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  • BIOETHICS FORUM ESSAY

More French Paradoxes

Death is hard to deal with anywhere, but France has some contradictory ways of providing end-of-life care, as two recent articles discuss.

On the lighter side, Agence France-Presse reports on a novel service that one French hospital will launch next month to improve the quality of life of terminally ill patients: a wine bar in the palliative care center, which will also stock champagne, whisky, and beer. The hope is that it will “cheer up the difficult day-to-day existence of patients,” the head of palliative care told the news service.

On the darker side, France is grappling with what to do when patients can no longer benefit from wine, champagne, or more medical forms of palliative care. While France has resisted proposals to legalize physician-assisted suicide or euthanasia, doctors nonetheless resort to these practices regularly–thus far without legal consequences, according to a recent article in the New York Times, which has received surprisingly little attention on social media but prompted conversation here at The Hastings Center.

“As nations across Europe have legalized euthanasia or assisted suicide in recent years, French lawmakers have publicly refused to do the same, often citing fears of misuse,” the article says. “Yet by empowering doctors with broad, discretionary end-of-life rights, France has in effect quietly authorized the practice of euthanasia, doctors and officials acknowledge.” These practices “account for an estimated 3 percent of total deaths, or about 17,000 each year.”

The French have long accepted a hefty dose of paternalism from their doctors–“Never have fears of ‘death panels’ become a matter of public debate, as they have in the United States,” the Times article says. But there are signs that support is weakening for paternalism in end-of-life care. As the population ages, patients and their families are expressing a desire to be more involved in end-of-life decision-making. In June for the first time a French high court heard a request to annul a doctor’s decision to let a patient die. And there is proposed legislation for changes in end-of-life care.

As in the United States, the law in France recognizes the right of patients to refuse treatment they judge to be unreasonable and it allows physicians to prescribe pain medications that could hasten death. However, unlike doctors in the U.S., doctors in France are not legally required to defer to the wishes of family members or other surrogates if a patient lacks decision-making capacity. In such circumstances, doctors typically have the final say.

In some respects the high degree of autonomy given to French physicians has advantages, says Michael Gusmano, a Hastings Center research scholar who has done international comparisons of health care, including France’s health care system. “Our research indicates that French GPs do an excellent job of managing chronic illness and helping their patients avoid hospitalizations for conditions that can be treated on an outpatient basis,” he says. “Indeed, the fact that physicians in France are able to practice without a great deal of state oversight addresses one of the myths about national health insurance systems–that government will interfere with the practice of medicine.”

“Having said that,” he continues, “clinical autonomy should not absolve physicians of the ethical obligation to discuss treatment options and seek consent with their patients or–if the patient does not have capacity–with family members or other surrogates when possible. The idea, discussed in the article, that doctors should ‘unburden’ families from making such decisions by failing to consult with them is an important component of what is ethically troubling about this scenario.”

Gusmano objects to the claim put forth in the article that this particular French paradox–rejecting legalization of physician-assisted suicide and euthanasia but permitting doctors to use these practices to relieve patient suffering–is consistent with French culture. “Culture should not be used as an excuse for practices that clearly violate the principle of respect for patients,” he says. “Allowing physicians to decide whether certain patients ought to be allowed to live is disturbing and threatens to undermine the public trust in doctors that has served the French health care system well for decades.”

Compassion for dying patients and their families comes out in all sorts of ways in France, from a palliative care wine bar to doctor-knows-best decisions that include euthanasia. Now that French people want more of a say, it will be interesting to see how doctors, patients, families, and the government reckon with the paradoxes in end-of-life care.

Susan Gilbert is The Hastings Center’s public affairs and communications manager.

Posted by Susan Gilbert at 08/08/2014 09:20:22 AM |

Published on: August 8, 2014
Published in: Chronic Conditions and End of Life Care, End of Life

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