In a unanimous decision released yesterday, in
Carter v.Canada (Attorney General), 2015 SCC 5, the Supreme Court of Canada held “that the prohibition on physician-assisted dying is void
insofar as it deprives a competent adult of such assistance where (1) the
person affected clearly consents to the termination of life; and (2) the person
has a grievous and irremediable medical condition (including an illness,
disease or disability) that causes enduring suffering that is intolerable to
the individual in the circumstances of his or her condition.”
The Supreme Court of Canada suspended the declaration of
invalidity for 12 months in order to give the federal and provincial
governments time to regulate physician-assisted deaths.
The case was brought be several plaintiffs,
including Gloria Taylor who “was diagnosed with a fatal neurodegenerative
disease, amyotrophic lateral sclerosis (or ALS), which causes progressive
muscle weakness. ALS patients first lose the ability to use their hands
and feet, then the ability to walk, chew, swallow, speak and, eventually,
breathe.” She did not want to die a slow, painful, death, nor did she want to
take her own life violently, while she was still physically capable of doing
so, but before she wanted to die. She set out her wishes as follows:
I do not want my life to end violently. I do not
want my mode of death to be traumatic for my family members. I want the
legal right to die peacefully, at the time of my own choosing, in the embrace
of my family and friends.
I know that I am dying, but I am far from
depressed. I have some down time - that is part and parcel of the
experience of knowing that you are terminal. But there is still a lot of
good in my life; there are still things, like special times with my granddaughter
and family, that bring me extreme joy. I will not waste any of my
remaining time being depressed. I intend to get every bit of happiness I
can wring from what is left of my life so long as it remains a life of quality;
but I do not want to live a life without quality. There will come a point
when I will know that enough is enough. I cannot say precisely when that
time will be. It is not a question of “when I can’t walk” or “when I
can’t talk.” There is no pre‑set trigger moment. I just know that,
globally, there will be some point in time when I will be able to say – “this
is it, this is the point where life is just not worthwhile.” When that
time comes, I want to be able to call my family together, tell them of my
decision, say a dignified good‑bye and obtain final closure - for me and for
them.
My present quality of life is impaired by the
fact that I am unable to say for certain that I will have the right to ask for
physician-assisted dying when that “enough is enough” moment arrives. I
live in apprehension that my death will be slow, difficult, unpleasant,
painful, undignified and inconsistent with the values and principles I have
tried to live by. . . .
[. . .]
. . . What I fear is a death that
negates, as opposed to concludes, my life. I do not want to die slowly,
piece by piece. I do not want to waste away unconscious in a hospital
bed. I do not want to die wracked with pain.
The Criminal Code of Canada prohibits a physician, or anyone
else, from assisting a person to commit suicide. The key provisions are section
14 and section 241, which read as follows:
14. No person is entitled to consent to have death inflicted
on him, and such consent does not affect the criminal responsibility of any
person by whom death may be inflicted on the person by whom consent is given.
241. Every one who
(a) counsels a person to commit suicide, or
(b) aids or abets a person to commit suicide, whether
suicide ensues or not, is guilty of an indictable offence and liable to
imprisonment for a term not exceeding fourteen years.
Ms. Taylor, and the other plaintiffs, Lee Carter, Hollis
Johnson, Dr. William Shoichet, and The British Columbia Civil Liberties
Association brought a claim in the Supreme Court of British Columbia,
challenging the prohibition on physician-assisted dying.
One of the difficulties the plaintiffs faced was that in
1993, the Supreme Court of Canada in a majority decision rejected a
constitutional challenge to section 241(b) of the
Criminal Code brought by a
lady who also suffered from ALS. The decision is
Rodriguezv. British Columbia (Attorney General), [1993] 3
S.C.R. 519. A decision of the Supreme Court of Canada is binding on all other
Canadian courts.
Madam Justice Lynn Smith, in the Supreme Court of British Columbia held
that it was open to her to reach a different conclusion than in Rodriguez for
two reasons. First, in subsequent decisions, the Supreme Court of Canada
modified the approach to be taken in determining whether a law offends a key
provision, section 7, of the Canadian Charter of Rights and Freedoms. Secondly,
there was a great deal more evidence about physician-assisted dying before her
than had been available in Rodriguez, including evidence about regulations and
safeguards from abuse in other jurisdictions that do permit physician-assisted
dying, notably Washington and Oregon, Netherlands, Belgium, Switzerland,
Luxembourg and Columbia.
After considering a great deal of evidence on physician-assisted dying,
Madam Justice Smith held that the prohibitions were unconstitutional. Her
reasons for judgment are at 2012 BCSC 886.
The majority of the British Columbia Court of Appeal (Chief Justice
Finch dissenting) allowed the appeal, holding that Rodriguez was binding
authority. The Court of Appeal decision is at 2013 BCCA 435.
The Supreme Court of Canada disagreed with the majority in the British
Columbia Court of Appeal and held that it was open to Madam Justice Smith to
reconsider Rodriguez because of the change in the Supreme Court of Canada’s
conception of section 7 of the Charter, and also the difference in the evidence
of the social and legislative facts before the Court in Carter.
The Supreme Court of Canada held that the prohibition violates section 7
of the Charter, which reads as follows:
Everyone has the right to life, liberty and security of the
person and the right not to be deprived thereof except in accordance with the
principles of fundamental justice.
In analyzing section 7, the Court first considered whether
the prohibition impinges “life, liberty and security of the person.” The second
question is whether the impingement is “in accordance with the principles of
fundamental judgment.”
The Supreme Court of Canada agreed with Madam Justice Smith
that the prohibition impinges on life because it had the effect of forcing some
people to take their own lives prematurely while they were still physically
capable.
The Supreme Court of Canada also agreed that the prohibition
on physician-assisted dying also limited liberty and security of the person:
[66]
We agree with the trial judge. An individual’s response to a
grievous and irremediable medical condition is a matter critical to their
dignity and autonomy. The law allows people in this situation to request
palliative sedation, refuse artificial nutrition and hydration, or request the
removal of life-sustaining medical equipment, but denies them the right to
request a physician’s assistance in dying. This interferes with their
ability to make decisions concerning their bodily integrity and medical care
and thus trenches on liberty. And, by leaving people like Ms. Taylor to
endure intolerable suffering, it impinges on their security of the person.
Having found that the prohibition impinges life, liberty and
security of the person, the Supreme Court of Canada then looked at whether it
did so in accordance with the principles of fundamental justice. There are of
course limitations on life, liberty and security of the person that are
constitutional, as long as those limits are in accordance with the principles of
fundamental justice.
The principles of fundamental justice require that “laws
that impinge on life, liberty or security of the person must not be arbitrary,
overbroad, or have consequences that are grossly disproportionate to their
object.” The Supreme Court of Canada again agreed with Madam Justice Smith that
the object of the prohibition on assisted dying was “to protect vulnerable
persons from being induced to commit suicide at a time of weakness….”
In this case, the Supreme Court of Canada held that the
prohibition, while not arbitrary, is overbroad. The question is whether the law
“goes too far by denying the rights of some individuals in a way that bears no
relation to the object….” The prohibition is overbroad in infringing on the
rights of people who are not vulnerable.
[86]
Applying this approach, we conclude that the prohibition on assisted
dying is overbroad. The object of the law, as discussed, is to protect
vulnerable persons from being induced to commit suicide at a moment of
weakness. Canada
conceded at trial that the law catches people outside this class: “It is
recognized that not every person who wishes to commit suicide is vulnerable,
and that there may be people with disabilities who have a considered, rational
and persistent wish to end their own lives” (trial reasons, at para.
1136). The trial judge accepted that Ms. Taylor was such a person —
competent, fully-informed, and free from coercion or duress (para. 16).
It follows that the limitation on their rights is in at least some cases not connected
to the objective of protecting vulnerable persons. The blanket
prohibition sweeps conduct into its ambit that is unrelated to the law’s
objective.
After the Court found that the prohibition infringed on
section 7 of the Charter, the Supreme Court of Canada considered whether the
prohibition was saved by section 1 of the Charter which reads:
The
Canadian Charter of Rights and Freedoms guarantees the
rights and freedoms set out in it subject only to such reasonable limits
prescribed by law as can be demonstrably justified in a free and democratic
society.
The Court set out the tests as follows:
[94]
In order to justify the infringement of the appellants’
s. 7 rights
under
s. 1 of the
Charter ,
Canada must show that the law has a pressing and substantial object and that
the means chosen are proportional to that object. A law is proportionate
if (1) the means adopted are rationally connected to that objective; (2)
it is minimally impairing of the right in question; and (3) there is
proportionality between the deleterious and salutary effects of the law:
R.
v. Oakes, [1986] 1 S.C.R. 103.
Although the prohibition is rationally connected to the
object of protecting vulnerable persons from being induced to commit suicide at
a time of weakness, the Supreme Court of Canada held that it failed the test of
minimally impairing the rights to life, liberty and security of the person. The
decision is based on Madam Justice Smith’s findings of facts that vulnerable
persons could be protected without the need of an absolute prohibition on
physician-assisted dying. I quote again from the Supreme Court of Canada
decision:
[104]
This question lies at the heart of this case and was the focus of much of the
evidence at trial. In assessing minimal impairment, the trial judge heard
evidence from scientists, medical practitioners, and others who were familiar
with end-of-life decision-making in Canada and abroad. She also
heard extensive evidence from each of the jurisdictions where
physician-assisted dying is legal or regulated. In the trial judge’s
view, an absolute prohibition would have been necessary if the evidence showed
that physicians were unable to reliably assess competence, voluntariness, and
non-ambivalence in patients; that physicians fail to understand or apply the
informed consent requirement for medical treatment; or if the evidence from
permissive jurisdictions showed abuse of patients, carelessness, callousness,
or a slippery slope, leading to the casual termination of life (paras.
1365-66).
[105]
The trial judge, however, expressly rejected these possibilities. After
reviewing the evidence, she concluded that a permissive regime with properly designed
and administered safeguards was capable of protecting vulnerable people from
abuse and error. While there are risks, to be sure, a carefully designed
and managed system is capable of adequately addressing them:
My review of the evidence in this section, and in the
preceding section on the experience in permissive jurisdictions, leads me to
conclude that the risks inherent in permitting physician-assisted death can be
identified and very substantially minimized through a carefully-designed system
imposing stringent limits that are scrupulously monitored and enforced. [para.
883]
[106]
The trial judge found that it was feasible for properly qualified and
experienced physicians to reliably assess patient competence and voluntariness,
and that coercion, undue influence, and ambivalence could all be reliably
assessed as part of that process (paras. 795-98, 815, 837 and 843). In
reaching this conclusion, she particularly relied on the evidence on the
application of the informed consent standard in other medical decision-making
in Canada, including end-of-life decision-making (para. 1368). She
concluded that it would be possible for physicians to apply the informed
consent standard to patients who seek assistance in dying, adding the caution
that physicians should ensure that patients are properly informed of their
diagnosis and prognosis and the range of available options for medical care,
including palliative care interventions aimed at reducing pain and avoiding the
loss of personal dignity (para. 831).
Twelve months from now, physician-assisted dying will be
permitted in Canada
for competent adults, who clearly consent, and “who have a grievous and
irremediable medical condition … that causes enduring suffering that is
intolerable to the individual in the circumstances of his or her
condition.”
Gloria Taylor passed away before the Supreme Court of Canada’s
decision.