Auton (Guardian ad litem of) v. British Columbia (Attorney General)

Auton (Guardian ad litem of) v. British Columbia (Attorney General)
Collection
Supreme Court Judgments
Date
2004-11-19
Neutral citation
2004 SCC 78
Report
[2004] 3 SCR 657
Case number
29508
Judges
McLachlin, Beverley; Major, John C.; Bastarache, Michel; Binnie, William Ian Corneil; LeBel, Louis; Deschamps, Marie; Fish, Morris J.
On appeal from
British Columbia
Subjects
Constitutional law
Notes
SCC Case Information: 29508
Decision Content
Auton (Guardian ad litem of) v. British Columbia (Attorney General), [2004] 3 S.C.R. 657, 2004 SCC 78
Attorney General of British Columbia and Medical
Services Commission of
British Columbia Appellants/Respondents on cross-appeal
v.
Connor Auton, an Infant, by his Guardian ad litem, Michelle Auton,
and the said Michelle Auton in her personal capacity, Michelle Tamir,
an Infant, by her Guardian ad litem, Sabrina Freeman, and the said
Sabrina Freeman in her personal capacity, Jordan Lefaivre, an Infant,
by his Guardian ad litem, Leighton Lefaivre, and the said
Leighton Lefaivre in his personal capacity, Russell Gordon Pearce,
an Infant, by his Guardian ad litem, Janet Gordon Pearce, and
the said Janet Gordon Pearce in her
personal capacity Respondents/Appellants on cross-appeal
and
Attorney General of Canada, Attorney General of Ontario,
Attorney General of Quebec, Attorney General of Nova Scotia,
Attorney General of New Brunswick, Attorney General
of Prince Edward Island, Attorney General of Alberta,
Attorney General of Newfoundland and Labrador,
Canadian Association for Community Living and Council of
Canadians with Disabilities, Women’s Legal Education and
Action Fund and DisAbled Women’s Network Canada,
Autism Society Canada, Michelle Dawson, Families for
Effective Autism Treatment of Alberta Foundation, Friends
of Children with Autism, and Families for Early Autism
Treatment of Ontario Interveners
Indexed as: Auton (Guardian ad litem of) v. British Columbia (Attorney General)
Neutral citation: 2004 SCC 78.
File No.: 29508.
2004: June 9; 2004: November 19.
Present: McLachlin C.J. and Major, Bastarache, Binnie, LeBel, Deschamps and Fish JJ.
on appeal from the court of appeal for british columbia
Constitutional law — Charter of Rights — Equality rights — Mental disability — Province not providing for controversial intensive behavioural therapy for preschool-aged autistic children — Whether Province’s refusal to fund treatment violates equality rights — Canadian Charter of Rights and Freedoms, s. 15(1) — Medicare Protection Act, R.S.B.C. 1996, c. 286, s. 1 “benefits”, “health care practitioner” — Medical and Health Care Services Regulation, B.C. Reg. 426/97, ss. 17-29.
Constitutional law — Charter of Rights — Equality rights — Appropriate comparator group — Canadian Charter of Rights and Freedoms, s. 15(1) .
Constitutional law — Charter of Rights — Fundamental justice — Province not providing for controversial intensive behavioural therapy for preschool-aged autistic children — Whether Province’s refusal to fund treatment violates s. 7 of Canadian Charter of Rights and Freedoms — Medicare Protection Act, R.S.B.C. 1996, c. 286, s. 1 “benefits”, “health care practitioner” — Medical and Health Care Services Regulation, B.C. Reg. 426/97, ss. 17-29.
The infant petitioners suffer from autism, a neuro-behavioural syndrome that impairs social interaction, hinders communication and results in repetitive behaviour. They brought an action against the province of British Columbia, alleging that its failure to fund applied behavioral therapy for autism violated s. 15(1) of the Canadian Charter of Rights and Freedoms . In the years leading up to the trial, the government acknowledged the importance of early intervention, diagnosis and assessment for autistic children but stated that services for their needs had to be balanced with services to children with other special needs. The government funded a number of programs for autistic children but did not establish funding for ABA/IBI therapy for all autistic children between the ages of three and six because of, inter alia, financial constraints and the emergent and controversial nature of this therapy. At the time of the trial, ABA/IBI funding for autistic children was not universal and was only beginning to be recognized as desirable. The trial judge found that the failure to fund ABA/IBI therapy violated the petitioners’ equality rights, directed the province to fund early ABA/IBI therapy for children with autism and awarded $20,000 in damages to each of the adult petitioners. The Court of Appeal upheld the judgment and added funding for ABA/IBI treatment pursuant to medical opinion.
Held: The appeal should be allowed; the cross-appeal should be dismissed.
A person claiming a violation of s. 15(1) of the Charter must establish: (1) differential treatment under the law, (2) on the basis of an enumerated or analogous ground, (3) which constitutes discrimination. The specific role of s. 15(1) in achieving its equality objective is to ensure that when governments choose to enact benefits or burdens, they do so on a non-discriminatory basis. This confines s. 15(1) claims to benefits and burdens imposed by law.
In this case, the government’s conduct did not infringe the petitioners’ equality rights. The benefit claimed — funding for all medically required treatment — is not provided by law. The Canada Health Act and the relevant British Columbia legislation do not promise that any Canadian will receive funding for all medically required treatment. All that is conferred is core funding for services delivered by medical practitioners and, at a province’s discretion, funding or partial funding for non-core services, which in the case of British Columbia are delivered by classes of “health care practitioners” named by the province. More specifically, the law did not provide for funding for ABA/IBI therapy for autistic children. At the time of the trial, the province had not designated providers of ABA/IBI therapy as “health care practitioners” whose services could be funded under the plan. Since the government had not designated ABA/IBI therapists as “health care practitioners”, the administrative body charged with administration of the provincial legislation had no power to order funding for ABA/IBI therapy.
The legislative scheme is not itself discriminatory in providing funding for non-core services to some groups while denying funding for ABA/IBI therapy to autistic children. The scheme is, by its very terms, a partial health plan and its purpose is not to meet all medical needs. It follows that exclusion of particular non-core services cannot, without more, be viewed as an adverse distinction based on an enumerated ground. Rather, it is an anticipated feature of the legislative scheme. One cannot therefore infer from the fact of exclusion of ABA/IBI therapy for autistic children from non-core benefits that this amounts to discrimination. There is no discrimination by effect.
Nor has it been established on the facts of this case that the government excluded autistic children on the basis of disability. When the relevant criteria are applied, the appropriate comparator for the petitioners is a non-disabled person, or a person suffering a disability other than a mental disability, who seeks or receives funding for a non-core therapy that is important for his or her present and future health, is emergent and has only recently began to be recognized as medically required. The claimant or claimant group was not denied a benefit made available to the comparator group. In the absence of evidence suggesting that the government’s approach to ABA/IBI therapy was different than its approach to other comparable, novel therapies for non-disabled persons or persons with a different type of disability, a finding of discrimination cannot be sustained.
The government’s conduct did not infringe the petitioners’ rights under s. 7 of the Charter .
Cases Cited
Applied: Andrews v. Law Society of British Columbia, [1989] 1 S.C.R. 143; Law v. Canada (Minister of Employment and Immigration), [1999] 1 S.C.R. 497; Hodge v. Canada (Minister of Human Resources Development), [2004] 3 S.C.R. 357, 2004 SCC 65; distinguished: Eldridge v. British Columbia (Attorney General), [1997] 3 S.C.R. 624; referred to: R. v. Turpin, [1989] 1 S.C.R. 1296; Corbiere v. Canada (Minister of Indian and Northern Affairs), [1999] 2 S.C.R. 203; Granovsky v. Canada (Minister of Employment and Immigration), [2000] 1 S.C.R. 703, 2000 SCC 28; Nova Scotia (Attorney General) v. Walsh, [2002] 4 S.C.R. 325, 2002 SCC 83; Battlefords and District Co-operative Ltd. v. Gibbs, [1996] 3 S.C.R. 566; Nova Scotia (Workers’ Compensation Board) v. Martin, [2003] 2 S.C.R. 504, 2003 SCC 54; British Columbia (Public Service Employee Relations Commission) v. BCGSEU, [1999] 3 S.C.R. 3; R. v. Malmo-Levine, [2003] 3 S.C.R. 571, 2003 SCC 74; Canadian Foundation for Children, Youth and the Law v. Canada (Attorney General), [2004] 1 S.C.R. 76, 2004 SCC 4.
Statutes and Regulations Cited
Canada Health Act, R.S.C. 1985, c. C-6, ss. 2 “health care practitioner”, “hospital”, “hospital services”, “insured health services”, “medical practitioner”, “physician services”, 3, 4 [repl. 1995, c. 17, s. 35], 7, 9, 10, 12(1).
Canadian Charter of Rights and Freedoms, ss. 1 , 7 , 15 , 24(1) .
Constitution Act, 1867 .
Interpretation Act, R.S.B.C. 1996, c. 238, s. 29 “medical practitioner”.
Medical and Health Care Services Regulation, B.C. Reg. 426/97, ss. 17, 22, 25.1.
Medicare Protection Act, R.S.B.C. 1996, c. 286, Preamble, s. 1 “beneficiary”, “benefits”, “commission”, “health care practitioner”, “medical practitioner”, “practitioner”, 2, 4(1), (2), (3), 5(1), (2), 26(1), (3), (4).
APPEAL and CROSS-APPEAL from a judgment of the British Columbia Court of Appeal (2002), 220 D.L.R. (4th) 411, [2003] 1 W.W.R. 42, 173 B.C.A.C. 114, 283 W.A.C. 114, 6 B.C.L.R. (4th) 201, 99 C.R.R. (2d) 139, [2002] B.C.J. No. 2258 (QL), 2002 BCCA 538, affirming a decision of the British Columbia Supreme Court, [2000] 8 W.W.R. 227, 78 B.C.L.R. (3d) 55, 77 C.R.R. (2d) 293, [2000] B.C.J. No. 1547 (QL), 2000 BCSC 1142, with supplementary reasons (2001), 197 D.L.R. (4th) 165, [2001] 3 W.W.R. 447, 84 B.C.L.R. (3d) 259, 80 C.R.R. (2d) 233, [2001] B.C.J. No. 215 (QL), 2001 BCSC 220. Appeal allowed and cross-appeal dismissed.
D. Geoffrey G. Cowper, Q.C., and Lisa J. Mrozinski, for the appellants/respondents on cross-appeal.
C. E. Hinkson, Q.C., and Birgitta von Krosigk, for the respondents/appellants on cross-appeal.
Graham Garton, Q.C., and Michael H. Morris, for the intervener the Attorney General of Canada.
Robert E. Charney and Sarah Kraicer, for the intervener the Attorney General of Ontario.
Isabelle Harnois, for the intervener the Attorney General of Quebec.
Catherine J. Lunn, for the intervener the Attorney General of Nova Scotia.
Written submissions only by Gaétan Migneault, for the intervener the Attorney General of New Brunswick.
Ruth M. DeMone, for the intervener the Attorney General of Prince Edward Island.
Margaret Unsworth, for the intervener the Attorney General of Alberta.
Donald H. Burrage, Q.C., and Barbara Barrowman, for the intervener the Attorney General of Newfoundland and Labrador.
Elizabeth J. Shilton, Fay Faraday and Ena Chadha, for the interveners the Canadian Association for Community Living and the Council of Canadians with Disabilities.
Dianne Pothier and Fiona Sampson, for the interveners the Women’s Legal Education and Action Fund and the DisAbled Women’s Network Canada.
Domenic A. Crolla and Meghan K. O’Brien, for the intervener the Autism Society Canada.
Douglas C. Mitchell, for the intervener Michelle Dawson.
Elizabeth M. (Ellie) Venhola, Janet L. Hutchison and Michael R. Loughlan, for the interveners the Families for Effective Autism Treatment of Alberta Foundation and the Families for Early Autism Treatment of Ontario.
Mary Eberts and Jonathan Strug, for the intervener the Friends of Children with Autism.
The judgment of the Court was delivered by
The Chief Justice —
I. Introduction
1 This case raises the issue of whether the Province of British Columbia’s refusal to fund a particular treatment for preschool-aged autistic children violates the right to equality under the Canadian Charter of Rights and Freedoms . The petitioners are autistic children and their parents. They argue that the government’s failure to fund applied behavioral therapy for autism unjustifiably discriminated against them. In the background lies the larger issue of when, if ever, a province’s public health plan under the Canada Health Act, R.S.C. 1985, c. C-6 (“CHA ”), is required to provide a particular health treatment outside the “core” services administered by doctors and hospitals.
2 One sympathizes with the petitioners, and with the decisions below ordering the public health system to pay for their therapy. However, the issue before us is not what the public health system should provide, which is a matter for Parliament and the legislature. The issue is rather whether the British Columbia Government’s failure to fund these services under the health plan amounted to an unequal and discriminatory denial of benefits under that plan, contrary to s. 15 of the Charter . Despite their forceful argument, the petitioners fail to establish that the denial of benefits violated the Charter .
3 The government must provide the services authorized by law in a non-discriminatory manner. Here, however, discrimination has not been established. First, the claim for discrimination is based on the erroneous assumption that the CHA and the relevant British Columbia legislation provided the benefit claimed. Second, on the facts here and applying the appropriate comparator, it is not established that the government excluded autistic children on the basis of disability. For these reasons, the claim fails and the appeal is allowed.
II. History of the Case
4 The four infant petitioners suffer from autism, a neuro-behavioural syndrome caused by a dysfunction of the central nervous system that impairs social interaction, hinders communication and results in repetitive, stereotyped behaviour. The symptoms and effects of autism vary from mild to severe. Over 90 percent of untreated autistic children end up in group homes or other residential facilities.
5 The cause and cure of autism remain unknown. However, a 1987 study published by a Texas researcher, Dr. O. Ivar Lovaas, suggested that applied behavioural therapy based on the repetitive use of stimuli and emphasized cues might help some autistic children between ages three and six. The therapy is intensive and therefore expensive — between $45,000 and $60,000 per year. It is not always successful; the trial judge found only that in “some cases” it may produce “significant results” ((2000), 78 B.C.L.R. (3d) 55, 2000 BCSC 1142, at para. 51). While increasingly accepted, Applied Behavioural Analysis (“ABA”) or Intensive Behavioural Intervention (“IBI”) therapy is not uncontroversial. Objections range from its reliance in its early years on crude and arguably painful stimuli, to its goal of changing the child’s mind and personality. Indeed one of the interveners in this appeal, herself an autistic person, argues against the therapy.
6 The infant petitioners received Lovaas therapy. Their parents, the adult petitioners, funded the treatment, although Connor Auton’s mother ultimately became unable to continue for financial reasons. Until the government forbade it on the ground that new options were being evaluated, some families used funds for support services from the Ministry of Children and Families to help finance Lovaas therapy for their children with the tacit support of Ministry workers in some regions. Over a period of years, the petitioners and others lobbied the Ministers of Health, of Education, and of Children and Families for funding for Lovaas therapy, without success. In 1995, the petitioners commenced this action.
7 In the years leading up to the trial in 2000, the government funded a number of programs for autistic children and their families. This was done through the Ministry of Children and Families, which in 1997 had been given responsibility for child and youth mental health. The programs included infant development, supported child care, at-home respite, respite relief, contracted respite, occupational therapy, physical therapy, speech and language therapy, homemaker and home support services, hearing services, child care workers and specific behavioural support. Under the latter category, some programs attempted to positively treat autism. The Ministry provided services to autistic children through contracted agencies, some of which employed some behavioural analysis techniques. However, the focus was on teaching families the techniques to enable them to work themselves with the children.
8 An early intervention ABA/IBI program called LEAP had been established in Ladner but it was underfunded and equipped to serve only six children. Other centres and groups provided some ABA/IBI but the Crown’s expert, Dr. Glen Davies, testified that these programs were not intensive, not delivered early enough in the child’s development, and were rarely of sufficient duration to maximize the child’s development. Finally, in May 1999, the Ministry announced an Autism Action Plan and an Autism Action Implementation Plan, which acknowledged the importance of early intervention, diagnosis and assessment, but stated that services for autistic children had to be balanced with services to children with other special needs. Moreover, the plan did not specifically target ABA/IBI therapy. As of the date of trial a year or so later, the Ministry had not produced much. No new funding had been provided and a concrete plan for intensive early treatment remained to be developed.
9 In a nutshell, at the time of trial the government funded a number of programs for young autistic children, and appeared to be moving toward funding some form of early intervention therapy. However, it had not established funding for intensive, universal ABA/IBI therapy available to all autistic children between the ages of three and six.
10 This delay appears to have been due to a number of factors. The first was the 1997 decision to transfer child and youth mental health from the Ministry of Health to the Ministry of Children and Families, which put a non-medical slant on treatment. The second was financial constraint: in 1998, the deputy ministers of the ministries of Health, Education, and Children and Families informed families that the government was not “in a resource position” to fund ABA/IBI therapy.
11 A final factor may have been the emergent and somewhat controversial nature of ABA/IBI therapy, although by the time of the trial the evidence was sufficient to convince the trial judge that it was “medically necessary” (para. 102). At the time of trial in 2000, ABA/IBI funding for autistic children was only beginning to be recognized as desirable and was far from universal. Alberta established funding for it in 1999, as did Ontario. Prince Edward Island was providing up to 20 hours of ABA/IBI per week at the time of trial, and Newfoundland and Manitoba had instituted pilot projects in 1999. In the United States “several jurisdictions” included ABA/IBI in educational or Medicaid programs, and the New York State Department Guidelines and the 1999 U.S. Report of the Surgeon General on Mental Health recognized ABA/IBI as the treatment of choice (trial judgment, at para. 82).
12 The petitioners sought funding for Lovaas therapy, a particular type of ABA/IBI therapy, from all three ministries. However, the trial judge dealt only with the claim against the Ministry of Health because she considered the issue “to be primarily a health issue” (para. 88).
13 Having thus narrowed the claim, the trial judge went on to find that applied behavioural therapy is a “medically necessary” service for autistic children. I note that she used the term “medically necessary” to mean, in a general way, a medical service that is essential to the health and medical treatment of an individual. She ruled that by denying a “medically necessary” service to a disadvantaged group (autistic children, a subset of the mentally disabled), while providing “medically necessary” services to non-autistic children and mentally disabled adults, the government discriminated against autistic children, since “[t]he absence of treatment programmes for autistic children must consciously or unconsciously be based on the premise that one cannot effectively treat autistic children . . . [which is] a misconceived stereotype” (para. 127). She concluded, at para. 139:
The Crown has failed to take into account and accommodate the infant petitioners’ already disadvantaged position, resulting in differential treatment. That unequal treatment, which is based on the enumerated ground of mental disability, is discriminatory. Here the only accommodation possible is funding for effective treatment.
14 The trial judge went on to find that the discrimination was not justified under s. 1 of the Charter . She accepted that the government was entitled to judicial deference in allocating finite resources among vulnerable groups, but held that this did not immunize its decision to deny funding for ABA/IBI from Charter review, given that the exclusion of ABA/IBI therapy undermined the “primary objective” of medicare legislation, namely the provision of “universal health care” (para. 151).
15 The trial judge granted: (1) a declaration that failure to fund ABA/IBI breached s. 15 of the Charter ; (2) a direction that the Crown fund early intensive behavioural therapy for children with autism; and (3) a “symbolic” award of $20,000 under s. 24(1) of the Charter to each of the adult petitioners as damages for the financial and emotional burdens of litigation ((2001), 197 D.L.R. (4th) 165, 2001 BCSC 220, at paras. 64-65). She did not direct funding or reimbursement for the specific therapy requested and used, Lovaas therapy, on the ground that it was up to the government, not the court, to determine the nature and extent of ABA/IBI therapy funded on appropriate professional advice (para. 25).
16 The Court of Appeal agreed with the trial judge that the government had discriminated contrary to s. 15 of the Charter and that this could not be justified under s. 1 ((2002), 220 D.L.R. (4th) 411, 2002 BCCA 538). The discrimination lay in “the failure of the health care administrators of the Province to consider the individual needs of the infant complainants by funding treatment” (para. 51). This, to the appellate court, constituted “a statement that their mental disability is less worthy of assistance than the transitory medical problems of others”, thus creating a “socially constructed handicap” that worsened the position of an already disadvantaged group (para. 51).
17 The government was unable to satisfy its justificative burden under s. 1 of the Charter . It failed to establish a rational connection or proportionality between the objective of properly allocating limited resources between multiple demands and the denial of ABA/IBI therapy, given the importance of meeting the needs of autistic children and the potential benefits for the children and the community that would flow from ABA/IBI treatment. The Court of Appeal allowed the cross-appeal by adding funding for ABA/IBI treatment pursuant to medical opinion.
18 The government now appeals to this Court, and asks that these decisions be set aside.
III. Analysis
A. Did the Government’s Conduct Infringe the Petitioners’ Equality Rights Under Section 15 of the Charter ?
19 Section 15(1) of the Charter provides:
Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination and, in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age or mental or physical disability.
20 This case engages s. 15’s guarantee of “equal benefit of the law without discrimination . . . based on . . . mental . . . disability”.
21 Different cases have formulated the requirements for a successful s. 15(1) claim in different ways. Nevertheless, there is “broad agreement on the general analytic framework”: Eldridge v. British Columbia (Attorney General), [1997] 3 S.C.R. 624, at para. 58. In Andrews v. Law Society of British Columbia, [1989] 1 S.C.R. 143, at pp. 168 et seq. — this Court’s seminal statement on the interpretation of s. 15(1) —, the s. 15 analysis was described in two steps: first, whether there is unequal treatment under the law; and, second, whether the treatment is discriminatory. Similarly in Eldridge, supra, which also concerned a claim for medical services, La Forest J., at para. 58, put the test as follows:
A person claiming a violation of s. 15(1) must first establish that, because of a distinction drawn between the claimant and others, the claimant has been denied “equal protection” or “equal benefit” of the law. Secondly, the claimant must show that the denial constitutes discrimination on the basis of one of the enumerated grounds listed in s. 15(1) or one analogous thereto.
22 The dual requirements of Andrews, supra, and Eldridge, supra, were broken into three requirements in Law v. Canada (Minister of Employment and Immigration), [1999] 1 S.C.R. 497, at para. 88: (1) differential treatment under the law; (2) on the basis of an enumerated or analogous ground; (3) which constitutes discrimination.
23 There is no magic in a particular statement of the elements that must be established to prove a claim under s. 15(1) . It is the words of the provision that must guide. Different cases will raise different issues. In this case, as will be discussed, an issue arises as to whether the benefit claimed is one provided by the law. The important thing is to ensure that all the requirements of s. 15(1) , as they apply to the case at hand, are met.
24 A complicating factor is that however one states the requirements for s. 15(1) , they inevitably overlap. For example, the nature of the benefit, the enumerated or analogous ground at issue, and the choice of a correct comparator play a role in all three steps: see Hodge v. Canada (Minister of Human Resources Development), [2004] 3 S.C.R. 357, 2004 SCC 65. Frameworks thus do not describe discreet linear steps; rather, they serve as a guide to ensure that the language and purpose of s. 15(1) are respected.
25 Whatever framework is used, an overly technical approach to s. 15(1) is to be avoided. In Andrews, supra, at pp. 168-69, McIntyre J. warned against adopting a narrow, formalistic analytical approach, and stressed the need to look at equality issues substantively and contextually. The Court must look at the reality of the situation and assess whether there has been discriminatory treatment having regard to the purpose of s. 15(1) , which is to prevent the perpetuation of pre-existing disadvantage through unequal treatment.
26 In this case, the following issues arise from an application of the language of s. 15(1) to the facts:
(1) Is the claim for a benefit provided by law? If not, what relevant benefit is provided by law?
(2) Was the relevant benefit denied to the claimants while being granted to a comparator group alike in all ways relevant to benefit, except for the personal characteristic associated with an enumerated or analogous ground?
(3) If the claimants succeed on the first two issues, is discrimination established by showing that the distinction denied their equal human worth and human dignity?
(1) Is the Claim for a Benefit Provided by Law?
27 In order to succeed, the claimants must show unequal treatment under the law — more specifically that they failed to receive a benefit that the law provided, or was saddled with a burden the law did not impose on someone else. The primary and oft-stated goal of s. 15(1) is to combat discrimination and ameliorate the position of disadvantaged groups within society. Its specific promise, however, is confined to benefits and burdens “of the law”. Combatting discrimination and ameliorating the position of members of disadvantaged groups is a formidable task and demands a multi-pronged response. Section 15(1) is part of that response. Section 15(2)’s exemption for affirmative action programs is another prong of the response. Beyond these lie a host of initiatives that governments, organizations and individuals can undertake to ameliorate the position of members of disadvantaged groups.
28 The specific role of s. 15(1) in achieving this objective is to ensure that when governments choose to enact benefits or burdens, they do so on a non-discriminatory basis. This confines s. 15(1) claims to benefits and burdens imposed by law. As stated in R. v. Turpin, [1989] 1 S.C.R. 1296, at p. 1329:
The guarantee of equality before the law is designed to advance the value that all persons be subject to the equal demands and burdens of the law and not suffer any greater disability in the substance and application of the law than others. [Emphasis added.]
29 Most s. 15(1) claims relate to a clear statutory benefit or burden. Consequently, the need for the benefit claimed or burden imposed to emanate from law has not been much discussed. Nevertheless, the language of s. 15(1) as well as the jurisprudence demand that it be met before a s. 15(1) claim can succeed.
30 In this case, the issue of whether the benefit claimed is one conferred by law does arise, and must be carefully considered. The claim, as discussed, is for funding for a “medically necessary” treatment. The unequal treatment is said to lie in funding medically required treatments for non-disabled Canadian children or adults with mental illness, while refusing to fund medically required ABA/IBI therapy to autistic children. The decisions under appeal proceeded on this basis. The trial judge, affirmed by the Court of Appeal, ruled that the discrimination lay in denying a “medically necessary” service to a disadvantaged group while providing “medically necessary” services for others. Thus the benefit claimed, in essence, is funding for all medically required treatment.
31 This raises the question of whether the legislative scheme in fact provides anyone with all medically required treatment. An examination of the scheme shows that it does not: see Appendix A (Relevant Legislative and Regulatory Provisions) and Appendix B (Interaction of the Relevant Legislative and Regulatory Provisions).
32 The scheme designates two distinct categories of funded treatment based on service. First, the scheme provides complete funding for services delivered by medical practitioners, referred to as “core” services. This is required by the CHA . Many medically necessary or required services, including ABA/IBI therapy for autistic children, fall outside this core.
33 Secondly, the CHA permits the provinces at their discretion to fund non-core medical services — services that are not delivered by physicians. British Columbia does this by naming classes of “health care practitioners” whose services may be partially funded. It then falls to the Medical Services Commission, an administrative body, to designate particular practitioners and procedures within these categories for funding.
34 It was suggested that the reference by the Medicare Protection Act, R.S.B.C. 1996, c. 286 (“MPA”), to “medically required” services is an indication that all medically required or necessary non-core services must be funded. However, the Act does not say this. Section 1 uses the phrase “medically required services” in conjunction with the services of doctors or “medical practitioners” or an “approved diagnostic facility” (s. 1 “benefits”, paras. (a) and (c)). Only these services are funded on the basis of being “medically required”. “Medically required” in the MPA does not touch the services of “health care practitioners” which are funded only if the Province chooses to place a class of health care practitioner on an “enrolled” list by legislation or regulation: MPA, s. 1 “benefits”, para. (b).
35 In summary, the legislative scheme does not promise that any Canadian will receive funding for all medically required treatment. All that is conferred is core funding for services provided by medical practitioners, with funding for non-core services left to the Province’s discretion. Thus, the benefit here claimed — funding for all medically required services — was not provided for by the law.
36 More specifically, the law did not provide funding for ABA/IBI therapy for autistic children. The British Columbia MPA authorized partial funding for the services of the following health care practitioners: chiropractors, dentists, optometrists, podiatrists, physical therapists, massage therapists and naturopathic doctors. In addition, provincial regulations authorized funding for the services of physical therapists, massage therapists and nurses. At the time of trial, the Province had not named providers of ABA/IBI therapy as “health care practitioners”, whose services could be funded under the plan.
37 It followed that the Medical Services Commission, charged with administration of the MPA, had no power to order funding for ABA/IBI therapy. The Commission, as an administrative body, had no authority to enlarge the class of “health care practitioners”. That could be done only by the government. Since the government had not designated ABA/IBI therapists as “health care practitioners”, the Commission was not permitted to list their services for funding. This is how things stood at the time of trial. British Columbia’s law governing non-core benefits did not provide the benefit that the petitioners were seeking.
38 The petitioners rely on Eldridge in arguing for equal provision of medical benefits. In Eldridge, this Court held that the Province was obliged to provide translators to the deaf so that they could have equal access to core benefits accorded to everyone under the British Columbia medicare scheme. The decision proceeded on the basis that the law provided the benefits at issue — physician-delivered consultation and maternity care. However, by failing to provide translation services for the deaf, the Province effectively denied to one group of disabled people the benefit it had granted by law. Eldridge was concerned with unequal access to a benefit that the law conferred and with applying a benefit-granting law in a non-discriminatory fashion. By contrast, this case is concerned with access to a benefit that the law has not conferred. For this reason, Eldridge does not assist the petitioners.
39 However, this does not end the inquiry. Courts should look to the reality of the situation to see whether the claimants have been denied benefits of the legislative scheme other than those they have raised. This brings up the broader issue of whether the legislative scheme is discriminatory, since it provides non-core services to some groups while denying funding for ABA/IBI therapy to autistic children. The allegation is that the scheme is itself discriminatory, by funding some non-core therapies while denying equally necessary ABA/IBI therapy.
40 This argument moves beyond the legislative definition of “benefit”. As pointed out in Hodge, supra, at para. 25:
. . . the legislative definition, being the subject matter of the equality rights challenge, is not the last word. Otherwise, a survivor’s pension restricted to white protestant males could be defended on the ground that all surviving white protestant males were being treated equally.
We must look behind the words and ask whether the statutory definition is itself a means of perpetrating inequality rather than alleviating it. Section 15(1) requires not merely formal equality, but substantive equality: Andrews, supra, at p. 166.
41 It is not open to Parliament or a legislature to enact a law whose policy objectives and provisions single out a disadvantaged group for inferior treatment: Corbiere v. Canada (Minister of Indian and Northern Affairs), [1999] 2 S.C.R. 203. On the other hand, a legislative choice not to accord a particular benefit absent demonstration of discriminatory purpose, policy or effect does not offend this principle and does not give rise to s. 15(1) review. This Court has repeatedly held that the legislature is under no obligation to create a particular benefit. It is free to target the social programs it wishes to fund as a matter of public policy, provided the benefit itself is not conferred in a discriminatory manner: Granovsky v. Canada (Minister of Employment and Immigration), [2000] 1 S.C.R. 703, 2000 SCC 28, at para. 61; Nova Scotia (Attorney General) v. Walsh, [2002] 4 S.C.R. 325, 2002 SCC 83, at para. 55; Hodge, supra, at para. 16.
42 A statutory scheme may discriminate either directly, by adopting a discriminatory policy or purpose, or indirectly, by effect. Direct discrimination on the face of a statute or in its policy is readily identifiable and poses little difficulty. Discrimination by effect is more difficult to identify. Where stereotyping of persons belonging to a group is at issue, assessing whether a statutory definition that excludes a group is discriminatory, as opposed to being the legitimate exercise of legislative power in defining a benefit, involves consideration of the purpose of the legislative scheme which confers the benefit and the overall needs it seeks to meet. If a benefit program excludes a particular group in a way that undercuts the overall purpose of the program, then it is likely to be discriminatory: it amounts to an arbitrary exclusion of a particular group. If, on the other hand, the exclusion is consistent with the overarching purpose and scheme of the legislation, it is unlikely to be discriminatory. Thus, the question is whether the excluded benefit is one that falls within the general scheme of benefits and needs which the legislative scheme is intended to address.
43 The legislative scheme in the case at bar, namely the CHA and the MPA, does not have as its purpose the meeting of all medical needs. As discussed, its only promise is to provide full funding for core services, defined as physician-delivered services. Beyond this, the provinces may, within their discretion, offer specified non-core services. It is, by its very terms, a partial health plan. It follows that exclusion of particular non-core services cannot, without more, be viewed as an adverse distinction based on an enumerated ground. Rather, it is an anticipated feature of the legislative scheme. It follows that one cannot infer from the fact of exclusion of ABA/IBI therapy for autistic children from non-core benefits that this amounts to discrimination. There is no discrimination by effect.
44 The correctness of this conclusion may be tested by considering the consequences to the legislative scheme of obliging provinces to provide non-core medical services required by disabled persons and people associated with other enumerated and analogous grounds, like gender and age. Subject to a finding of no discrimination at the third step, a class of people legally entitled to non-core benefits would be created. This would effectively amend the medicare scheme and extend benefits beyond what it envisions — core physician-provided benefits plus non-core benefits at the discretion of the Province.
45 Had the situation been different, the petitioners might have attempted to frame their legal action as a claim to the benefit of equal application of the law by the Medical Services Commission. This would not have been a substantive claim for funding for particular medical services, but a procedural claim anchored in the assertion that benefits provided by the law were not distributed in an equal fashion. Such a claim, if made out, would be support