Report n° 42 – Proposition of End of Life law discussed in National Assembly

13/03/2015

Alliance VITA decrypts the latest legislation

THE EVENT

On Tuesday & Wednesday March 10-11, 2015, the French National Assembly examined and voted on 11 articles of the proposition of law creating new rights in favor of the ill and of people at the end of their life“. The solemn vote on the whole text takes place on Tuesday March 17, 2015.

Remember that the two MPs reporting, Alain Claeys (Socialist Party, PS) and Jean Leonetti (Populist Movement Union, UMP [now known as Republican]), had developed this text at the request of the President of the Republic. After nearly two years of various consultations, the objective was to fulfill commitment n°21 of his presidential campaign, expressed in January 2012 : “I will propose that any adult person in an advanced or terminal phase of an incurable illness, provoking an insupportable physical or psychological pain that cannot be calmed, may ask, under precise and strict conditions, to benefit from medical assistance to terminate his life with dignity“.

The two main novelties are the creation of a “right to a deep and continuous sedation until death” and henceforth the anticipated constraining directives, which leave the door wide-open toward the increasing use of practices which are essentially euthanasia.

 

THE FIGURE

1068 amendments were deposed regarding this text – proof that important dividing lines were manifest on the proposed measures. Nonetheless, they were presented by the government as work expressing a national consensus. In reality, this consensus doesn’t even exist, because the contested measures go too far for some, and not far enough for others.

 

SUMMARY OF THE DEBATES

a) The general discussion and the announcements of the government

During the first four hours of the parliamentary debate, numerous MPs succeeded each other on the tribune to express their convictions on the end of life. Among the main themes dealt with we can cite : accompanying the patients and the relief of their suffering, criticism on lack of palliative care units, the conflict of values between those who give priority to ethics of autonomy (sacredness of the liberty of choice) and those who uphold the ethics of vulnerability (priority of respecting the dignity of the weakest.), the ambiguity of candidate Hollande’s proposition 21, which is the source of the diverging interpretations on the measures which should be taken, the real risks of veering towards euthanasia or disguised assisted suicides, and the uselessness of a new law, as long as palliative care is not really being put to use everywhere.

In her introductory exposé, Minister Marisol Touraine made several announcements :

A triennial development plan of palliative care (promised since 2012) will be launched in the next weeks. It will be centered on access to palliative care in residential homes for elderly dependant persons (EHPAD) and at home, on training health personnel in palliative practices and on the elaboration by the High Authority of Health of a common repository for health professionals.

About anticipated directives, she argued against registering them on the Carte Vitale (National Health Card) and instead proposed the creation of a national automated register, easily consultable by doctors.

– In conclusion, whilst considering that this text constitutes “a balance point”, the minister has opened the door to further modifications, by declaring: “Obviously the debate remains open (.). The next step will be to see how this law is applied and, in the case where an extra step appears necessary, to reflect on the best way to include it.

 

b) The amendments aiming at legalizing euthanasia and/or assisted suicide

To avoid having these amendments voted in the late evening of Wednesday March 11 by a small minority of members, the government changed the agenda to make sure of a larger number of members in the middle of the afternoon (after the questions to the government). There was a great risk of ending up with a law explicitly introducing euthanasia in France, by way of an amendment dealing with an article on sedation.  The government took the risk of opening “Pandora’s box” on euthanasia, since the Parliament was consulted on measures which, in reality, could be taken without having recourse to the law.

The principal amendment, presented by Socialist Party (PS) MP Jean-Louis Touraine and supported by 121 MPs, aimed to create an “active medical assistance to die” (euphemism employed to avoid pronouncing the word euthanasia, which, as many MPs have underlined, would scare the French). With two more identical amendments, one presented by radical Roger-Gérard Schwartzenberg and the other by Ecologist Party MP Véronique Massonneau, a common vote by public scrutiny was requested. Out of 161 voting, 70 members were “In Favor”: 50 of whom were socialist (PS), and 89 were “Against”: 40 socialist votes and 43 UMP votes.

Two other amendments, somewhat different but following the same objective, one from Roger-Gerard Schwartzenberg, and the other from Véronique Massonneau, were rejected by a “sit-stand” vote, that is, without counting numbers as in the public scrutiny.

c) Other significant amendments

In general, the two reporters and the minister contrived the situation so that almost all of the amendments were refused, whether they were proposed from the right or left wing. They only accepted a few minor adjustments and gave some verbal agreements to better formulate litigious expressions during the consultation with the Senate. But all the propositions made by the opposition to clarify the ambiguities or avoid side-door entries for euthanasia, were rejected.

Article 1 introduces the basic principle that “all persons have the right to a dignified and peaceful end to life“. In this framework, an amendment by member François de Mazières (UMP) was voted in; allowing the affirmation of the principle of the right to training in palliative care for medical personnel, knowing that implementing this program depends on the government powers. It was a symbolic way of “saying yes to palliative care after having said no to euthanasia”, the member summarized.

Article 2 concerns halting treatments and conditions of unreasonable therapeutic obstinacy. Not one amendment was accepted among those aimed at clarifying distinctions between care and treatment, or defining the expression “artificial maintenance of life ” more clearly. The definition given by Jean Leonetti – “major and irreversible cerebral lesions, leading to an absence of consciousness of oneself and an absence of relating to others” – will certainly need to be developed, since we are dealing with a major concern for patients at the end of their life, but also for seriously handicapped persons (the example of Vincent Lambert was cited several times).

In the same way, the affirmation by which “artificial food and hydration constitute treatments” continues to pose serious problems, since the reporters have refused any idea of reducing this contestable principle. Since every person can demand a stop to his or her treatments, even if he or she isn’t at life’s end, the door remains open to assisted-suicide requests, and doctors could be required to accept.

Article 3 constitutes the heart of the law’s proposition, by creating a right to a deep and continued sedation until death. In two of the three cases where this right could be imposed on the doctor (see their definitions under the Decoder n°40 December, 14, 2014), the risks of disguised euthanasia remain high. For more than two hours the opposition members tried to make the reporters clarify the meaning of certain essential expressions, notably :

* in the expression “not to prolong one’s life uselessly” (can one ever affirm that a life is useless ?), they obtained that a better formulation will be researched in the consultation with the Senate ;

* in the expression “short term vital prognostic “, Jean Leonetti affirmed that the term is more precise for professionals, and that it can be measured in days or in weeks, while the expression “in terminal phase” is regarded as vaguer, and can be measured in weeks or in months. This affirmation will likewise merit deeper reflections with professionals dealing with the end of life.

* on the penalization of palliative care in calculating the price of medical acts (T2A), the minister committed herself to reviewing the reimbursement quotations of these acts, whose value is currently esteemed lesser than those in curative cases, such as surgical operations and serious treatments. However, all the other amendments for clarifying the situations or for restricting the risks of euthanasia of cases n°2 or n°3 were rejected, as well as those aiming to introduce a conscience clause. It was the same for reverse amendments which tried surreptitiously to reintroduce forms of exceptions for euthanasia.

Article 4 concerns the right to pain relief. In the proposition of law, the expression “secondary effect” was deleted, leaving it to be understood that treatments which relieve difficult pain could henceforth have the termination of life as their primary objective. Faced with the members’ request to reintroduce this notion, Jean Leonetti explained that these treatments (using a semantic analysis of the expression, “even if they may have the effect of shortening life”) still remain within the framework of the principle of the so-called double effect.

Article 4 b was added by the Social Affairs Commission on February 17, so that regional annual reports would examine the development of palliative care throughout the French territory. In complement to this, an amendment from Mme Le Dain (PS) was voted in, in opposition of the reporters and of the government, so that every case of profound and continued sedation would be recorded in a special register held by each establishment concerned.

Articles 5 to 7 were adopted without any significant modification.

Article 8 concerns the anticipated directives that have become constraining for the doctor, except in cases of life-threatening emergency or if they “appear manifestly inappropriate”. There again, all the amendments to avoid changing doctors into service operators, only serving to execute the “patient’s orders” were refused. Alain Claeys recalled that respecting a person’s autonomy is at the center of the text, and Jean Leonetti clarified that these directives are binding or constraining, but not enforceable in all circumstances since one could bypass them.

However one important point merits recall. In the case of manifestly inappropriate directives, it was situpulated in the initial text that the doctor can circumvent them by consulting a confrere and by justifying his decision in writing in the medical file. The Social Affairs Commission voted in an amendment by Véronique Massonneau (Green Party) which changes the procedure : from now on the doctor must solicit a collegial opinion, and it is the collegial decision which stands (without specifying who takes part in the decision). This new formulation, passed largely unnoticed, strongly reduces the physician’s power of assesment.

The government passed an amendment aiming to facilitate recording and consulting these directives : the inscription on the National Medical Card (Carte Vitale) is to be dispensed with, to be replaced by the creation of an automatic national register consultable by the doctors. This register, to be created after consulting the CNIL, the French Data Protection Authority, will be facultative.

Article 9, which concerns the status of the “trusted person”, was completed by an amendment by Véronique Massonneau (Green Party) which authorizes this person to consult the medical file of the patient concerned.

The last articles 10 & 11 gave rise to a vote on a few amendments on diverse consequences of the text, the principal of which, introduced by Sandrine Hurel (Socialist), charges the Government to submit a report to Parliament every year on the application of the law and on the development of palliative care.

 

THE BEST

A group of MPs strongly committed themselves during the debates on the proposition of law. Members of “Parliament for the Family” (Entente Parlementaire pour la Famille), tried to deflect the most dangerous aspects. Among the most active throughout the two days : Xavier Breton, Nicolas Dhuicq, Philippe Gosselin, Marc Le Fur, Hervé Mariton, François de Mazières, Jean-Frédéric Poisson, Frédéric Reiss.

Four of these members – Breton, Gosselin, Mariton, Poisson – came to support the movement Kill the Pain, not the Person (“Soulager mais pas tuer”) at its gathering on the Esplanade des Invalides on March 10, 2015, a few hours before the start of the parliamentary debate.

THE WORST

Watch out for the trap of the “foot in the door”, as we are faced with the ambivalence of numerous majority leaders. These people say they seek common consensus, but they are only dreaming of the next step towards a legalization of euthanasia, pure and simple in our country.

The following words of these last days are eloquent :

Prime-Minister Manuel Valls asks that Parliament “could bypass differences and agree on the most important points”, but lets it be understood “it’s without any doubt a step”, reminding us that he himself tabled a motion on the legalization of euthanasia in 2009.

Marisol Touraine, Health Minister, calls MPs not to “upset the French people”, but at the same time affirms “it consists in seeing how this law is applied and, if an additional step is needed, to reflect on the best way to put it into action”, assuring us that “the government will support this reflection”.

Bruno Le Roux, president of the Socialist Party in Parliament, wishes “that we have a serene, peaceful debate, and that at the end of it we’ll have made a step further, a position of compromise which doesn’t exclude any development“.

 

FOR FURTHER READING

Press Release: Kill the pain, not the patient, March 11, 2015

Decoder n°40, December 19, 2014, decrypting the Claeys-Leonetti report and the proposition of law in appendix.

– Recent Editorials in the press:

* Tugdual Derville “Proposition de loi sur la fin de vie : vers la sédation pour tous ?”,  Figaro Vox, 9th  March 2015

* 17 professeurs de médecine “La médecine est sous la menace d’un danger d’euthanasie”, Le Monde,      9th March 2015

* 175 médecins “La proposition de loi sur la fin de vie risque de renforcer l’isolement des patients”: Le Figaro 9th March 2015

* 5 représentants des grandes religions “L’interdit de tuer doit être préservé”, le Monde, 9th March 2015

* Cyrille et Magali Jeanteur : “Avec cette nouvelle loi, Cyrille ne serait pas là”, Le Figaro, 10th March 2015

Dr Sylvain Pourchet “Le droit à la sédation en fin de vie est un écran de fumée”, Le Figaro 10th March 2015

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