, honourable senators, I move:

That Bill C-14, as amended, be not now read a third time, but that it be amended in clause 3, on page 6, by replacing line 5 with the following:

"-sistance in dying after having had a palliative care consultation and having been informed of treatment, technology or support options available to relieve their suffering.".

Thank you.

The Hon. the Speaker: It is moved by Senator Eaton seconded by honourable Senator Unger, that Bill C-14, as amended, be not now read a third time but that it be amended in clause 3, on page 6 — shall I dispense?

Some Hon. Senators: Dispense.

The Hon. the Speaker: Senator Eaton, are you willing to take a question?

Senator Eaton: Yes.

Hon. Claudette Tardif: Like you, I am also concerned about the issue of palliative care. It is crucial that all Canadians have access to excellent quality palliative care. I agree that proper palliative care is lacking in this country.

However, palliative care is associated with the kind of care given to people who are dying, one or two months before the end of their lives. How can we reconcile the fact that the proposed amendment would allow palliative care for people who may be suffering from an irremediable disease and whose suffering is intolerable, but who are not in end-of-life situations and whose death is not immediately foreseeable? How could such a system be implemented in a practical sense?

The Hon. the Speaker: Senator Eaton, before you start, you will need more time. There are other senators who would like to ask questions. Can we grant another five minutes, colleagues?

Hon. Senators: Agreed.

The Hon. the Speaker: Senator Eaton.

Senator Eaton: Thank you very much. I think, as you heard me quote Dr. La Delfa, most people do not understand what palliative care is. With palliative care, we instinctively think, "Oh, it's end of life." But palliative care is equally good for people suffering from a chronic disease. It can give you a better quality of life.

By forcing an assessment as part of the regulatory framework that you be given a palliative care assessment, that is, you're told what is possible for your particular ailment, by putting it in the legislation will force the provinces and the federal government as well as medical schools to take note that palliative care is not a luxury anymore. It's not just a specialty over in the corner. If we're going to adopt medical assistance in dying, the other option has to go along with it. We have to offer people this option.

Hon. James S. Cowan (Leader of the Senate Liberals): Would Senator Eaton entertain another question?

Senator Eaton: Absolutely.

Senator Cowan: Sorry, Senator Eaton, but I had to slip out during part of your speech. You and I had a conversation a little while ago about this. We share a concern about the need to ensure more palliative care and to make sure that people understand what palliative care can do. I appreciate the response that you just gave to my colleague.

One of the things that we heard in the discussions at our joint committee, where there was broad support as well for palliative care, was that at the moment — and I'm sure you agree — there is an uneven availability of palliative care access across the country. I'm sure we'd also agree that that needs to be fixed. We need to press government at all levels, as you just said, to improve, enhance and expand the availability of services.

The only concern I had — and I think in our previous conversation you addressed it — is that we are looking here to have a palliative care assessment and to have an informed discussion with the patient about the palliative care that is available, recognizing, unfortunately, that palliative care is not available everywhere in every community. So we're not looking at this as a bar. We had a lot of discussion earlier in the day about a bar to accessing medical assistance in dying. I wouldn't want the lack of availability of palliative care, through no fault of the patient who is seeking this, to be a bar to access. Would you agree with that?

Senator Eaton: I completely agree with you. Were you around in 1995 in the Senate?

Senator Cowan: No.

Senator Eaton: No; far too young.

Senator Cowan: I may look like it, but I wasn't.

Senator Eaton: That was when Senator Carstairs started a study on this and there have been three or four reports since.

I think that you're quite right. You would never want somebody stopped. As our esteemed colleague Senator Joyal said, it is not up to us to micromanage how the provinces will do this. I think it's up to us to try and force the governments to think about what they can do to make this more readily available.

Another issue that has come up in this chamber — and we haven't discussed this very much — is I don't think there will be hordes of people rushing towards the gates of eternity when this law is passed. There might be a small increase in every province and, perhaps slowly, they will learn to manage what is asked of them in this bill.

Hon. Mobina S. B. Jaffer: Senator Eaton, at committee you raised palliative care. I am really glad you did. As you said it's not just end of life. It can be chronic disease. It can be a lot of things. I'm hoping that from here we will look — whether it's you or a private member's bill — at doing a further study. This is so important. This is really what we're talking about. If people had good palliative care, it would be so effective.

The thing I'm struggling with, Senator Eaton — I'm sure you looked at it, as have I, but I haven't been successful — is how does this become part of the criminal act, because this is a criminal bill; and how does this become palliative care? How does it fit into the criminal act? I'm struggling with that.

Senator Eaton: If you're struggling, I'm not a lawyer, so it would be a huge struggle for me. I think it just becomes part of the criteria. If you ask for medical assisted death, part of the criteria is two independent people assessing your competence. You are then given a palliative care assessment. It just becomes one box to check so the patient has all the options.

I guess if it was somebody I loved who wanted this, I would feel better if they were told how they could be medicated or supported in other ways before seeking death.

Hon. Joseph A. Day: Will Senator Eaton take another question?

Senator Eaton: Yes.

Senator Day: It flows from Senator Cowan's question. I am looking at your amendment to proposed section 241.2 on page 6. In fact, it's one of the prerequisites in subsection (1) to being able to access medical assistance in dying.

One of the tests that you have applied, which it says has to be done, is having had a palliative care consultation. "Consultation" is the word in the amendment. "Assessment" might be an interesting amendment, but the word is "consultation" here. We're talking about some communities that have no palliative care, or very little. If there is any, it's for end of life.

How do we avoid your amendment becoming a block for the individual to receive the care?

Senator Eaton: We have had three Senate reports recommending that palliative care be more widely available in Canada. We have had the present Minister of Health say that Canadians have spoken and that there will be up to $3 billion set aside for home care and palliative care. How do we make sure that gets done? How do we make sure that someday in Nova Scotia or Yukon or Northwest Territories a hospital and medical schools will start training doctors and nurse practitioners? Because it is an expertise. It's not something you can learn. How do we push people? How do we push the government into making palliative care more widely available if we don't use the instance of this bill, which is saying to Canadians, "You can have medically assisted death," and yet we don't push the government also to try and start building palliative care resources across the country?

Senator Day: I have a supplementary.

The Hon. the Speaker: No, Senator Andreychuk is next.

We are running out of time, Senator Day. We will come back to you if we have more time left, but I saw two other senators standing.

Hon. A. Raynell Andreychuk: The amendment talks about "palliative care consultation," whereas the word palliative care "assessment" has been used by you and by some of the senators. My understanding of "consultation" could be — and this is where the provinces and the doctors will have to pick it up — basically an explanation of what palliative care is and, contained therein, what is available. They have a right to take it or not to take it. An assessment leads to what you need as opposed to what might be available. Am I reading too much into your amendment?

Senator Eaton: If I have a terrible, chronic illness and require medically assisted death, I want somebody to come and say, "You know, senator, this is available, this is available and this is available," something your family doctor would not know anything about and your local nurse practitioner would not know anything about because it is an expertise. It's like being a neurosurgeon or an obstetrician. It's an expertise. And we don't have enough of them in this country.

My amendment to this bill is to try and force the government — and we have been talking about it since 1995 in this chamber — to spend the money to try and build up the expertise and the availability of palliative care.

The Hon. the Speaker: On debate, Senator Unger.

Hon. Betty Unger: Honourable senators, I would like to speak in support of Senator Eaton's amendment. When I was appointed to the Senate, I hoped that I might make a difference in some way — perhaps Senate reform, which Albertans have wanted for decades. I never, however, imagined this nightmarish scenario. I am dismayed that Parliament's gift to Canada on its one hundred and fiftieth birthday is going to be the dark scourge of physician- assisted suicide and euthanasia. I had hoped for so much better.

Today I stand in support of this amendment because I believe we must make certain that no one is ever forced to request a physician's assistance in dying simply because they have not received palliative care.

In my view, this amendment is imperative. Providing assistance to end a person's life without first providing assistance to alleviate their suffering is to deny the person the option of living. Such a situation would be incomprehensibly unjust, and yet this is exactly what will happen if we do not amend this bill.

We have never been on this path before. We do not know all the consequences that will arise now that the Supreme Court has launched us down the road of euthanasia and assisted suicide.

We are undertaking a dangerous societal experiment. Personally, I don't think this road will lead anywhere good. I believe that future generations will judge us harshly for our cavalier attitude toward the sanctity of life.

We must be certain that we do all we can to minimize the damage and unintended consequences. Safeguards around this legislation must be strong, sufficient and secure. If we are going to err, let us err on the side of caution, not on the side of ambivalence. Life is far too valuable to do otherwise.

The value and importance of palliative care have been widely acknowledged during the debate over physician-assisted dying. There is broad support for palliative care and an overwhelming recognition that more needs to be done.

In its report to Parliament, the External Panel on Options for a Legislative Response to Carter v. Canada said it this way:

. . . a request for physician-assisted death cannot be truly voluntary if the option of proper palliative care is not available to alleviate a person's suffering.

The Special Joint Committee on Physician-Assisted Dying also underscored the importance of palliative care, noting that "there was an overwhelming consensus among witnesses that palliative care needs to be improved", and that "many Canadians do not have access to high quality palliative care when they need it." Their recommendation "to develop a flexible, integrated model of palliative care by implementing a pan-Canadian palliative and end-of-life strategy with dedicated funding, and developing a public awareness campaign on the topic" is an excellent goal.

In 2015, in a one-day House of Commons debate on physician- assisted dying, palliative care was mentioned 115 times. Conservative MP Harold Albrecht said: ". . . I could not agree more that we need a better palliative care system in this country."

Liberal MP Carolyn Bennett, now Minister of Indigenous and Northern Affairs, stated: "We have to know that real choice in end of life does not happen if people do not have optimal palliative care . . . ."

These are just a couple of examples.

Honourable senators, there is no debate over the importance of palliative care. The debate is over. The question is what are we going to do about it?

Ironically, it was our current Prime Minister who stated last year that: ". . . we cannot have any responsible conversation about physician-assisted death and not have a full discussion of palliative care in this country. . . . it should never be a conversation where we have one without the other." He promised that $3 billion would be invested in palliative care, and yet there was nothing in the budget and today we still see nothing. Was his promise fiction or reality?

We find ourselves here today being asked to consider a bill which contains no safeguard to ensure that palliative care services are available to those desiring physician-assisted suicide.

I am aware that the House of Commons Standing Committee on Justice and Human Rights added two amendments to the bill related to palliative care. One is found in the preamble and one is found in the body of the bill. Both are welcome amendments, but they do nothing to prevent the tragedy of a physician killing a person without first making them aware of their other options.

This is not an academic scenario, fellow senators. This is real life — and I would add death.

Allow me to illustrate this by reading from an e-mail sent to me by a registered nurse:

I first heard of him from my colleague — the symptom control nurse at the cancer clinic.

She was very concerned about his escalating symptoms which would likely soon be beyond what their outpatient clinic could control. She had encouraged hospice registration but the young man, and his loved ones would have nothing to do with hospice because they were focused on life, and despite assurances otherwise, they were certain that involvement with hospice meant hastened death.

As feared, his symptom burden became such that they were desperate for help.

This was certainly not a case for the emergency department, and the acute care wards are simply not trained and equipped to deal with this complex of a case.

I had multiple telephone discussions with loved ones regarding how medications could safely be used to ease his distress, and that palliative care was not about hastening the death of this beloved boy.

It was with fright and despair that they brought him to the hospice unit, but then something happened — something amazing. The medications worked!

Although, he continued to deal with obstacles that any of us would have found horrendous, in a very short time, he was able to be out in the hospice lounge, hanging around with his ever present family and friends, playing music.

This young man continued to be so full of life that soon they all felt that he was safe in our care.

He was discharged home, and readmitted a few times over several weeks, when he wasn't with us he chose to "couch surf" with loved ones. One fine day he left the unit on a pass with his friends. They all came bustling back in the evening. And then, after some laughter and settling in, he suddenly, quietly, and naturally died.

This is a success story of hospice palliative care, and it underscores the need for this amendment. How can we, as a society, possibly endorse public policy which says to those who are suffering terribly: "Here, we have a doctor available to help you die. But, sorry, we have no doctors available to help you live." Or, "We have allocated resources and public funds to make sure that you can die prematurely, but unfortunately we are short on resources to help you live as comfortably as possible."

We must not allow such an injustice to happen.

Let me be clear: This is not an attempt to block access to a physician's assistance in dying; it is a necessary measure to make sure that no one chooses death due to pain or suffering which couldn't be alleviated.

Obviously, the person can refuse palliative care and that would not affect their eligibility for medical assistance in dying. To not alleviate someone's pain when it is entirely possible to do so would be terrible, but to offer them death without first offering pain management should be criminal.

I fully realize we have some distance to go before palliative care is available to all who need it, but I would suggest we have to start somewhere, and Senator Eaton had some excellent recommendations.

We have passed the expiry date of the Supreme Court's four- month extension. There is no need to rush. Let's take the time to get it right, and make sure that we get it right.

However, there is a misunderstanding. Effective pain management is available. Pain management in palliative care is making great strides. Let me give you an example.

Dr. Neil Hilliard is a palliative care consultant physician in Abbotsford, B.C., and the program medical director for the Palliative Care Program at Fraser Health. In 2014, Dr. Hilliard had a female patient with locally advanced cervical cancer and uncontrolled pelvic pain. As her disease progressed, the patient's pelvic pain intensified, despite many different treatments. However, when treated with a continuous subcutaneous infusion of dexmedetomidine, the patient's pain and delirium cleared. The treatment was successful in fulfilling the patient's goal of care, which was not to be deeply and continuously sedated but to be rousable and of clear mind while still having good pain control.

This is an example of how proper palliative care enabled an end-stage cancer patient with intractable neuropathic pain and delirium to be successfully managed during the last three weeks of her life, with no need to hasten her death. While this is just one example, it illustrates how proper palliative care can reduce suffering while improving the quality of living and dying.

Honourable senators, in its ruling, which legalized physician- assisted death, the Supreme Court of Canada said that the government should enact stringent safeguards to protect the vulnerable. There are many such safeguards that could and should be enacted but perhaps none as important as what this simple amendment provides, that the offer of palliative care must precede medical assistance in dying.

I support this amendment and I urge you to do so also.

Hon. Salma Ataullahjan: Honourable senators, I rise before you today in support of Senator Eaton's proposed amendments and to share some of my interrelated thoughts about Bill C-14.

As a Canadian senator of Muslim faith, I will speak briefly about what people in my community have said to me about this bill and touch upon some concerns expressed by the Canadian Council of Imams.

In Islamic faith tradition, neither euthanasia nor assisted suicide are supported or encouraged. However, the issue of physician- assisted dying has been decided by the Supreme Court of Canada, and the majority of Canadians, including many people of the Muslim faith who have spoken to me personally, agree that some form of physician-assisted dying legislation should be enacted, as do I.

From my own experience, I think back to when my husband's brother was in the hospital and his illness was at the stage where his lungs were failing. At that time, he made the decision to withdraw from treatment. The pain and suffering that he endured before his eventual death could have been avoided if he had the option of physician-assisted dying.

The concerns of Muslim faith leaders with regard to this bill centre around issues of patient vulnerability, safeguarding the interests of patients who are suffering, conscience protection for health care providers, as well as faith-based facilities, extended funding for medical research to find cures and improve pain management methods, and the availability and affordability of quality palliative care that meets national standards for all Canadians.

While I share all these concerns, the last two issues — specifically, access and funding for quality palliative care and investment in medical research, particularly in the area of pain management — are of great importance that I do not wish to be forgotten in this discussion. Every Canadian should have access to high-quality, affordable palliative care and the best pain management regimes possible.

I believe that both of these issues will form an integral part of the conversation that people will have with themselves and their families when considering whether the option of physician- assisted dying is the right choice for them. As such, people must be informed of their options.

Accordingly, I support the proposed amendment to include a provision that every patient be informed of all feasible palliative care options available to them through palliative care consultation, which include being informed about available supports, possible treatment plans and pain management options to relieve their suffering.

I know, personally, that I would never wish to be a burden to my family, as I'm sure many Canadians feel as well. So I want to have confidence that the choices people make about whether to live or die are not clouded by the fear of being a burden to their families for whatever time they have left to live.

I would urge the government to ensure that extended long-term funding is the place for both palliative care and medical research in pain management should this bill be passed.

Again, I reiterate my support for Senator Eaton's proposed amendments to include a palliative care consultation requirement and a provision that no person who wishes to avail themselves of medical assistance in dying may give informed consent to receiving such assistance without first being advised of all feasible palliative care options available to them.

The Hon. the Speaker: Question?

On debate, Senator Fraser.

Hon. Joan Fraser (Deputy Leader of the Senate Liberals): Honourable senators, I would like to thank Senator Eaton for bringing this amendment, and I intend to support it. But I would like to say why.

I'm not supporting it because I believe the goal you enunciated is feasible, Senator Eaton. I do not believe that the Parliament of Canada can or should force provincial governments to increase the provision of palliative care, and that is who would have to do it, provincial governments.

I believe they should do it. Absolutely. And I believe that passing this amendment would send a signal, a very important symbol of the fact that in adopting this legislation, Parliament is not in any way rejoicing in the prospect of people choosing death. Parliament is trying to help individual Canadians who are in situations of extreme, unendurable suffering.

To that end, sending a message that we know that palliative care would help some fraction of them, and that some fraction of those Canadians would choose palliative care if they knew about it, is very important. The provincial governments that have to do a great deal of the actual implementation of the medical system required in this bill will get that message.

However, that doesn't mean that we can force them to act. We can individually continue to put pressure on them to act, and I believe that we should, all of us individually. I believe that we should send this very serious message. Therefore, I truly, sincerely congratulate you. I just don't want to hold out false hope to anyone who may be listening to or reading these debates that somehow, magically, if we adopt this amendment it will all come true. It won't. We still have a long way to go.

I thank you also for recalling the work of Senator Carstairs in this field. For years and years she worked, and I believe continues to work, to advance this cause. I was very glad to hear you recognize that contribution.

Finally, on the matter of consultation versus assessment, which has been raised by a couple of senators, I am quite glad to see that you refer here to consultations, although in your speech you talked about assessments. But in the actual text before us, you speak about consultation. Given what I just finished saying about how we cannot force the provision of palliative care, if it is true, as I believe, that an assessment would be a far more rigorous and possibly difficult procedure for the patient to undergo, unless we can promise a positive outcome, I think it's asking too much. But a consultation, where that person may be properly informed about what is available, I think that is an excellent addition to this legislation.

Hon. Jane Cordy: I also want to thank Senator Eaton very much for bringing forward her amendment and for encouraging this dialogue that we are having this afternoon, because palliative care — I have spoken on it a number of times in the chamber in the past — is something we should have to continue to debate in this chamber. With the leadership shown by Senator Carstairs and Senator Neiman starting in the mid-1990s, the Senate is an excellent place to continue the dialogue.

I listened to the speeches by my three colleagues, and I also commend them for their speeches today and the suggestions that they have made.

One of Senator Eaton's initial comments was that assisted dying should not become the norm in our country, that it should be done under exceptional circumstances. I think a lot of the speeches that senators have made yesterday and today indeed reflect that they have taken this very seriously and have spoken from the heart and passionately about why they felt that there was a need. In light of Supreme Court ruling, we know that that is the case, but I think that Senator Eaton's comment that it not become part of the norm is extremely important.

Regarding Senator Eaton's comment that we need more education about palliative care, she and I have spoken about this a number of times. Many people think that if you have palliative care, people are going to try to keep you alive with tubes and all kinds of things. As Senator Eaton said, palliative care doesn't hasten a death, nor does it prolong it or slow it down. I think that Canadians really have to get a better sense of what palliative care is, because palliative care allows Canadians to die with dignity.

As I said earlier, I'd like to thank Senator Carstairs for the work she has done. She has worked tirelessly to encourage medical schools to teach their students about the importance of palliative care. Before she started this work in the mid-1990s, medical schools were spending, I believe she said, an hour or a couple of hours over three years talking about palliative care. We know the importance of palliative care.

I had the privilege of working with Senator Mercer on a committee studying aging, and we visited palliative care units across the country, which was very informative for us.

I live in Dartmouth, and there is a palliative care unit at the hospital in Halifax. I was there and saw how effective it was.

I also travelled to Cape Breton because I had heard about what a wonderful palliative care centre they have. I met with Dr. Anne Frances D'Intino, who brought me through the palliative care unit. It was so moving to be there. It was like a second home not just for the patient in palliative care but for their families as well. They had a kitchen and living room. It was really wonderful.

One of the big challenges that they had in Cape Breton was because so many of the young people in the area were working in Alberta or in Saskatchewan, many of the people in palliative care didn't have any children living in the area. She said the challenge that they faced was when do you phone the children in Alberta and say, "I think that it's time to come home"?

The doctors and nurses that I met at that palliative care unit in Cape Breton really moved me, because they, in many cases, were the family for the people in the palliative care unit.

The people of Cape Breton don't have a lot of money, but they contributed significant amounts of money because they know how important it is to have a palliative care unit. In fact, they were, at that time, raising money to have a hospice centre in a different building on the same site.

When Minister of Health Jane Philpott was in the chamber, she said that she is fully supportive of better and more accessible palliative care. As a doctor, she understands the importance of it.

Leo Glavine, Minister of Health and Wellness in Nova Scotia, is fully supportive of better and more accessible palliative care. In fact, he established a palliative care commission to work on making things better in Nova Scotia. Dr. Anne Frances D'Intino is part of that commission. I know that she and the others who are on it are working very hard to ensure that palliative care becomes the norm across the province.

While I agree with the comments that my colleagues have made about palliative care — and I really want to thank you again, Senator Eaton, for bringing forward the amendment — I cannot agree with the amendment because I believe it infringes on provincial jurisdiction.

We should be encouraging the provinces to continue to invest in palliative care. Perhaps it would be a good issue to discuss with provincial and federal Ministers of Health. Perhaps we can work on a national strategy — not a federal but a national strategy — where all of the provinces and the federal government buy in to develop a strategy across the country.

Perhaps the Senate can have an inquiry, or perhaps we can bring forward a motion that one of our committees study it once again — because 1995 was quite a long time ago — to evaluate and update palliative care.

When I look at the amendment that you brought forward, which is very good, I have to say, as Senator Cowan said earlier, there are uneven levels of care across the country. There are uneven levels of care within my province of Nova Scotia.

If we're looking at a palliative care consultation, do we take somebody from Clark's Harbour in Nova Scotia and tell them, "You may not have palliative care, but we are going to bring you to Halifax for palliative care and for evaluation and consultation"? At that point in my life, I wouldn't want to be leaving my community where my family and friends are living.

While I thank you very much, because I think the discussion today on palliative care has been very helpful and perhaps will give us that little nudge to do more within the Senate, I cannot support it at this time.

The Hon. the Speaker: Are honourable senators ready for the question?

Hon. Senators: Question.

The Hon. the Speaker: In amendment it is moved by the Honourable Senator Eaton, seconded by the Honourable Senator Unger:

THAT Bill C-14 be not now read a third time, but that it be amended in clause 3, on page 6, by replacing line 5 with the following:

"-sistance in dying after having had a palliative care consultation and having been informed of treatment, technology or support options available to relieve their suffering.".

Those honourable senators in favour of the motion in amendment will please say "yea."

Some Hon. Senators: Yea.

The Hon. the Speaker: Those honourable senators opposed to the motion in amendment will please say "nay."

Some Hon. Senators: Nay.

The Hon. the Speaker: In my opinion, the "nays" have it.

And two honourable senators having risen:

The Hon. the Speaker: Do the government liaison and the opposition whip have a time on the bell?

Senator Mitchell: Fifteen minutes.

The Hon. the Speaker: The vote will take place at 7:04. Call in the senators.

Motion agreed to on the following division:



Andreychuk Marshall
Ataullahjan Martin
Batters Massicotte
Beyak McInnis
Carignan McIntyre
Dagenais Mercer
Doyle Mockler
Eaton Ngo
Eggleton Oh
Enverga Patterson
Fraser Plett
Frum Pratte
Housakos Runciman
Kenny Smith
Lovelace Nicholas Stewart Olsen
Lang Tannas
MacDonald Tkachuk
Maltais Unger
Manning White—38



Baker McCoy
Bellemare Merchant
Black Meredith
Campbell Mitchell
Cools Moore
Cordy Munson
Day Ogilvie
Downe Omidvar
Duffy Poirier
Greene Ringuette
Harder Tardif
Jaffer Wallace
Johnson Wallin
Joyal Watt—29



Dyck Seidman
Gagné Sibbeston—5