Bill C-14: The Law's Passing And Its Impact

Bill C-14, also known as the Medical Assistance in Dying bill, received Royal Assent on June 17, 2016. The bill amends the Criminal Code to allow medical practitioners and nurse practitioners to provide medical assistance in dying and to permit pharmacists and other persons to assist in the process. The bill sets out eligibility criteria and safeguards that must be respected before medical assistance in dying may be provided to a person. It also requires medical practitioners and pharmacists to provide information for the purpose of monitoring medical assistance in dying and authorizes the Minister of Health to make regulations in this regard.

Bill C-14's impact on palliative care

Bill C-14, which received Royal Assent on June 17, 2016, amends the Criminal Code to decriminalise medical assistance in dying (MAID) and allow further regulation of the practice by provinces and territories. The bill sets out eligibility criteria and safeguards that must be respected before MAID can be provided.

Bill C-14 has had a significant impact on palliative care in Canada. Firstly, it has raised the profile of palliative care and advanced care planning as a priority. The public attention and tension between MAID and palliative care have shone a light on palliative care, prompting questions about why someone might choose MAID over palliative care options. This has led to a sense of urgency around advance care planning.

Secondly, the bill has created ethical concerns about patient options and choice at the end of life. Inequities between MAID and palliative care funding have influenced which services are more accessible to patients. For example, MAID prescribers are funded to travel to provide an assisted death, whereas palliative care physicians are not compensated for their travel to provide home-based palliative care. This has resulted in MAID being more accessible than good palliative care in some cases.

Thirdly, Bill C-14 has impacted the integration of MAID and palliative care services. The degree of integration between the two varies across Canada, from no integration to full clinical program integration. While participants in a study published in the *BMC Health Services Research* journal in 2021 advocated for the benefits of integrating MAID and palliative care, they also acknowledged the importance of keeping the programs separate to protect the philosophies of care unique to each.

Finally, the bill has influenced eligibility criteria for MAID and, by extension, palliative care. Under Bill C-14, MAID is available to adults who are mentally competent, have a grievous and irremediable medical condition, make a voluntary request, give informed consent, and are eligible for health services funded by the government. A grievous and irremediable medical condition is defined as having a serious and incurable illness, disease, or disability; being in an advanced state of irreversible decline; experiencing enduring physical or psychological suffering that cannot be relieved in a way the patient considers acceptable; and having a reasonably foreseeable natural death. This final criterion has been particularly contentious, with some arguing that it should be defined more clearly in the legislation.

Bill C-14 has also had an impact on palliative care by committing to studying three key issues beyond the scope of the Carter v Canada ruling: eligibility for persons under 18, advance requests, and requests for MAID solely on the basis of mental illness.

The bill's constitutionality

Bill C-14, which received royal assent on June 17, 2016, amends the Criminal Code to allow medical assistance in dying. It creates exemptions from the offences of culpable homicide, aiding suicide, and administering a noxious thing, enabling medical and nurse practitioners to provide medical assistance in dying. It also allows pharmacists and other persons to assist in the process.

In response to these concerns, it is important to note that the Supreme Court of Canada's unanimous Carter decision, which Bill C-14 addresses, did not require Parliament to enact a specific medical assistance in dying regime. Instead, it directed Parliament to address the deficiencies of the previous law, which imposed a complete prohibition on medical assistance in dying. The court recognised that this was contrary to the charter and that it restricted the rights of Canadians.

Bill C-14 respects the charter and complies with the Supreme Court's ruling by recognising personal autonomy, protecting the vulnerable, and affirming the inherent value of every human life. It creates a consistent national framework regarding eligibility and procedural safeguards under the federal criminal law power, ensuring safety for all Canadians.

However, the bill does not define the term "reasonably foreseeable death," leaving it open to interpretation by medical practitioners. This ambiguity has raised concerns about the potential for inconsistent application and the risk of vulnerable individuals being inadvertently harmed.

To address these concerns, some have suggested amendments to include a clear definition of "reasonably foreseeable" and enhance protections for conscience rights. These suggestions aim to ensure that the bill respects the charter rights of all Canadians, including patients, physicians, and vulnerable persons.

In conclusion, while Bill C-14 takes a significant step towards respecting the Supreme Court's Carter decision and protecting charter rights, there are ongoing discussions and potential amendments to further enhance its constitutionality and protect the rights of all stakeholders.

The bill's effect on vulnerable people

Bill C-14, which became law in 2016, amends the Criminal Code of Canada to legalise medical assistance in dying (MAID). The bill outlines eligibility criteria and safeguards that must be respected before MAID is administered. It also requires medical and pharmaceutical professionals to provide information for monitoring purposes and creates new offences related to non-compliance with the regulations.

The bill's impact on vulnerable individuals has been a significant point of discussion, with some arguing that it puts vulnerable Canadians at risk. The bill recognises the importance of maintaining respect for human life and protecting vulnerable people. However, critics suggest that allowing euthanasia could devalue respect for life and expose vulnerable individuals to potential risks.

One suggestion to mitigate this risk is to require judicial authorisation for each euthanasia request, providing an "effective safeguard" for vulnerable people. This proposal highlights the need for a balanced approach that considers both individual autonomy and the protection of vulnerable individuals.

The definition of a "vulnerable person" in the context of Bill C-14 is also important. Vulnerable people may present as someone who wants to die, but the concern is that they are acting on a momentary impulse rather than a well-considered decision. The protection for vulnerable individuals in this context is to ensure that their autonomy is respected while also safeguarding them from decisions made in weakness or impulsivity.

The subsequent Bill C-7, which amended some of the provisions of Bill C-14, has also been criticised for prioritising individual autonomy over the protection of vulnerable people. This includes concerns about expanding eligibility for MAID to individuals with mental illness, which some experts argue cannot be safely determined on an individual basis.

Overall, the effect of Bill C-14 on vulnerable people has been a complex and ongoing topic of discussion, with efforts made to balance individual autonomy with necessary safeguards to protect those who may be at risk.

The bill's impact on the rights of physicians

Bill C-14, which received royal assent on June 17, 2016, decriminalised medical assistance in dying (MAID) and allowed physicians and nurse practitioners to provide assistance in dying to eligible competent adults. The bill's impact on the rights of physicians is detailed below.

Protections for Conscientious Objectors

Bill C-14 does not include protections for physicians who refuse to provide or refer patients for MAID. This has been criticised by some, including Larry Worthen, executive director of the Christian Medical and Dental Society of Canada, who believes that this will lead to a constant fight for conscience rights. However, others, such as Carolyn Pullen, director of policy, advocacy and strategy for the Canadian Nurses Association, argue that the current protections for conscientious objection are usually sufficient.

Procedural Safeguards

Bill C-14 includes a number of procedural safeguards that physicians must follow before providing MAID. These include confirming that the patient meets all eligibility criteria, ensuring the patient's request is made in writing and signed by the patient, and ensuring that a second independent medical practitioner or nurse practitioner provides a written opinion confirming the patient's eligibility. These safeguards are intended to protect vulnerable persons and ensure that MAID is provided responsibly.

Eligibility Criteria

Bill C-14 outlines five criteria that must be met for a patient to be eligible for MAID. These include being at least 18 years old, having a grievous and irremediable medical condition, making a voluntary request without external pressure, giving informed consent, and being eligible for government-funded health services in Canada. The inclusion of these criteria ensures that physicians are providing MAID responsibly and to eligible patients only.

Criminal Exemptions

Bill C-14 amends the Criminal Code to exempt physicians and nurse practitioners from criminal liability for culpable homicide when providing MAID. This protects the rights of physicians by ensuring they are not criminally liable for providing MAID.

Monitoring System

Bill C-14 establishes a monitoring system to collect and analyse data on the provision of MAID across Canada. This system will help ensure that MAID is provided responsibly and in accordance with the law, protecting the rights of physicians.

Further Training

The Canadian Medical Association, Royal College, College of Family Physicians of Canada, and Canadian Nurses Association are all developing resources to prepare physicians to talk about and provide MAID. This will help ensure that physicians are well-informed about the legal and ethical considerations of MAID and can make decisions responsibly.

The bill's implementation

Bill C-14, which received royal assent on June 17, 2016, amends the Criminal Code to allow medical practitioners and nurse practitioners to provide medical assistance in dying (MAID) to eligible adults. The bill also permits pharmacists and other persons to assist in the process.

To be eligible for MAID, a person must meet the following criteria:

• Be eligible for health services funded by a province, territory, or the federal government.
• Be at least 18 years old and mentally competent to make health care decisions.
• Have a grievous and irremediable medical condition.
• Make a voluntary request for MAID, free from coercion.
• Give informed consent to receive MAID.

The bill defines a "grievous and irremediable medical condition" as:

• Having a serious and incurable illness, disease, or disability.
• Being in an advanced state of irreversible decline in capability.
• Experiencing enduring physical or psychological suffering that cannot be relieved under conditions the person considers acceptable.
• Having a natural death that has become reasonably foreseeable, taking into account all medical circumstances, without requiring a specific prognosis.

The bill also specifies several safeguards that must be respected before MAID can be provided. These include:

• Two independent medical assessments to confirm eligibility and provide a written opinion.
• A written request for MAID, signed and dated by the individual and witnessed by an independent party.
• A minimum 15-day waiting period between the written request and the provision of MAID, unless death or loss of capacity is imminent.
• Confirmation of consent immediately before providing MAID.

The bill also creates new offences for failing to comply with the safeguards, forging or destroying documents related to MAID requests, and failing to provide required information. It makes related amendments to other Acts, such as the Pension Act and the Canadian Forces Members and Veterans Re-establishment and Compensation Act, to ensure that recourse to MAID does not affect pensions or benefits. Additionally, it amends the Corrections and Conditional Release Act to state that no investigation is required under Section 19 in the case of an inmate who receives MAID.

The implementation of Bill C-14 has been a complex and challenging process, with ongoing debates and court challenges. The legislation has undergone revisions, and healthcare providers have had to adapt to new procedures and eligibility criteria. There have been concerns about the impact of MAID on palliative care, the workload and remuneration for practitioners, and the need for clear guidelines and adequate resources. Overall, the implementation of Bill C-14 has been a significant step in legalising MAID in Canada, but it has also highlighted areas that require further attention and improvement.

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