From a critique of the principle of autonomy to an ethic of heteronomy.

Etymologically, autonomy is the ability to give oneself rules and follow them. It is an important principle of medical ethics, which can sometimes raise some tensions in the care relationship. We propose a new definition of ethics, the ethics of heteronomy: a self-normative, discursive and responsible autonomy. Autonomy cannot be considered without the responsibility each person must have towards others. In the care relationship, autonomy would be more the ability of each person to reach out to others than the ability to decide alone. The care relationship must be seen as an accompaniment of equals where each person allows the other to be rephrased. Autonomy would then no longer be absolute but relative to each situation. Being autonomous would become an ability for adaptation of the patient-doctor pair. The accompaniment allows the birth of a relationship of trust, giving the patient and the doctor the ability to touch and let themselves be touched, thus making each one progress in this reciprocal dialectic. The care relationship becomes the possibility of considering autonomy as a collective and not as an individual notion only. Paradoxically, by promoting the autonomy of the patient-doctor pair, they both develop their own autonomy.

Pandémie de COVID-19 : le « dilemme du tramway ¼ pour expliquer l'allocation des ressources rares.

INTRODUCTION: The SARS-CoV-2 virus that appeared in December 2019 in the city of Wuhan in China spread rapidly. Severe forms of this virus infection cause acute respiratory distress syndromes (ARDS) requiring hospitalization of affected patients in intensive care units (IUCs), providing mechanical ventilation. The capacity of ICUs in the countries most affected by this health crisis quickly became overwhelmed, forcing healthcare providers to choose the patients who would benefit from care. Managing the overload of a healthcare system is the role of disaster medicine, for which one of the principles is the triage of patients according to their severity. Having to choose between patients means choosing a statement between deontology (judging the morality of an action according to its intention) and utilitarianism (judging the morality of an action by its consequences). AIM: The aims of this article are, through the analysis of the trolley problem, to understand and justify the process of allocation of scarce resources found in the guidelines used in the context of the COVID-19 pandemic. RESULTS: The analysis of the trolley problem allows us to understand in what way our choices are utilitarian or deontological. Saving as many lives as possible", as advocated in the guidelines, is utilitarian. CONCLUSIONS: These answers will provide a better understanding of all of the different ways of allocating scare resources according to the deontological or utilitarian approach, especially the one found in the disaster medicine guidelines.

Access to information and oncofertility consultation for young women with breast cancer: a population-based study.

Non-menopausal women with breast cancer treated with chemotherapy are at intermediate risk of post-treatment amenorrhea and decreased fertility. Although they should receive appropriate information, studies until now show that this is inadequate. We investigated the proportion of women who received information about this risk during the pre-treatment consultation, and those who received an oncofertility consultation to preserve their gametes. We also analysed the medical and non-medical factors influencing the transmission of information to patients and their uptake of oncofertility consultations. We included women aged 18-40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Midi-Pyrénées region (ca. 3 million inhabitants), France. Studied variables were included in a multilevel model. Among the 575 women, 41% of the women received information and 28% received an oncofertility consultation. These two steps on the care pathway were significantly influenced by the type of care structure, the woman's age, her parity at the time of diagnosis, and the metastatic status of the cancer. Female oncologist gender was significantly associated with higher transmission rate. We found no association between neoadjuvant chemotherapy status, level of deprivation (EDI), triple-negative status, marital status, and first-degree family history of cancer and information transmission or uptake of oncofertility consultation. Our study shows that not enough women are informed and have recourse to an oncofertility consultation. Despite a legal obligation, the health care system does not offer the necessary conditions for access to oncofertility care.

The stake of informing patients of the risk of hypofertility after chemotherapy for breast cancer.

Introduction: Too few women with invasive breast cancer are informed of the risk of hypofertility after chemotherapy. However, this risk can be prevented by offering gamete preservation by a specialized team. We believe that if more women were informed about gamete preservation, more of them would accept it. Objectives: The primary objective is to describe each step of the oncofertility care pathway from provision of information to gamete preservation. The secondary objective is to estimate the impact of not receiving information by determining the proportion of women who would have undergone gamete preservation if they had been informed. Method: 575 women aged 18-40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Ouest-Occitanie region (~3 million inhabitants) were included. We first constructed a multivariate predictive model to determine the parameters influencing the uptake of the offer of gamete preservation among women who were informed and then applied it to the population of uninformed women. Results: Only 39% of women were informed of the risks of hypofertility related to chemotherapy and 11% ultimately received gamete preservation. If all had been informed of the risk, our model predicted an increase in gamete preservation of 15.35% in the youngest women (<30 years), 22.88% in women aged between 30 and 35 years and zero in those aged ≥36 years. We did not find any association with the European Deprivation Index (EDI). Conclusion: Oncologists should be aware of the need to inform patients aged ≤ 35 years about gamete preservation. If all received such information, the impact in terms of gamete preservation would likely be major.