The difficulty of saying goodbye: The Hassan Rasouli case

The family of Hassan Rasouli, a retired engineer on life support for the past three years, won its appeal to the Supreme Court of Canada. The court denied doctors the power to remove the devices keeping him alive against the wishes of his family.

His physicians argued they are morally distressed that they are obliged to order painful treatments, distressed because the best outcome they can hope for is to keep Mr. Rasouli in a state of living death. The medical and nursing treatment of individuals in critical condition entails the extensive handling and manipulation of the body. Patients have the right to avoid the degrading invasion of their bodies for no good purpose.

His wife believes that he, as a devout Muslim, would wish to be kept alive. Mr. Rasouli had not expressed a wish. His lawyer described him as an individual who cannot communicate.

In Ontario, legislation dictates that physicians need to explain to an intellectually competent patient the consequences of having or not having the treatment, and to obtain his consent to the treatment plan. When the patient does not have the ability to decide for himself, the substitute decision-maker (SDM) is expected to step into the shoes of the patient and make decisions based on the patient’s known wishes, or, if unknown, in the person’s best interest. The SDM cannot decide based on what they would prefer for the patient.

If physicians feel that the SDM is not following the patient’s wishes, or, not acting in his/her best interest, the case may be referred to the Consent and Capacity Board. The board must convene within three days. In the past 17 years, the board has developed a strong track record in handling precisely the issue raised in this case.

The family still retains the right of appeal to the courts in case of disagreement with the decision by the board.

The Supreme Court ruled against the Sunnybrook physicians because they did not follow the law — they did not apply to the Consent and Capacity Board. In the words of Chief Justice McLachlin, “The (Supreme) Court’s task is simply to determine what the statute (law) requires.”

Here are the facts. Medical technology and drugs are now so powerful that we can sustain patients for years in our intensive care units. Some patients choose such care even when the quality of life at best is and will be poor. They may so choose because death is unacceptable, or because only God can end life or because they do not wish to cause sorrow for loved ones. The substitute decision maker may not be able to say good-bye. These are some examples.

Such care is very expensive. A year in the ICU costs $1,000,000. Here in Sudbury, we continue to advocate for funding for subsidized housing for the poor elderly; for funding to shorten wait times for surgery; to improve the pay and working conditions of personal support workers. For the second year, the budget of Health Sciences North is frozen in spite of increasing patient demand and inflation.

What is the right course of action? The opinion of our highest court is clear. The Supreme Court of Canada has just ruled that the decision on how to deal with an issue like Mr. Rasouli’s is up to government. It is up to the men and women we elect to decide whether to pass new laws or change old ones.

Here are the key issues of the case from my perspective. Should there be limits on what a patient/family can demand from physicians when those demands are deemed not only of little value but indeed harmful? Should there be limits on what a patient/family can demand our publicly funded health care system when the demands are deemed of little value, harmful and are costly?

I am convinced that our political leaders must face these issues squarely and legislate limits, after due public consultation and consideration.

Dr. Peter Zalan is president of the medical staff at Health Sciences North. His monthly column tackles issues in health care from a local perspective.