Claire Anne Brule

[CP] – Abortion in the Constitution: A Confiscated Debate Far from Reality

by Claire Anne Brule | November 24, 2022 | Abortion, Press Releases

The French Parliament has just adopted on first reading the inclusion of abortion in the Constitution. Once again, the subject of abortion has been instrumentalised by the political parties in a game of tactical politics. There was no true debate, merely discussions totally disconnected from the reality of abortion and what many women have to endure.

Whereas France is experiencing a difficult economic and social situation, the priority should be above all to support the French population, which has been totally evaded by the majority of parliamentarians.

Caroline Roux, the Deputy General Manager of Alliance VITA and hot line coordinator makes the point: “At Alliance VITA we are witness to the fact that not all women abort freely and by choice. Many of them abort against their will, under pressure from their partner, their family circle or their economic situation. The deafening silence surrounding these obscured situations is a serious injustice. By claiming abortion as a right, situations are being ignored despite their being known by the authorities: The poorest women resort most often to abortion. Moreover, at no moment during the debate was any mention made of the link between violence and repetitive abortions although this has been confirmed by studies.

We are counting on the Senate not to give in on what appears as a headlong rush: It is time to face up to reality and analyse the causes, the conditions and the consequences of abortions over the last 20 years in order to develop a true policy for prevention. That would contribute to solving a large number of personal tragedies, by providing appropriate support for women wishing to avoid abortion.”

Press contact
contactpresse@alliancevita.org

[CP]- Abortion in the Constitution: The Wrong Debate

by Claire Anne Brule | November 23, 2022 | Abortion, Press Releases

The French National Assembly is to examine tomorrow a law proposal tabled by LFI (La France Insoumise) suggesting that “Nobody may undermine the right for abortion and contraception. The law guarantees that any person who so wishes should have free and effective access to such rights.” Alliance VITA denounces this as the wrong debate.

From the very beginning of this parliament legislative term, the idea has been growing among certain politicians that the Constitution should be modified in response to the decision by the United States Supreme Court on 24^th June 2022.

The situation in France is however fundamentally different from that in the United States. In France there is no federal law governing abortion. The ruling by the Supreme Court now transfers the legislation on abortion to the federated States. In France as in many other nations, abortion is controlled by laws adopted by the French Parliament.

In our nation, the number of abortions remains at a high level, with 223,300 pregnancy terminations recorded in 2021 and a record rate of use (15.5 pregnancy terminations per 1000 women aged between 15 and 49 in 2021).

This wrong debate over constitutionalisation hides the reality of abortion today. Not only does the latest report by *DREES show that the overall rate of resorting to abortion is tending to increase, but that organisation also established in 2020 that it is the poorest women who abort most (2020 report). Abortion is thus shown to be a marker of social inequality which should be a wake-up call for the authorities.

Recent studies have also shown the links between domestic violence and repeated pregnancy terminations. In France, the link between abortion and violence remains little explored however: very few doctors systematically raise the question of domestic violence with women requesting an abortion[1]. Nevertheless, it is known that with 40% of the 201,000 women concerned each year by violence from their spouse, the violence began with their first pregnancy.

Moreover, the inclusion of an unconditional right to abortion in the constitution could jeopardise the current legal framework and lead to unlimited access to abortion. One might justifiably fear that it could then become possible to demand an abortion right up to the term of the pregnancy or due to the sex of the foetus.

These political gesticulations obscure the reality of what women have to endure: the need is ever more pressing for abortion prevention and support to enable those who so wish to complete their pregnancy.

Press contact
contactpresse@alliancevita.org

[1] Pelizzari Mélanie et al., “Pregnancy termination and violence: A qualitative study with general practitioners in the Île-de-France region”, Cliniques méditerranéennes, 2013/2 n° 88, p. 69-78.

Euthanasia and Assisted Suicide: Vigilance on the Semantics

by Claire Anne Brule | November 18, 2022 | End of life, Euthanasia and Suicide, News

According to Le Figaro newspaper, Erik Orsenna, the member of the French Academy has been mandated to explain the vocabulary used for the end of life with publication of the first items in early December 2022 to correspond with the launch of the “citizens’ convention“.

Whilst the citizens’ consultation on the end of life is gradually being established, the debate is revealing all its complexity. Sedation, double effect act, curative treatments or palliative care, are all terms which need to be explained for the uninitiated.

Beware of “smokescreen” words used to hide the reality of euthanasia and assisted suicide.

The French President says he hopes for a calm debate: “To avoid tensions, the Macronists have therefore gradually banned the use of the word “euthanasia” and use instead the expression “end of life” according to Le Monde. During his meeting in Rome with the Pope, Emmanuel Macron claimed to have told him that he did not like the word euthanasia. But to refute the word, without excluding the act merely injects confusion into the debate.

The CCNE (French ethics consultation committee), on the other hand, in its Notice No. 139 speaks of active assistance to die which covers both assisted suicide and euthanasia. In 2012, François Hollande who at the time was a candidate for the French Presidency, included in his measure 21 a mention of “medicalized assistance to end one’s life with dignity.” This vague expression, which maintained ambiguity, led to the adoption of the Claeys Leonetti law which has inevitably resulted in divergent interpretations. That expression was not however adopted by the law.

The Canadian legislators on the other hand attempted to anaesthetize the word euthanasia by using the acronym AMM for medically assisted death. This practice unfortunately is far from convincing in this nation which has embarked on a slippery slope regarding euthanasia. Since the legalization in 2016, the eligibility criteria have been extended to include the handicapped who are not at their end of life. Defenders of the handicapped and human rights have warned of the “discriminatory impact” of this measure. To the extent that people suffering from illness or handicap call for euthanasia as an alternative to poverty, as they are unable to provide for their basic needs.

From semantic subterfuge to manipulation, is but a small step. Vigilance is therefore required for any attempts at manipulation of words which could hinder the understanding of the stakes by the general public. The challenges to be met are multiple. They concern in particular the accompaniment of ageing and end of life, the finalisation of a law on old age and autonomy, the fight against social death for the very old or dependent, access to palliative care everywhere in France, or the link and solidarity between generations. Finally, it is crucial not to cover up the pernicious consequences of the deletion of the prohibition to kill on human dignity and the relationship between carers and patients.

Advance Directives, Benefits and Limitations

by Claire Anne Brule | November 18, 2022 | Advance directives, End of life, News

Introduced by the “End of life” law in April 2005, the so-called Leonetti law, the system of advance directives was reinforced and specified in 2016, by the second “End of life” law, so-called “Claeys Leonetti” law. In the form of a written and signed document, the advance directives “express the will of the person relative to their end of life concerning the conditions for continuing, limiting, terminating or refusing treatment or medical care”. They are intended to take over when the patient is “unable to express his/her wishes” at the time (even if the patient is not necessarily at the end of life).It is worth recalling the three essential elements of the current system:

“Any adult may prepare advance directives.”
“At any moment and by any means, they are revisable and revocable.”
“Advance directives are executory for doctorsfor any investigation, operation or treatment decisions, except in the event of life-threatening urgency during the time required for a complete evaluation of the situation and when the advance directives appear manifestly inappropriate or not applicable to the medical situation.”

On this 3^rd point, the law avoids making the patient an all-powerful self-prescriber and the doctor a mere servile executor of the advance directives. The Constitutional Council has just validated the non-opposable nature of the advance directives in the cases specified by the law, in particular, therefore, if the doctors consider that what has been requested in advance by the patient is “manifestly inappropriate” in relation to the medical situation. In such case, the final word still remains with the medical team.

In view of the lack of enthusiasm of the French public for this system, the public discourse, in the debate on the end of life, multiplies the obligation for them, whether or not in good health: “Write your advance directives” as if it were simple, but also as if it was a determining factor to guarantee a peaceful death. However, not only is its writing far from obvious, but additionally it does not constitute any guaranteed relevance.

It should be mentioned before explaining this advice, that Alliance VITA, being aware of these difficulties, has elaborated, tested, improved, published and distributed hundreds of thousands of copies of a Guide to advance directives and persons of confidence. Complete, educational and understandable, this document, which can be downloaded, suggests first validating a general charter; which charter indicates the universal ethics for the end of life: neither disproportionate treatment, nor euthanasia but proportional treatments and palliative care; the document then provides for expressing specific wishes and details, linked to one’s convictions and not only the foreseeable consequences of an existing illness. The document therefore goes beyond the strict scope of advance directives.

If the idea of anticipating situations where one would no longer be capable of expressing oneself appears attractive, in reality it is confronted with multiple obstacles. Several questions call for an answer:

Am I capable, whilst I am in good health to consider in advance what will be right for me if I become dependent? Many patients discover “in situation”, to be capable of living – and keeping a thirst for life –, whereas when in good health, they would have thought death to be preferable to that type of life. To take a person at his/her word on past declarations may paradoxically lead to going against the present will that he/she is no longer capable of expressing.
How can one consider, with no particular medical knowledge, not only the multiple catastrophic medical scenarios which one might have to face, but also the adequate responses to claim in such cases (resuscitation or not? tracheotomy or not? artificial feeding or not?). It is quite simply impossible, and may be inhuman or simply naive to ask us to project ourselves in that way.
How can one consider – without any specific medical knowledge – the consent or refusal of such and such a treatment when one is not yet concerned? Most people do not wish to end their life “covered in tubes”, but – in the event of an accident, the various drips and life-support machines which relieve and save (analgesics, antibiotics, saline solutions, blood, air) are welcome. They cannot be rejected in advance.
The same uncertainty, exists for peripheral subjects, not included in the official directives: like thinking of the place where one wishes to die. Most French people in good health say they wish to end their days at home; however, even if certain patients are pleased to return home to end their days, many others prefer to be hospitalised when hospitals appear to provide better security, better relief… There again, too much anticipation can lead to going against the patient’s will: “every day has its own problems to solve”.
Finally, there is the risk that advance directives can evolve into advance requirements – more or less consciously – for euthanasia, afflicted with the same criticisms as any other anticipation. Besides, such a request – which today is manifestly illegal –would be inoperative. It should be noted that many people who believed that they had to prepare this kind of “will for life” subsequently were able to bear witness (after recovering their ability to communicate) that they were worried that the document would be found in their pocket and that their advance “wish” would be executed. A Canadian family doctor had received from one of his patients a letter requesting that – if he became seriously ill – to be euthanised. Then when diagnosed with a terminal disease, the patient kept an anxious watch on the prescriptions from the same doctor who he suspected would act. The doctor concluded: “Could it be that one doesn’t see life in the same way when in good health as when ill and at the end of life?”

It should therefore come as no surprise that, like most French people, the experts and ministers who promote advance directives have not in most cases prepared their own ! Two comments should be made: First of all, respect for medical ethics everywhere and for everyone, is more essential than the call for advance directives; also, it is quite illusory to expect every healthy person to write down something sensible and effective on the future of their life. On the other hand, a person who is seriously ill, with a spreading disease, should discuss with their doctor and decide in advance to refuse such and such invasive treatment. Thinking for example of artificial respiration, when it becomes vital. If correctly enlightened, the will of the patient to refuse such a device (which would prevent speech) must be respected, and it would be right to do so, even if the patient is incapable of confirming it. The same applies to a gastrostomy (an operation consisting in opening an orifice in the abdomen between the stomach and the outside with a view to artificial feeding.

In conclusion, over and above the writing of advance directives, it is the designation of a person of confidence which is essential. Even if, they in turn, cannot guarantee a peaceful death. The person of confidence has no responsibility for prescribing the treatments. No document, no procedure can possibly substitute for the exchanges between the carers, the patients and their families, and the establishment of reciprocal trust in respect of the competences of each and without transgressing the immutable ethics of medicine as so wisely defined by the ancient Hippocratic oath. Obviously, if a future law was to validate euthanasia, one would have to protect oneself from it by appropriate advance directives. But with no absolute certainty of the effectiveness of the document. The quality of a procedure can never replace that of a relationship.

New CCNE notice: Rethinking Healthcare System Based on Ethics

by Claire Anne Brule | November 10, 2022 | Health, News

Following the publication in September of a notice opening the door to the legalisation of euthanasia and assisted suicide, the CCNE (Comité Consultatif National d’Ethique) has just issued a new notice, number 140, headed “Rethinking Healthcare System Based on Ethics”. Passed by unanimous vote by the members present at the plenary session on 20^th October 2022, the notice is intended to lay down firm markers to face up to the deep crisis being experienced by the French healthcare system.

The pandemic, a detonator for a pre-existing crisis

The sub-heading of the notice “Lessons from the sanitary and hospital crisis, diagnosis and prospects” illustrates their approach. The sanitary crisis linked to the COVID 19 pandemic acted as a large scale indicator of tensions, and accelerator of the trends, weighing down the care system, and more broadly the health system in France.

The CCNE defines both terms at the start of their notice. The care system includes all the organisation and coordination aspects of medicine. The health system includes the care system in “a broad perspective, extending to the social aspects and the determining factors for health“.

The crisis in the care system has been widely documented and analysed. The official reports are ever increasing, such as the Senate report “Hospitals: Leaving A & E“. It is also among the main concerns for the French people, who have seen the dramatic illustration through the strike action this year in hospital A & E departments.

The health system is “impaired” according to the expression used by the CCNE. Whilst recognising the remarkable work performed by healthcare workers, in particular during the pandemic”, the CCNE delivered its diagnosis of a “systemic” and “far-reaching“ crisis.

The factors contributing to the crisis according to the CCNE

The document lists a number of factors which have contributed to the crisis. The CCNE thinking is in line with that of many analysts. Life expectancy in France has increased “significantly” over the last 30 years, resulting in an increase in needs. The ageing of the population moreover brings with it specific additional needs, linked for example to chronic disease, as indicated in the yearly DREES report. Medical demography has been moving in the opposite direction. Thus, between 1977 and 1997, the number of vacancies for medical studies (numerus clausus) fell from 8671 to 3576. A recovery programme was introduced to return to the 1977 level in 2018 (8205 places). This evolution has gone hand in hand with an approach including a focus on cost control. The CCNE considers that “this new form of management has attempted to apply to healthcare the concepts and methods adopted by industry (the “hospital-company” concept). This has resulted in a transformation of the health function to the benefit of a purely economic logic based on incitements and indicators…“.

This approach, with for example charging per treatment, combined with the undeniable progress achieved in medical and pharmaceutical techniques, has favoured a healthcare culture considered as treatment for cure at the expense of an approach incorporating closer relationships with patients, whereas it is a central factor in the motivation of many healthcare workers in their choice of career. The time spent by healthcare workers with their patients has been compressed in the technical times at the expense of attentive listening. The partitioning within the healthcare system: community medicine versus hospitals, medical versus administrative staff, also contributes to inefficiencies.

The consequences of the crisis

First consequence:

The inequalities of access which are deepening, to the detriment of the most vulnerable, inequalities which the Covid 19 crisis illustrated quite dramatically.

Second consequence:

A “crisis of trust” by both the public and healthcare staff with respect to the authorities, which trust had already been severely tested by a series of scandals (contaminated blood, Mediator etc.), accentuated by the centralised management of the sanitary crisis.

Third consequence:

Situations of suffering for all the players in the healthcare system. Suffering of patients unable to access care, of not having their needs considered. Suffering by healthcare workers, extending to a loss of direction and disillusionment resulting in psychological suffering. The CCNE reported that “The deterioration in working conditions in hospitals is the cause of ethical suffering resulting in confrontation between healthcare workers and other professionals in the sector on ethical dilemmas which are often stifled“. Ethical suffering “appears when the healthcare professionals are forced to act against their social, professional or personal values, without being able to express themselves openly on such tensions and the feelings which they generate.”

The CCNE proposals

All these observations and warning signals have led the CCNE to launch an appeal to “reposition ethics at the centre of healthcare”. Starting from the premise that “access for all to healthcare is the strongest indication of national solidarity opposing the uncertainties of disease, dependency and malaise“, the CCNE is proposing 4 themes.

First theme: Integrate and deploy an ethical culture in professional practices.

This theme includes, for example encouraging a culture of dialogue between carers, avoiding to confine ethical matters to committees, the training and appreciation of ethical thinking within the teams.

Second theme: guarantee social justice in access to healthcare.

France is among the nations where the healthcare costs for households are the lowest, but this general statement overshadows many disparities. The CCNE states that “The economic model must be thoroughly reviewed to include all activities and services and taking into account the specific nature of territories“. Recognised as being “The true backbone of the healthcare system“, the public health system must be the subject to extreme vigilance.

Third theme: support the notion of an ethical respect for the parties concerned.

Behind these words, the CCNE is proposing materially that the time assigned to healthcare/patient relations be upgraded, and that healthcare workers be better rewarded both financially and in their quality of life at work. The democracy health organisations represent a piece of the puzzle which must not be neglected, according to the CCNE.

Fourth theme: regain trust by sharing knowledge and educating on health issues.

Although the trust between the public and healthcare workers remains high despite the tensions in the system, the CCNE repeats its proposal from its notice 137 for the “Implementation of a convention for ethical public health, which could be established in coordination with the national or regional public health organisations and with regional ethical thinking platforms“.

In conclusion

The CCNE is calling for an “in-depth review” in 3 directions:

ensure equal access to the health system, including treatments,

re-establish a sense of purpose for healthcare workers,

listen to all the players involved in the system.

The “French model which until now has taken into account these high ethical values is now undermined” as stated by the CCNE.

Heavy trends are currently penetrating society which are upsetting the “French model”: The primacy of individual desires, the merchandising of living matter, the demande for performance.

As a recent protagonist for an about-turn on the question of euthanasia and assisted suicide in the name of individual autonomy, can the Committee call for solidarity whilst prioritising such autonomy in its recent decisions ?