Source: http://hwlawyers.ca/cuthbertson-v-rasouli-2013
Timestamp: 2019-04-19 22:32:55+00:00

Document:
Referred to: Reibl v. Hughes,  2 S.C.R. 880; Hopp v. Lepp,  2 S.C.R. 192;Fleming v. Reid (1991), 4 O.R. (3d) 74; Malette v. Shulman (1990), 72 O.R. (2d) 417; E. (Mrs.) v. Eve,  2 S.C.R. 388; B. (R.) v. Children’s Aid Society of Metropolitan Toronto,  1 S.C.R. 315; Re S.D.,  3 W.W.R. 618; Starson v. Swayze, 2003 SCC 32,  1 S.C.R. 722; Golubchuk v. Salvation Army Grace General Hospital, 2008 MBQB 49, 227 Man. R. (2d) 274; Sweiss v. Alberta Health Services, 2009 ABQB 691, 483 A.R. 340; Children’s Aid Society of Ottawa‑Carleton v. C. (M.) (2008), 301 D.L.R. (4th) 194; E.J.G. (Re), 2007 CanLII 44704; G. (Re), 2009 CanLII 25289; A.K. (Re), 2011 CanLII 82907;Scardoni v. Hawryluck(2004), 69 O.R. (3d) 700; R. (Burke) v. General Medical Council,  EWCA Civ 1003,  3 W.L.R. 1132; Conway v. Jacques (2002), 59 O.R. (3d) 737; K.M.S. (Re), 2007 CanLII 29956; D.D. (Re), 2013 CanLII 18799; P. (D.), Re, 2010 CarswellOnt 7848; E.B. (Re), 2006 CanLII 46624;E. (Re), 2009 CanLII 28625; H.J. (Re), 2003 CanLII 49837; M. (A.) v. Benes(1999), 46 O.R. (3d) 271;D.W. (Re), 2011 CanLII 18217; S.S. (Re), 2011 CanLII 5000; N., Re, 2009 CarswellOnt 4748; Crits v. Sylvester (1956), 1 D.L.R (2d) 502, aff’d  S.C.R. 991; McInerney v. MacDonald,  2 S.C.R. 138; Norberg v. Wynrib,  2 S.C.R. 226.
Young, Hilary. “Why Withdrawing Life‑Sustaining Treatment Should Not Require ‘RasouliConsent’” (2012), 6:2 M.J.L.H. 54.
 The appellant physicians in this case take the position that the HCCAdoes not apply because consent is not required for withdrawal of life support that does not provide any medical benefit to the patient. The courts below rejected that contention, as would I. It follows that the appeal should be dismissed. Where a substitute decision-maker does not consent to the withdrawal of life support, the physicians’ remedy is an application to the Board.
 This case turns on statutory interpretation — what the HCCAprovides. It is not a case about who, in the absence of a statute, should have the ultimate say in whether to withhold or withdraw life-sustaining treatment. Nor does the case require us to resolve the philosophical debate over whether a next-of-kin’s decision should trump the physicians’ interest in not being forced to provide non-beneficial treatment and the public interest in not funding treatment deemed of little or no value. The Ontario legislature has addressed the conflicting interests and arguments that arise in cases such as this in theHCCA. The Court’s task is simply to determine what the statute requires. I note that the parties did not address resource implications or Charter issues in this appeal.
 However, the traditional common law approach to medical treatment is more problematic when a patient is incapable of appreciating the nature, purpose, and consequences of the proposed treatment. As explained in Malette v. Shulman(1990), 72 O.R. (2d) 417 (C.A.), at pp. 423-24, the common law doctrine of informed consent “presupposes the patient’s capacity to make a subjective treatment decision based on her understanding of the necessary medical facts provided by the doctor and on her assessment of her own personal circumstances”. When such capacity is lacking, the patient is not in a position to exercise his autonomy by consenting to or refusing medical treatment.
 The HCCA starts from the general premise that medical treatment cannot be administered without consent: s. 10(1). Building on this premise, the HCCAgoes on to provide a detailed scheme governing consent to treatment for incapable patients. It provides that a substitute decision-maker must consent to treatment of an incapable patient: ss. 10(1)(b) and 20. The statute sets out a clear hierarchy designating who will serve as substitute decision-maker: s. 20(1). This will often be a close family member of the patient, furthering the statutory objective of ensuring “a significant role for supportive family members when a person lacks the capacity to make a decision about a treatment”: s. 1(e).
 In summary, withdrawal of life support aims at the health-related purpose of preventing suffering and indignity at the end of life, often entails physical interference with the patient’s body, and is closely associated with the provision of palliative care. Withdrawal of life support is inextricably bound up with care that serves health-related purposes and is tied to the objects of the Act. By removing medical services that are keeping a patient alive, withdrawal of life support impacts patient autonomy in the most fundamental way. The physicians’ attempt to exclude withdrawal of life support from the definition of “treatment” under s. 2(1) of the HCCAcannot succeed.
 One of the legislature’s primary motivations in enacting the HCCA was to simplify the law governing the treatment of incapable patients. The HCCA sets out clear rules requiring consent before treatment can occur, identifying who can consent for an incapable patient, stating the criteria on which consent must be granted or refused, and creating a specialized body to settle disputes. The legal framework of theHCCA has been used to resolve end-of-life disputes in Ontario for 17 years. I would be reluctant to close off access to this established regime and cast these matters back into the courts.
 However, the converse is not true. As discussed below, there is no clear right under the Act or at common law for a patient to insist on a particular treatment if the doctor is not prepared to provide or continue to provide it. The HCCAreflects the consensus at common law, and does not require that a patient’s wishes prevail. When the issue is the withdrawal of treatment that is no longer medically effective or is even harmful, a patient’s choice alone is not an appropriate paradigm. A patient’s autonomy must be balanced against broader interests, including the nature of her condition, the implications of continuing the treatment, the professional obligations of her physicians, and the impact on the broader health care system. This reflection of the common law is evident from the purposes, provisions, and scheme of the Act.

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