The concept of consent extends far beyond the realm of sexuality. The special section “Consent, Ethics, Care, and Health” in Issue No. 464 of La Santé en action provides an opportunity to explore its meaning in the care relationship as well as in several other areas. It analyzes the conditions that professionals in healthcare, education, and social services must meet, and all the questions they must ask themselves to obtain consent from individuals before any procedure or action. Underlying this challenge is the need to take the time to build consent, from the very beginning and throughout the consultation and care process. How can we take the time to inform, to talk, to postpone, and to meet again?

Promoting consent as an ethical requirement

At every stage of life, individuals are called upon to give—or withhold—their consent to a decision they did not initiate, thereby choosing what they desire. This applies to emotional and sexual life, as well as to contraception, voluntary termination of pregnancy, medical consultations, medical procedures (particularly those involving intimacy), end-of-life care, and so on.

Consent has a political, moral, and social dimension

Consent is the combined result of deliberation with another person and an internal decision. It therefore reflects tensions between freedom and constraints, between adhering to and tolerating. It cannot, therefore, be separated from the social characteristics of the individuals involved or from the power dynamics and hierarchies that bind them to others. As part of interactions between individuals, consent is thus also collective and therefore has a political, moral, and social dimension: making a personal and reasoned choice is, in reality, an act subject to a set of norms and the social context. Consent concerns everyone, particularly those affected by vulnerabilities (age, mental or physical disability, gender, health status, the case of migrants, etc.). The issue of the care relationship allows us to grasp its full complexity.

Consent in the field of health

In healthcare, consent has had a legal definition since the early 2000s: it must be “free and informed” based on information that is freely provided, understandable, and truthful. The law of March 4, 2022, on patients’ rights requires healthcare providers to give people all the information they need to make an informed choice. In practice, this involves obtaining the patient’s agreement on what is proposed during their care journey: the procedures performed on their body, prescriptions, etc. This requires a shift in the healthcare provider’s approach. It is not enough to simply explain the course of treatment to the patient and ask for their opinion or even if they have any objections; indeed, patients do not always dare to object to an authority figure who has undergone training and to whom they owe respect and trust. There is an imbalance between the power conferred by the white coat and expertise, and the potential vulnerability stemming from the reasons for seeking care.

Furthermore, throughout the La Santé en action special issue, it is noted that the concept of consent requires time, which healthcare providers no longer have. Beyond the question of the effective application of the numerous existing standards surrounding this issue, there is the challenge of professionals integrating reflection on the subject into the care relationship throughout their practice and, upstream, into their training.

The various articles in this special issue examine consent in a range of situations: they address vaginal and rectal examinations, for which consent is rarely questioned, preventing the patient from making an informed decision; voluntary termination of pregnancy, the terms of which are not always freely chosen; and gynecological consultations, including those for women with disabilities, during which sufficient time must be taken to include them in the discussion and establish a relationship of trust.

Care in closed settings (psychiatric facilities, drug users, prisons)

Psychiatry, an exception to the principle of consent where the free will of those involved is restricted, is the subject of another article, as is the mandatory treatment of perpetrators of sexual violence or certain drug users. In all these cases, consent gives way to obligation, but the challenge remains to forge a specific and unique therapeutic alliance with the patient.

Consent of the Most Vulnerable Individuals

Protection of minors: ages of sexual consent

One article explores the ages of consent in Canadian criminal law, and another examines the French law of April 21, 2021, aimed at protecting minors from sexual crimes and offenses and incest. This law, which eliminates the presumption of consent in many cases, also allows for the criminal liability of an adult who violates the integrity of a minor aged 15 (or 18 if there is a relationship of authority) to be established without the need to prove that violence, coercion, threats, or surprise were used.

Migrants and People at the End of Life

The report concludes by illustrating two other situations: that of migrants and the need for interpreters for those who do not understand French, and the case of end-of-life care, where the healthcare provider may have difficulty determining what the person truly wants, even if the person has provided advance directives. But even for people who are no longer able to express their views, decisions should be made based on who the person was, or even what they would have wanted.

The dossier includes documentary resources organized into eight categories: reference texts (laws, reports, and opinions); ethical and legal aspects; consent and sexuality; consent among vulnerable populations; consent to care and consent to psychiatric care; tools and resources; and literature.

What emerges from all these contributions is the importance of obtaining consent by engaging in a thorough dialogue with patients (no care without patient-caregiver dialogue) and of providing all professionals with the tools to understand that by practicing their profession in this way, they are “good caregivers.” It may also be a matter for them to resist this erosion of the time dedicated to the therapeutic relationship that characterizes the field of care. But they cannot act alone: it is the entire healthcare system that must be adapted to meet this ethical requirement.