OTTAWA - Doctors cannot unilaterally decide to withdraw life support without the consent of the patient, their family members or a substitute decision maker, the Supreme Court of Canada has ruled.
The highly anticipated decision, hailed as a victory by some religious groups, upholds existing legislation in Ontario and several other provinces.
But it does little to resolve some of the more intractable ethical dilemmas posed by advances in modern medicine that allow patients in vegetative states to be kept alive for years.
In a 5-2 split decision on what the top court called a "tragic, yet increasingly common conflict," Chief Justice Beverley McLachlin wrote for the majority that, in provinces where such laws exist, disputes over end-of-life care decisions must go to independent tribunals or courts for resolution — and are not the sole purview of either doctors or patient's families.
Those independent tribunals may take into account non-medical factors, including the moral, ethical and religious views of the patient and their family.
Justice Andromache Karakatsanis, in a dissenting opinion, argued that Ontario's Health Care Consent Act does not "give patients, or their substitute decision-makers, the right to insist on the continuation of treatment that is futile, harmful, or contrary to medical standards of care."
The case involves 61-year-old Hassan Rasouli, who has been kept alive on a ventilator and feeding tube since brain surgery in 2010 went wrong.
Doctors at Toronto's Sunnybrook hospital have determined there is no therapeutic hope of recovery and that keeping Rasouli on life support will result in a series of progressively worse medical complications.
However, Rasouli's wife, Parichehr Salasel, refused consent, citing the couple's Shia Muslim religion and a belief that her husband's movements indicated some level of minimal consciousness.
Salasel screamed in approval Friday when the decision came down, saying she was "happy for all humans because we are, as a human, on top of the creation of God." She maintains her husband is responsive.
The Supreme Court elected not to wade into the intersection of science and faith, ruling simply that Rasouli's doctors couldn't do an end run around the Ontario Health Care Consent Act.
The "treatment" provisions of Ontario's law cannot be confined to something that doctors say is of therapeutic benefit to the patient, said the court.
"While the end-of-life context poses difficult ethical dilemmas for physicians, this does not alter the conclusion that withdrawal of life support constitutes treatment requiring consent under the HCCA," McLachlin wrote.
"If death is considered harmful or a manifestation of ill health, then life support serves a preventive purpose so long as it is effective in preventing death," the court dryly observed.
The ruling revolves around a statutory interpretation of Ontario's consent act. Similar legislation exists in five Canadian provinces.
"All the Supreme Court decided is that if you two disagree, please follow the procedures that are in place already," professor Udo Schuklenk, the Ontario Research Chair in Bioethics at Queen's University, said in interview.
Erica Baron at McCarthy Tetrault, a lawyer for one of the two doctors in the Rasouli case, said the court had provided "clarity" on when Ontario's law applies.
"Before this, our doctors were guided by the medical standard of care as well as well as College (of Physicians and Surgeons) and hospital policies," said Baron.
The ruling highlights a murky area for doctors and patients in provinces that do not have patient consent laws.
Jocelyn Downie, a bioethicist at Dalhousie University in Halifax, said other jurisdictions should take note and introduce a statutory regime that can both enhance patient autonomy and ensure proper care.
McLachlin, in her ruling, noted the judgment does not resolve who should have the ultimate say in end-of-life decisions in the absence of such legislation.
"Nor does the case require us to resolve the philosophical debate over whether a next-of-kin's decision should trump the physician's interest in not being forced to provide non-beneficial treatment and the public interest in not funding treatment deemed of little or no value," McLachlin cautioned.
That didn't stop Rasouli's family and some faith groups, including the Evangelical Fellowship of Canada, from claiming the ruling as a victory for religious rights.
Dahne Jarvis, who specializes in litigating health law with the Toronto firm Borden Ladner Gervais, said religious groups are reading too much into the judgment.
Experience shows that Ontario's consent and capacity board, which adjudicates consent disputes, has "not allowed religious beliefs to trump any of the considerations and factors that are brought to bear on what is considered to be in a patients' best interests," Jarvis said.
The high court has not decided "that everyone has the right to whatever treatment they choose at the end of life," Jarvis added.
"All they've decided is what process should be engaged."
— With files from Helen Branswell and Colin Perkel
Also on HuffPost:
Euthanasia In Canada
Here's a look at the state of Euthanasia laws in Canada and their history.
Suicide Not A Crime
Suicide hasn't been a crime in Canada since 1972. (Shutterstock)
Doctor-Assisted Suicide Illegal
Doctor-assisted suicide is illegal, although the ruling of the B.C. Supreme Court will force Parliament to alter the law within one year.<br><br> The <a href="http://laws-lois.justice.gc.ca/eng/acts/C-46/page-113.html#h-79" target="_hplink">Criminal Code of Canada states in section 241</a> that:<br><br> "Every one who (a) counsels a person to commit suicide, or (b) aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years." (Alamy)
Passive euthanasia involves letting a patient die instead of prolonging life with medical measures. Passive euthanasia is legal in Canada.<br><br> The decision is left in the hands of family or a designated proxy. Written wishes, including those found in living wills, do not have to be followed by family or a proxy. (Alamy)
<a href="http://en.wikipedia.org/wiki/Rodriguez_v._British_Columbia_(Attorney_General)" target="_hplink">Sue Rodriguez</a>, who suffered from amyotrophic lateral sclerosis (also known as Lou Gehrig's disease), launched a case asking the Supreme Court of Canada to allow her to end her own life on the grounds that the current law discriminated against her disability.<br><br> Because suicide is legal in Canada and Rodriguez was unable to end her life because of a lack of mobility, she argued it was discriminatory to prevent her from ending her own life with the aid of another.<br><br> The court refused her request in 1993, but one year later she ended her life anyway with the help of an unnamed doctor. (CP)
<a href="http://en.wikipedia.org/wiki/Robert_Latimer" target="_hplink">Robert Latimer was convicted of second-degree murder in the 1993 death of his severely disabled daughter Tracy</a>. A lack of oxygen during Tracy's birth led to cerebral palsy and serious mental and physical disabilities, including seizures and the inability to walk or talk. Her father ended Tracy's life by placing her in his truck and connecting a hose to the vehicle's exhaust.<br><br>The case led to a heated debate over euthanasia in Canada and two Supreme Court challenges. <br><br>Latimer was granted day parole in 2008 and full parole in 2010. (CP)
Bills To Legalize
Former Bloc Québécois MP Francine Lalonde tried repeatedly to get legislation legalizing euthanasia in Canada passed. Bill C-407 and Bill C-384 were both aimed at making assisted suicide legal. C-384 was defeated in the House 228 to 59, with many Bloc MPs and a handful of members from all other parties voting for the legislation.<br><br> Tetraplegic Tory MP Steven Fletcher, pictured, made the following statement after C-384 was defeated: <br><br> "I would like to be recorded as abstaining on this bill. The reason is I believe end of life issues need to be debated more in our country. I believe that life should be the first choice but not the only choice and that we have to ensure that resources and supports are provided to Canadians so that choice is free. I believe, when all is said and done, the individual is ultimately responsible. I want to make this decision for myself, and if I cannot, I want my family to make the decision. I believe most Canadians, or many Canadians, feel the same. As William Henley said in his poem Invictus, "I am the master of my fate: I am the captain of my soul."<br><br>(CP)