Decoding

By Maxime Huot Couture, interim director of LWD and Ph.D. candidate in ethics and political philosophy

Technical developments in medicine raise new ethical questions, especially since we have widened its field of intervention not only to healing, but to the very existence of individuals, as for example in the case of euthanasia. In this context, some people put forward the concept of “conscientious objection” to avoid being forced to do acts they disapprove of. However, in this debate, others maintain that the right to conscientious objection is not absolute, since it is the interest of the patient or the “client” that must prevail. In fact, they say, one should not prevent someone from receiving recognized medical services because of the “beliefs”, religious or moral, of health professionals.

Conscientious objection is indeed a right, and an absolute right. The primary reason is that conscientious objection is not, as these critics argue, first and foremost a matter of religious or moral “beliefs”. Consciousness is rather an “internal sense of rectitude”, a conviction that this or that specific action is good or bad. Consciousness is therefore a judgment on the merits, or not, of an action. Thus, the refusal of a health professional to perform a particular act is justified by the conviction that this act is bad for the patient. The healthcare professional does not refuse to act in order to ensure respect for his beliefs, but precisely to ensure the well-being of his patient, since this is the very purpose of his function.

Of course, many health professionals may have different judgments. One of them may be wrong. That is why one cannot simply appeal to the authority of conscience in order to have a right to do this or that. The issue of conscientious objection is different. Rather, it is the right not to do something considered wrong. Forcing someone to act against his or her conscience is an attack on one’s integrity. And who would want to have a doctor without integrity, that is to say a doctor who performs certain actions without thinking that they are good for the patient? It is not beneficial for the patient that his or her doctor is “neutral” and that he obeys all his requests, even if they are bad for him or her. It must therefore be understood that conscientious objection is not a refusal of care, but the offer of different care, in line with the best judgment of the health professional.

By Dr. Patrick Vinay, president of Living with Dignity, former dean of the Medical Faculty of Université de Montréal

Sedation is a medical procedure that is part of everyday medical practice. Sedation translates the search, by medicinal means, for a decrease in alertness. It is mainly used in intensive care for seriously ill patients by reducing the caloric needs of people who can no longer eat naturally. It is a healing tool.

In palliative care, sedation seeks a decrease in alertness that can go as far as loss of consciousness. Its goal is to reduce or eliminate the patient’s perception of a situation experienced as unbearable while all the means available and adapted to the situation have been implemented without making it possible to obtain the expected relief. It is therefore a medical procedure of last resort, with its indications, conditions and methods of application. The medication used is safe and always the same. When the sedation is temporary or intermittent, it constitutes a respite from the crisis situation and allows therapeutic adjustments while immediately relieving the patient. When it is continuous, it maintains relief that cannot be obtained otherwise and it is then often maintained until death because the source of the distress cannot be stopped. The patient’s analgesic medication is of course maintained under sedation, because it does not eliminate the pain or its effects. Sedation is therefore an essential option in the therapeutic arsenal applicable at the end of life.

Like any therapeutic gesture, continuous sedation can cause complications. These could affect the lifespan of the sedated patient, particularly in exceptional situations where the dosages required to ensure patient comfort are higher. But this situation is rare and is never the result of an aim of euthanasia: there is no desire to interrupt life here.

Continuous palliative sedation leads to cessation of feeding and hydration, which could shorten the life of a patient if administered to a patient with a long prognosis for survival (several weeks) and still capable to eat and hydrate. Indeed, it is commonly accepted in medicine that the capacity of survival of a sick human being decreases rapidly beyond a week without hydration. Maintaining artificial hydration (solutes) during continuous sedation at the very end of life is, however, not advisable because of the risks of fluid overload at the end of life. This is why continuous palliative sedation is mainly administered to a terminally ill person whose death is imminent, that is to say, whose prognosis for survival is very short. Few patients require continuous palliative sedation more than a week before their death. Various publications demonstrate that neither analgesic medication nor properly administered continuous palliative sedation accelerates death.

In addition, prolonged palliative sedation lasting more than 15 days should be avoided due to the associated complications which then increase significantly (the patient becomes rigid, very suffering from mobilization, etc.). We will therefore not offer continuous sedation for more than two weeks.

For further information, you should consult the document prepared by the Quebec Society of Palliative Care Physicians (SQMDSP) which can be found on the PalliScience site of the Maison Victor-Gadbois.

By Louis-André Richard, Ph.D., professor of philosophy at Cégep de Sainte-Foy

How to express briefly the political situation in which we find ourselves? Philosopher Alexis De Tocqueville noticed how the search for equality, the foundation of democratic life, gave birth to individualism. Individualistic logic is at the basis of what we now see as “autonomy”, that is, the freedom for everyone to follow a norm or rule that he has chosen. Surely, the concept of autonomy is nothing but new, it is however uncommon in history to reduce it to the claim of unlimited individual rights.

A brief analysis of the history of ideas shows that autonomy was understood as a quality dependant to otherness or, in other words, as a way of acting freely that involves others. This is why my research on the subject led me to speak of “allonomy” (“allo” [other] and nomos [“law or rule”]) as a better concept to grasp human freedom. It is a substantive noun restoring its raison d’être to an integrated understanding of autonomy where the other is omnipresent. What we mean is another person, of course, but also the recognition of “otherness” in the form of heteronomy, a normative anchoring of our actions on something other than our own will. These anchors differ from one person to another, but some have always accompanied humanity: the sacredness of life and the body, the love of one’s family and one’s homeland, or the openness to the divine word.

Palliative care today responds to a particular context. This new approach of end-of-life care emerged when medicine, with its efficient technological prowess, was at the same time experiencing the limits of its healing posture. Based on the human dimension of patient support, palliative care has ensured that the medical procedure is maintained and even given its human and relational character. After more than 20 years of diligent observation of palliative care actors, I have noticed, not without admiration, how much they have induced a very impressive interpersonal culture. The palliative community is a microsociety marked by the depth of human bonds.

Over time, in the vocabulary of this microsociety, expressions such as “relational autonomy”, “altruistic autonomy” or “reciprocal autonomy” appeared. I discern here a healthy reaction from the experience of ultimate care. It corrects and refocuses on what is essential and refines social and political ties in our liberal democracies. Palliative care is a possible catalyst for a culture of allonomy. But in the current context where social pressure tends to make amalgams between end-of-life care and euthanasia in the form of medical aid in dying, where the common good is reduced to utilitarian claims such as “effective altruism”, the palliative culture is threatened. Will it be able to resist assimilation? In any case, if the palliative experience has felt the need to add a relational aspect to individual autonomy, are there not reasons to reflect on this intrinsic and fundamental link between these two dimensions?

Translated by Maxime Huot Couture