Saturday, December 8, 2012

Hassan Rasouli’s end-of-life case in the hands of the Supreme Court

A faint smile flickers over Hassan Rasouli’s face when family members update him on their landmark legal fight to keep him on life support. Or, at least, so the Rasouli family believes. “We reassure him everything is going well,” said his 29-year-old daughter, Mojgan. “My father has become a representative of the value of life. ” But on the other side of a chasm that divides the family from the medical team at Sunnybrook Health Sciences Centre that keeps Mr. Rasouli alive, doctors see a man with no quality of life and no hope of recovery. To them, Mr. Rasouli’s facial movements are involuntary and mechanical; they believe there is no realistic course of treatment to offer, aside from a dignified death. The result is a clash between deeply religious Islamic family members who believe life must be maintained at all costs, and a medical team that believes keeping Mr. Hassan alive borders on torture. Two critical-care physicians at Sunnybrook, Brian Cuthbertson and Gordon Rubenfeld, have taken the case to the Supreme Court of Canada. On Monday, the court will hear arguments in the precedent-setting battle. When it releases its ruling, likely several months from now, it could decide that doctors are free to withdraw life support unilaterally. Alternatively, the court could say the wishes of a patient and his family are paramount. Or, the court could opt for a middle road, giving the last word to a board of neutral arbiters. Lawyers who work with mentally disabled or elderly clients are looking to the Supreme Court to bring clarity to an uneven, emotionally fraught area of law. Jan Goddard, a Toronto lawyer who specializes in the field, said there has been a strong move in recent years for people to create documents expressing their wishes for when they would want to be taken off life support if they are ever incapable of deciding themselves. Ms. Goddard said the Sunnybrook case could throw a wrench into these efforts. “Termination of treatment that supports life is probably the issue most commonly raised by clients making advance directives,” she said. “I wonder what those conversations might be like between lawyer and client – or a person and his or her substitute decision-maker – if the court agrees with the doctor’s position that consent is not required?” Doctors and legislators also hope the court decision will provide much-needed guidance for dealing with people whose brains or minds have been irretrievably damaged. “Every single intensive-care unit has at least one patient who is not benefiting from being kept alive,” said Mark Handelman, a Toronto lawyer who represents families and doctors in end-of-life cases. “Listen, I understand why politicians aren’t debating this – nobody wants another abortion-type debate,” Mr. Handelman said. “But we have to address it. Frankly, I think this debate is going to make the abortion debate look like a Tuesday tea party.” Patients who are in a state of severe brain deterioration, he said, cause moral distress to both medical staff and family members who are trying to do the right thing. “Those beds cost roughly a million dollars a year, and we have an aging population of yuppies with a great sense of entitlement to everything – including health care,” Mr. Handelman added. The clash of interests has been coming for a long time. Medical science can slow the process of death in ways that were once inconceivable. At the same time, ever-more-sensitive instruments can detect minute variations in the brain activity of deteriorating patients. The two advances have collided, creating pressure to keep patients on life support based on their faintest responses to stimuli. Anand Kumar, a Winnipeg physician with experience in end-of-life treatment, said it is theoretically possible to conduct one organ transplant after another, and hook patients up to a succession of machines that remove fluids, cleanse blood and replace failing processes indefinitely.

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