On September 11, Judge Christine Baudouin of the Quebec Superior Court issued a ruling that struck down parts of the federal and Quebec legislation concerning medically assisted dying, opening the door to a renewed debate on the sensitive issues surrounding medically assisted dying and end-of-life care. In her 187-page decision, Judge Baudouin ruled that the federal and Quebec laws both included critera that were too restrictive and contravened the landmark Supreme Court of Canada decision in the 2015 Carter case. She singled out the provision in the federal legislation that the patient be facing a “reasonably foreseeable death” and, in the Quebec legislation, that the patient be “at the end of life.”1

The case that led to Judge Baudoin’s ruling involved two severely handicapped individuals, Nicole Gladu and Jean Truchon, who were both denied access to a medically assisted death because neither of them was terminally ill. Gladu, who contracted polio as a child and now struggles with post-polio syndrome, and Truchon, who suffers from cerebral palsy, petitioned the court to put an end to their suffering and grant them access to a medically assisted death. The court agreed and gave the federal Parliament and the Quebec National Assembly six months to redraft their legislation to respect the Carter decision. She also granted the two petitioners the possibility of ending their lives within the same period.2

The decision came five years after the Quebec National Assembly passed legislation on end-of-life care. Recently, calls to review the legislation have been more and more persistent. The Superior Court ruling, if it is not appealed, will add additional pressure on governments, legislatures and citizens to take up the debate in the near future. Before embarking on a new round of discussions, however, it is important to recall the debates that led to the adoption of the current legislation.

Bill 52 Revisited

On June 5, 2014, the Quebec National Assembly adopted Bill 52, An Act Respecting End-of-Life Care. The legislation included new commitments toward access to palliative care and ushered in new access to medically assisted death. Where are we five years later? How have the new provisions regarding medically assisted dying been applied? How often have these procedures been used? These questions are all relevant because the new Coalition Avenir du Québec (CAQ) government, elected in 2018, has promised to hold public consultations to examine the possibility of enlarging the criteria for a medically assisted death to include individuals suffering from Alzheimer’s disease and other forms of dementia.

It is important to recall the exceptional manner in which the original debate was conducted in Quebec. The legislation was the fruit of a débat de société that lasted more than four years and took place under three different governments. Opinions were divided among the witnesses who appeared before the select committee of the National Assembly that studied the issue, and again on the floor of the legislature. Given the importance and sensitive nature of the subject, the members of the National Assembly were called on to vote according to their conscience. The final vote was 94-22, with the governing Liberal caucus divided. Several senior cabinet members voted against the bill.

In other parts of Canada the debate centred on the courts, leading to the groundbreaking Carter decision in 2015. In contrast, the debate in Quebec was led by the select committee, which I had the privilege of chairing during the public phase of its work. The goal was to listen to experts and citizens from across the province. With my colleagues from all parties in the Assembly, we crisscrossed the province, holding hearings in eight cities and hearing 239 witnesses. In addition, the committee received more than 6,500 replies to an online questionnaire and garnered extensive media coverage. Before setting out, we heard from 32 expert witnesses who helped shape the questions to be raised in the consultations. It was a unique experience for all the MNAs who participated. One remarkable aspect was that the majority of the witnesses were individual citizens who took the time and found the courage to share their sad and often difficult stories about deaths in their families.3

Once the hearings were completed in the spring of 2011, the hard work of crafting a final report began. It took the committee 51 working sessions before a unanimous report was tabled in the Assembly in March 2012.

Over the next two years, there were two elections which produced first a Parti Québécois and then a Liberal government. Despite these electoral distractions, legislation was prepared under the watchful eye of Véronique Hivon, the PQ minister responsible for social services and the former vice-chair of the select committee. Many more hours of debate ensued as legislators grappled with the challenges of translating notions such as “terminally ill” and “imminent death” into legislative terms. These were some of the criteria to be used to provide a framework for individuals seeking a medically assisted death.

The bill as it was finally adopted contained three main conditions: individuals seeking medical assistance in dying must be 18 years of age or older, be able to give their consent repeatedly to a doctor, and be in the final phase of a terminal illness. In addition, the Commission sur les Soins de Fin de Vie (Commission on End-of-Life Care) was created to monitor the application of the law. The commission is required to table an annual report in the Assembly, and its most recent report covers the period ending on March 31, 2018. Between December 2015 and March 2018, the commission received 2,482 requests for an assisted death, of which 1,664 were granted. The most common reasons for a refusal were that the patient did not meet the criteria (344 cases), died before the evaluation was completed (289), or changed his or her mind (128).4

Calls for a Review

It took more than a year after the legislation was adopted before the first medically assisted death occurred in Quebec in December, 2015. But before long there were calls to reopen the debate, especially as it regards people suffering from Alzheimer’s disease and other forms of dementia. The select committee had examined this question but had found no consensus, so it had recommended that the Collège des Médecins du Québec, the professional organization of Quebec’s physicians, study this question further.5 In January 2017, François Bonnardel, now the Transport Minister in the CAQ government but then an opposition MNA, hit a nerve with a Facebook post on his mother’s 80th birthday.6 Mme Bonnardel has suffered from Alzheimer’s for more than a decade; confined to a chronic care facility, she no longer recognizes the members of her family. Her son said that his mother, had she known the course of her illness, would have told him, “You will have a mandate to make decisions for my life one day, and I trust you, and I trust the doctors … to say that perhaps I am a burden on society. And I will let you make a decision that could end my life.”7

Bonnardel’s post and subsequent media interviews drew a great deal of attention to this issue in Quebec. Partly in response to this, the Minister of Health and Social Services at that time, Dr. Gaetan Barrette, formed a committee of experts to examine this question. Cochaired by the Public Curator, Nicole Filion, and Laval professor and ethicist Jocelyn Maclure, the group has examined whether the scope of medically assisted death should be extended to include patients who can no longer give their consent but who have previously expressed their desire and willingness to end their lives in certain circumstances. This anticipated consent would be a legal document such as a living will. Although their report has yet to be tabled in the National Assembly, it was reported in June that the group will make a favourable recommendation to widen access.8 Minister Barrette also asked the Commission sur les Soins de Fin de Vie to review the cases that were met with a refusal and reflect on whether the criteria should be reconsidered.9

Two court cases related to widening access to medically assisted dying also made headlines. As we have seen, the Gladu case raised the question of limiting access to medically assisted dying to those patients who were near the end of their lives. The Superior Court ruling placed its emphasis on individuals and their suffering, regardless of their prognosis of a “foreseeable death.” The court expressed its confidence that the existing system of granting consent under the supervision of physicians is sufficient protection for vulnerable patients.10

The second case involved Michel Cadotte, who was convicted of killing his wife, Jocelyne Lizotte, who had suffered from Alzheimer’s for more than a decade. Confined to a chronic care facility, Lizotte’s quality of life was gone. In February 2017, Cadotte took a pillow and suffocated his wife, then called the nursing station to inform the nurses of what he had done. He claimed that he felt compelled to put an end to his wife’s suffering.

While no one condones taking someone’s life in this manner, no matter the hardships, the Cadotte case raised sympathy for those family members called upon to be “natural caregivers” and the heavy burden they must carry. According to the Quebec Alzheimer’s Society, 145,000 people in Quebec are afflicted with the disease. This number is expected to nearly double by 2025. How to help these caregivers cope with the mental challenges and physical reality of burnout will be a major public policy issue in the future. The director-general of the society, Sylvie Grenier, testified during the Cadotte trial and observed that “services are lacking. They are not ready, nor is our society, to face the tsunami that is coming.”11

How do we improve the support given to individuals in a situation similar to the one faced by Michel Cadotte? How will we manage the growing number of families facing the grim reality that a family member is lost in the fog of dementia, or curled up in a fetal position in a long-term care facility? These are some of the concerns raised by the Cadotte case. Cadotte himself was convicted of manslaughter and sentenced to two years in prison.

During the Quebec election campaign in the fall of 2018, the CAQ pledged to hold public hearings on the question of broadening access to medically assisted dying. Clearly there will be no shortage of material to be considered. There will be the report from the group of experts chaired by Nicole Filion and Jocelyn Maclure. There will be the review that was conducted by the Commission sur les Soins de Fin de Vie of the requests for a medically assisted death that were turned down. The decision in the Gladu case that both federal and provincial laws are too restrictive and do not comply with the Carter decision must be looked at. And given the continued public and media interest in this debate, the stage is once again set for an important public policy discussion.

Conditions for Success

Given the sensitive nature of the debate, which touches the deepest chords of our humanity, there are several conditions that must be respected if this debate is to be constructive and as serene as possible. Having chaired the public consultations in 2010 and 2011, I will offer four suggestions:

  • The debate must be nonpartisan. This is easier said than done, but the first set of hearings and drafting of a final report are proof that it is possible. It was a struggle: the fact that it took 51 working sessions of the select committee to prepare the final report reflects the complexity of the issues that the MNAs had to grapple with and the desire of all members to present a unanimous final report to their colleagues in the National Assembly. It must be remembered that this was a legislators’ initiative, not a government initiative. This nuance is important to ensure cooperation among parties and keep the debate away from partisan considerations.
  • Space must be given both to experts in our society and to citizens at large. The select committee met first with experts to help shape the debate, identify the issues that must be considered and discuss the questions to be asked during the public consultations. This was an essential first step. But it is equally important to listen to the population. In our travels across Quebec, the committee members were impressed by the quality of the comments we received, and touched by the emotional nature of many of the testimonies. This included 114 people who took part in the “open mike” period at the end of each public session. Many of our fellow citizens have given the question of dying gracefully and in a dignified manner a great deal of thought. It is important to give them room to be heard again.
  • Respect the opinions of others. While there are some polling data indicating that many Quebecers and Canadians are open to granting greater access to medically assisted dying, this view is far from being unanimous. Once again it will be important to listen to and respect those people who will express legitimate concerns about the protection of vulnerable individuals in our society. This will be a key element in the debate. Other individuals will come at this question from a faith-based perspective. Even in our newly proclaimed secular society, these views should be heard with respect.
  • Finally, be prepared to allot a considerable amount of time to this debate. The first débat de société took more than four years, from the initial debate in the National Assembly in December 2009 to the final adoption of the bill in June 2014. Even in areas where a consensus is established, it is no easy task to translate popular sentiment into legislative wording. The long debates over defining end of life and terminally ill are proof of this. Defining these terms in a legal text was a big challenge. If we go beyond a system based on the informed consent of clear-minded adults, the challenges of definition will be even greater. Any modifications to the current regime will also require time and careful consideration. The recent ruling in the Gladu case includes the requirement that the Assembly redraft the legislation within six months. It will be impossible to address all of the concerns raised in such a short time. The government will either have to ask the court for more time, or else deal with the specific issue raised by the Gladu case separately from the wider debate over granting access to patients who are no longer able to give their consent but who have signed legal instructions to that effect beforehand.
Key Challenges

The proposal to give access to medically assisted dying to individuals who are no longer able to give their consent will be controversial. Rereading the Carter decision, one is struck by the frequent references to “consent” and “competence.” Quoting the first trial judge in British Columbia, the Supreme Court echoed her conclusion that “there is a strong consensus that it would only be ethical with respect to voluntary adults who are competent, informed, grievously and irremediably ill, and where the assistance is ‘clearly consistent with the patient’s wishes and best interests, and in order to relieve suffering.’”12

How can we move forward from a system based on consent given on a repeated basis to medical professionals? How can we satisfy the point raised further on in the Carter decision that “the risks associated with physician-assisted death can be limited through a carefully designed and monitored system of safeguards”?13

The Court partially answered this question by drawing parallels to current practices regarding the withdrawal of lifesaving and life-sustaining treatments, and the granting of access to palliative sedation. In some cases, these decisions are based on advance directives or “DNR” wishes that are expressed through legal documents such as living wills and interpreted by family members and physicians. The Court noted that these practices also raise important questions about the protection of vulnerable patients, especially those who are no longer able to express their views or consent to a given procedure or decision affecting them. These risks are “already part and parcel of our medical system,” said the Court.14

Extending access to medically assisted dying will focus attention on the various forms of anticipated directives that allow individuals to give instructions about levels of care in situations where they can longer give consent. In 2016, the federal Minister of Health and Minister of Justice asked the Council of Canadian Academies (CCA) to examine three key areas of concern regarding medically assisted dying. Three panels were formed to look at assisted dying for mature minors, assisted dying where a mental disorder is the sole underlying medical condition, and advance requests for medically assisted dying.

The panel of the CCA charged with looking at advance requests recommended that these requests be contained in a document distinct from current documents that indicate patients’ advance wishes regarding treatment. The CCA panel proposed a series of safeguards on advance requests for medically assisted dying. These include access to palliative care education for individuals; well-defined criteria for these requests; time limits on the requests and the need for them to be renewed periodically; oversight mechanisms; and training, counselling and support for families of the patients. But the panel report is aware of the potential risks, and offers the following observation: “A judgment about whether to continue to prohibit or to permit some form of advance requests for medical assistance in dying would need to consider the inherent tensions among values respecting autonomy, alleviating suffering, and protecting against vulnerabilities, in light of risks and benefits to each scenario.”15

In short, designing these advance requests will take a great deal of thought. They would have to be as specific as possible about what end-of-life conditions would be intolerable. They would have to take the form of a legal document that should be renewed on occasion. And they should be fully discussed with doctors and family members before an individual loses his or her capacity to consent to an end-of-life procedure. This will be a tall order.

In 2010, the select committee examined the question of how to treat patients who were no longer able to give their consent when seeking a medically assisted death. I was struck by an exchange the committee had with two physicians with extensive experience in geriatric care Dr. Howard Bergman from McGill University and Dr. Marcel Arcand from the Université de Sherbrooke (coincidentally, both were brothers of sitting members of the Assembly at that time). Both of them offered a cautionary note to the committee. They outlined some of the difficulties they had encountered in the administration of advance directives. Often these directives caused divisions within families, as members differed in their appreciation of the patient’s intent at the moment that the living will was signed. Doctors themselves were often torn, and reluctant to stop treatments in certain cases.

If making decisions regarding the withdrawal of treatment is already complicated, the two witnesses warned that the use of advance directives or living wills regarding medically assisted dying would be even more difficult. Their advice to the committee was to provide access to medically assisted dying only to those patients able to give their consent, and exclude those who could no longer do so.16 Consulting physicians who work with Alzheimer’s patients will be an essential starting point for any new debate over medically assisted dying. Almost a decade later, I remain impressed by the points raised by these physicians regarding the importance of securing a patient’s consent.

As we have seen, the Gladu case will necessitate amendments to the current legislation. Judge Baudoin’s decision noted that the Quebec legislation was adopted before the Carter ruling, and was never revisited after the Supreme Court decision was rendered. In addition, no effort was made to review the Quebec legislation in light of the federal legislation adopted in 2016. The bills were similar but contained significant differences. Has the time come to try to harmonize the criteria? This would be another daunting challenge given the short period given to prepare new legislation.

The Debate Enters New Territory

Quebec society is once again poised to hold a debate that touches many central tenets of our humanity. We will have to take into consideration the pain and suffering that many people in our world face – family members, friends and neighbours. The care for patients with Alzheimer’s and other forms of dementia will come under greater scrutiny. The support given to their caregivers and family members must be increased. In a society with an aging population, these concerns can only grow in importance. They must be part of the debate over extending access to medically assisted dying, just as the importance of access to palliative care was a central concern when the select committee discussed end-of-life care. The importance of protecting the most vulnerable individuals in our society will also be in the spotlight.

Over the past five years, Quebec has developed a responsible system to govern medical assistance in dying. Patients, their families and physicians work together to examine requests before end-of-life procedures are initiated. But the foundation of the current system remains the clear and informed consent of a terminally ill adult patient.

Now the debate will enter new territory, where consent is no longer available. The use of advance requests, anticipated directives or living wills may provide a measure of guidance for those who will be charged with deciding for those who can no longer make these decisions themselves. Is it possible to put into place a system that protects the vulnerable, gives explicit guidelines to physicians and family members and addresses the suffering of people living with dementia? It will be necessary if we are to satisfy the Supreme Court’s conclusion in the Carter case noted above, that “the risks associated with physician-assisted death can be limited through a carefully designed and monitored system of safeguards.”

This will take time and a great deal of thought. But Quebec society, its citizens, and its politicians managed to conduct a debate marked by respect, civility and care for the fundamental dignity of all human beings. I am confident that the same spirit will animate the next chapter in this important débat de société.

Continue reading “Medically Assisted Dying: New Challenges”

For eight of the past 13 years, I have had the privilege of serving as Quebec’s ministre responsable des Affaires autochtones. It has been a challenging period, to say the least, in the development of relations between ten First Nations, the Inuit and the Government of Quebec. In all, there are 55 Indigenous communities, representing approximately 1 per cent of Quebec’s total population, which have their own realities, needs and challenges. In light of many recent significant changes to the landscape, the government is looking to adapt its policies and programs.

These changes include landmark decisions of the Supreme Court of Canada on issues such as the duty to consult and accommodate Indigenous peoples and on aboriginal title, the 94 Calls to Action contained in the Final Report of the Truth and Reconciliation Commission, and serious allegations concerning government actions or inaction with regard to various issues. These allegations led to the creation of two inquiries – at the federal level, the National Inquiry into Missing and Murdered Indigenous Women and Girls (MMIWG), and at the provincial level, the Public Inquiry Commission on Relations between Indigenous Peoples and Certain Public Services in Québec: Listening, Reconciliation and Progress (the Viens Commission). All of this in the context of a changing demographic reality, where more and more Indigenous people are arriving in our cities and towns, creating challenges for provincial services, notably in the area of health care and education.

The challenges for the new minister holding this portfolio are significant, and I cannot list them all in this article. But I will lay out four areas of concern, and share my hopes for the future of our relations with the First Nations of Quebec and the Inuit of Nunavik.

Challenge 1: Qui fait quoi?

The federal government is preparing a major proposal to help define more clearly self-government for Indigenous people in Canada. The area of governance and constitutional responsibilities for governments is a murky one. The principles are not always easily applicable in practice, and the changing demographic reality has created a significant Indigenous presence in our cities. This presence has led to increased demands for provincial government services, notably in health, education, housing and employment.

For example, despite federal responsibilities for education, fully one third of Indigenous students are now enrolled in Quebec’s public school system. In addition, once secondary studies are completed, students enter the provincial CEGEP and university system, or move toward employment training programs. Over the past decade, the Quebec government has opened four adult education centres in Lac-Simon, Uashat, Kahnawake and Listiguj to attract young adults back into the educational sector, and to prepare them for postsecondary studies. A First Nations college, the Kiuna Institute, was opened in Odanak and continues to develop new programs for a primarily Indigenous clientele.

In addition, our colleges and universities, with some support from Quebec’s Ministère de l’Éducation et de l’Enseignement Supérieur, have increased their efforts to welcome Indigenous students and to provide them with support, to include more Indigenous content in their courses and to strengthen the preparation of various professionals who will work with Indigenous communities. The creation of the Pavillon des Premiers Peuples in Val-d’Or as part of the Université du Québec en Abitibi-Témiscamingue (UQAT), the work on Indigenous school success done by the Université du Québec à Chicoutimi (UQAC), McGill University’s ambitious Provost’s Task Force on Indigenous Education, Université Laval’s work on the challenges facing northern Quebec and John Abbott College’s work with Inuit students are just a few examples of the progress being made.

But much work remains to be done. The First Nations and Inuit want a greater say in the management of their schools, and seek greater emphasis on Indigenous languages, cultures and history as part of the curriculum. In Quebec, under the auspices of the James Bay and Northern Quebec Agreement (JBNQA), the Cree and Inuit have their own school boards, and the Naskapi have special status for their school. Over 40 years have passed since the signing of the agreement, and these institutions have struggled with issues related to academic success rates and with helping students transition to college or other training programs. But the JBNQA has allowed for a definition of the respective roles and responsibilities of the federal and Quebec governments, as well as the Indigenous population.

Things are less clear for the eight First Nations in southern Quebec. Given the importance of improving academic success rates for Indigenous communities in Quebec, the parties should now sit down and develop a comprehensive plan for ensuring that young Indigenous people receive the education they will need in the future. The curriculum must be designed in collaboration with the First Nations and Inuit. It must include instruction on their languages, cultures and history, but there is a delicate balancing act required to ensure that these students pursue core subjects (reading and writing of both official languages, mathematics and science) in the Quebec curriculum. Without mastering these subjects, Indigenous students cannot aspire to be teachers, doctors, lawyers, nurses and other professionals necessary for the future success of Quebec’s Indigenous communities.

Another area where the lack of a clear assignment of responsibilities has created disappointing results is health and social services. Quebec and Ottawa recently “agreed to disagree” over the funding for ambulance services for the Atikamekw community of Manawan and the construction of a long-term care facility in Wendake. In both cases, since these essential services are provided on-reserve, the costs should be covered by the federal government. However, both projects have consequences for the Quebec health and social services network. In the case of the long-term care facility, the elders of Wendake are now often cared for by provincial services in neighbouring municipalities. Transferring the elders back to their community in their cultural setting is a favourable outcome for the provincial health care network. Once again, community partners, including the Indigenous communities, must find a better formula for assigning roles and responsibilities to ensure that the most vulnerable in our society receive the care and services that they deserve.

Finally, on the question of who is responsible for what, issues related to the production, distribution and consumption of cannabis are very much on everyone’s minds. Opinions in Quebec’s First Nations and Inuit communities on the legalization of marijuana are mixed. In a day-long consultation held in the fall of 2017 in Quebec City, many Indigenous leaders requested the authority to prevent the sale – and even the use – of marijuana in their communities. This was especially true for the 14 Inuit communities in Nunavik. But as the experience with alcohol has shown, it is impossible to limit access to a product which is legal and readily available in Quebec. How can the federal government help Indigenous communities govern the use of marijuana?

This question becomes even more complex on the other side of the issue. Some communities are interested in the production and sale of cannabis. The production question is a federal matter, but key retailing questions, including the age of consumers and whether the sale should be in the hands of a crown corporation or the private sector, are left to provincial jurisdiction. The experience of tobacco sales has shown that this is a recipe for conflict, as several Indigenous communities sell tobacco on a tax-free basis – a boon to smokers, but a huge loss for the Canada Revenue Agency in Ottawa and Revenu Québec in Quebec City, and a disappointment to public health advocates, who believe higher cigarette prices are a valuable deterrent, especially in discouraging use among young smokers.

In these and many other areas, overlapping jurisdictions and the absence of a clear definition of the roles and responsibilities for the federal, Quebec and Indigenous governments will continue to be a challenge for the next minister responsible for Indigenous affairs.

Challenge 2: Sharing the wealth

A key prerequisite for self-government is finding sources of revenue for Indigenous governments. As long as the bulk of the funding is dependent on government programs and subsidies, it will be difficult for Indigenous governments to set their own priorities and tackle the challenges they confront. How can we discuss self-government and the consequent accountability without some form of own-source revenue?

This includes the necessary debate over taxation in First Nation communities. Once again, the Quebec experience is uneven. The Inuit of Quebec, who were not governed by the Indian Act, do pay taxes. We have had success as a result of the JBNQA and the subsequent Paix des Braves (2002), which provides a steady income for the Cree of Eeyou Istchee, indexed to the level of economic activity on the territory. On a more ad hoc basis, we have had success in developing energy projects with Hydro-Quebec and the First Nations. For example, the three Mi’kmaq communities in the Gaspé, in partnership with a company led by non-Indigenous management, have developed a 165-megawatt wind farm near Escuminac. Also, the Innu community of Mashteuiatsh, in partnership with local Regional County Municipalities (known in French as MRCs), have built two modest hydroelectric projects that provide needed income for the community. For other First Nations, timber harvesting permits have been granted. In addition, since 1999, the Quebec government has made funds available within an Aboriginal Initiatives Fund to promote economic development. The third edition of this fund, announced in 2017, makes $135 million available over the next five years for businesses, for infrastructure projects and to finance the costs linked to consultation on various government initiatives.

But this remains a piecemeal approach, especially for the eight First Nations which benefit from neither a modern treaty nor a 19th-century treaty comparable to those signed west of Quebec. For many years, some of these First Nations have embarked on comprehensive land claim negotiations that have not borne fruit. As a result, there is no consensus on the extent of traditional territories of the various First Nations. This has important consequences. First, the Quebec government is bound by several Supreme Court of Canada decisions regarding the duty to consult and accommodate First Nations. This duty is especially significant where no comprehensive land claim settlements have been completed, to ensure that development does not infringe on the rights of the First Nations.

Quebec remains dependent on the development of natural resources – in the mining sector, forestry and energy production. Both for private promoters of projects in this sector and for the government, the lack of clearly identified boundaries makes the duty to consult a complex challenge. When the JBNQA was signed 44 years ago, it created problems for the Anishnabe, Atikamekw and Innu nations, which felt that their rights had been compromised by the establishment of a boundary for Cree territory. They continue to contest the boundaries set out in the JBNQA.

For a promoter seeking to obtain approval for a natural resource project, and for a government called upon to issue permits and to give a project a green light, court decisions have created requirements for consultation and benefit sharing with Indigenous communities that are far from clear. What is meant by “effective” consultation? How do we apply the concept of “social licence”? To ensure social acceptability of natural resource projects, it is important to sign agreements that can provide employment, training, procurement guarantees and royalties. But which community should benefit? If more than one community is affected, how should the benefits be shared?

This question is also of great importance when trying to apply the principles contained in the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP). There are frequent references to “their traditional territories” in the Declaration. However, in the absence of a mutually accepted notion of where those territories are located, application of the UNDRIP is difficult. This is coupled with the debate over the meaning of “clear, prior informed consent” of Indigenous peoples before government projects can proceed. Some have argued that this obligation does not create a veto power for Indigenous peoples. Others disagree. It will be important to have a common understanding of the concepts of “traditional lands” and “consent” if we are to succeed in implementing UNDRIP.

We must, as a society, correct past wrongs and provide for a more equitable sharing of the wealth, particularly that wealth which is created by natural resource development on lands claimed by the First Nations. But if we are going to attack the endemic poverty in far too many First Nations and Inuit communities, if we are going to overcome chronic housing shortages, unemployment and unsatisfactory academic success rates, we must find ways for communities to develop own-source revenues.

Challenge 3: Responding to the public inquiries

In 2019, if everything goes according to schedule, two important public inquiries will submit their final reports. In August 2016, the federal government established the National Inquiry into Missing and Murdered Indigenous Women and Girls, which has held public sessions across Canada, including stops in Quebec. The cases of women who have been reported missing or murdered and the treatment their families have received from various police forces have been under the spotlight. But the hearings have also shed light on Indigenous women living in vulnerable situations, the lack of resources to help women living in violent relationships, and the acute housing shortages and pervasive poverty in far too many Indigenous communities. The legacy of residential schools and the more general impact of the colonial mindset that informs the Indian Act make for a daunting body of evidence for the MMIWG commissioners to work with. The MMIWG inquiry is due to publish its report in April.

In December 2016, the Quebec government of Premier Philippe Couillard announced a second inquiry, the Public Inquiry Commission on Relations between Indigenous Peoples and Certain Public Services in Québec: Listening, Reconciliation and Progress, chaired by Jacques Viens, a retired judge of the Superior Court of Quebec. It was mandated to examine the situation brought to light by accusations of police misconduct in Val-d’Or, revealed in a Radio-Canada report that aired in October 2015. After police investigations failed to lead to criminal charges, the commission was established to examine existing police policies and practices. While the police forces were intended to be at the root of the inquiry, the mandate was expanded to include other government services, notably in the health and social services sector. Much of the testimony focused on the issue of youth protection. Judge Viens has held hearings across Quebec, and is finishing public sessions at the end of 2018. His report is due in September 2019.

These are independent public inquiries, and I do not know what recommendations they will make to the government. What follows is merely my hunch as to what those recommendations may be, and what challenges the government will face thereafter.

In the area of policing, two major issues must be addressed. Most Indigenous communities in Quebec have their own local police forces, jointly funded by Ottawa (52 per cent) and Quebec City (48 per cent). Indigenous leaders maintain that this funding is inadequate to meet the needs of the communities served, despite recent increases brought about by an agreement signed in 2018. No doubt more resources will be requested in the inquiries’ final reports. In addition, there will be renewed calls for increased awareness training for members of the Sûreté du Québec and municipal police forces, and stronger external review mechanisms for complaints about police misconduct. It will be up to the newly created Bureau des Enquêtes Indépendantes (BEI) to develop these review mechanisms.

Another key area will be youth protection. Steps have already been taken to strengthen the obligation to keep children in their culture should recourse to a foster family be necessary (Bill 99, adopted in October 2017), and to implement measures to recognize traditional adoption practices (Bill 113, adopted in June 2017). The Quebec government has also signed a groundbreaking agreement with the Atikamekw communities, Manawan and Wemotaci, to transfer the responsibility for youth protection to the communities. This agreement came about after a pilot project demonstrated the advantages of local management of these sensitive services. Researchers found that families at risk were identified more quickly and services were provided before the situation got out of hand and required more drastic measures. It is hoped that other communities will sign similar agreements and thereby enhance Indigenous control over the protection of at-risk children.

The situation facing vulnerable women will no doubt be the subject of recommendations. Part of the solution is funding of shelters for women who are survivors of domestic violence, both in their communities and in urban areas. Healing for violent spouses also needs to be addressed. In addition, chronic housing shortages on reserve – a federal responsibility – will undoubtedly be cited as part and parcel of the problem.

In June 2017, the Quebec government unveiled an unprecedented five-year action plan, the Government Action Plan for the Social and Cultural Development of the First Nations and Inuit 2017–2022, with total funding of $147 million. This fund was intended to remedy some of the social and cultural challenges facing our Indigenous population. The government understands that the recommendations from the inquiries will require additional resources.

Challenge 4: Demographic changes

The Indigenous population in Quebec presents two vital demographic challenges. The first is the striking youth of the population. Fully 40 per cent of Quebec’s Indigenous population is under 25 years of age, a population pyramid that is very different from that of the rest of Quebec. What kind of future will these young people face? I’ve already noted the urgent need to focus on education. We need more high school graduates. We need more postsecondary students. We need more young people taking courses in vocational and technical education. In the recent election campaign, many observers pointed to labour shortages in the regions of Quebec. In a cruel irony, many of these regions include Indigenous communities where the unemployment rate exceeds 50 per cent.

For many reasons, a high proportion of Indigenous students fail to complete secondary school by their early twenties. It is therefore important to expand adult education to enable young Indigenous adults to obtain high school equivalency and, hopefully, postsecondary training. Often these students are young parents, so access to daycare is an essential component of academic success. Progress has been made in this sector, but much more needs to be done. As a society, we have an important rendez-vous with this young generation. Failure to provide them with education, training and employment opportunities is a recipe for further hardship.

The second demographic shift is from the reserve to urban settings. Increasingly, for a variety of reasons, Indigenous people leave their communities of origin and move to Montreal, Val-d’Or or other municipalities. For those who are moving with a game plan, for example to accept a job or enrol in CEGEP or university, this shift can be accomplished fairly smoothly. But for others who arrive with no direction, often escaping from difficult situations in their home communities, the path can be much more uncertain. Poverty and homelessness are often the result. Women are preyed on by the sex trade. People encounter problems when trying to find a job or rent an apartment.

In 2016, the Quebec government set up the Programme d’Aide aux Autochtones en Milieu Urbain (PAAMU), an $11 million fund to strengthen Native Friendship Centres and other social services working with Indigenous people. Fifty per cent of the money is allocated to improve infrastructure, and the other 50 per cent is for program funding. The goal of Friendship Centres is to provide a reference point for individuals arriving in the city, as well as to organize cultural activities to keep newcomers in touch with their Indigenous identity. Finally, the centres build bridges between the growing Indigenous population and the rest of society. There are now 11 centres across Quebec. Recently, a 55-bed homeless shelter for Indigenous clients, Projets Autochtones du Québec, moved to a more modern facility. Kijaté, a 24-unit housing project, opened its door to vulnerable Indigenous families in Val-d’Or. Meanwhile, new Friendship Centres were opened in Maniwaki and Roberval. But with the Indigenous urban population growing rapidly, more will need to be done in our municipalities to provide housing, employment and social services to this new clientele.

Over to you, Sylvie D’Amours

I am writing in mid-October, on the day on which Premier Legault revealed his new cabinet. Sylvie D’Amours, first elected to the National Assembly in 2014, is Quebec’s new ministre responsable des Affaires autochtones. I trust that what I have said here will be taken as friendly advice, and not as partisan warning. The cultivation of warm and productive Nation-to-Nation relations in Quebec is important for the future of the First Nations and Inuit, and for our entire society. Economic development, protecting and preserving the natural environment and sustainability require harmonious relations with Indigenous peoples. The social and cultural challenges associated with the Herculean task of lifting communities out of poverty, reconnecting and strengthening the link to Indigenous culture and traditions, and the duty to preserve and promote Indigenous languages in the era of the internet also require cooperation and mutual respect at all levels of government. I wish the new minister every success as she grapples with these and other challenges.

On December 4, 2009, the Quebec National Assembly unanimously adopted a motion creating a special parliamentary committee to examine the question of dying with dignity. The four political parties represented in the Assembly at that time (the Quebec Liberal Party, the Parti Québécois, Action Démocratique du Québec and Québec Solidaire) approved a motion that would lead to extensive public consultations on end-of-life issues, including palliative care, living wills and, most contentiously, the difficult issue of euthanasia. The result was a rewarding experience for all concerned – parliamentarians, the media and the general public, as citizens and representatives of civil society came forward to comment on one of life’s most emotionally charged moments and to explore how death and dying are dealt with in our modern world.

From the outset, the goal was to reach out to the public. In the 20 years that preceded the committee’s work, the debate over euthanasia in Canada had focused either on the courts (as in the Sue Rodriguez and Robert Latimer cases) or on votes in the House of Commons to amend the Criminal Code of Canada. This time, the goal was to generate and allow as many people as possible to express an opinion on the matter.

The process

The motion adopted in the Assembly was quite specific as to how the special committee was to proceed. The first step was to invite 32 experts drawn from medical, legal and ethical fields, along with various professional associations interested in the issue, to testify at the National Assembly in Quebec City. At this stage, the experts were asked for their advice on how to craft a consultation document, which questions needed to be answered, and how best to engage the population on these issues. The committee asked them to refrain from giving their personal opinion for the moment, as it was expected that they would return during the next stage of the committee’s deliberations to add their voices to the general consultation. The committee members were probably engaging in wishful thinking, as many of the experts clearly took sides in the euthanasia debate right from the start.

Of particular interest was the testimony of the Collège des Médecins (Quebec’s college of physicians), which had published a document on euthanasia in October 2009 and had concluded that several “grey zones” existed in end-of-life treatment and care.1 The Collège asked legislators to clarify issues associated with palliative sedation, living wills and a new concept known as “medically assisted dying.” The Collège’s position was reinforced by the two medical federations (general practitioners and specialists), which claimed that their members supported the idea of permitting euthanasia.2 Once the expert testimony had concluded, a 42-page consultation document was released in May 2010. It was hoped that the document would help define the various concepts in play (euthanasia versus assisted suicide, for example), provide specific case histories to illustrate the choices facing doctors, patients and society, and inspire citizens to participate in either public hearings or an online survey.3

The adventure was launched. Over the summer of 2010, the committee began to receive briefs from across the province. The initial motion had promised that the committee would travel across Quebec to hear witnesses. Eight cities were selected to host the hearings: Gatineau, Montreal, Quebec City, Saguenay, Sherbrooke, Saint-Jérôme and Trois-Rivières. Starting on September 7, 2010, in Montreal,4 a parliamentary odyssey began that included 29 days of public hearings, 273 briefs received, the testimony of 239 individuals and associations and the participation of 114 individuals in “open mike” sessions at the conclusion of each hearing. In addition, 6,558 people completed the online survey – a record number for a National Assembly survey. Finally, the work of the special committee received a great deal of media attention both in Quebec and from across Canada. This attention paid to a “citizens’ debate” helped stimulate interest in the issue at hand.

After the public hearings ended, several members of the committee travelled to France, Belgium and the Netherlands to meet with elected officials, doctors, lawyers and ethicists who had taken part in the debate on euthanasia in their respective countries. During the Quebec hearings, the positions of these countries had been depicted in contradictory ways, from a progressive paradise (Belgium, the Netherlands), where euthanasia is practised without restriction, to sinister lands where the vulnerable perish against their will.

The final chapter was the drafting of a final report, which was tabled on March 22, 2012, and contained 24 recommendations. The report was adopted, once again unanimously, after 51 working sessions of the committee.

One of the challenges of any parliamentary initiative that emanates from the legislative branch rather than the executive branch is to keep the momentum alive. In August 2012, shortly after the report of the special committee was tabled, Premier Jean Charest called an election, and Quebecers went to the polls. The PQ and the new Coalition Avenir Québec (CAQ) included pledges in their election platforms calling for legislation to enact the recommendations in the report, including the idea of medically assisted dying. The Quebec Liberal Party took no formal stand on this issue.

On September 4, 2012, the election produced a PQ minority government and an Assembly where 75 of the 125 members represented parties that had endorsed the committee report. The new Premier, Pauline Marois, named Véronique Hivon, the former vice-chair of the special committee, as the Minister responsible for Social Services. She was given the arduous task of drafting legislation to reflect the work of the committee.

On June 12, 2013, Bill 52, An Act Respecting End-of-Life Care, was tabled in the National Assembly. A further round of hearings on the text of the bill was organized in September 2013, and 55 groups and individuals commented on the legislation, which had three broad sections. First, it established a right for patients to have access to palliative care, and guidelines on how this care should be provided in Quebec. Second, the bill introduced the procedure to be followed by anyone seeking a medically assisted death. The steps to be taken to obtain clear consent from a terminally ill adult of sound mind were defined. Various oversight mechanisms and reporting obligations were set out. Finally, a formal status was granted to the “living wills” that many citizens have prepared to ensure that their final wishes will be respected, and instructions were provided as to how to include the contents of these documents in decisions regarding a patient’s treatment.5

In addition to a new government, the Assembly now included a new Leader of the Official Opposition, Quebec Liberal Leader Philippe Couillard. One of the first decisions he made as party leader was to indicate that members of his caucus would be free to vote according to their consciences. Votes of this nature are extremely rare in Quebec’s National Assembly, and Dr. Couillard’s decision added a new wrinkle to the proceedings. On October 29, 2013, Bill 52 was put to an initial vote on the principle of the legislation. The bill passed this hurdle, with 84 MNAs voting in favour and 26 voting against. Twenty-five Liberal MNAs voted against the principle, as did one CAQ MNA.

The bill was then referred to the Assembly’s Standing Committee on Health and Social Services, where clause-by-clause study took place. More than 50 amendments were made, including a series of important changes to the definitions of medically assisted dying, palliative care and continuous palliative sedation. The rights and responsibilities of doctors and other medical professionals were clarified, and specific reporting requirements regarding medically assisted deaths were added. The bill passed the committee stage, and returned to the Assembly for a final debate.

Once again, the vicissitudes of parliamentary life intervened. With election rumours in the air in early 2014, the time left for debate was limited. There was now a strong possibility that Bill 52 would die on the order paper – as in fact happened on March 5, when Premier Marois called an election for April 7 – and the parties’ parliamentary leaders blamed each other for the Assembly’s failure to adopt the bill. A debate that had been conducted to date on a nonpartisan basis was caught in the crossfire. However, the new Assembly can take up the bill if all the parties give their consent, and they have all gone on record as supporting a speedy return to the debate once the Assembly reconvenes.6

Issues raised

There were two broad areas of concern expressed before the committee. The first was the need to improve access to palliative care across the province. Palliative care doctors are passionate advocates for their cause. Eloquent cases were made for additional palliative care beds in hospitals, long-term care facilities and free-standing hospices, and for services to patients in their own homes. The debate was over to improve access to these services. No one questioned their relevance.

Palliative care advocates also wanted more training for physicians and other medical professionals regarding the benefits of palliative care. Too often, patients and their doctors put off the discussion about palliative care until too late. It should be part and parcel of the care afforded to a patient facing a terminal illness and not a form of surrender once all heroic treatments have been tried. One palliative care doctor went so far as to say that far too many cancer patients receive treatments that are ineffective, unnecessary and expensive. A more judicious use of treatments could save money, and these resources should be redirected toward the funding of palliative care.

The testimony of many families echoed these concerns. Stories of dying patients lying on stretchers in crowded emergency rooms or in rooms shared with other patients reinforced the need for appropriate spaces for patients to die with dignity.

Most palliative care groups spoke out against euthanasia. Their arguments were twofold. First, they believed that with modern pain management techniques, all or almost all patients could be comfortable in their final days. There is no need to suffer. If all patients had access to appropriate palliative care, there would be no need for a discussion about euthanasia. Second, certain groups feared that governments and the health care system would encourage euthanasia, thus reducing the need to invest more money in palliative care. The concern was that euthanasia would let governments off the hook when it came to investing the necessary dollars in palliative care.

Generally speaking, there was a broad consensus on the questions related to palliative care. But this consensus vanished once the debate shifted to the difficult question of euthanasia, or the Collège des Médecins’ concept of medically assisted dying. Here, the battle lines were drawn early, and there was little or no room for compromise.

For many witnesses, taking the life of another person was morally wrong at all times. This belief either was founded on religious motives or stemmed from a profound ethical concern that a decision to permit some form of euthanasia or assisted suicide7 would be the first step toward a dangerous erosion of the respect for the sanctity of life that, according to this school of thought, would have dramatic consequences for our society. These witnesses felt that the protection of the vulnerable, the elderly, the disabled and other oft-marginalized groups would be compromised, and that these first tentative steps would lead to a slippery slope where certain people would be reduced to mere burdens on society. From there, they argued, it was easy to envision a scenario where the argument could be made that these individuals should be disposed of for the overall benefit of society. Many of these witnesses were highly critical of the situation in the Netherlands and Belgium, and told of a dramatic decline in the respect for human dignity in these countries.

Certain people were worried about the apparent contradiction of a society which is attempting, on the one hand, to prevent suicide through the use of ad campaigns, support groups and psychological therapies while, on the other hand, encouraging a form of suicide for the terminally ill. Suicide prevention groups were concerned that the debate over ending the lives of the terminally ill would have a negative impact on their work with people struggling with suicidal tendencies.

The proponents of euthanasia or medically assisted death advanced several arguments. For many, the debate centred on individual choice, free will and the ability to control one’s own life. This group believed that patients who were facing declining quality of life, and were suffering or in acute psychological distress, should have the right to end their lives. This view of the matter was nothing less than an extension of individual liberty to end-of-life issues. Coupled with this argument was a critique of those who would impose their values or beliefs on others. “I will not choose for you, so please do not choose for me” was a common refrain.

Others asserted that palliative care could not successfully manage the pain of every patient. This is particularly true for individuals who have degenerative illnesses such as ALS (Lou Gehrig’s Disease), who often suffer at the end of their long ordeal. Palliative care cannot always alleviate their misery. Several of the witnesses were either people facing a grim destiny with one of these diseases or family members who had witnessed the sad, slow death of a loved one. Their testimony was often compelling.

In addition, there was discussion of the possibility for abuse. Would family members put undue pressure on an ailing parent to put an end to his or her ordeal? Would terminally ill patients feel as if they are a burden on their families, and put an end to their lives to avoid the guilt of “hanging on”? A fear was expressed that vulnerable and often elderly patients would be pressured into giving their consent to euthanasia.

Proponents of medically assisted dying pointed to the experience with the “right to refuse treatment,” which was granted as part of a major reform of the Civil Code in 1994. Many of the same concerns over undue family pressure, or a patient feeling that he or she is an encumbrance on society, could be made in the case of those who refused treatment. Often a refusal to receive treatment accelerates the death of the patient. For example, one family described the emotional moment when the decision was made, with informed consent, to unplug a woman from life support, and her subsequent demise. Yet, over the past 20 years, our system has managed, without controversy or evidence of abuse, the delicate issues associated with the right to refuse treatment. If this can be done to preserve the right to refuse treatment, why can we not enshrine the right to request a medically assisted death?

Many other issues were discussed during the long public consultations. Living wills, prior consent and refusal of treatment were all issues examined in great detail. The situation of patients in advanced stages of dementia was discussed. Could patients in this condition ever fully consent to putting an end to their lives? Recent proposals to extend the right to euthanasia to Alzheimer’s patients may reignite this debate. During the public consultations, doctors who treat dementia patients strongly advised against including their patients in any legislation, as no clear and informed consent could ever be obtained. So they were excluded from Bill 52, although Minister Hivon asked the Collège des Médecins to continue to reflect on this matter.

Finally, much attention was given to the constitutional aspects of this issue. Euthanasia is covered by the Criminal Code, and is therefore under federal jurisdiction. However, the Collège des Médecins’ argument is based on the belief that medically assisted death can be incorporated into a definition of a continuum of care, and the delivery of health care services falls under provincial jurisdiction.8 Furthermore, the Quebec Bar Association argued that the administration of justice falls under provincial jurisdiction. A provincial government can thus direct crown prosecutors not to lay charges if a certain protocol has been followed to obtain the consent of the patient.9

My vote

The preceding sections have attempted to give a flavour of the extensive public consultations that surrounded the debate on medically assisted dying, palliative care and other end-of-life issues in Quebec. As a member of the National Assembly who followed this debate closely, I found it an extraordinary event. It featured members of all political parties working together. It showed that our legislature can host a compelling “débat de société.” It provided a citizens’ forum for a debate that is often confined within the walls of our courthouses. Citizens responded generously, pouring out their views on this delicate and emotional topic from their hearts and their convictions. Civil society also responded generously, providing many serious arguments for legislators to consider. Finally, the media responded generously by giving extensive coverage to the debate. A book was even published, a thoughtful exchange of letters between two doctors, one for and one against euthanasia.10

On October 22, 2013, I spoke in the National Assembly, outlining the reasons for my vote in favour of Bill 52.11 First, I reiterated my support for the palliative care movement, recalling the deaths of both my parents at the West Island Palliative Care Residence. No one wants to face cancer and die, but the staff and volunteers at the residence provided great comfort and care to my parents. All terminally ill Quebecers should have access to care of this quality.

But palliative care cannot alleviate the suffering of each and every patient. Throughout this debate, my mind kept returning to the lucid testimony of Ghislain Leblond, a former Quebec deputy minister who now suffers from a lingering degenerative disease. He has become involved in the dying with dignity movement, and despite his extremely limited mobility he often participates in our public debate on the right to end one’s life. He was a frequent visitor to our committee hearings and followed our work closely online.

Mr. Leblond was one of the first witnesses to testify before the committee, and he challenged the legislators by simply outlining the expected course of his illness and expressing his desire to put an end to his suffering when it became intolerable. Throughout the hundreds of hours of testimony and debate, I kept listening for an argument or a set of principles I could use to deny Mr. Leblond his request. I did not find one. He is of sound mind, his illness will enter a terminal phase one day, and he has repeatedly given his consent. I believe he is a candidate for a medically assisted death.

At the same time, I expressed my opposition to the extension of this debate to those who are unable to give their full and informed consent. I agree with the warnings given by the specialists who treat dementia patients that no consent can be provided by individuals with this debilitating condition. However dreadful their ordeal may be, we cannot know their intentions on this crucial question.

It was the first time in my 20-year parliamentary career that I cast a vote according to my conscience. I felt more than usually responsible for my vote, because I have received many letters and calls from constituents whose views differ from mine. I respect their views, and hope that they will respect mine.

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Continue reading “Medically assisted dying”

Election night in Quebec was a long night for the Quebec Liberal Party and its candidates. The party lost a third of its seats in the National Assembly, and its share of the popular vote fell from 46 to 33 per cent. Gains made in the 2003 election in Quebec City and the regions were wiped out, leaving a caucus formed primarily of MNAs from Montreal, the Outaouais and the Eastern Townships.

The good news, if there was any, centred on the plight of the Liberals’ longtime adversary, the Parti Québécois, which also had a long night on March 26. Its popular support fell to 28 per cent, the lowest since the 1973 election. More significantly, the PQ was reduced to third-place status in the legislature, holding 36 seats.

The big winner was the upstart Action Démocratique du Québec, which made big gains in the Quebec heartland. It swept the Chaudières-Appalaches and Beauce regions southeast of Quebec City, won seven of eleven seats in Quebec City itself and made significant gains in the Mauricie, Lanaudière, Laurentian and Montérégie regions surrounding Montreal. These victories catapulted ADQ leader Mario Dumont into the role of Leader of the Opposition in the Assembly, and represented a startling rise from four seats in 2003 to 41 in 2007. The result was the first minority government in Quebec since 1878, with a battered Quebec Liberal Party holding on to power.

What does this mean for the parties? For the PQ, the answer came quickly. On the eve of the first sitting of the new Assembly, leader André Boisclair resigned. He was replaced by Pauline Marois, who has signalled her intention to rethink the PQ’s strategy on holding another referendum and to revamp its program. Clearly, the new leader has work to do in the next few months to reposition her party.

For the ADQ, the challenge is to consolidate the gains made, develop more comprehensive policies on key issues and learn the ropes as new members of the legislature. The party’s decision not to participate in finding a solution to the impasse over the spring budget drew some criticism from the media, which felt that the ADQ had a duty to try to make the minority parliament work.

The challenges for the Liberals are complex. First, they must find a way to reinvent themselves while governing at the same time. This is never an easy task. With key ministers caught up in the day-to-day grind of managing the province’s business, they have less time for policy matters. In addition, with a smaller caucus, Premier Jean Charest was forced to reduce his cabinet to 18 members, the smallest cabinet in recent memory. Several ministers are called on to take on two or even three cabinet responsibilities.

A key event for the Quebec Liberal Party and its renewal is a members’ convention scheduled for March 7–9, 2008, in Quebec City. Over the next few months, working groups will be set up to prepare policy proposals for this event. Three groups have already been formed to this end: one group is examining the question of economic and regional development; a second is looking at issues related to sustainable development; and a third is tackling the question of Quebec’s identity and its relations with Canada. In launching these groups, the Premier indicated that these themes were chosen to “clearly distinguish ourselves from our adversaries.” He appealed to Quebecers who “want a society that is more prosperous, greener and that grows within Canada.”1

The reflection within the party on its future direction must also take into account the traditional values that it has always defended. These were most clearly enumerated by its former leader, Claude Ryan, in 2002 in a document prepared for the party. Liberal Values in Contemporary Quebec lists seven values that have always guided the party:

1. the primacy of individual freedoms;

2. identification with Quebec;

3. emphasis on economic development;

4. commitment to social justice;

5. respect for civil society;

6. attachment to democracy;

7. the sense of belonging to the Canadian federation.2

How will these values be reflected in the renewal process announced by the party? How can they be used to differentiate the Quebec Liberal Party from its two main rivals? Five questions spring to mind that arise from the election results. How the party answers them will go a long way toward shaping its next platform.

Immigration and the Quebec identity

The first question focuses on the Quebec identity. Much ink has been spilled on the debate over “accommodements raisonnables,” the issue that proved to be the surprise element of the 2007 election campaign. In making comments about how far “we” were willing to go to accommodate “them,” Mario Dumont tapped into a broad current of insecurity over the future of Quebec’s culture and identity. The media quickly joined the debate, giving significant coverage to a wide range of issues, ranging from whether a fitness class window should be frosted to respect the modesty requirements of a minority community to whether it is appropriate to remove ham from the traditional pea soup at a springtime cabane à sucre. More recently, a huge furor has been created over the identification of voters wearing a burka, even though no one has attempted to vote wearing this garment. Talk about making mountains out of molehills!

This is not to say that the question of intercultural relations is not important. The arrival of newcomers in our midst poses certain problems and requires a constant dialogue between members of the host society and the new communities. However, when compared to other large cities, such as Paris, which must deal with its colonial legacy in northern Africa that has been imported into its suburbs, or Toronto, where relations between the police and the black community are often strained, or western Canadian cities coping with an Aboriginal urban underclass, the problems raised in the Quebec reasonable accommodation debate do not loom as large.

To regain control of the situation, the government appointed two respected university professors, Charles Taylor and Gérard Bouchard, to chair a commission of inquiry, conduct public hearings and make recommendations to the Premier by March 31, 2008.

Two considerations must guide the party in this area. The Quebec Liberal Party has traditionally been the only political party at the provincial level to make room for Quebecers of all origins. In terms of its membership, candidates and elected representatives, the Liberal Party has worked as a coalition, reflecting the diversity of the Quebec population. As a general rule, it has been the party of choice for nonfrancophone voters in Quebec.

Another consideration is the demographic challenge facing Quebec. Despite a slight rise in the number of births in the last two years, Quebec’s birth rate remains low. With many baby boomers set to retire in the next few years, shortages of skilled individuals are forecast in the workforce. Immigration is therefore a key component of Quebec’s economic future. It will have to accept more immigrants in the future, not fewer, and add to the diversity of its population, especially in the Montreal region, where 88 per cent of all immigrants to Quebec settle.

The Liberal Party must therefore develop policies that help welcome newcomers to Quebec while reassuring the host society, especially outside Montreal, that the Quebec identity is not threatened by these changes. The Bouchard-Taylor Commission is spending September, October and November crisscrossing the province, listening to citizens’ concerns and, it is hoped, demystifying some of the issues surrounding pluralism. However, it remains to be seen whether the commission will face the same challenges as the Stasi Commission in France in 2003, which was established to examine the question of “the application of the principle of laicité in the Republic” following controversy over the wearing of headscarves in French public schools. As the public hearings were conducted, the commission was under increasing pressure to “do something.” This is often a poor climate in which to draft public policy. The commission responded by proposing a law regulating the wearing of “conspicuous” religious symbols at school. This was done despite the warning of then–Minister of the Interior Nicolas Sarkozy, who opposed the law, and urged “a France that gave women the right to vote only in 1945 to show some humility when preaching gender equality to Muslims. He attacked those who, decades after France encouraged the massive migration of Muslim workers to its shores, would even pose the question of whether Islam is compatible with the Republic.”3 At the end of the day, the commission raised more problems that it solved, and relations remain uneasy in La République.

The Liberal Party must mount a vigorous defence of the need for immigration, the need to be a welcoming society and the need to strengthen services, particularly French language training, for new arrivals. It must also work on the recognition of foreign diplomas and work experience to help professionals who are attempting to offer their skills for the benefit of Quebecers. Quebec quickly embraced the free trade agreements in the 1980s and 1990s, and the increased mobility of individuals is a direct result. To be coherent with previous decisions our society has made, we must vigorously build “une société d’accueil.”

Montreal and the regions

The second question facing the party is addressing the uneasy relationship between Montreal and the regions. Once again, this question poses a unique challenge for the Quebec Liberal Party. Its adversaries have tended to write off the ridings located in the 514 area code on Montreal Island, with the exception of the few PQ strongholds in the eastern part of the island. The Liberal Party must again do a delicate balancing act between its traditional base in the Montreal area (29 of its current 48 seats are in Montreal and neighbouring Laval) and the regions. Obviously, the debate over reasonable accommodation is part of this balancing act. However, it also extends to economic development, investment in infrastructure and the governance of the Montreal region.

It has often been stated that “Montreal is the motor of the Quebec economy” (some think it should become the motto of the city!). Montreal politicians often claim that their city is taken for granted in Quebec City, in part because of its loyalty to one political party. The city faces huge challenges today – crumbling infrastructure, inadequate transportation (especially public transit), universities calling out for new funding and a tax base that is being eroded as people continue to flee to off-island suburbs. Given the size of the projects, any announcement made to improve conditions in Montreal is greeted with resentment outside Montreal. For example, the decision to build the long-delayed teaching hospitals, with a public investment of roughly $2 billion, has been openly criticized as too generous to Montreal. However, if Montreal wants to continue to attract cutting-edge medical researchers and build on its reputation as a “ville de savoir,” these investments are necessary.

The Liberals must also address the economic development concerns of the regions, which over the years have fought to obtain some revenue from the exploitation of natural resources and to diversify their economy to be less dependent on a single industry. Given the current difficulties facing the forest industry – including overharvesting, the collapse of the American housing market and the expensive Canadian dollar – this question has taken on new urgency. Investment in transportation and communication infrastructure (new highways and broadband Internet access, for example) and decentralization of the decision-making process are required to strengthen regional economies. However, there is only so much money in the pot, and the competing demands of the metropolis and the regions cannot all be met.

Social programs and wealth creation

This leads us to the third question: how will Quebec create the wealth necessary to support its public policy lifestyle? Over the years, Quebec has earned a good reputation for public policy innovation. A highly subsidized daycare program, a low-tuition policy for university students, an ambitious new parental leave program and an extensive public prescription drug plan are among the social programs offered to Quebec residents – but these programs all have a price tag attached to them.

The popular $7-a-day daycare program, for example, costs $1.6 billion per year, and even though 200,000 spaces are now available, many parents still have their name on waiting lists to enrol their child. Quebec’s public health insurance agency, the Régie de l’Assurance Maladie du Québec, struggles each year to limit the premiums charged to members of the prescription drug insurance plan. Despite its efforts, the costs have risen from $175 in 1998, the year the plan came into effect, to $557 this year. The 13-year tuition freeze, which was lifted this September, has created a funding squeeze for Quebec’s universities, which have fallen well behind the per capita funding received by other Canadian universities.

Part of the answer to this dilemma is to create more wealth, and therefore more revenue for the government. The energy sector has great potential, moving toward (in particular) more hydroelectric development and the use of wind power. However, the Liberal Party will have to make a strong case for further development, as many new projects have run into stiff opposition from environmentalists and other interest groups. For example, concern over “visual pollution” has led several regions to prohibit the construction of windmills in their area. New dam projects are hotly contested by groups and individuals who argue that Quebec’s goal should be limited to energy self-sufficiency. In their view, the lucrative export market for electricity should not be developed further. These arguments must be overcome in public opinion if Quebec is going to find ways to fund its ambitious social programs.

The role of government

The fourth question facing the Liberals is how to rebalance roles and responsibilities between government on the one hand and individuals and the private sector on the other. The public policy activism that was spawned during the Quiet Revolution and thereafter reinforced the role of government in Quebec in both social and economic domains. In health care, regional development, labour relations and many other sectors, government was a more active player than in most North American jurisdictions. More recently, the modèle québécois has been critically examined, especially by a blue-ribbon panel chaired by former premier Lucien Bouchard. The so-called Lucides called for a review of Quebec’s economic model to ensure that Quebec remains competitive in the global economy.

The ADQ has staked out a position that emphasizes less government interference and a much greater role for the private sector, potentially in health care. The PQ remains determined to defend a strong interventionist role for the state. The challenge for the Liberals will be to find and defend the middle ground between these positions. It is true that government cannot do everything, but it must provide leadership and appeal to the individual’s sense of responsibility. In many areas, from environmental protection to the promotion of physical well-being to school success, government must put in place policies and incentives to change people’s habits and promote best practices. However, these efforts will have a limited impact if citizens do not buy into the new program.

Similarly, the role of the private sector in providing public services must be examined. In the Charest government’s first term, much debate occurred over the place for public-private partnerships (PPPs) in providing government services. To date, the debate has provided lots of talk, but little action. The Liberal Party will have to pressure the government to get these projects up and running, whether in the transportation, cultural or health care field, to demonstrate the advantages afforded by the PPP model.

The government has also asked a former minister of health from the early days of the Bourassa era, Claude Castonguay, to examine the role of the private sector in health serivces. The Liberal Party will have to react to the recommendations made, and explain how any increased role for the private sector would help overcome the personnel shortages now being experienced. Will more doctors, technicians and nurses working in private practice alleviate or accentuate the human resources problems faced by the public health care system?

Quebec in Canada

The final question facing the Quebec Liberal Party is the external reflection on Quebec’s place in the Canadian federation. Traditionally, provincial political parties have invested their energies in preparing lists of demands to be made on the federal government. From fiscal imbalance to controlling the federal spending power, the Liberal Party has defended Quebec’s interests by forcefully demanding its due in Ottawa.

The arrival of the ADQ and its ambiguous autonomiste policy stance vis-à-vis federalism complicates the situation for the Liberals. To distinguish themselves from the ADQ, they will have to demonstrate and explain the tangible benefits of their brand of federalism to Quebec voters. The establishment of the Council of the Federation, a new deal on health and negotiation of the parental leave program are all examples of how the Charest government’s approach was effective in its first term in office. The Liberals will have to build on these successes while discrediting the ambivalent ADQ position and the some-day-but-not-today referendum position of the renewed PQ.

This is an ambitious list of issues to be addressed. Time is a huge factor, because a minority government cannot control its destiny. However, for the Liberal Party to be prepared to do battle in the next election, it must pursue its reflection on Quebec’s identity, the role of Montreal and the regions, the creation of the wealth needed to support our social programs, the role of government and the individual, and the constant question of Quebec’s place in Canada. To distinguish themselves from their rivals, and to continue to play a fundamental role in Quebec politics, the Liberals must apply the key values identified by Claude Ryan to tomorrow’s challenges.

Working for the consummate public servant

In 1990, I went to work for Claude Ryan, then Quebec’s Minister of Education. Following a cabinet shuffle in October 1990, Mr. Ryan was named Minister of Municipal Affairs, Minister of Public Security and Minister responsible for the application of the Charter of the French Language. I served as a political staffer to Mr. Ryan until 1994.

Working for Claude Ryan was one of the greatest privileges I have known. He was the consummate public servant, and taught all of us who worked with him the importance of public life. The first lesson we learned was the need to work hard. Claude Ryan had an amazing capacity to read everything that came his way, from government papers to academic studies to the daily newspapers he devoured. He also remembered what he had read, and would often question a staff member or a civil servant on a point he found in a footnote at the end of a document. So it was imperative to read all relevant documents before making a presentation to the minister.

The second lesson was the importance of curiosity. Despite his long and varied career in public life in Quebec, Claude Ryan always wanted to know how things worked and how things were organized. From providing safe drinking water in Quebec municipalities to the policing of Native communities to the challenges of delivering affordable housing, there was no topic that failed to capture Mr. Ryan’s interest. After leaving the education portfolio, a job that he adored, Claude Ryan threw himself into the at times arcane world of municipal affairs with great enthusiasm and curiosity. We all learned from his approach.

Finally, Claude Ryan encouraged a healthy exchange of ideas before he made a decision. This practice ran counter to the public perception of Claude Ryan as a somewhat authoritarian figure. Nothing could be further from the truth, in the period leading up to a final decision. We were even encouraged to think up arguments to oppose the minister’s thinking. However, once a decision was made, we were all expected to defend it vigorously. No one was more energetic in this regard than the minister himself.

In short, the years spent working for Claude Ryan provided many memorable moments. It was an honour to work for such an interesting and engaged public servant, and such an outstanding individual.

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