The advancements in modern medicine in the last few decades are responsible for new treatment methodologies in treating deadly diseases. However, there are some areas of the human body that still remain a mystery. The human brain is one of the more complex organs and there is no forseeable outcome irrespective of the infirmity. The medical community faces hard choices whenever they encounter a difficult situation involving brain damage. The chances for recovery from a severe brain damage are slim. Hence, during such times, a hospital staff will request the family for consent to withdraw specific medical treatment or life support for vegetative patients. If allowed, the hospital can utilize the resources (physicians, nursing staff, and equipment) for patients who have a realistic chance to recover. The resources in a hospital can never anticipate their patient intake or escalation of a patient’s condition (Braddock III, “Termination of Life-Sustaining Treatment”).
B. Issue
Can the hospital withdraw or withhold treatment that can prolong the life of a terminally ill patient? The law and medical ethics confirm that the withdrawal must have the consent of the family or the patient if he/she is competent to make that decision. While the physicians can contend that the withdrawal of treatment will benefit the patient by reducing the period of time spent in pain, there is no case for them when they do not have the consent of the patient’s family (Corfield, Granne, and Latimer-Sayer 34). Furthermore, the law dictates that medical interventions and treatments for vegetative patients must continue if they reduce pain. The other important facet of the problem is the lack of communication. This can relate to incomplete information on the religious tenets of the patient and the misinterpretation of behavior.
C. The Parties
The parties involved in this case are the Sunnybrook Hospital medical physicians and Mrs. Salasel Rasouli, the spouse of the patient. Mr. Hassan Rasouli underwent surgery for brain tumors and contracted an infection post-surgery. The patient’s brain suffered severe damage and he remains in a vegetative state. The medical physicians of Sunnybrook Hospital provided treatment to Mr. Rasouli through a ventilator. However, with no improvement in his medical condition, the hospital’s medical physicians concluded that it will be in the best interest of the patient to withdraw the ventilator-based life sustenance. When requested for consent, Mrs. Salasel Rasouli refused to accept the hospital’s request.
D. Section 1 – Sunnybrook Hospital Medical Physicians
1. Concise Statement of Sunnybrook Hospital Medical Physicians’ Position
All patients require treatment and care to improve their chances of cure. When a patient does not have a chance of survival despite extensive medical interventions, the best option is to withdraw the life supporting treatment. The chances for recovery in Mr. Rasouli’s case are nonexistent. The prolonging of the treatment only blocks other patients who have a chance to survive to avail the best possible care. There is vindication to remove and withhold certain types of treatment for Mr. Rasouli. This will result in a less painful death and within a shorter duration.
2. Detailed Rationale of Sunnybrook Hospital Medical Physicians
The patient Mr. Hassan Rasouli has severe brain damage and is unable to sustain any improvement. All the lab tests conducted for the patient indicate that his condition will not improve. Although he is probably not brain dead, he is still not in a progressive medical state. This means that the time and resources (staffing, lab hours, and treatment costs) spent on this patient is futile. In a case of medical futility, the physicians who treat the patient can provide their findings to a group of doctors for approval to remove the life support mechanisms or halt a particular medical intervention.
The infection causing the brain damage will enable the patient to feel pain since his brain is not dead yet. The Muslim religion only propagates the right to treatment when there is a chance of recovery. In this case, there is no chance of recovery and of Mr. Rasouli regaining consciousness. Moreover, the mild signs supposedly witnessed by the family might be no more than reflexes. According to Sherer M and Vaccaro M, eye movements such as blinking are signs of a vegetative state (Sherer and Vaccaro, “Facts about the Vegetative and Minimally Conscious States after Severe Brain Injury”). Hence, despite the fact that the patient is not in a position to make the decision to withhold certain treatment, the hospital must have the authority.
The court only considers the Ontario Health Care Consent Act in the case without widening the scope (Blake, “Rasouli v Sunnybrook Health Services Centre: End of Life matters reach the Supreme Court of Canada”). The patient will eventually die despite sustenance on ventilator support. Although, it might be more painful. Removing life support systems will help the patient to pass on peacefully. The duty of a hospital and its physicians does not curtail in enabling the patient to have a less painful experience overall. In the case of Mr. Hassan Rasouli, the intent is to limit the patient’s suffering and not to harm. The court must not rule only based on the emotions of family members, but on the absolute rule of the law. The Health Care Consent Act specifies that the patient reserves the right to decline treatment based on mental capacity.
The court ruled favorably towards the patient in the 2003 Starson v Swayze case because has the mental capacity. In this case, there is no medical or irrefutable physical evidence that Mr. Rasouli is capable of making that decision. In such a case, the court must consider the ramifications of allowing a suffering patient to prolong his life. The family is only looking at the religious beliefs and even in understanding the Koran, they are inaccurate.
3. Mrs. Rasouli’s position and why the Rationale of Sunnybrook Hospital Medical Physicians is more compelling
The life support machine that the family of the patient cleaves to is in reality an organ support machine. The ventilator keeps the organs functioning to ensure the possibility of donation. The reason why hospitals usually use ventilators is to allow families to say goodbye to their loved ones. The ventilators allow out of town relatives an opportunity to reach on time to pay their final respects. The patient in question, Mr. Hassan Rasouli was on the ventilator for more than two weeks. There are no signs of improvement. Emotionally compromised family members are incapable of making the right decisions in such situations. Hospital staffs receive intense training to save lives and it is a very difficult decision for them to give up on a patient. However, it is not advisable to utilize resources on a patient who is brain dead since death is an eventuality in such cases.
The chance for recovery becomes real only when the brain retains function and that is not the case here. Furthermore, the physicians will examine the patient once more before concluding the removal of the ventilator. If the patient exhibits any brain stem reflexes, the hospital will not remove the ventilator. This process proves that the hospital is only looking out for the best interest of the family and the patient. Mr. Rasouli did not pass the apnea test where the carbon dioxide levels reach a state where a human being will start breathing without ventilator support. This is proof that the chances of recovery are nonexistent for this patient. Terri Schiavo in 2004 remained unconscious in a vegetative state despite her eyes wide open. The family was unable to comprehend that she was in fact unconscious. The more recent case of 13-year old Jahi McMath, where a US Judge ruled in favor of the hospital is almost the same as Hassan Rasouli (Rettner, “Life After Brain Death: Is the Body Still 'Alive'?”). The patient has a very rare chance of recovery and there is no way to be sure of that. Hence, the position of the Sunnybrook Hospital is more compelling.
e. Section B - Mrs. Rasouli, patient’s spouse
1. Concise Statement of Mrs. Salasel Rasouli’s Position
A Muslim has the right to seek treatment when he is sick. It is the word of the Prophet Mohammad. It is against the Koran and the religion to forego medical treatment. The hospital lacks knowledge in the religious tenets or is ignorant of it. Mr. Rasouli is not vegetative and he is showing signs of improvement. There are cases where a vegetative state is misdiagnosed and there are people who made a complete recovery from that condition.
2. Detailed Rationale of Mrs. Salasel Rausuli
The Islamic religion dictates absolute authority through the Koran. There are no exceptions to the rule. There is no provision to take a human life and there is no provision to deny medical treatment when it is available. The ventilator is what keeps Mr. Rasouli alive. However, he is improving and there are signs indicating this. Relatives from different visits noticed blinking of eyes, movement of fingers, and other signs that indicate improvement. Under Islamic tenets, if there are signs of life, the treatment must continue (Rosen, “Rasouli V. Sunnybrook Hospital: A Case About End-Of-Life Decision Making”).
The hospital cannot overlook the signs since there is a chance that their diagnosis is incorrect. Rom Houben of Belgium diagnosed with a vegetative state made a full recovery despite doctors at the hospital writing him off as in a “vegetative state”. Houben stayed trapped in an induced coma until doctors found normal brain activity in his twenty-three years later. They assumed that he did not have feeling or consciousness. However, the evidence after newer tests revealed that he was conscious the entire time (Tutton, “Trapped 'coma' man: How was he misdiagnosed?”).
In 2011, a team of international scientists conducted an experimental test on patients marked as “vegetative”. They passed the electric signal through the brain and realized that some of them had regular brain activity despite the physicians’ diagnosis. The signs they revealed in their subsequent research were winking eyes and movement in the fingers. This is absolute proof that the physicians at Sunnybrook Hospital made a mistake in the diagnosis. The hospital has the duty to run the tests since they are Journal published. There is proof that the tests will prove the patient’s condition without doubt (Stein, “New technique spots patients misdiagnosed as being in ‘vegetative state’”).
3. Sunnybrook Hospital’s position and why the Rationale of Mrs. Rasouli is more compelling
The people who concluded that Mr. Rasouli will not recover did not conduct the electrical signal test on the brain. This leaves the chance that they are wrong about the decision. In addition, their experts do not profess to the experimental process that the American scientists used. Without trying out all possible strategies, their conclusion to remove life support from the patient is unacceptable. The Sunnybrook Hospital did not establish without any doubt since they are not considering the experimental process. Therefore, there is a chance that the patient might recover.
The problem of misdiagnosis among vegetative patients is not new. The problem persists through the last decade. There are multiple studies dating back to 2005 which point out discrepancies. The European Neurological Society conducted a study in 2007 and concluded that over forty percent of the patients diagnosed with a vegetative state were in fact misdiagnosed. The study also underlined the fact that the statistic for the misdiagnosis did not record any change in the fifteen-year period before (The News-Medical.net, “High rate of misdiagnosis in patients in an acute vegetative state”). This being the case, how does the Sunnybrook Hospital staff decide that this statistic changed in the last twelve years and let alone assume that they are not wrong about the diagnosis for Mr. Rasouli?
Researchers in the medical community are constantly reporting cases of misdiagnosis. In a published journal in 2014, Dr. Omar Hasan Kasule, concludes that hospitals should review legal cases and update hospital practices every three years (Kasule, “Brain death: Criteria, signs, and tests”). If the Sunnybrook Hospital updated practices, they will know of the new test which can identify cases of misdiagnosis. It is also not uncommon for hospitals to pressurize families from lower income communities into removing ventilator support. The case of Chris Dunn is an example. In this case, despite the patient’s ability to respond to questions, the hospital sticks to its decision to remove life support. The lack of medical insurance and the middle class status of Mr. Dunn are hard to ignore (Corombos, “Hospital set to 'pull plug' on a patient who wants to live”). The case is not very different for the Rasouli family financially.
The possibility of recovery allows the religious tenets of the Koran to also take effect. Hospitals should expand on medical practices to ascertain whether or not their diagnosis is 100% error free. When there is a record of misconception, it is always viable to try out newer technology. The examination of the brain with electrical signals is experimental, however; it is certainly worth it if a life is at stake. Unlike medical errors relating to treatments, there are no alternatives to death. No treatment can bring back a dead patient. Hence, the hospital should remain sensitive to their mission of improving the quality of life for their patients. The case of the Belgian was sufficient evidence for the hospital to probe for signs of brain activity by introducing electrical signals (Tutton, “Trapped 'coma' man: How was he misdiagnosed?”). Their lack of initiative is regrettable.
Works Cited
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