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Criminal Code

Consideration of Subject Matter in Committee of the Whole

February 14, 2024

The Chair [ + ]

Honourable senators, the Senate is resolved into a Committee of the Whole to consider the subject matter of Bill C-62, An Act to amend An Act to amend the Criminal Code (medical assistance in dying), No. 2.

Honourable senators, in a Committee of the Whole, senators shall address the chair but need not stand. Under the Rules, the speaking time is 10 minutes, including questions and answers, but, as ordered, if a senator does not use all of their time, the balance can be yielded to another senator. The committee will receive Mark Holland, P.C., M.P., Minister of Health, and Arif Virani, P.C., M.P., Minister of Justice and Attorney General of Canada.

I would now invite them to enter, accompanied by their officials.

(Pursuant to the Order of the Senate, the Honourable Mark Holland and the Honourable Arif Virani, along with their officials, were escorted to seats in the Senate Chamber.)

The Chair [ + ]

Ministers, welcome to the Senate. I would ask you to introduce your officials and to make your opening remarks.

Hon. Mark Holland, P.C., M.P., Minister of Health [ + ]

I am pleased to be here for the first time, not just as Minister of Health, but also as an MP. I was elected in 2004 so it is quite remarkable that this is my first time here.

We are dealing with a sensitive topic today. I greatly appreciate all of your efforts on this issue.

I want to take a moment to thank the Senate for its very thoughtful deliberations in this matter. I know this is an area of great emotionality. This is something that touches us all deeply and personally, and whether or not it’s in the joint committee or in the debate that’s been happening in this chamber, I want to take a moment to really appreciate the conversations that have taken place.

Let me say as well that I completely agree that there is no question that there is an equivalency between physical and mental suffering. There’s no doubt in my mind that those two sufferings are equal, but while that suffering might be equal, the readiness of our system and the resources invested in preparation for dealing with these issues are not equal. That’s where we are today.

It’s certainly true that individuals within the system are ready and have been trained on the curriculum, but the system overall is not. That’s an extremely important distinction.

When I became health minister some six months or so ago, in my initial conversation, I believed the system was ready. We had done a lot of important work. In the year since we had made the decision to have a delay and developed the medical assistance in dying, or MAID, practice standards, we developed and delivered the national MAID curriculum, and there were over 1,100 clinicians who were registered. I went to Charlottetown and had a meeting with all the health ministers from every province and every territory and made the case that the system was ready. Every health minister from every province and every territory said they were not. They said so emphatically.

They said so for a number of very important reasons. One, of course, the provinces and their elected jurisdictions are responsible for the administration of health care. But they also identified that only 2% of psychiatrists have currently been trained — that of the 1,100 clinicians that I mentioned, only 40 of them have received a full training module. If you take a look at provinces like Manitoba or Quebec, in Manitoba, only 26 have received the full training, and in Quebec, only 139.

We certainly heard from the Centre for Addiction and Mental Health, or CAMH, that they believed we should go further than practice standards and develop clinical standards, and that time was needed to do that. We heard from provinces and territories that they also believed they needed additional safeguards. Indigenous communities and leaders across the country also let us know that the Indigenous engagement wouldn’t be completed until 2025, and they believed that that consultation must be deeper before we proceed. Disability advocates across the country all said that more time was needed. As well, those with lived experience said that they needed greater opportunities. So it certainly became clear that the system needed more time as we moved through that.

Now, I would point out, senators, that the House had a motion before it — brought forward by Member of Parliament Ed Fast — asking for an indefinite pause. We also received a letter from 10 of the 13 jurisdictions in the country saying they wanted an indefinite pause. Instead, we’ve said, three years. We’ve got work to do. We need to get ready, but if our interest was simply indefinitely delaying this, we would have concurred with the motion of Ed Fast or with the letter from ten of those 13 jurisdictions. Instead, we’re saying we need to move forward at full speed. I’ll end on this because I know I’m nearing my time.

We’re balancing two very difficult truths. One, that there are people who are suffering terribly as a result of horrific mental anguish. My heart goes out to them, and we have an obligation as regulators to get ready as quickly as we can to meet their requests. But, on the other side, we must make sure that our system is ready, that mistakes are not made and that across the board we have an even application and enough training to make sure that we get this right. That’s what this balance is about.

I appreciate the opportunity to be before the Senate, and I look forward to your questions. Thank you.

The Chair [ + ]

Thank you, Minister Holland.

Minister Virani, your comments.

Hon. Arif Virani, P.C., M.P., Minister of Justice and Attorney General of Canada [ + ]

Thank you, Madam Chair and senators, for inviting us here. I always take pleasure in engaging with the Senate and also being in this illustrious chamber, if only because the fine carpet that I’m standing on right now was designed in Parkdale—High Park, which is my riding. I thought I would note that. Perhaps only Senator Hassan Yussuff recognizes that.

I am very happy to be here to speak to Bill C-62, which proposes to extend the mental illness exclusion from MAID until March 17, 2027.

A three-year extension was deemed reasonable, considering that some provinces and territories are asking for more time to prepare their health care systems for the expansion of MAID, as my colleague just mentioned.

There are two very important things I want to mention at the outset and that Minister Holland alluded to: One, mental illness can cause the same levels of suffering as physical illness — that is a very important point — and two, the fact that a person suffers from a mental illness does not mean that they are unable to make decisions.

Let me be extremely clear, senators, that the mental illness exclusion that we’re discussing is not based on harmful assumptions or stereotypes about people living with mental illness. It is based on the complexities associated with assessing requests for MAID of persons whose sole underlying medical condition is a mental illness.

We’ve heard concerns extensively about the difficulties distinguishing between someone contemplating suicide and a valid request for MAID. For example, we’ve heard from medical experts that suicidal thoughts may be a symptom of the mental illness that has led the person to request MAID. We’ve also heard that there are concerns about how to determine that a mental illness is irremediable — without cure or treatment — given that the course that a mental illness may take is often less predictable than that of a physical illness.

Lastly, let me just say that as the practice of MAID in Canada still remains relatively new, the body of evidence and research on current and potential future practice, including in relation to mental illness, is still very much in development. We’ve heard that some people believe that the current Criminal Code safeguards are simply not enough to ensure the safety of those who may be vulnerable.

I want to make it abundantly clear that our government believes that, as a matter of social policy, eligibility for MAID should be expanded to include mental illness. That is why we thought it was essential to propose expanding eligibility when we introduced former Bill C-7. However, we believe that this needs to be done in a careful and measured way. This three-year extension would give us more time to delve into some of these complexities.

The adoption and implementation of the model practice standard for MAID and the accredited MAID curriculum could also help increase knowledge in this area and help practitioners and the public to feel more comfortable with it. However, time is needed to integrate these resources into the provincial and territorial health care systems. Minister Holland just said precisely the same thing.

We recognize that there are experts who believe that we are ready for the expansion, others who believe that we are not, and still others who oppose the expansion altogether. We can’t convince everyone to support this expansion.

There will always be divisions of opinion in this regard.

We also can’t ignore the concerns that have been raised. This lack of consensus shows that we need more time. We want to take the time to address some of these concerns to ensure that MAID can be safely provided in these complex circumstances.

I want to conclude, in my ministerial capacity, by touching on the Charter of Rights and Freedoms, Madam Chair, which has animated much of the debate on this issue since the beginning.

The Supreme Court of Canada has been clear — and I agree with the court — that there are competing interests on both sides of this complex issue. There’s the autonomy and dignity of individuals who seek MAID, on the one hand, and the need to protect those who may be vulnerable and at risk in a permissive regime, on the other.

What the Supreme Court has acknowledged throughout all of the judgments that have been rendered in this matter is the task that Parliament faces in balancing these competing interests. It has also been suggested that the courts should give a high degree of deference to the balance that Parliament’s response strikes.

I believe that the Charter does not dictate a particular answer to this very difficult question. Both permitting and prohibiting MAID in these circumstances fall within a range of reasonable alternatives open to the federal government under the Charter. You have seen the Charter Statement I tabled last week which outlines the Charter considerations of both allowing and temporarily excluding MAID for those with mental illness as a sole underlying condition.

I’ll end there. Thank you, Madam Chair.

The Chair [ + ]

Thank you. Ministers, before we move on to a lot of questions, I would like to remind both of you that senators truly appreciate succinct and direct answers to their questions.

Senator Plett [ + ]

Welcome, ministers. My first question is for Minister Holland.

I was disappointed that in your opening remarks you only said the system wasn’t ready, psychiatrists weren’t ready. You never mentioned that Canadians aren’t ready.

Minister, most provinces and territories are asking the federal government to indefinitely hold off — you’ve already talked about it — on your plan to expand eligibility for assisted dying to those Canadians whose sole disorder is mental health. You’ve talked about Ed Fast’s motion. Now, you answered their request with yet another delay, instead of doing the right thing and putting this dangerous and reckless plan indefinitely on the shelves, where it belongs.

Minister, you alluded to it, but I was not happy with the answer, and I hope you can expand a bit. Why are you not heeding the call of the majority of provinces and territories — which you say are in charge — which have to implement this? They are asking you to indefinitely put on hold medical assistance in dying where mental disorder is the sole underlying condition. Why are you not listening to the provinces, minister, when they say they aren’t ready, they have to administer it, and they want you to do this, and yet you are just bulldozing ahead?

Mr. Holland [ + ]

Thank you for the question, senator. First, all of my comments are directed to the fact that the provinces are not ready, and we are respecting the request for time. Different provinces have different positions in terms of why they’re asking, and some have asked for it to be indefinite, and some have not. They want it to be indefinite so that they can have their own timelines.

But as I stated at the beginning, there are people — and we have to acknowledge this, and it’s deeply uncomfortable to acknowledge this, senator — who, after decades of suffering through mental illness, having lived a life of complete torture, through their own volition, in an irremediable circumstance, are asking to use MAID.

I appreciate your position is that a person who is suffering in that way and is in that kind of torture should not be afforded the opportunity to make that choice. I respect your position, but I would say that most provinces don’t have that position. Instead, their position is to ensure that everything has been done —

Senator Plett [ + ]

I understand that, minister. I’m sorry. As Madam Chair said, we are limited in time. I would like direct answers. I don’t want you to tell me what the provinces are saying. I’m asking you why you didn’t do something.

Let me be clear, minister. Not only do I disagree with this part of the bill, but I disagree with the entire assisted suicide bill, just to be clear. I appreciate that we have a difference of opinion, and I appreciate the fact that you respect me.

But with all due respect, minister, how many more extensions does your government need? Your government is yet again holding on to an ideology, instead of doing what is right. There is no medical consensus in our country, as has been said time and time again by experts and parliamentary committees. There’s no social consensus, as many polls have shown, and, finally, there are no legal directives from the Supreme Court.

Your government said Bill C-14 would be admissible for just a small number of people. With Bill C-7, you said the same thing. Instead of being a slippery slope, your government has brought Canada off a cliff in becoming the world leader in assisted suicide, minister.

When will your government stop following an ideology and start following common sense by halting the expansion of assisted suicide?

Mr. Holland [ + ]

May I respond?

Senator Plett [ + ]

Yes, please.

Mr. Holland [ + ]

Senator, very recently, my uncle was diagnosed with terminal cancer. He was in a circumstance regarding the number you’re citing in terms of the number of folks currently accessing medical assistance in dying, or MAID. Over 96% of them have a terminal diagnosis like my uncle.

It was a horrible circumstance for my family. When he was facing the end of his life, and when the ravages of cancer were taking hold of his body, my uncle made the determination to end his life on his terms. That’s over 96% of the cases we’re talking about.

I appreciate that you don’t feel that my uncle or people in those circumstances should be afforded that opportunity, and that you feel you should be able —

Senator Plett [ + ]

Minister, please, this is not — I’m trying my best not to make this personal. I would ask you to do the same thing. You want to make this personal — my mother just celebrated her ninety-sixth birthday the day before yesterday. We had a party for her. She’s in a wheelchair. She has crippling arthritis, and she has had it for years. She lives in constant pain, and she wants nothing but to live here with her grandchildren, and pray for her grandchildren and her children every day. She wants to live a life here as long as she can, even though she’s in pain. She’s assured of where she’s going after she dies.

You want to make this personal — I’ll make this personal. That’s not what I want to do. You’re talking about an uncle who had cancer. We’re talking here today about mental disorders. Your uncle didn’t have a mental disorder; he had terminal cancer. Please, minister, just answer my question.

Mr. Holland [ + ]

First of all, I’m deeply sorry that you have a family member in that state of distress, and I am very proud that we have a country where she can make that choice. This is an issue that is, of course, deeply personal to all of us. I don’t mean to imply that because you have a different opinion, it’s wrong, but we live in a country where we have to navigate these incredibly difficult choices.

You had said we were driving off a cliff, and it was inappropriate that we had so many people who are accessing MAID. I’m simply observing the fact that over 96% of the people that you’re referring to were in the same circumstance as my uncle.

My uncle had a choice. Of course, he could have allowed cancer to take him. He might have had two weeks or another month instead of being able to make that difficult choice himself.

I believe this is why we’re elected: to navigate these incredibly difficult issues. I don’t do it to challenge you, sir. You’re entirely entitled to your opinion, and that’s a great aspect of our democracy. I absolutely respect the challenge that your family member is going through.

But what we have to do is make a decision about what we, as a society, are going to do when people are in unimaginable, horrific pain — pain that, with all due respect, I can’t begin to put myself into. And when I talk to people, that’s what we’re dealing with here.

When we’re talking about mental illness, I want to make a distinction. We’re not talking about mental health or suicidal ideation. We’re talking about mental illness, where a person has exhausted all avenues of appeal, where their circumstance is irremediable, where they are trapped in a mental nightmare, and where they — under their own recognizance — are begging for the opportunity of relief. Sir, that’s what we’re talking about, and it is deeply personal to their families and that individual. That’s why I speak in direct and personal terms.

What I’m saying is that they’re suffering. The suffering of somebody as a result of mental illness has equivalency to physical illness and, therefore, must be treated as such, but we need a system that is ready.

To directly answer your question about how long it will take, we believe it’s three years.

Senator Plett [ + ]

The next question is for the Minister of Justice. Last year, your predecessor David Lametti said in this chamber — in response to a question from Senator Batters — that although neither Carter nor Truchon studied the question of mental illness, eventually we’ll get there.

David Lametti remains adamant that MAID should be expanded for mental disorder, saying two weeks ago — before stepping down as an MP — that he “. . . wouldn’t be afraid personally of moving forward. . . .”

Minister, has David Lametti blindly misled your government and Canadians by going down this dangerous road of medical assistance in dying for people with mental disorders on personal beliefs?

Mr. Virani [ + ]

I would say categorically not, Senator Plett. What David Lametti did — when he was in my position — is he ensured that we were responding to Supreme Court jurisprudence, and to the jurisprudence of other courts in our country, in the case of Truchon.

He was also responding to something that originated here in the Senate. If you recall, the genesis of the legislation — the idea of putting a sunset clause on the mental illness exclusion — originated in the Senate. Minister Lametti, as he then was, endeavoured to respond to it.

By way of other responses, sir, in your interactions with Minister Holland, you indicated you had a disagreement with the entire apparatus that has existed since 2016. I would say to you that in a rule of law country, sir, we’re required to abide by Supreme Court directives, and when there’s a finding that the law was not complying with the Charter, we must abide by that. That’s how a democracy functions.

Senator Plett [ + ]

I’m not challenging that, minister. I understand that. I gave you a personal opinion. Minister Holland was talking about a personal experience; I relayed one as well. I’m personally opposed to it, whether the Supreme Court said it or not. I’m not challenging that, and I’m not challenging you on that, so let’s be clear on that. The initial bill was brought forward because of a Supreme Court ruling. I understand, appreciate and respect them for that.

The Chair [ + ]

We’re now moving to the next block of 10 minutes.

Senator Batters [ + ]

Minister Holland, today I’m thinking of my late husband Dave Batters. Dave served with you in the House of Commons from 2004 to 2008. He sadly died by suicide in 2009. As such, this issue is highly personal for me, and I’ve fought against assisted suicide for mental illness for the last eight years.

Minister, in the 2021 election, your Liberal election platform promised to establish and fund the Canada mental health transfer — a commitment of $4.5 billion over five years. According to your own platform’s cost breakdown, your government should have invested $2.5 billion of that money into mental health care by now, but, in reality, you haven’t spent one penny.

This total lack of funding on this promise was confirmed by the Canadian Mental Health Association’s CEO Margaret Eaton when I asked her about it at the Legal Committee. The Canadian Mental Health Association’s CEO said:

We were very disappointed that the Liberal government did not live up to that promise. There is also the opportunity through the transfers to provinces through the bilateral agreements that some of that funding may go to mental health, but the beauty of the mental health transfer was that those funds would be earmarked and it would be a requirement that the provinces spend that funding on mental health. We don’t know how much provinces are spending on mental health or whether those bilateral agreements will actually deliver the kind of increase in mental health spending that we are looking for.

Minister, Canada’s mental health system is in full-on crisis mode. Canadians with mental illnesses face wait lists of months, even years, for psychiatric treatment, and now the Trudeau government will offer assisted suicide to vulnerable people suffering from mental illness. As you have said, it’s not if, but when.

Why has your government broken this major commitment on mental health, and why will your government offer Canadians with mental illness death before treatment and hope?

Mr. Holland [ + ]

Thank you so much, senator. Let me first say I deeply appreciate your advocacy, and it was an honour to serve with Dave, and his passing was enormously tragic. I’ve spoken very openly about my own struggles with mental health, including a moment of great darkness in my own life when things could have gone very differently for me. It’s something that is deep within my heart as we have these conversations.

On that basis, it’s important to make two distinctions. Let me talk about the question of investments in mental health.

With the Canada Health Transfer, I’ve seen an increase of $50 billion, which is an increase of 9.3%. There’s $200 billion being put over the next 10 years into the health system, specifically with respect to mental health.

On the bilateral agreements, we now have signed bilateral agreements in B.C., Alberta, Ontario, Nova Scotia and P.E.I. I was in the Northwest Territories yesterday, where we announced — in Yellowknife — their plan. Each of them has targeted and very specific actions with respect to investment in mental health.

We have also launched a national suicide prevention hotline to provide support. Together these investments are critical. But we have to be very careful about making a distinction between somebody who is suffering an incidence of suicidal ideation or on the brink of a mental health crisis and somebody who has mental illness. When we’re talking about somebody with mental illness, what’s being contemplated — not now but when the system is ready — is they would have had to have gone before two clinicians and demonstrated they have tried everything. It’s one of the things we want to ensure.

We have in this instance, senator, people who have been seeking relief for decades and decades, going through every possible remedy they could find, and are at the end.

As somebody who escaped the type of thing that we’re talking about, I can tell you that it’s in my heart to make sure everybody has the resources they need. But there are also instances with mental illness where people are trapped in a circumstance that is irremediable, in decline and from which they cannot escape. I wish that were not true, but it is materially different than a situation where somebody is in a mental health crisis.

Senator Batters [ + ]

Well, we will see. Irremediability is obviously a huge question in that. My next question is to Minister Virani.

We could not find your gender-based analysis for Bill C-62 where it would normally be posted. Please provide us with such a document as soon as possible if you have one.

If you don’t have one for this bill, I would guess that is because your gender-based analysis for your Bill C-39 last year was devastating. Your own analysis showed that women will be disproportionately adversely affected by the expansion of assisted suicide to people with mental illness, noting:

It can be expected that should MAID be made available in Canada for individuals whose sole underlying condition is mental illness, we would see an increase in women seeking MAID for psychiatric suffering, and at younger ages.

It also notes it can be expected that controversial MAID deaths similar to those seen in Benelux countries “. . . would emerge in Canada under this option.” And your own analysis notes that:

. . . currently, men are three times more likely to complete suicide. But with access to assisted suicide — a 100% lethal means of suicide — women may even those odds. That’s hardly the kind of gender parity that we want.

Minister, can you please tell us why, with all of these dire warnings, your government will put Canadian women at risk by pushing ahead with this expansion of assisted suicide when you implement it?

Mr. Virani [ + ]

Thank you very much, Senator Batters, for the question and for raising very important subject matter. The first part of your question was about providing the Gender-Based Analysis Plus, or GBA Plus. We will provide that to you.

Second, GBA Plus is not just gender analysis. The “Plus” relates to various equity-seeking groups and people who are disproportionately impacted. I would highlight that the studies I have seen on Bill C-39, et cetera, talked about differential impacts that might be there for people who are Indigenous or racialized and many other marginalized and vulnerable groups.

Some of the senators who sat on that committee would note that in the Special Joint Committee on Medical Assistance in Dying report that came out at the end of January, the MPs and senators suggested not only to reconvene the committee one year prior to the advent of March 2027, but also ensure more consultation and engagement, particularly with Indigenous communities. We are very committed to doing that to cure some of the problems that you have just identified.

Lastly, it’s not about putting women or Indigenous or racialized people at risk. It’s about ensuring the safeguards are in place and that the learning and tools that have been developed but not yet taken up sufficiently by assessors and providers in this country are sufficiently robust, and there’s been enough take‑up such that existing safeguards are adequately and properly applied. I’ll be blunt with you — the interests at stake are very significant and the consequences are permanent. We are determined to get this right before proceeding.

Senator Batters [ + ]

Yes, in terms of dealing with Indigenous people, et cetera, we definitely heard at our Legal Committee, when we studied this in depth, that many of those groups are very concerned about how vulnerable they are under the underlying legislation.

Minister Virani, as your government has tried to sell the concept of psychiatric MAID to the Canadian public, your predecessor David Lametti and others in the government have occasionally implied that extending assisted suicide to people with mental illness has been mandated by the courts.

Minister, you will know that is not correct. Last year, then‑Justice Minister Lametti received a substantial letter about this from many notable Canadian law professionals. They stated that neither the Carter case nor the Truchon case ruled on the constitutionality of expansion for mental illness, and neither plaintiff requested MAID based on psychiatric grounds.

When I asked former Minister of Justice Lametti about this last year with respect to Bill C-39, he said I was right but that “. . . I do feel that eventually we will get there.”

Minister Virani, that is no way to craft laws. Since the courts have not required the expansion of assisted suicide to people with mental illness and science cannot prove that mental illness is not irremediable, why won’t your government just back down entirely on this?

Mr. Virani [ + ]

Thank you, Senator Batters, for the question. This points at the heart of what I call the deferential approach on the part of the courts. If I could drift into legalese here, the courts constantly talk about a dialogue between Parliament and the courts themselves. That’s important. It’s a back and forth exchange.

The courts also talk about the notion that when crafting complex social policy, there’s a margin of deference that is enlarged. Courts have said, particularly in the Carter case, when dealing with something as delicate and complex as medical assistance in dying, that margin of deference is elevated.

That being said, it is important to understand that, while it hasn’t been directly opined upon in terms of litigants that have come before the court with respect to psychiatric illness or mental illness as their sole underlying condition — that is correct — there is a trend that you can trace back to those who follow this jurisprudence, back to the Rodriguez case in the 1990s, where societal norms start to move the courts along in terms of their appreciation of autonomy, dignity and how the Charter is interpreted. I think that’s what David Lametti was referring to in his response to you. What I would say to you is we are working to ensure —

The Chair [ + ]

Thank you, minister, but we need to keep to the time allotted.

Senator Petitclerc [ + ]

Minister Holland, one the one hand, we have governments that are saying they are not ready; on the other hand, a majority of assessors and providers are saying that they are ready. Most regulatory bodies and professional associations are also claiming that they are ready. It is reasonable to believe that this divergence will not change by 2027. In this context, how do we justify the fact that people will continue to suffer? How do we justify the fact that their rights will continue being violated? The law currently provides for safeguards that are said to be solid. Are the measures in this second component not sufficient or adequate to enable the professionals who say they are ready to do their job properly?

Mr. Holland [ + ]

Thank you very much for your question, senator. It’s a good question, and I understand why you’re asking it.

My first point is this. Two things happened at the same time. Individuals, physicians and nurse practitioners said they were ready, but the system, broadly speaking, was not. I spoke with Minister Dix from British Columbia about this issue on Monday. It was clear from our conversation that the minister needs time to prepare the health care system and ensure that its level of readiness is sufficient so that there is no room for error. Any error in this area is very serious. If any part of the system is not ready, there is a possibility we will see serious consequences.

There’s no doubt that some people are suffering enormously, and I find that really troubling. However, it’s important not to create other problems that can have very serious consequences. We need to make sure that the system is ready, and we will continue to prepare for this as quickly as possible.

Senator Omidvar [ + ]

Minister Holland, my question is for you following up on the readiness question from Senator Petitclerc. I received — I imagine a bunch of us received — a letter from 127 physicians and nurse practitioners from across the country, and they stated that all the metrics to administer MAID to people with severe mental health issues had been met. In fact, they stated categorically there is nothing more for the federal government to do.

You are saying that we are not ready. I understand that in some part, you’re relying on a letter from provinces and territories. What metrics and analyses did you use to assess their readiness claims, or did you just take them at face value?

Mr. Holland [ + ]

Thank you, senator. It certainly wasn’t the letter. As I indicated, when I went to Charlottetown to the health ministers’ meeting, I believed the system was ready at that moment based on limited conversations. I had just become the health minister some months prior. The conversations not with one but with every health minister — some with a New Democratic government leader now, Uzoma Asagwara; or a Liberal government with Tom Osborne in Newfoundland and Labrador; the CAQ government with Minister Dubé — where they explained to me in great detail what their concerns were. And then it was subsequent conversations with leading organizations like CAMH who also indicated they had great concerns around consistency. That led to conversations as well with leaders within the disability community, the lived experience community and with Indigenous communities, all of whom said they needed more time.

None of these objections were ideological in nature. All of them had to do with the level of preparation. As I said, certainly we’re never going to get to a point where everybody agrees and where everyone says the system is ready; I completely agree with you. But when you have no province or territory anywhere that says they’re prepared and you have leading agencies like CAMH saying they’re not ready and when we have communities that have vulnerable populations like Indigenous, lived experience and disabled communities saying they need more time, that’s obviously something that catches my attention.

The more I dug into it, I determined that more time was required. The reason why three years is because it gives us two years to really go pedal to the metal to get the system ready, to work with provinces and territories, to work with clinical standards, to make sure — when Senator Batters was asking her question — there aren’t errors or mistakes when dealing with people with mental illness, that we’re dealing with the most severe cases with people who have intractable conditions, irremediable conditions, we want to get that right. We have an opportunity for a parliamentary review in two years’ time to ensure that.

Senator M. Deacon [ + ]

Mr. Holland, this question is for you and we heard it said different ways. Over the past three years, medical professionals, regulators, government officials, many of the players have been working diligently to meet the criteria and the deadline laid out by the government. We’ve also sat at many round tables to listen to this work. They’ve worked in good faith under the direction of your departments, knowing that they were developing key procedures and safeguards for equitable health care delivery.

These same professionals have had, as you’ve said, a range of readiness. We’re ready to go, we think we’re ready to go, we know we’re ready to go. But at this point, we don’t want their work to be in vain.

My question is: Specifically, what will your departments be doing over the next three years to ensure we’re in a better, well-informed, progressive place? What do we say? Because we’re ultimately servants and messengers here. What do we say to those already overstretched providers to justify this decision to delay this work?

Mr. Holland [ + ]

Thank you very much for the question, senator. First of all, let’s very quickly go through what was done in that year. You’re absolutely right, there was a good-faith effort taken on all parts to meet that one-year deadline. As I said, there was the development of the practice standards; there was the development and delivery of a national accredited MAID curriculum; there were 1,100 clinicians who were registered; there were revised monitoring regulations to collect more data on MAID requests, including disaggregated data; there was significant Indigenous engagement that had started; there was knowledge exchanged at round tables that brought together practitioners and clinicians. So there was an enormous amount of effort that was undertaken.

Notwithstanding that, as I said, if you go below those numbers, even those 1,100 clinicians that I was talking about, so many of them hadn’t had the opportunity to fully complete the training. As I said, only 40 of 1,100 had an opportunity to complete that training — not from a lack of interest but a lack of time. I’ll speak specifically about conversations I had with Uzoma Asagwara, the health minister of Manitoba; or Adrian Dix, who is the health minister in British Columbia, these are people who get it, who understand the suffering that’s there and who want to really work with us to get us there, but they’re saying they don’t have the number of people trained.

The other thing I do think we have to look at is the point that CAMH has raised, which is: Do we need clinical guidelines? The advantage of clinical guidelines is they can provide uniformity across the country and experience. There’s a great concern that certain provinces might be ready to do that work and that others may not be applying it in the same way or as equitably. If there is a decision to move forward with clinical guidelines, then we’re going to need time to train folks up on that and to develop that.

I hope you’re hearing in this conversation somebody, first of all, who came into the job wanting to see this done — because I’m equally concerned with people who are trapped in these horrific circumstances — but sees there are very earnest efforts being made by provinces, that we want to be the wind in their sails. At the same time, to do everything we can — again, we’re talking about mental illness, not mental health — on mental illness to continue to work and research with provinces to find solutions for those intractable mental illness issues. I’ll continue later.

The Chair [ + ]

We will move to the next block of 10 minutes.

Senator Kutcher [ + ]

Thank you, ministers, for being with us. I’ll be sharing my time with Senator Cotter and Senator Duncan. I will ask two questions and request each of you to respond respecting our short timeline.

This bill has changed the readiness goalposts for those who have been waiting for three years to apply. I’ve heard from many who feel abandoned, who see either suicide or travel to another country as their only option.

Minister Virani, is there anything that can be done to accommodate that very small number of people who have been waiting for such a long time? Is there a remedy or an exemption order that can be put into place for them?

Minister Holland, you have been telling us that there are things that have not been done in the systems. These statements are contradicted from what we’ve heard from on-the-ground clinicians. Could you please tell us today what specifically has not been done in each of these systems that you have been told have not been enough compared to what we’ve been hearing from clinicians?

Mr. Virani [ + ]

Thank you directly to you, sir, for even broaching this issue for Parliament to address because it was the genesis of the work done in this chamber going back to Bill C-7 that resulted in the mental illness clause having a sunset. That’s due to your work and has prompted some of the work that Minister Holland has mentioned that has already been done to date, things like the curriculum and the model standard being devised.

In terms of those who are suffering right now, I just want to echo some of the sentiments that Minister Holland has been indicating: We understand that suffering, we value that suffering, we equate it to physical suffering, we understand the decision‑making capacity of people who are mentally ill and we validate that and stand by it. This is not about negative stereotypes vis‑à‑vis those people.

With respect to some surgical approach to altering this bill, what this bill is doing is categorically indicating that there is a time when this will take place. That’s why it has a provision of three years. It’s not a never; it is a decision about when. Importantly, what we are saying is this issue needs to be addressed by addressing now and in the future the mental health supports that people like Senator Batters raised for those people who are suffering and ensuring that the dollars we are providing as a federal government assuage the mental health concerns of people who are suffering.

Mr. Holland [ + ]

Thank you. First, I will echo Senator Kutcher. Thank you for the work you have done in this space, and for your advocacy. I know exactly where your heart is, where you are coming from and why you are doing it. I deeply respect it. I respect the conversations that we’ve had.

I would say: What hasn’t been done? I would agree with you. There are clinicians who are absolutely ready, fully trained, fully absorbed their curriculum and fully done their training. That I don’t take exception with. The problem is there are not enough of them — 40 is not enough. Only 2% of psychiatrists are not enough.

We can’t have a situation where somebody walks in in one part of the country and encounters someone who is ready and somebody walks into a different part of the country, or even in the same province, and encounters a part of the system that isn’t ready and a terrible error is made.

What I would say to people who have waited their whole lives, decades of suffering in many cases, is I am so deeply sorry for the suffering they’re going through. We’re trying to repair the system as quickly as we can. I hope they would understand that we can’t afford mistakes. We can’t afford getting it wrong. The consequences are too grave.

That’s why, three years, we’re trying to move through this as fast as we can.

Senator Cotter [ + ]

Thank you, ministers, for being here, especially Minister Holland for the special efforts you made to be here tonight. I have two questions, but we’ll never get to the second one for Minister Virani. Let me ask this one of you, Minister Holland.

You’ve indicated repeatedly that you’re attentive to needs for the system to be ready and to protect vulnerable individuals who suffer from a mental disorder, whether that’s services, supports or the process itself.

However, three years ago, your government wasn’t in the least attentive to this same kind of question for those who suffered grievous physical disability in 2021 when we adopted Bill C-7. Those people were equally vulnerable, maybe more so. Why the change?

Mr. Holland [ + ]

Thank you, senator.

As I’m sure you appreciate from your time in this chamber, you get exposed to people’s stories, suffering. Your understanding of what needs to be done modifies and changes. That is certainly the case here.

I can say, as an example, that — prior to the Senate raising the issue of mental illness as the sole underlying condition with access to MAID — it’s not something that I had heard a lot about. I hadn’t talked to many clinicians who had encountered that circumstance, because it is a very rare circumstance. My understanding wasn’t as great as it should be.

One of the strengths of our democracy is that it’s responsive to our population. Sometimes we get the opportunity to catch things we didn’t before.

Senator Duncan [ + ]

Thank you, ministers, for being here. My question is for Minister Holland.

Minister Holland, we’ve spoken about the letter from ministers of health and wellness and ministers of mental health and addictions from throughout the country. It’s a compelling argument in support of Bill C-62.

That letter states that implementation of extending the eligibility where mental illness is the sole underlying medical condition requires further federal-provincial-territorial work and that the comprehensiveness and delivery of mental competency exams are inconsistent.

The ministers asked for an indefinite pause. Bill C-62 provides for three years. There’s no timetable or commitment to a deadline to get the collaborative work done for Canadians. We’ve talked about the fact that Canadians are suffering and they’re unable to access care.

What assurance can you give these suffering Canadians that the kind of collaborative work that the ministers requested will be done within the next three years?

Mr. Holland [ + ]

Thank you for that question.

Canadians rightfully have an expectation on health that we work collaboratively and set aside our differences, partisanship and find a path forward.

The challenges facing our health system are enormous, as they are around the world coming out of the pandemic. All health systems are yawning under the strain of burnout and backlogs.

What I will say to you — it’s demonstrative of how constructive the meeting we had in Charlottetown was — if you look at the bilateral agreements, they have been constructive in working collaboratively to find solutions. All of my conversations have been incredibly productive.

I’ll be straight. There are some jurisdictions that don’t ever want to come around to this. There are some provinces that share Senator Plett’s view that this should never be done. Those will be challenges. But those are not all jurisdictions. Most are really about readiness.

One of the reasons why three years is so important is it’s respectful of provincial jurisdiction, of the fact that they are the ones who have to administer these systems. It gives them a finite timeline and it allows us an opportunity to work on an ongoing basis.

On a parliamentary basis, we know we only have two years before we review our progress and that Parliament will have to be back in front of this chamber giving an update on what it did. I expect the Senate will hold me to account, whether having me here in Question Period or otherwise, to ask: Where are we? How is it moving? How are the conversations going?

I’m totally committed to making sure we get this right, that we use this time well. The greatest evidence of that — I can see Madam Chair looking at me here as I’m finishing — is what we did over the last year. We made enormous progress over the last year. It just wasn’t enough.

The Chair [ + ]

You still have a minute and a half.

Mr. Holland [ + ]

There you go.

Mr. Virani [ + ]

If I could add to that, Madam Chair?

The Chair [ + ]

Yes, Minister Virani.

Mr. Virani [ + ]

Senator Duncan, you raised the letter. It’s also important, even in the letter itself, there are some annotations to it. Prince Edward Island and Nova Scotia indicate their state of readiness is actually ahead of some of the other provinces. You see that differentiation already occurring, reiterating the point that many steps have been taken thus far because we’ve put parameters and timelines in place.

Senator Wallin [ + ]

Thank you. I’m a little puzzled with your argument that because not everybody is ready, then we can’t proceed.

We all know that in the health care system in Canada we don’t have enough diabetes specialists, oncologists, doctors or nurses. We don’t withhold care because not everybody is ready to go. We actually treat the people who need care.

The readiness and preparedness criteria were met, criteria you established which was evaluated by experts you appointed and who testified in front of us at the joint committee. You have moved the bar again. To follow up on what Senator Kutcher was saying, what’s the new bar? What is point five or six you will now establish to say readiness has been achieved?

I don’t want to hear the argument about the provinces, because that’s irrelevant to the delivery of MAID. Those are decisions. Health care ministers can decide they’re in favour, opposed or will never allow it to happen.

What we’re talking about is the state of readiness of those who are prepared to provide MAID in this country. There is a substantial group of people who are ready and prepared to do it now, so why wouldn’t we?

Mr. Holland [ + ]

Thank you, senator, for your advocacy on this issue. I know you told me not to talk about provinces, but I will for a second.

It is not inconsequential that every elected legislature in every province and territory of every political stripe is unanimously saying they’re not ready. I’m hard-pressed to think of another example in Confederation where there was such unanimity.

Provinces are responsible for the administration of their health systems.

Senator Wallin [ + ]

The overall delivery — I understand it’s a jurisdictional question. You’re talking about whether there are enough assessors and providers in the system; there will probably never be enough, as there will never be enough doctors and nurses in our system. We see that.

If we have those who are ready and able — we have a list of 127 at least that we know about for sure in this country — and have access to training, if all of that is available and there, why wouldn’t we proceed?

Mr. Holland [ + ]

I’ll give you three specific reasons. The first is 40 isn’t enough — 40 fully trained clinicians is not enough for this country.

Senator Wallin [ + ]

There will be 50 by next month. There will be 60 four months later.

Mr. Holland [ + ]

Right. They are not there now. We have a deadline on March 17 and people accessing this system on March 17. There aren’t enough people — 2% of psychiatrists are not enough.

The second point I would make is with respect to the provinces. We work in a very collaborative way. It would be extremely difficult for this chamber and our chamber to say to the provinces, “We know your systems. We think you’re ready,” and then ignore all of them.

Senator Wallin [ + ]

It’s not you saying that they’re ready. It’s the practitioners who are saying they’re ready. You have lists and testimony in front of the joint committee that is specifically and directly telling you that.

Mr. Holland [ + ]

It’s some, but the Centre for Addiction and Mental Health, or CAMH — and, with all due respect, CAMH is the authority on mental illness and mental health in this country — has said very clearly that the system is not ready, and there are a huge number of clinicians, psychiatrists and other mental health professionals who are saying the system isn’t ready. In regard to the fact that some say the system is ready, I believe them to be earnest, and I believe they are ready, but we don’t live in a country where we can ensure that people are only going to go to that small number of people who say they’re ready. The whole system has to be ready because the consequences —

The Chair [ + ]

After you’ve completed your answer, Minister Virani has a comment.

Mr. Virani [ + ]

First of all, thank you for your work on that joint committee, Senator Wallin. Second, there’s a qualitative difference between a lack of health care practitioners, generally speaking — who are providing general health care delivery models, including for diabetes, to Canadians — and people who are assessing and providing medical assistance in dying. I know it’s fairly obvious to everyone in this room, but we’re talking about significant interests that relate to how people pass from this earth. The consequences are, by definition, permanent. I would argue that the stakes are much, much higher compared to any other health care provision or service in this country. Therefore, given that imperative, we are determined to ensure that the number of assessors and providers — who are sufficiently trained and ready to implement the safeguards — is more than adequate. We have to get it right before we advance.

Senator Wallin [ + ]

I guess what I’m trying to get at is your actual commitment to this. We know that the whole question of mental illness as a sole underlying condition was a priority of your government. You had the choice to choose an issue like advance requests, which is near and dear to my heart. You said this was a priority issue, and you were going to work on it immediately and make sure it was done — because the courts have ruled: We’re not litigating MAID. We’re talking about the rights of Canadians to have access to this. After that, you said it would be a year’s delay. Then, we approach the March 17 deadline — if we have time, we can discuss that, because I think you’ve built safeguards into the system, so I don’t think we’re in the panic on the time that you’re suggesting. However, you were the ones who said that this was a priority issue.

Now you’ve said you will delay this for three years until after the next election. I did say — in my speech the other night — that this was a political issue, and I believe it. We can all read the public opinion polls, and, it is likely that if there were an election in the next little while, the Conservatives will be elected, and the leader has made it very clear that this will never happen on his watch. If you were committed to this issue, and committed to delivering on the promise you made to Canadians that this is your priority, then I do not understand why you would take three years and put this after another election where nobody can really predict the outcome.

Mr. Holland [ + ]

Thank you, senator. You’re absolutely right; nobody can predict the outcome. In the next election, I will enter for the ninth time my name on a ballot —

Senator Wallin [ + ]

I’m sure you will.

Mr. Holland [ + ]

— and I can tell you that many prognostications have been made about my political doom. In 2011, they were right, and to some people’s happiness and to some people’s dismay, I returned. In all those journeys of being on a ballot 12 times — there were a bunch of other times municipally — you don’t know what’s going to happen. However, I’ll tell you what you don’t do: You don’t make policy based on trying to guess what government might be out there in the future. I think we have to make policy on the basis of what is good, reasonable and fair, and what represents the best public interest.

Just to finish, I have been an advocate. In regard to the fact that we keep dealing with this, if we wanted it to go away, we would have voted for Ed Fast’s bill, and we would have put it off indefinitely. If that was our secret hidden motive, we would have just voted for Ed Fast’s bill, made it go away indefinitely and achieved what you are saying.

When I became the health minister, I was in a room with health ministers and argued with them about why I thought the system was ready. It was after hearing from all 13 of them that I started to have pause. It wasn’t even at that point when I switched direction. It was just that I had pause, and I started to go a lot deeper and have other concerns. I come at this as an ally — as somebody who shares the same concerns that you do. I share your concern about all the things that a Conservative government could mean to this country. I share your concern about what Poilievre represents to so many things that are near and dear to my heart. However, we can’t make a decision on the off chance that he and the politics he represents are successful — to ram through things that aren’t ready with potential consequences that are very serious. I think Minister Virani said it really well; this is unlike so many other elements. If we make mistakes here, they are permanent and enormously consequential.

Senator Wallin [ + ]

But the experts whom you have asked to rule on this have said that you’re not taking that kind of chance. There is readiness in the system. There may not be enough so that everybody in rural Saskatchewan has the same treatment as those at CAMH, but we’ve got to start somewhere, as we did with MAID. There were not enough practitioners at the beginning until the system was there, but as long as you keep this issue under the auspices of the Criminal Code, why would anybody stand up and take those risks? The change is possible. The people are there, and they’re ready to begin this process to alleviate the suffering of those who have been waiting at your behest when you said that it was right around the corner.

The Chair [ + ]

Time has expired on this 10-minute block. We’re moving to the next block.

Senator Cardozo [ + ]

Welcome, ministers, and thank you very much for being here to take our questions. As you know, senators and, indeed, all Canadians care very much about this issue, and your time is greatly appreciated today.

I want to quote briefly from a letter that I received in order to give voice to this viewpoint and obtain your response. The writer says:

It is wrong and unconstitutional to continue to exclude individuals with mental disorders from equal access to the law. People across Canada who have been suffering from mental disorder that cannot be relieved under conditions they find acceptable should have the same right to autonomy and choice as individuals with grievous and irremediable physical conditions.

What would your response be to this Canadian?

Mr. Virani [ + ]

Thank you, Senator Cardozo, for the question. Obviously, the constitutionality has been at the heart of the MAID discussion since the Carter decision was rendered back in 2014-15. What I would say to that individual is this: When you get at the heart of an equality analysis under the Charter, you look at whether you’re perpetuating negative stereotypes, or attacking or impugning the dignity of the individual. Our government, Minister Holland and I have all said that there’s an equivalence between mental suffering and physical suffering. There is no daylight between those two. As well, there is no perpetuation of a negative stereotype about the decision-making capacity of an individual who is mentally ill.

However, there is an appreciation of the complexity of applying determinations about capacity and decision making in the context of people who are struggling, and who may be making requests in a time of crisis — that has to be distinguished from a considered and reasoned application of MAID — and where suicidal ideation can enter as part of, as a feature of or as a symptom of someone’s mental illness. We have to be absolutely sure that the people who are doing the assessments have the ability to distinguish what is a symptom of a person’s condition versus what is a reasoned request for MAID. It’s deeply complex.

If I’d had the time, I would have said the following to Senator Wallin: It’s not just that MAID is different from what general health care practitioners do, but it’s also that providing MAID in this context is substantively different — qualitatively different — than any other context that has been provided. Are there Charter issues at stake? Absolutely the Charter is at stake. But what I firmly believe, and what is reflected in that Charter statement, is that we have to make triple sure that we have the rigorous assessment and training in place so that people can make the evaluation. It’s critical to get that evaluation right. I don’t think the Constitution mandates me or our government to provide a health care service when it is not safe to do so, and that’s our determination: It is not safe at this time.

Senator Cardozo [ + ]

Thank you. I do appreciate your keen arguments about the Constitution.

My other question is this: Why three years? A year ago, when your predecessors were before us, they asked for one year. Why did you not take one year or two? Why three?

Mr. Virani [ + ]

In terms of this timing piece — and this came up in the interaction with Senator Wallin as well — we’re trying to reflect what we’ve heard from health care providers. We’re trying to ensure that we’re not repeatedly back in front of this chamber or the House of Commons, continuously seeking extensions. We’re looking at the road map in front of us in terms of having a sense of when we will have a better understanding and appreciation of the development of further mechanisms.

One thing that hasn’t been elaborated upon here is that a critical component is back-end oversight, analysis and case reviews. My understanding — and Minister Holland will correct me if need be — is that it’s only the coroner’s offices in Quebec and Ontario that mandate a review of such cases of MAID across the board. We want to see rigorous application of such oversight processes as well as rigorous take-up. We feel confident that within two years’ time, a joint committee made up of senators and MPs will be able to evaluate that and, within three years’ time, we’ll be able to go ahead. Having a back-end timing window ensures that people continue to do the work that is necessary. That’s critically important.

Senator Cardozo [ + ]

Thank you.

Senator Cuzner [ + ]

To my two friends and former colleagues, I’m down here in the far reach, although I’m sure my Senate colleagues would confess there’s no such thing as a bad seat in the upper chamber.

Minister Holland, on January 3, 2017, Corporal Lionel Desmond, from Upper Big Tracadie in Nova Scotia, using a semi-automatic rifle, took the life of his wife, Shanna, 31 years old; his 10-year-old daughter, Aaliyah; his 52-year-old mother, Brenda; and then turned the gun on himself and took his own life.

As you know, the Desmond Fatality Inquiry Final Report was released two weeks ago in Nova Scotia. The findings were very concerning around mental health treatment in my home province of Nova Scotia. I’m not in any way running down the professionals who continue to do a tremendous job for the people of Nova Scotia, but it has become obvious that there are certain realities. In the discussion around MAID, there are certain realities around access to mental health services and the delivery of those services in Nova Scotia.

The story of Lionel Desmond’s access to treatment for his post-traumatic stress disorder, or PTSD, touched on rural challenges, on challenges of race, on barriers that face veterans, on access to firearms and so on. This former Canadian soldier fell through the cracks in the health system, and those cracks in the health system resulted in this tragedy.

My difficulty is squaring that with further access to MAID for mental health conditions. There are concerns in the report’s findings. What processes are in place that will give us some kind of comfort that we can extract the lessons and learn from this incredible tragedy?

Mr. Holland [ + ]

Thank you very much, Senator Cuzner. It’s wonderful to see you in this chamber, having had the opportunity to serve with you in the other chamber. I look forward to you doing phenomenal work here, as you did in the other chamber, and to our continued conversations.

First, the tragedy you describe is horrifying — horrifying in the lives that it took and horrifying in the story that led to Corporal Desmond committing the acts that he did. It underscores a mental health crisis that we have not only in this country but also in the world. One in three Canadians — and this is not dissimilar to anywhere else in the world — report having serious mental health challenges.

I say “health challenges” because that’s completely different than illness. When you have a mental illness, much in the same way as a physical illness, it is often unrelated to the things you’re talking about, namely, PTSD and trauma. This is an underlying physiological condition that is not necessarily environmental and, therefore, can be intractable. We’re talking about something incredibly rare. It’s important not to conflate these things. I want to put a firm wall between these two things because it’s not what we’re talking about here.

Let me talk specifically about Nova Scotia. I want to say how much regard I have for Minister Thompson, the health minister in Nova Scotia. She’s somebody who gets it. As a former nurse, she’s somebody who has been on the ground, somebody who understands the changes that need to occur. The bilateral agreement that was signed with Nova Scotia, the money that’s flowing through that agreement, enables critical action that we’re taking in mental health. It has to be a whole-of-society approach.

Senator Cuzner, I’ll be straight with you: It’s not going to be enough for the federal government to act alone in this. How we are treating each other in this world has to change. The hostility, the anger, the negativity, the way in which we engage with one another as human beings and in our workplaces — all of it has to change. This is sickness. The health issues that are pervasive right now exist because of how we’re treating each other. It is no accident that the more victimized somebody is, the more they face colonialism or racism, the more they’ve had PTSD, the more they’ve been subjugated, the worse their mental health. Our path out is clear, and it’s going to take a lot more than just investments.

I think it’s dangerous in this conversation to conflate these two issues because it’s not what is in front of us today when we’re discussing Bill C-62.

Senator Martin [ + ]

Thank you to both ministers for being here. I share the concern that Senator Cuzner has raised. Although we’re not conflating, we can’t ignore the concerns related to mental illness and mental health and how it plays a part in what we’re talking about.

Minister, experts have indicated that expanding MAID could harm suicide prevention in Canada. According to a study by CAMH, which I know you have mentioned as being a very important body, Canada ranked sixth in 2019 for the highest suicide rates in the Americas. With the risk that expanding MAID MD-SUMC, or MAID where a mental disorder is the sole underlying medical condition, could have on suicide prevention in Canada, why is the government adamant on expanding MAID in three years rather than introducing an indefinite pause, as the majority of provinces requested?

I do share the concerns that Senator Plett raised and the efforts of MP Ed Fast. It’s something that I would have supported. The majority of provinces are calling for an indefinite pause. Would you please speak to that?

Mr. Holland [ + ]

Sure, senator. Thank you. I’ll try to be more explicit, and hopefully this distinction will be better illuminated.

For somebody who has a mental illness, this is somebody who, under the regime we’re speaking about, would have to have seen two clinicians and demonstrated that they’ve tried all sorts of different interventions and that their situation is irremediable, meaning it cannot be reversed, and that they have sought extensive help. They would have to have demonstrated that this is an illness. Much like if you have cancer, you don’t choose to have cancer; it’s only medicine that can get you out. That’s an extremely important distinction.

When we’re talking about mental health, I can be very direct and personal here. When I was going through a deep mental health crisis and I made an attempt on my own life, the distinction that is different is that I was able to get help, and that help was transformational for me. We want to make sure that when we’re talking about mental health, we do everything as a whole of society to overcome those challenges.

It’s uncomfortable. I understand it’s uncomfortable. We have to be honest and straight about the fact that there are some folks whose suffering is irremediable and that we have no way of repairing it. I’ve talked to those physicians who have tried absolutely everything and who have people who are trapped in an absolute mental hell and who, of their own recognizance, are asking for relief. That is an extremely rare circumstance, but it is materially different. That’s why I say we shouldn’t conflate these two issues or confuse them as we’re talking about what is in front of us today.

Senator Martin [ + ]

The Special Joint Committee on Medical Assistance in Dying, of which I am the joint chair, indicated in our report that it is too difficult to differentiate between suicidality and a regular medical assistance in dying, or MAID, request. With medical assistance in dying where a mental disorder is the sole underlying medical condition, or MAID MD‑SUMC, the difficulty to differentiate will only increase. It is therefore clear that it will be nearly impossible to accurately differentiate between the two.

Knowing that difficulty, why is your government not putting efforts into suicide prevention instead of continuing down this road of expanding MAID?

Mr. Holland [ + ]

First of all, as I said, we recently launched a national suicide prevention hotline. We’re signing bilateral agreements that have critical investments in mental health in every province and every territory. The conversations that Minister Saks, the Minister of Mental Health and Addictions, and I are having are happening every day. We’re totally seized with trying to stop people from getting to that point.

One of the reasons Canada has a higher rate of suicide than just about any other country is because of the horrors that have happened to our Indigenous peoples. One of the things we’ve heard with our Indigenous people is that they need more time to understand this so that there is a clear distinction, so that we’re not creating any blur between mental illness — and let’s be very direct about that, if you talk about what a distinction is.

If somebody — after trying everything and after decades of trying to escape mental hell — is unable to find a way out, that is a materially different circumstance than somebody who is in a moment of mental health crisis who is seeking support in that moment.

If somebody over the course of 20 or 30 years — I would pose this back to you: How long does somebody who is suffering mental illness have to go to a doctor? How long do they have to suffer? How long do they have to go to their doctor? How many treatments do they have to try? Is there any point at which you would listen to that person? Are there any number of decades after which you, senator, would listen to that person and say, “Yes, you have tried everything and you have a right to access MAID”? Is there a circumstance that you would ever see after any number of decades, after any number of treatments where you would ever allow that person under their own recognizance if they had an irremediable position? If not, I understand we have a difference that is a bridge that can’t be crossed.

Senator Martin [ + ]

I’m asking the questions at this time, but I appreciate the questions you have given back to me. However, I have a question for Minister Virani as well.

Minister, the data is clear that Canadians support MAID, generally, for grievous and irremediable conditions, but it’s equally clear that Canadians do not support MAID for mental illness. The Special Joint Committee on Medical Assistance in Dying heard testimony from experts, organizations and individuals that Canada is not ready for MAID MD-SUMC.

Minister, when the consensus is not there among experts, and there’s such a lack of support among Canadians, why would your government not table legislation to stop this expansion rather than simply delay it now for three years? If your government is certain that we will eventually have a professional consensus that would justify this expansion, why not just table legislation if and when that time arises instead of just doing a three-year extension?

Mr. Virani [ + ]

Thank you, Senator Martin, for the question. I will say a few things.

One is that through the leadership of the Senate, mental illness was put on the table with respect to a sunset clause. That started here, not in the House of Commons. Second, putting a timeline on it keeps people motivated to take action. This has come up repeatedly over the last hour — what action has been taken. A curriculum has been designed; a model practice standard has been designed. Those are positive steps that are prompted by and incentivized by having a back-end chronological deadline to be working toward.

By putting a three-year deadline on it, we’re demonstrating to Canadians that we firmly believe that MAID will be evolving to this point such that mental illness as a sole underlying condition will be made available to Canadians, as would be required in the context that has been described by Minister Holland — someone who has grievous and irremediable suffering that is intolerable to them. By having the deadline, we’re indicating to Canadians that we believe in that prospect and are working toward that prospect.

I would say to you that some of the indicators will be that when we get not just a thousand people taking the course and having 40 people concluding it to its final conclusion but having much more take-up, so we can make that distinguishing factor.

In response to the interaction you just had with Minister Holland, there is a differentiation between suicidal ideation and a well-considered, thought-out request for MAID that comes after a long and prolonged period of suffering. There are people in this chamber, even, who I think have the expertise to make that differentiation. We need to see more people with that capacity or ability to make that determination around the country and across the provinces and territories to give us comfort in the fact that this can be delivered safely because the consequences are so severe.

Senator Martin [ + ]

My position is that three years will not be enough time. Within the past year, I know there has been some consultation or engagement with First Nations, Inuit and Métis, but there was a huge gap in that regard. There are other issues. We can debate about irremediability and suicidality and how we distinguish that from choosing MAID, but my question is actually regarding the reconstituting of the committee.

This recent committee, we only had it since October. We had five sessions. It was so rushed. It was on the tightest of timelines. Are you planning on reconstituting the committee a bit earlier? In the meantime, will you be putting the funding in place to ensure that if and when MAID for mental illness as a sole underlying condition becomes legal that we will have the adequate funds to roll out the program?

But first of all, regarding the reconstitution of the committee, would you speak to that?

Mr. Virani [ + ]

Senator Martin, this is the second time the MAID committee had looked at this issue. In the first report — what I recollect, and I stand to be corrected on this — they said around October, about five or six months prior to the advent of March 17, the committee should be reconstituted. That’s exactly what we did. We followed the directives of the committee you sat on in that first report.

Second, you asked about when the committee should be re‑struck, the statute before you, Bill C-62, talks about it happening two years from Royal Assent on this bill, so that is when it will be reconstituted —

The Chair [ + ]

Thank you, minister. We are now moving to the next block of 10 minutes.

Senator Poirier [ + ]

Minister Holland, according to a survey conducted by Angus Reid, a large majority of Canadians are concerned about the mental health resources available across the country and about the state of Canadians’ mental health overall.

The joint committee received a brief from a social worker from Alberta who described the situation facing too many Canadians. She talked about a lack of resources, as well as the waiting lists and financial barriers that are preventing adequate access to mental health services.

Minister, would you agree that it’s more important to improve access to mental health care and services so people can live with dignity, rather than to take another three years to expand medical assistance in dying so they can die with dignity?

Mr. Holland [ + ]

Thank you very much for that question. These are two different things. It’s not just a problem in Canada, but across the world. It’s a mental health crisis. It takes a lot of effort, action and cooperation from all levels of government, and we also have to work with the private sector.

In this case, we’re talking about someone struggling with a condition that can’t be treated, a person whose well-being is impossible to improve. It is an unfortunate situation, and a very rare case, but still, it exists. I think it’s dangerous to confuse the two issues, because we certainly must do everything in our power to improve mental health care.

When someone has been fighting their whole life to find a solution, that’s an entirely different situation; these are two separate concerns, although they can exist at the same time.

Senator Poirier [ + ]

Minister, I understand why some people who are suffering and who are at the end of their lives choose medical assistance in dying, and I respect that choice. I have sympathy and compassion for them and for their families, who must go through difficult times. No one will be spared such moments, because everyone will experience them at some point.

My biggest concern has to do with the normalization of MAID as a treatment rather than a last resort in Canada. Although your government is calling for another three-year hiatus, it still intends to move forward with the expansion of medical assistance in dying in Canada.

Minister, are you not concerned that, if you move forward with the expansion of medical assistance in dying, then it will quickly become a solution rather than a last resort?

Mr. Holland [ + ]

I absolutely love life. I feel fortunate to be able to continue living, and I hope that everyone in the country feels the same way. If people choose to access MAID, we must ask ourselves why they are making that choice. It is not because they have a mental health problem — in fact, MAID is not currently offered in our health care system. However, there are people who are struggling with extremely severe illnesses.

I’m going to ask an important question. If I see someone in front of me who has been suffering for 10, 20 or 30 years, with no possibility of improving their quality of life, and if that person says that their life is terrible and that they are suffering atrociously, does that person have the right to access MAID? That is the question we are asking ourselves today.

Is it normal? No, it is not normal for someone to want to end their life. Unfortunately, when a person is faced with an illness, whether physical or mental, such situations are likely to occur. That is why we are debating this bill today. Mr. Virani may have something to add.

Mr. Virani [ + ]

I want to come back to the numbers quoted by Minister Holland that show a worrisome increase in requests. That is not the case at all. In fact, more than 96% of cases where MAID was granted were terminally ill patients. Track 1, introduced in 2016, was for patients suffering from diseases such as cancer. Only 3.5% of cases that chose track 2 or who were not at the end of life were provided MAID.

Saying that numbers and requests have increased is absolutely incorrect.

Senator Poirier [ + ]

Minister, last month, the Toronto Star published a report that should concern all Canadians.

The use of MAID in Canada seems to be skyrocketing. In fact, 4.1% of deaths in Canada are associated with MAID after only 6 years — a rate that the Netherlands still has not reached after 14 years.

Minister, aren’t you worried that Canada could be leading the world in MAID requests and has gotten there so quickly? Given the speed at which Canada is responding, should we not put this on pause indefinitely instead of delaying the expansion of MAID by three years, especially since it has been shown that Canada is the country with the highest number of people seeking MAID?

Mr. Holland [ + ]

It’s really important to note this percentage. Over 96% of the people requesting MAID are terminally ill, usually with cancer. These people are choosing MAID, when the alternative is to die of a disease that leaves them with an absolutely terrible quality of life.

My family went through this experience three or four months ago with my uncle. It was a very sad situation.

We’re talking about nearly 100% of cases. This is about deciding, as a society, to empower people living with a disease like cancer or who are at the end of life, giving them the opportunity to make a choice for themselves. That’s what a system like this can do, when someone is suffering atrociously. It has to be their choice. It’s not my choice or your choice. That is the basic idea behind MAID.

When it comes to incurable diseases, that’s the debate we need to have today. We need to make sure that the choice is really limited to cases where a patient has examined all options and where there are no other alternatives to improve their health, after having suffered a great deal.

Mr. Virani [ + ]

I’m really proud of the policy the government has put in place in response to Carter. It points out that the Canadian Charter of Rights and Freedoms protects the autonomy and dignity of individuals by giving them the right to make their own decisions about their end of life. That is the policy the government established in 2016.

Ninety-six per cent of these cases are dealing with the end of life. These are people who will be passing. The fact that we have a policy in place that allows them to die with dignity is something I think we should all be proud of.

Senator Miville-Dechêne [ + ]

Minister Holland, I will ask my question in English because I want to be sure that we are precise in the answer.

You seem to say that there is a very small number of very sick people who want MAID for a mental disorder. In the Netherlands and Belgium, as you know, they did that many years ago. There was an explosion in demand. You cannot predict what’s going to happen. In Belgium and the Netherlands, the euthanasia regime — which is what they call it — requires that people who request MAID have exhausted all reasonable treatment options. That is not the case in Canadian law.

Can you explain why that decision was made? Obviously, I’m speaking here of mental disorders. Why isn’t this particular safeguard in the law?

Mr. Holland [ + ]

With respect to folks who are suffering from mental illness and who are in a state of permanent decline with an intractable, irremediable condition, in the conversations that I’ve had with physicians across the country, they estimate it to be a very small number. You’re right; I don’t have exact knowledge of what that number is, because I’m not a physician. I’m not seeing clients. When I asked physicians, they would say that in the entirety of their practice, they would see one or two cases in their careers that would match that. That’s something I’ve heard from clinician after clinician.

That isn’t to undermine the suffering of those individuals. As I said, I believe that those individuals should absolutely have access to a system where they can make that choice after they’ve exhausted all reasonable options and after —

Senator Miville-Dechêne [ + ]

Minister, it’s not in the law.

Mr. Holland [ + ]

No, but that’s what I’m trying to explain. If someone in front of me were in that circumstance, suffering terribly and saying they wanted to access MAID and that they’d tried everything else, I would say the problem today is that we’re not ready. I’m sure that person wouldn’t want us to have a system that was unclear, unprepared and didn’t include a sufficient level of training to make sure that people were put into the appropriate channels.

We want to take this as seriously as possible to ensure MAID is available only in those cases where absolutely no other options exist and we can’t give the person the joy of life and relief of pain.

We don’t want to proceed with a system that isn’t prepared, where, yes, the people you’re referring to would get relief but irreversible errors could occur through not having appropriate or efficient training. That would be a tragic outcome.

Senator Moodie [ + ]

Thank you, Minister Holland and Minister Virani, for being here today. My question is for Minister Holland.

It is my understanding that the government has accepted the constitutional right of individuals with mental illness as a sole underlying condition to access MAID. I’d like to use my question to confirm this by digging a bit more into the readiness issue.

Minister, you have stated that 40 physicians are not enough, that 2% of physicians are not enough and that 250 individuals are not enough. Minister, what percentage would be enough? What deliberations have you carried out that estimate and guide us to the percentage that would be enough? What specific system interventions need to be in place to reassure you that we are ready and prepared? Can you state unequivocally that if these numbers and systems were in place, this government would allow access for Canadians who have mental illness as their only medical condition?

Mr. Holland [ + ]

Thank you very much for the question, senator. As a starting point, we would need at least one jurisdiction somewhere in the country to say they are ready. I respect that some senators are saying the health ministers don’t know their systems, but in the systems we have, health ministers are responsible for their systems. They have ultimate accountability. Ministerial accountability means that we are accountable for the decisions we make.

We have a New Democratic health minister, a Conservative health minister, a Liberal health minister and a Coalition Avenir Québec, or CAQ, health minister with their names on the line and the responsibility ending with them. When every one of them says they’re not ready, senator, we must listen to them. It would be irresponsible not to.

Senator Moodie [ + ]

Minister, I want to clarify. What system interventions does this government feel need to be in place in addition to the targets of physician and practitioner preparedness? Can you give us hard numbers? We really want to understand whether this will proceed if those are in place in three years. Some are concerned that this is the first step toward never allowing MAID.

Mr. Holland [ + ]

First, if I were opposed to allowing MAID, the other questions I’m being asked would be a lot easier to answer. I would just say, “I agree with you. Let’s never do it.” We would have voted for Ed Fast’s bill and I would be agreeing with the people who have been pushing very hard in the other direction. The fact that I am vociferously defending the need to move forward is ample evidence that I agree with you.

Second, with respect to readiness, because we do not administer health care in these systems, it is essential to have at least a few jurisdictions stand up and say, “Our systems are ready.” For me to pick the number of clinicians or psychiatrists would be inappropriate because I’m not the one administering those health systems.

However, we have several governments that are working very earnestly. They agree on this question of there being equivalency between physical and mental suffering. They want their systems to be ready but are asking for more time. They are saying that more folks need to be trained, that the engagement with Indigenous folks has not been deep enough, that the engagement with —

The Chair [ + ]

Minister, I’m sorry, we have to move to Senator Coyle.

Senator Coyle [ + ]

Thank you for being with us, ministers. This is a critical moment for all Canadians.

When testifying on Bill C-7, MAID assessor and provider nurse practitioner Julie Campbell said:

As I follow this process of legislative review and the media surrounding it, I often think of two words: trust and fear. It would be impossible to legislate every aspect of medical care, and so we have a system where legislation provides a framework, and clinicians act within that framework to establish and uphold the public trust.

Fear is fuelled by inaccuracies or lack of information. Trust is built by ensuring access to transparent, comprehensive and accurate information.

Ministers, if Bill C-62 passes, what will the government do and what milestones will be set to first prepare and then provide MAID for people whose sole underlying condition is mental illness and, very importantly, to provide the kinds of information that Canadians will need in order to earn their trust and allay their fears?

Mr. Holland [ + ]

First, yes, trust is vital here. Hopefully, the debate that Canadians are watching us have in both chambers demonstrates the weight and seriousness with which these issues are being considered. Hopefully, that is inspiring trust.

Working with and listening to provinces and territories, and demonstrating that we’re deferential to their concerns when they are reasonable and earnest, is very important in establishing trust. Then we can collaborate by increasing the number of folks who have fully completed their training modules and psychiatrists who have participated, making decisions — as we must — on whether clinical guidelines will be necessary and moving forward with Indigenous communities and leaders.

I’ve been having a lot of trilateral meetings, nation to nation, with Indigenous peoples. In every single one, they’ve been very grateful for the additional time. We’ve had rich conversations on the margins about health agreements on MAID as well as other subjects. These are very important conversations. This is not some abstract idea of what we will do in the future; this is happening right now. It’s a general conversation about all aspects of our health system.

The Chair [ + ]

We’re now moving to the next block of 10 minutes.

Senator Ravalia [ + ]

Thank you, ministers, for being here today. With a health care system that is in crisis, are you convinced that, in three years, we will have adequate resources to satisfy your criteria and get provincial and territorial buy-ins to proceed with this expansion? Do you recognize that, across the board, medical professionals are suffering from burnout and leaving the profession? Accessing psychiatric care in my province can take upwards of three years, which places individuals with mental health issues at significant risk of reaching irremediable states.

Minister, can you convince me that you feel the processes you’re putting in place will be such that we won’t be having this very same discussion three years from today?

Mr. Holland [ + ]

Thank you very much for the question. It’s an important one. As health minister, I have been extraordinarily buoyed by the level of cooperation and commitment to wholesale transformation of our health system. I can look at the Nova Scotia College of Nursing as they totally transform their approach to nursing. I can look at actions taken by certain provinces with respect to team-based family medicine or changing fee structures or working with data. I can look at the incredible advances happening in bioscience. When we overlay, on top of that, the $200 billion we’re putting into the health system over the next 10 years, we can see we are transforming our health system.

We already have one of the best systems. Every system around the world is under dire stress because of what you describe. We’re coming out of it; it was a tough time. Thank God we had the people we did in our health system, holding us up as we went through those incredibly dark days of the pandemic. But I am totally confident about the future of our health care system.

We believe that this three-year period is a substantive enough time to, in the next two years, make enough progress that when we have a parliamentary review in two years’ time that the progress will be evident in the system and we can see that we’re moving towards that three-year date for readiness.

It was chosen with deliberation because, as Minister Virani said, we don’t want to be in a situation where we’re Ping‑Ponging back and forth to this chamber. This is a painful and difficult debate. I’m frankly very glad that we’re having it because I think it does allow the public to be more informed and understanding of the issues facing us, but we don’t want to have it every year. That’s not healthy.

So three years, I think, is enough time. I talk to some folks who are not intractable. There are some health ministers who say, “Forget it, I’m never interested,” but when I talk to those who share that belief of equivalency between mental and physical pain, they believe this timeline is appropriate and can be worked with.

Mr. Virani [ + ]

Senator Ravalia, among the $200 billion announcement, four pillars relate to the health care funding. One of them is increasing mental health and substance use services and support. That’s been identified by us in terms of the agreements that Minister Holland is signing as we speak with the various provinces and territories.

Ministers, many of us continue to be concerned about the virtual elimination of choices when it comes to the most marginalized and disadvantaged. As you’ll know, poverty is the number one social determinant of health. Ongoing inadequate social, economic, housing and health supports leave the most marginalized virtually devoid of equitable access to choices, particularly when it comes to medical assistance in dying.

Just this weekend, disability groups again asked for assurances that the Canada disability benefit will be funded in the upcoming budget, citing the urgent need for support.

What concrete measures is the government taking to meet the commitment it made to the Senate to roll out the Canada disability benefit by the end of 2024? What other economic supports will be provided to ensure equal protection by the Charter and equal access to housing, food and health?

Mr. Holland [ + ]

Thank you very much, Senator Pate. I agree with you. As health minister, I often say health is at the centre of everything. If you want to talk about productivity, public safety or quality of life, it’s at the centre of absolutely everything. One of the things I was surprised to learn when I was the Executive Director at the Heart and Stroke Foundation of Canada’s Ontario Mission was that the number one risk factor for heart disease and stroke was mental health and that the number one risk factor for mental health was being from a marginalized community.

So on poverty, you’re 100% right. That’s why, whether it’s the Canada Child Benefit or the action we’ve taken with seniors, we’ve been able to significantly move the needle. There are 2.1 million fewer people in poverty now than in 2015, but the disability community remains one that is of serious concern. You’re right to identify the disability benefit as being a major opportunity to drive change there.

I’m not the Minister of Finance or the Minister of Diversity, Inclusion and Persons with Disabilities, but I can say that that remains a really important priority for our government. Certainly, on housing and all of the action that we’re taking, it’s really going after those determinants of health. If we’re going to really get where we need to go in terms of productivity, reduction of costs and quality of life, then we have to invest upstream. One of the things that is frustrating about that is if we do things right it’s like a reverse boiling of the frog.

One of the challenges of talking about this is to say, “Great news. If we make the investments upstream and do it right, then people will slowly have their lives get better. We’ll spend less money, we’ll be healthier, we’ll be more productive, and no one will know it happened and no one will give anyone any credit.” As political actors, that is the greatest challenge we have. How do we get people excited about the invisible? How do we get them excited about avoiding another crisis before it happens? How do we get people excited about totally changing the future in a way that they just gradually wake up in an ever-better society?

The Chair [ + ]

Thank you, minister.

Senator Arnot [ + ]

Minister Holland, I have three questions. First, how much money is being invested right now in this fiscal year to guarantee that the current gaps in readiness in the provinces and territories will be resolved? What’s the specific dollar amount now? What is your ministry projecting for a dollar amount in the next fiscal year?

Second, what will the federal government do to guarantee that all provinces comply with the law? Recently, the equality and Charter rights of vulnerable Canadians have been seriously curtailed in my home province of Saskatchewan.

Finally, how will the government guarantee that we do not have a patchwork of MAID across our country? Canada does not need to follow the example of our neighbours to the south where women seeking reproductive health care have to travel at personal risk outside of their home state to a state that has a safe haven.

Mr. Holland [ + ]

Senator, thank you very much. First of all, with respect to the Working Together bilateral agreements, 34.6% of the dollars for the targeted bilateral amounts are specifically for mental health and addictions. It’s a very substantive amount. I think if you look at the six agreements that are already out — there will be others — you can see the exact details in each province of how that’s manifesting.

One of the things with mental health is that the solutions really are understood at a community level and have to be led at a community level so that the interventions and actions taken are going to look different in every single different situation.

I was just in Saskatchewan meeting with Minister Hindley and talking about the challenges in Regina and Saskatoon and elsewhere in the province, in the North and with Indigenous communities. We need bespoke solutions, particularly when we’re talking about mental health. Minister Hindley and I had a really great conversation about tackling mental health and really working together and how imperative that was. So there is some difference on MAID, no question.

That gets to your last point, which is one of patchwork. It’s the same concern, frankly, that CAMH has raised, which is why CAMH is saying they feel clinical guidelines are the path to ensuring that consistency across the board. Of course, with the practice standards, if someone violates those, that’s a criminal offence. If someone is inappropriately applying, that’s a criminal offence. But the idea of clinical guidelines is interesting to me and worth exploring because CAMH believes, and I’ve heard from many others who believe, that will ensure uniformity and eliminate the concern you have about patchwork.

Mr. Virani [ + ]

Just to add to that, the fact we have a unitary system of criminal law in the country helps to inform some of that uniformity. While MAID is delivered by health care practitioners, it’s regulated by the Criminal Code of Canada. That helps, by definition, to preserve some of that uniformity. Thank you, Senator Arnot.

The Chair [ + ]

Thank you. We’re now moving to the next 10‑minute block that will be shared between Senator Osler and Senator Dagenais.

Senator Osler [ + ]

Ministers, thank you both for being here. Minister Holland, my question has three parts and will expand on Senator Ravalia’s question.

Tonight we’ve talked about crises, a mental health crisis and Canada’s health care system is in crisis, evidenced by the fact that 6.5 million Canadians do not have access to a primary care provider and emergency rooms across the country are closing.

My first question is this: Is our health care crisis a contributing factor to the unreadiness of the provinces and territories for MAID where the sole underlying medical condition is a mental illness?

This is my second question: If it is, what is the federal government’s plan to help each jurisdiction treat the health care system crisis and to help them become ready?

And my third question is: Would you consider an in-depth study of our health care system to inform that plan?

Mr. Holland [ + ]

Thank you so much, senator. Is the health care crisis experienced here in Canada and around the world a contributing factor to not being ready? To some extent it’s how quickly the curriculum can be taken up and the training can be done, because, for example, to complete the full curriculum you need to be in person. That could be a major challenge in some instances for clinicians, but I wouldn’t say it’s the biggest factor. I think time is the biggest factor.

In terms of whether we have a plan to get out of where we are, the answer is, absolutely, yes. One of the things I’ve really focused on as a health minister is not just using a stick. I’m not going to be provincial opposition parties and criticize what governments are doing. Instead, I want to focus on what’s working and create a race to the top. I believe certain jurisdictions are really committed to health transformation and are doing extraordinary things.

With this additional $200 billion that we’ve put in the health system, it’s no longer about money. It really is about that deep transformation. It’s about data; it’s about moving to team-based models of care; it’s about getting rid of legacy ways of dealing with problems. We have to get overtop of the crisis.

The other thing we have to do is to invest deeply downstream. What we’re doing on dental coverage is incredibly important. What we’re talking about on pharmacare and the work we’ve done on bulk purchasing to reduce drug costs are so important; what we’re doing in terms of the Canada Child Benefit and in terms of housing — all of these things are critical because they are tied, as mentioned by Senator Pate, to the social determinants of health.

I see that clear line of us all working and collaborating in the same direction, so I have deep confidence in the ability of our health system to overcome this challenge.

In terms of whether I would be in favour of an in-depth study, 100%. I think the Senate has an incredible opportunity to take more time and ask questions that, frankly, I can’t. If I try to pontificate about something, I’ll hear, “Liberal health minister says this,” and suddenly, “Oh, my goodness.” Meanwhile, you as a senator have the opportunity to say, “Let’s think about something completely different” and have that conversation, and not have everybody have an incredible reaction to that.

I think the Senate can take a look at that, go deeper, have an in-depth study and really look at what deep transformation means and looks like for our health system. How do we ask blue-sky questions just to put it out there and explore it, without the consequence of “gotcha” moments for the opposition, saying that you have some evil and nefarious plot to do that thing that you’re just testing as an idea? The Senate has a real advantage and opportunity there.

Senator Osler [ + ]

I have a brief follow-up. I did not mean to imply that the current health care crisis is the sole reason for the unreadiness, but certainly a contributing factor.

Without breaking any confidentiality, in the discussions you’ve had with health ministers, were they able to identify any specific system factors, beyond what you’ve identified? If the system is on fire in their province, they’re less likely to take this on. Were there any specific crises that you would be able to share with us?

Mr. Holland [ + ]

As a general comment, senator, what is happening is that you have extraordinary people. I get to work with my counterparts in the provinces and territories. Just this week, I was with several of them, and last week, I was with several others. We’re talking almost every day. They come from different political parties, but they’re men and women of extraordinary determination to get us through this.

There is so much complexity to the challenges that face our health system that, frankly, it is a little overwhelming. If I were to ask what we are dealing with in health right now, I’d need 17 hours to talk about all the different issues we’re facing. However, there is a spirit of cooperation and an understanding that sniping at each other and focusing on differences — there are many areas for us to cross swords, but we can’t do it on health. We need time to work through these things.

Senator Dagenais [ + ]

My question is for Minister Virani. Minister, I should tell you that I don’t like pre-studies. Studying a bill that hasn’t been passed in the other place is what we would call putting the cart before the horse. I want to discuss with you Quebec’s exemption request, which is ready, from a legal and medical standpoint, and doesn’t need the three-year delay that you want to give yourself.

Since your government’s record is not that great when it comes to MAID, I would like to know if your refusal to accept Quebec’s requests comes from political stubbornness or if it’s based on the opinions of independent legal experts — and if that’s the case, you could at least provide us with copies of these opinions to help us assess your position.

Mr. Virani [ + ]

Thank you for the question, senator. I have two points to make, because there were two parts to your question. First, Quebec’s health minister completely agreed with the other health ministers’ position. He said that, with respect to the part where mental health is the sole underlying condition for MAID, he wasn’t ready and neither was Quebec’s health care system.

As for advance requests, concerns have been raised multiple times over the past couple of weeks by the National Assembly and the Government of Quebec, and the federal government is taking an active part in that conversation. What we have been saying repeatedly in the House of Commons is simply that there’s only one Criminal Code in Canada. Right from the outset, in 2016, when we initiated the process to respond to the Carter decision, we chose to act cautiously and deliberately, and we took our responsibilities very seriously.

We moved forward within a national framework. The first part was Bill C-14, and the second was Bill C-7. All of that took place in 2019, 2020 and 2021. We’re going to do the same thing with advance requests. We are fully aware that Quebec has taken a position of leadership with its own bill — which has already been passed — but we’ll need to have many more conversations before considering advance requests across Canada. These conversations are taking place.

Senator Dagenais [ + ]

For some people, Bill C-62 will delay access to medical assistance in dying for three years. This waiting time reminds me that, sadly, in the recent past, some people affected by this legislation tragically decided to end their lives because they had no access to medical assistance in dying. That’s happened. Over these three years, when your government will very likely call an election, I’d like to know how you intend to explain this delay to those Quebecers struggling with the suicide of a loved one who couldn’t wait any longer. Some people just can’t wait any longer.

Mr. Virani [ + ]

The first thing I want to say is that this is a very complex and delicate situation. I understand the situation of these people and I have compassion for those who are going or have gone through it. I understand their suffering and we have to relieve that suffering. However, we still need to be able to protect the most vulnerable, especially people who may be victimized. Considering that the consequences are so serious and permanent, we need to be absolutely sure that the safeguards we have put in place can be applied by the physicians, the nurses and all those involved in the health care system in a rigorous and respectful way.

The Chair [ + ]

Thank you, minister. We will now move on to the last block of 10 minutes with Senator Dalphond.

Senator Dalphond [ + ]

First, I would like to thank both ministers for being here this evening. I know that we have been in this Committee of the Whole for two hours already. I realize that I’m the final hurdle that you have to clear before you’re free to go. I will ask you some questions, but I also want to look to the future. Senator Dagenais covered part of what I wanted to ask you.

We mentioned the Select Committee on the Evolution of the Act Respecting End-of-Life Care, which concluded that there was no medical or societal consensus to authorize access to MAID in cases where a mental illness is the sole underlying condition. The Quebec National Assembly subsequently amended the Act Respecting End-of-Life Care to specifically exclude access to MAID when mental illness is the sole underlying condition.

However, the select committee also recommended that we move ahead with advance requests, particularly for illnesses like Alzheimer’s, which is an irremediable diagnosis and can deprive the patient of the ability to choose an end of life that is dignified, according to the patient’s own criteria. Last week, three Quebec ministers asked you to respond to this, and that is what Senator Dagenais alluded to in his question. I want to add that polls show that 85% of Canadians — including a very large majority of Albertans — agree that advance requests should be authorized in irremediable cases like Alzheimer’s.

Is the government listening to the 85% of Canadians who are ready and to the Quebec National Assembly and the three Quebec ministers who are asking you to get this done?

Mr. Virani [ + ]

Thank you, senator. With regard to the three ministers you mentioned, I am having discussions with them, including Minister Simon Jolin-Barrette. I told him the same thing I told the House: We need to be having this conversation and talk about this aspect, but we must be careful and not cut corners, given the complexity of the circumstances.

We are talking about a situation where people would make a request right now but might only receive MAID 20 or even 40 years down the road, in completely different circumstances, so certain safeguards have to be in place to cover every aspect and every circumstance that could arise in the future.

That being said, as I just told Senator Dagenais, right from the outset, in 2016, we have moved forward within a national framework regarding the Criminal Code, which applies everywhere in Canada. It is crucial to all Canadians, not only Quebecers, to have that clarity.

I am fully aware of and appreciate the leadership that Quebecers have shown concerning MAID. The federal government will continue to be engaged on that front.

Senator Dalphond [ + ]

My question is for Mr. Holland. Can you tell us whether you are currently consulting with the other provinces for other reasons? Are you willing to commit to discussing what you referred to as a national approach to advance requests with the provincial ministers?

Mr. Holland [ + ]

Absolutely. This is a really complex issue. Take, for example, Alzheimer’s. That is a really difficult situation. When a patient has dementia, one member of their family might feel ready for medical assistance in dying to be administered, while another family member might not. The person with dementia will no longer be able to explain their choice and position, and it will be up to the doctors or the health care system to find a solution. That is a really complicated situation.

I completely understand the reasons why there is a lot of support for advance requests, because there are a lot of people, not just in Quebec but across the country, who want access to such an option. We will continue to discuss the issue of advance requests with the provinces and territories, while also continuing to discuss the issues related to mental illness. We will continue with the discussions.

Senator Dalphond [ + ]

I have one final question for the Minister of Justice. In Quebec, some people — including politicians and professors of constitutional law — have been saying in the media that Quebec could go ahead with advance requests even if the Criminal Code isn’t amended, because amending the Criminal Code isn’t actually necessary. Do you agree, minister, with these professors of constitutional law and others who believe that amending the Criminal Code isn’t necessary for Quebec to allow advance requests?

Mr. Virani [ + ]

Thank you very much for the question. All I can say is that the fact that MAID is delivered through provincial health care systems, as I mentioned earlier — Actually, all of that falls under a single law called the Criminal Code of Canada.

I’ll continue in English. When we talk about medical assistance in dying, what we’ve done since the start in 2016 is allow for an exception to prohibitions that relate to causing the death of an individual or the charge of murder under the Criminal Code. It’s very critical, when we understand that the context in which it’s placed in the Criminal Code of Canada, that steps taken around the country are cognizant of that fact. I would say that there is a concern about advanced requests. We’re alive to that concern. An expert panel was struck to deal with that concern and we have reviewed that particular study. We’re reviewing what Quebec is seeking to do, but our approach from the start has always been to proceed with caution and prudence, always ensuring that there is a balance between the autonomy and dignity of an individual, and that there are safeguards in place to protect those who could be victimized.

Senator Dalphond [ + ]

So if Quebec were to proceed without the Criminal Code amendment, the federal government would consider the situation to be unconstitutional?

Mr. Virani [ + ]

I’m not going to speculate about what a Quebec government might do going forward, Senator Dalphond. What I would say to you is that the conversation has begun about the issue of advanced directives. What we’re dealing with here is mental illness.

I want to stress that we have already responded to the will of the Government of Quebec regarding the fact that access to MAID cannot be provided when mental illness is the sole underlying medical condition. On that specific aspect, we are listening. As far as the other context goes, we will continue the conversation.

Senator Dalphond [ + ]

Thank you very much, ministers.

The Chair [ + ]

Honourable senators, the committee has been sitting for 130 minutes. In conformity with the order of the Senate, I am obliged to interrupt proceedings so that the committee can report to the Senate.

Ministers, on behalf of all senators, thank you for joining us today to assist us with our work on the bill. I would also like to thank your officials.

Hon. Senators: Hear, hear!

The Chair: Honourable senators, is it agreed that the committee rise and I report to the Senate that the witnesses have been heard?

Hon. Senators: Agreed.

The Hon. the Speaker [ + ]

Honourable senators, the sitting of the Senate is resumed.

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