06/12/2013 05:08 pm ET Updated Aug 12, 2013

The U.S. and France: Same End-of-Life Struggles

I was recently the keynote speaker at an end-of-life International Congress in Strasbourg, France. It was an amazing professional and personal experience. What I found particularly near and dear to my heart was learning and hearing about how people in another country deal with end-of-life issues -- or do not deal with them -- similar to us here in the U.S. There are many similarities and several differences. According to French chaplains with whom I talked, the French are also less likely to talk about the fact that they will, one day, die.

One major difference is that the chaplains there are less likely to be involved with patient care. Most professional chaplains in the U.S. are integrated into the multi-disciplinary care teams of their health care institutions. They provide valuable information to the rest of the team about spiritual/religious issues that may be impacting the patient's physical condition, since studies have shown that a patients' physical condition can be affected by their psycho/social/spiritual concerns.

The French also struggle with many of the same issues that we have been dealing with since the Patient Self-Determination Act was passed here in 1990. A majority of our society is still ignorant of our rights in terms of how we want our bodies treated as we near the end of life. In 2005, France passed Leonetti's Law which, among other things, enabled the citizens of France to name a "Person of Confidence" or "Trusted Person," similar to our designated health agent or proxy. Prior to that, doctors could make decisions to end care without consulting either the patient or family. France is struggling with people not knowing that they can select someone to make health care decisions for them when they cannot make them themselves. I am not sure what the answer is to this lack of education. Perhaps there needs to be more public cases like the Terri Schiavo case that will wake people up to ensuring that their loved one knows what their wishes are as to how they want their body treated especially when the choice is quality of life vs. quantity of life.

Additionally, France is moving toward legalizing euthanasia. In March of this year, France's medical ethics council ruled that "assisted suicide should exceptionally be allowed when ailing patients make 'persistent, lucid and repeated requests' to end their life." [1] With this ruling, France is moving closer to allowing "assisted death" under very specific circumstances, although there are factions that believe that euthanasia should be legalized. In my research in preparation for my presentations, I learned that according to France's national demographics council, there are about 3,000 euthanasia cases in France annually on average, all of them illegal. [2]

While we do not allow euthanasia here, I do wonder if it happens here anyway. For example, there is the principle of the "double effect," which means that someone is given medication for one purpose and it unintentionally causes a harmful side effect, which was not intended. [3] So, if someone is in a great deal of pain and the doctors prescribe more pain medication, and that pain medication happens to hasten the person's death, that is not considered euthanasia. However, if the intention of giving additional medication is to hasten death, that is not allowed in the U.S. There are those who now think that there is no such thing as a double effect, since medications can be given in such a way that death would not "unintentionally" occur by properly increasing the medication. There are others who continue to argue that there is still a double effect doctrine. In either case, who really knows what the "intention" is either on the part of the medical team or of a family member who asks that the patient receive more pain medication because they "appear to be in pain" or "appear to be struggling."

In any case, whether there is or is not the possibility of the double effect, we need to be educated properly so that we can ensure that our loved ones and we ourselves are cared for in the manner we want. We need to have choices in how we and those we care for are treated, particularly as we near the end of our life. But, we need to do so having been educated, not being in a place where decisions may be made without our understanding the ramifications and perhaps without our knowledge or consent.





The doctrine (or principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end. It is claimed that sometimes it is permissible to cause such a harm as a side effect (or "double effect") of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end.

For more by Rev. Dr. Martha R. Jacobs, click here.

For more on death and dying, click here.