The role of 'accompagnement' in the end-of-life debate in France: from solidarity to autonomy.

Marie Gaille,Ruth Horn

doi:10.1007/s11017-016-9389-1

Abstract

This article traces the way autonomy has become a recognised value in health care in France. In a country that based its social fundamentals on the very idea of solidarity for many years, autonomy has long been considered a foreign ‘Anglo-American principle’. Taking the example of the end-of-life debate, the article shows, however, how the use of the French term ‘accompagnement’ allowed autonomy to be redefined and to be associated with the concept of solidarity. Exploring the arguments used over the past 25 years in professional guidelines, parliamentary reports, ethics committee reports, and legal texts, the authors describe the shift that took place in public and legal discourses on end-of-life care. The analysis demonstrates how the scope of autonomy has been limited by other social values, such as the protection of the dying person, in order to become an accepted social value in its own right. The example of the French end-of-life debate shows that depending on how the concept of autonomy is adapted and applied in a specific context, it can be compatible with the idea of solidarity. Such compatibility has been challenged previously in the international bioethics debate. By demonstrating the possibility of combining autonomy and solidarity, this article makes an important contribution to the international bioethics debate and to the dialogue between countries that are often perceived as significantly different.

Highlights

Continental European and Anglo-Saxon approaches to health care are often associated with two seemingly opposed conceptions of care: in continental European countries, solidarity appears to be the core value of health care systems, whereas a rights-based, individualistic conception seems to prevail in Anglo-Saxon countries
The example of the French end-of-life debate shows that depending on how the concept of autonomy is adapted and applied in a specific context, it can be compatible with the idea of solidarity
In 2014, the CCNE report on the public debate about the end of life made a similar use of the notion of accompagnement [54] and discussed the same association between autonomy and solidarity

Summary

Introduction

Continental European and Anglo-Saxon approaches to health care are often associated with two seemingly opposed conceptions of care: in continental European countries, solidarity appears to be the core value of health care systems, whereas a rights-based, individualistic conception seems to prevail in Anglo-Saxon countries. In 2014, the CCNE report on the public debate about the end of life made a similar use of the notion of accompagnement [54] and discussed the same association between autonomy and solidarity It argues in favour of a ‘veritable accompagnement humain’ aiming to offer both care and cure and to address the fear of abandonment, pain, and social inequalities in access to care. A different pattern is set by the recent shift of the French debate about end-of-life care: autonomy is not respected because individual freedom is the prevalent (if not unique) moral and political value, but rather because society as a whole grants importance to individual freedom and wants to care for the dying in the name of solidarity. There is still strong disagreement as to how much autonomy should be granted to a patient at the end of life both when patients are able to express their will and when they are not and have left advanced directives [55]

Conclusion

Compliance with ethical standards