Mobilization in favour of palliative care: the opinion 108 of the CCNE

 

At the end of November 2009, deputies have rejected with 326 votes against 202, the bill supported by the socialist Manuel Valls on euthanasia. He wanted to establish a “medical assistance to die in dignity”. Concretely, the text proposed that a board of four physicians can evaluate the receivability of a request for euthanasia, reserved to major people in a serious and incurable condition. The “aid to die” would have been administered under medical surveillance and after death, each file would have been sent to a control commission. The text foresaw the possibility of a conscience clause for the professionals, provided they refer the patient to another physician. It also created a national register of “anticipated directives” on which any major people could have been registered. 

 

 

A number of personalities have reacted against this text. “The right to die is not a medical act” reminded Jean Leonetti, author of the law on the end of life of 2005. “The palliative approach cannot end with euthanasia approach. It is antinomic. The medical philosophy of the accompaniment is not the one of the rupture of life”. For Luc Ferry, it is unacceptable to establish equivalence between “dependence” and “indignity”: “the idea itself that a human being can lose her/his value because she/he would be weak, ill or old, and by the same occasion, in a situation of loss of autonomy, in actual fact seems to me intolerable on the ethical level“. He speaks in the newspaper Le Figaro1 “for an absolute right of human beings to heteronomy, to dependence and to weakness even the more extreme ones” denouncing “speeches aiming at letting third people understand that it would be better to make a clean sweep and to stop disturbing people“. Alain Monnier, chairman of the voluntary accompaniment association in palliative care is worried: “When the end of life is more and more expensive, we could switch from a “right to die” to a “duty to die” for economic reasons.” Régis Aubry, who follows the palliative care plan launched by the head of state for the period 2008-2012, estimates that if the law is not sufficiently known, the situation is changing: “…at the beginning of 2010, all the University Hospital Centres will have a palliative care team. The national observatory on end of life must also be established. Finally, a university section dedicated to these questions will be open next year.

 

 

Interviewed, the National Consultative Ethics Committee (CCNE) pronounced on 12th November 2009, its Opinion “on the ethical questions related to development and financing of palliative care” answering the following question: “how to establish a financing system of the care, which avoids the senseless obstinacy by the article L.1110-5 of the French Public Health Code and facilitates the palliative care?“. The committee wanted to answer more widely than on a strictly financial level because he estimates that the “accounting aspects are not the only causes of the noted delay, in the application of the law of 2005.”

The CCNE, reminding that “the obstinacy is not senseless in itself” and the true way between obstinacy and the abandonment has to be found, recommends to spread the knowledge on the practices and to favour the dialogue to contribute to avoiding the senseless obstinacy. 

 

Then examining the complexity of the palliative care costing and then the conditions of a fair access to quality care, the CCNE noted that “each of the financing systems successively established in the hospital induced perverse effects“. The last system relied on an activity-based costing: “the shorter the stays, the more profitable they were” what generated a “selection of admissions according to the foreseeable duration of the stay, a discrimination of some slow progressive diseases or some ill patients, etc.” These effects have been corrected and today, the CCNE notes, “the remuneration of palliative care stays becomes satisfactory and incentive“. However if less than 10 % of end of life situations justify resorting to palliative care units, “the lack of beds dedicated to palliative care, as well as the lack of health professionals makes that the situation is beyond the scope of the expectative“. 

 

The CCNE mentions the need for training and pronounced itself in favour of the “creation of hospital-university jobs in internal medicine, with palliative care option” to increase the appeal for this discipline. 

 

Finally the opinion proposes to develop the palliative mobile units: “far from being in an expert position, these teams have to complete the competences in a fraternity spirit. Their in situ support, within the services, has an irreplaceable pedagogic efficacy”.

 

In conclusion, the Committee reminds that “palliative care is not a luxury that only an affluent society can afford, it is an innovative potential of the care activity“.