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These countries have an obligation to implement the directives of the convention nationally. However, national approaches to this implementation can differ markedly. In this article we focus on two countries, England and France, and the way the international directive regarding respect for dignity has been translated at a national level. We argue that in England respect for dignity is mainly understood as respect for autonomy, whereas in France respect for dignity is mainly understood as respect for humanity, solidarity, and public order.
Refusal of Treatment []. Human Rights and Healthcare. Dignity in the English End-of-Life Context: Respect for dignity is invoked as one of the fundamental principles in moral debates and international guidelines on end-of-life issues. In addition, the right of the individual to self-determination was successfully defended by Lord Donaldson of Lymington M.
Efforts to establish respect for patient dignity have already appeared in international documents. As mentioned previously, the European Convention on Human Rights and Biomedicine emphasizes the obligation to seek free and informed consent from patients, prior to any health intervention Article 5 , as essential to the respect for patient dignity and freedoms Article 1.
Furthermore, the convention requires healthcare providers to show respect for the dignity and freedom of patients by taking into account their wishes regarding end-of-life treatment. Since the Mental Capacity Act of , which came into force in England and Wales in , written advance decisions to refuse treatment have become legally binding also under statute law, provided that certain criteria are met.
The act introduced advance decisions as a way of enhancing the autonomy of patients who had become incompetent. It stipulated that a patient has the right to refuse any treatment, including clinically assisted nutrition and hydration Public Health Code Article L. The law stipulates that all competent patients can compose such a document. However, unlike in England, advance decisions are currently not legally binding in France. However, it is made clear that it is the physician alone who makes the decision to withdraw or withhold life-sustaining treatment.
Despite many attempts in recent years to strengthen patient rights in France, a strong commitment to protect the vulnerable person and to delegate responsibilities to the physician remains the leading element in regulating end-of-life decisions. Looking at the legal landscape regarding end-of-life practices and advance decisions in England and France, one could argue that although both countries are committed to protecting patient dignity in end-of-life care, their way of achieving this aim is different.
A helpful definition of how human dignity is understood in the English medical context comes from the Nuffield Council on Bioethics. In addition, the right of the individual to self-determination was successfully defended by Lord Donaldson of Lymington M. It is well established that in the ultimate the right of the individual is paramount. In the liberal, rights-based context of English culture, 29 dignity is often associated with self-governance.
As stated elsewhere, 30 this right has been backed up by important English thinkers such as Locke, who argued that no authority should intervene in the private life of a person, 31 and Mill, according to whom a person should be free to act autonomously, as long as he or she does not restrain the liberty of others. As we will see in the next section, France takes a different approach to dignity. In the French context, the person is more embedded in society, and the emphasis is on the equal rights of all members of the community, rather than on individual rights.
Kings, ministers, bishops, and doctors had special dignities that came with their roles and positions. It extended dignities to all people regardless of their class or rank, based on the idea that all humans shared a common nature and were equal in the eyes of the law. According to Article Law is the expression of the general will. It must be the same to all whether it protects or punishes. All citizens, being equal in the eyes of the law, are equally eligible to all dignities and for all public positions and occupations, according to their capacities, and without other distinction than that of their virtues and talents.
Three parliamentary reports on end-of-life issues discuss the different use of the notion of dignity in the debate on end-of-life and euthanasia. The report acknowledges that many proponents of euthanasia use this definition of dignity to support their arguments. The alternative understanding of dignity, however, signifies the notion of dignity as an intrinsic characteristic of human life, an unalienated quality that all humans share and that cannot be lost or diminished. This is the notion of dignity that opponents of euthanasia usually invoke.
All three reports tend to favor the meaning of dignity as an intrinsic quality of human life.
The French National Ethics Committee, in a report, states that the different meanings of dignity are not a priori contrary to each other. The understanding of dignity as a value that is intrinsic to every human being and that should be protected by public authorities or representatives of society directs not only the debate but also the law and policies on end-of-life practices in France.
Given the differences in the way dignity is understood in England and France, it is worth looking deeper into these two different understandings of the term. Dignity is often described as an elusive concept. Some authors have argued that the two notions often collapse into one. Therefore, because autonomy is much easier to define, it has been suggested that the concept of dignity is redundant and should be removed. Many philosophers have taken it upon themselves to articulate the exact meaning of dignity, and they have proposed a number of different definitions of the term.
Immanuel Kant was the philosopher who put dignity and respect for persons at the center of moral theory. Dignity as respect for humanity is a value that has been used to defend situations in which individual decisions and rights are curtailed. Human dignity was invoked, most famously, in the dwarf-tossing case in France.
Although Manuel Wackenheim, the dwarf who was making his living by hiring himself to be tossed, appealed and even took his case to the International Committee on Civil and Political Rights, the committee ruled against him, on the grounds that banning dwarf tossing was necessary for the protection of human dignity. Respecting dignity means respecting the humanity of every single person who forms the group, rather than the right of each individual to act independently. It is the close relationship between the notions of humanity and autonomy that has given rise to the second understanding of dignity we discuss in this article: He argued that the capacity for autonomy is one of the main characteristics that differentiate humans from other animals, and that they also endow human life with special moral value.
He who lets the world, or his own portion of it, choose his plan of life for him has no need of any other faculty than the ape-like one of imitation. He must use observation to see, reasoning and judgement to foresee, activity to gather materials for decision, discrimination to decide, and when he has decided, firmness and self-control to hold his deliberate decision. And these qualities he requires and exercises in proportion as the part of his conduct which he determines according to his own judgement and feelings is a large one. But what will be his comparative worth as a human being?
The English model of end-of-life care seems to favor the view of dignity as respect for autonomy. The best way to honor human beings and show due esteem for their dignity is to recognize them as autonomous individuals, and allow them to pursue their own goals and dreams.
When it comes to patients approaching the end of their lives, the appropriate way of treating them is allowing them to keep pursuing their own individual accounts of the good life until the end, and even beyond. Our analysis of the theoretical underpinnings of the English and French attitudes toward end-of-life decisions reveal a difference in the accounts of dignity adopted by the two countries.
In the French context, dignity seems primarily to signify respect for humanity. Protecting and respecting human dignity is central in many European and international declarations and guidelines regarding end-of-life issues. Given that the role of these guidelines is the alignment of law and practice across countries, understanding the contextual meaning of central concepts such as dignity will help anticipate how these guidelines could be implemented locally.
Ruth Horn , Ph. Angeliki Kerasidou , Ph. For a philosophical analysis of the meaning of dignity, see Wood AW. Cambridge University Press; ; Foster C. Human dignity in bioethics and biolaw. Human dignity in bioethics: From worldviews to the public square. Two riddles and four concepts.
Cambridge Quarterly of Healthcare Ethics ; 17 2: Another look at dignity. Cambridge Quarterly of Healthcare Ethics ; 13 1: One, two, three, four, five, still counting. Cambridge Quarterly of Healthcare Ethics ;19 1: Dignity is a useless concept. British Medical Journal Convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine. Council of Europe; Universal declaration on the human genome and human rights; Universal declaration on bioethics and human rights.
End-of-life care in the 21st century: Advance directive in universal rights discourse. See note 2, Schroeder It is important to note that in England and France the law gives patients the right to refuse but not to request treatment.
University of Chicago Press; Refusal of Treatment [] 4 All ER Journal Officiel ; Presses Universitaires de France; Advance directives in English and French law: Different concepts, different values, different societies. Health Care Analysis ; Published by Oxford University Press; all rights reserved.
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