End-Of-Life Legal Analysis

Mr. Rasouli and His Family (1994)

Module 3 of Queen’s University’s BMED 373 course focuses on the ethical, legal, and policy issues related to end-of-life care. We were presented with the IDEA Ethical Decision-Making Framework and used it to discuss the Supreme Court case of Cuthbertson v Rasouli. Hassan Rasouli was a 59-year-old patient at Sunnybrook Health Sciences Centre who became comatose after bacterial meningitis spread throughout his brain. As Mr. Rasouli was initially admitted to undergo a routine surgery, he was never afforded the opportunity to directly express his wishes. According to Section 20 of the Ontario Health Care Consent Act (HCCA), Parichehr Salesel, the patient’s wife, was identified as the substitute decision-maker. Although Mrs. Salesel’s role as the substitute decision-maker was undisputed, Mr. Rasouli’s medical team did not agree with her decision to continue life-support.

Mr. Rasouli and His Family (2012)

Two of Mr. Rasouli’s physicians, Dr. Cuthbertson and Dr. Rubenfeld, believed that ending his current treatment in favour of palliative care was in the patient’s best interest. Matters were further complicated when Mozhgan Rasouli, the patient’s daughter, released a video pleading her father’s case. This leads us to the elephant in the room. When the opinions of a patient’s family and medical team are in direct conflict, what do we do? In order to answer this, we must first take a look at the cause of dispute within this case, the definition of treatment.

The Ontario Health Care Consent Act defines treatment as “anything that is done for a therapeutic, preventative, palliative, diagnostic, cosmetic or health-related purpose…”

The attending physicians argued that “life support that is not ‘medically indicated’ is not ‘treatment’” under the previously mentioned definition in the HCCA. While the Supreme Court addressed the ambiguity of the definition, they ultimately ruled that starting palliative care does constitute treatment. They further added that the removal of life support impacts patient autonomy and directly violates the underlying principles of the HCCA.

Personally, I agree with the decision made by the court. As Mr. Rasouli is unable to communicate, altering his treatment plan must be consented to by his substitute decision-maker. The HCCA is a lawful document that clearly outlines how the substitute decision-maker is selected and we must respect her ability to express the patient’s best interests.

The responsibilities of health advocacy are fourfold: (1) Patient needs, (2) Community needs, (3) Identifying social determinants of health, and (4) Health promotion. As such, there are two main facts that, if different, could result in me taking a different stance. Firstly, if Mr. Rasouli had personally expressed that he did not wish to be kept alive by life support, either through discourse with a physician or an advance care directive, I would argue that Mrs. Salesel’s stance no longer represents the best interests of the patient. Secondly, if Sunnybrook Health Sciences Centre had grossly limited resources such that the continuation of Mr. Rasouli’s treatment became detrimental to the larger community, I would be more inclined to side with the physicians. This would dramatically change the case and it’s impossible to speculate on the legal outcome of this hypothetical situation.

After identifying the facts in the IDEA Framework, we are encouraged to determine the ethical principles. The most glaring ethical dilemma in this case is that the removal of life sustaining treatment that is in line with the patient’s best interest (in this case expressed by his substitute decision-maker) largely violates the patient’s autonomy. Additionally, it is known by all that the discontinuation of Mr. Rasouli’s life support will directly cause his death. This situation reminded me of the Hippocratic Oath that one of my classmate’s quoted in an earlier discussion board and the doctor’s pledge to “keep patients from harm.” To me, engaging in an action that will bring about the death of a patient, knowing it is in violation of what they want, goes against this part of the oath. Lastly, the various news articles surrounding this case demonstrate the role culture plays in decisions surrounding end-of-life care. It is extremely important that physicians demonstrate cultural sensitivity and recognize the roles that our unique beliefs and experiences as humans bring to ethical situations.

When weighing the patient’s autonomy, role of physicians to keep patients from harm, and the cultural differences of the family, I would agree with the legal reasoning of this case. I believe that the decision of the Supreme Court is not only in line with the literal wording of the HCCA, but also it’s underlying theme of protecting patients’ rights to ownership of their own medical treatment.

– Michael

If this post interested you and you would like to better understand the case of Mr. Rasouli, please explore the following:

Hassan Rasouli Case: Top Court Upholds Right To Demand Life

Rasouli Case: Supreme Court Mulls Tough Questions On End Of Life Care

A Life Interrupted: Hassan Rasouli’s journey from an earache to a high-stakes battle over end-of-life decisions

The Supreme Court Decision In Rasouli

References

Cuthbertson v. Rasouli. (2013). SCC 53, [2013] 3 S.C.R. 341
https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/13290/index.do

Health Care Consent Act. (1996). Ontario. https://www.ontario.ca/laws/statute/96h02

Queen’s University. (2021). BMED 373 – Health Ethics, Law, and Policy