Each month, the team and the collaborators of Living with Dignity decode a social issue or a concept linked to ethics of care or bioethics. Short, precise and informed analyses.
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
By Maxime Huot Couture, interim director of LWD and Ph.D. candidate in ethics and political philosophy
It is always good to dig again into the notions that structure our society and our relationship with others. One of the most important notion in our ethical discourse today is human dignity. Despite that, it is easy to see that dignity can be taken in multiple senses which are sometimes contradictory.
We can distinguish two principal meanings that are attached to human dignity. First, dignity is referred to in an objective sense when we say that a person is dignified no matter what his or her physical or psychological condition is. This is what it is meant by “intrinsic dignity”. On the other hand, we speak of subjective dignity when we refer to the feeling that a person has of his or her dignity. This feeling then depends on the circumstances and on the actions and words of the others. Of course, even in the case of a sentiment of indignity, a person never loses his or her objective dignity: it is a universal principle that is independent from the context.
That said, what is dignity exactly and where does it come from? The Enlightenment philosopher Immanuel Kant has given a famous definition: A person is worthy because he or she exists as an end in itself, and not simply as a mean or a tool that could be used at will. Human dignity therefore implies reverence, respect and protection for each person, as a free being, endowed with a unique existence. This is recognized, for example, by the Universal Charter of Human Rights when it states that everyone has rights by sole reason of his or her humanity. Therefore, the expression “dying with dignity” is misleading, since it implies that a person may lose his or her dignity by illness or vulnerability.
Human dignity is based on the superior value of the human being, endowed with reason. We call conscience this specific human concern to do good freely. Although dignity is linked above all to the freedom due to human intelligence, being human also means having a will, feelings, a body. It is all of this at once (an individual is “indivisible”). Human dignity requires an integral vision of the person. Consequently, a person whose mental faculties are impaired also has human dignity, and so does a person with a physical disability. In the same way, a person who loses his memory remains dignified, since it still exists as a human being, with a body, a personality and a history of his own which always remains. To put an end to the days of someone under the pretext of “respecting his or her will” is therefore a mistake and an attack on dignity: one cannot go against the dignity of the body to honor the dignity of the will. There is something contradictory about this that endangers the integral and civilized vision of dignity.
By Patrick Vinay, M.D., Ph.D, president of Living with Dignity, former dean of the medical faculty of Université de Montréal
The often brutal arrival of illness violently shakes the former healthy person whose familiar landscape then inescapably changes. The shock is sometimes brutal: “I’m not immortal! I did not have enough time! I wasted precious moments of my life, I will not have time to say this, to do that…” With the physical transformations, the low endorphins, the pain, depression, addiction, she lives with a devaluing self-image. She pulls the sheet over her head. She seeks meaning for a present that does not guaranty a future. The neglected priorities of her life become urgent.
This is where palliative care is involved, to restore the physical comfort first and thus allow meetings with family and friends, a restoration of identity and the putting together of a significant legacy. The practice of narrativity in a significant context allows a desired reinterpretation of past life and interactions with others. It opens a space of identity confirmation full of encounters, discoveries and significant new relationships with caregivers and volunteers, who may become part of an extended family. Identity is rebuilt, richer, more authentic.
This palliative space, which lasts from a few months to a few days, also opens a space of adaptation for family and friends before the departure of the loved one. It is a precious period, a melting pot of humanity where each and everyone discovers the weight of gestures and words in a different light, the strength of fraternity and the true notion of love that extends from age to age. It is this space that should be protected by offering quality palliative care to all who need it and want it. It is also the space that is sacrificed when one chooses a premature death. We must therefore collectively provide the conditions required for a palliative space to be offered to all those who make this choice.
Translated by Maxime Huot Couture