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In France, terminal stage medicine is not hopelessly ill.

In France, Terminal Stage Medicine Is Not Hopelessly III

In France, decisions regarding care for the terminally ill have produced a great deal of conflict for physicians and patients in many areas. Physicians must weigh their traditional obligations of respect for life against their patients' requests for passive or active euthanasia. Patients, meanwhile, are confronted with objections to their decisions not only by physicians but also by their relatives.

This situation appears similar to current debates in other Western countries. The French public has gradually become more aware of the specific difficulties of decisions about death, in which an emphasis on relief of suffering is increasingly pitted against new techniques of resuscitation, therapeutic overtreatment, and medical paternalism in general.

Patient Autonomy and

Paternalistic Care

One indication of this conflict has emerged in recent polls that show stronger than expected support for active euthanasia. In survey results released in November 1987, 63 percent of the respondents approved of a patient's "right to be actively helped in dying" on request. When such a request is made, 46 percent indicated the physician should decide on the moment and the means of administering lethal "help," while 37 percent viewed the patient as the primary decisionmaker, and 7 percent held this was a role for the family. According to 76 percent of those surveyed, physicians should not be held legally culpable for performing active euthanasia when the dying person has given his or her consent; and 79 percent affirmed that doctors should respect the wish of a patient expressed consciously and in written form. This finding of an increase in the firm rejection of discomfort and an "unworthy life" is very significant in a country noted for being conservative in its moral views and strongly influenced by the Roman Catholic tradition.

Nevertheless, the actual decisions and practices of families, even when a dying relative has indicated his or her desire not to have life prolonged, shows a tendency to respect life deeper than illustrated in the survey. Many families care for an elderly hemiplegic or semi-demented person at home; others will visit repeatedly a comatose person in an intensive care unit. Yet families often agree with physicians' judgment that in some cases "there is nothing to do," in part out of affection for their dying family member, and in part because their own fear of death and feelings of guilt are obviated by relinquishing decision-making authority to 'one who knows." An easy deference to the doctor in the case of a dying parent, then, appears at odds with a strong demand for autonomy for oneself.

Physician Authority and Discretion

Is, however, the physician's judgment bound by any rules? French law on euthanasia is quite simple: it is not permitted. Indeed, living will legislation that would have permitted only passive euthanasia was rejected by the National Assembly in 1978. Passive euthanasia or "letting die" would be an offense against the statute prohibiting failure to assist imperiled persons. The concern about the acceptability of passive euthanasia is partly influenced by slippery slope reasoning, that "letting die" will ultimately lead to "putting to death."

Professional practice, however, often diverges sharply from these official, legal considerations. There is, for example, an implicit agreement among members of the medical profession that at some point in the dying process it is permissible to let nature take its course. Quality of life considerations, particularly the capacity or incapacity for physical and intellectual autonomy, become more decisive than preservation of life itself. There has not yet occurred in France any significant debate about the validity of withdrawing nutrition and hydration from a terminally ill patient. In general, however, it is accepted that a determination about the use or withdrawal of medical technology is the responsibility of a physician or specialist.

In private some physicians will admit to having "helped" a patient to die, which is commonly understood as a reference to active euthanasia. As a colleague explained to a small group of students: "We don't do that qua physicians, as such, but qua friends, as an act of charity." It should be understood that active euthanasia is the exception, rather than the rule, among French medical professionals. Nevertheless, in rare cases physicians who believe their principal duty is to put an end to the sufferings of imploring patients have publicly affirmed their involvement in active euthanasia.

An additional element of secrecy exhibits what we ourselves refer to as the "French illness," and is supported by the paternalism rampant in French medicine. Disclosure of important information to a terminally ill patient is not considered a primary professional responsibility. Indeed, the Professional Code of French Physicians (which is approved by the National Assembly and therefore has the status of law in France) at Article 4.I reads: "The ill person may be kept in ignorance of a serious diagnosis or prognosis, for sound reasons that the physician determines in all conscience." Depending on the discretion of the professional, in certain cases withholding information from the "ill person" is expanded to withholding information from "the persons or family who care for the ill person."

What motivates this medical secrecy that keeps all dying patients in ignorance of their lethal prognosis? The answer has in part to do with the self-understanding of French medical professionals. French doctors generally entertain a high and proud sense of their own responsibility. A physician maintains that he alone has acquired the skill necessary to make a qualified decision; therefore, it is his duty to bear the weight of the decision. The physician is idealistically understood as a personification of truth and wisdom and a repository for the complete and absolute confidence of the patient.

Given this model of the physician-patient relationship, the main professional concern is that physicians maintain their liberty to decide on treatment. Hence, the profession has continually resisted any change in the laws governing medical practice that would draw the attention of the public to elements absent in both practice and the law, and would heighten the possibility of professional malpractice litigation. The parliamentary defeat of "living will" legislation has one of its real roots in opposition by the medical profession.

The Ethical Challenge for

French Medicine

Despite significant cultural and professional obstacles, various French care-givers, experts, and associations are initiating new procedures and relationships to meet the main difficulties in the care of the dying: relentless, unrelieved suffering, lack of partnership between physician and patient, and lack of professional education that results in meaningless communications and sometimes arbitrary decisions.

Progress is being made in the struggle against discomfort and suffering. The traditional taboo against providing morphine to relieve pain is now decreasing, though this risks placing the patient in a state of semi-consciousness. Roman Catholic doctrine, which is an unavoidable part of the French intellectual landscape, permits the use of drugs for the relief of pain even if they act to hasten the death of the patient. In a practice growing more slowly, families and teams of charitable volunteers render compassionate service to relieve the loneliness of the dying. The British and American hospice models will probably not be imitated directly in France, but their indisputably humane countenance, one could say, is softly beaming even on our old continent.

There is also need for physician paternalism to give way to a partnership between doctors and patients. Whether this will occur will depend on many factors, but there are signs that favor such a trend. Medical education emphasizes that a good relationship with one's patients is of great value in a time of growing competition between practitioners. Debates on medical issues on television have highlighted the problems caused by poor communication and the importance of physician truthfulness. Caregivers are beginning to feel that they ought to allow the patient to choose for him or herself, rather than being forced to undergo treatment decided upon by others.

In any case, the right freely to refuse therapeutic overtreatment is slowly becoming more acknowledged among practitioners. I recently proposed that if the National Assembly continues to reject legalization of the living will, which would compel physicians to stop treatment, the medical professional code could at least oblige a physician to make an initial inquiry into the patient's wishes. This would be a substantial step towards establishing a partnership between doctor and patient.

When will the terminal stage of life recover its human meaning? Perhaps only when we can all recognize each other, whether as patients or as caregivers, as made of the same flesh, experiencing the same fears and hopes, needing the courage to be, knowing that others trust in us, and that to care is to love. Tota medicina amor.

Charles Lefevre was formerly professor of philosophy at the Catholic University of Lille, France, and cofounder of the Center for Medical Ethics. He passed away March 2, 1988.
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Title Annotation:Special Supplement: International Perspectives on Biomedical Ethics
Author:Lafevre, Charles
Publication:The Hastings Center Report
Date:Aug 1, 1988
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