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In the Name of National Solidarity : importing “Personalized” Care into the Public Hospital. A Study of Palliative Care Professionals

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French

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Abstract

The opening of the first palliative care units (PCUs) within hospitals in the summer of 1987 was met with resistance. Because this health care model emerged from within North America and Britain and the private sector, PCUs were first established in clinics and private hospices before opening in general hospitals, private hospitals providing public service, and less frequently, university hospital centers (UHCs). The year 1986 was a landmark in the history of palliative care in France: a decree—the Circulaire Laroque—authorized health care professionals to open PCUs, thereby paving the way for the first “public” units.This study demonstrates that PCUs opened a “window of opportunity” for doctors seeking to position themselves at the margins of medical power. Likewise, among both “mediterranean” women and bourgeois white women working in private hospices, the careers of geriatricians improved when they gained employment in public hospitals. Upward mobility was also observed among nurses, whereas those with the least social privilege and caregivers who faithfully tended to the ill saw their careers stagnate.This dissertation intends to renew PCU and “dying well” approaches by questioning the limits of the private-public divide. The public sector currently provides the majority of palliative care services available today (69% of PCUs operate within public institutions, compared with 31% in the private sector), a trend toward nationalization that was confirmed in 1991 when the provision of such treatments was officially declared a “public service mission.” Yet the first PCUs were modeled after “private” institutions in Britain (Hostel of God) and Quebec (Maison Michel Sarrazin) or after early private French institutions like the Fondation des Oeuvres du Calvaire.The provision of these services therefore raises issues regarding the introduction of “private” working methods in public hospitals in general and, more specifically, an eventual “privatization” of public hospitals, at least with regard to end-of-life patients. Despite the statistical realities, these changes relegate the principles of public service—neutrality of service providers, continuity of care, equal treatment—to the margins.

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