The Citizens’ Convention on the end of life convened from Friday 3rd till Sunday 5th February, for its fifth weekend. After the presentation by Régis Aubry on deep and continuous sedation until death, this session was largely devoted to a debate on the authorisation of active assistance in dying and its implementation procedures.
The presentation by Régis Aubry
On deep and continuous sedation until death
For the introduction to this third and penultimate session of the deliberation phase, professor Régis Aubry, President of the National End of Life Observatory and co-spokesman for CCNE notice No. 139, was invited to provide his experience on the practice of deep and continuous sedation until death and to answer any questions from the citizens.
He began by explaining what it entails. This measure is defined in the 2016 Claeys-Leonetti law. It corresponds to a “pharmacological, medicinal coma” where vigilance is diminished till death. The medicine used is Midazolam.
Régis Aubry also recalled the three cases in which this type of sedation may be used:
- Serious and incurable illness where life expectancy is threatened in the short term,
- Interruption of “vital” treatment (for example, artificial respiration),
- Patient unconscious, having refused unreasonable therapeutic obstinacy, following a collegial procedure.
A question was quickly raised concerning the effectiveness of sedation for pain relief. On this subject, Régis Aubry indicated that there still remained some “degree of uncertainty” and that research was currently in progress. Especially, it is important to distinguish between physical pain, which can be treated with analgesics, and moral or existential suffering, which are frequent at the end of life. For that, sympathetic listening is of major importance but is not always available.
Euthanasia versus assisted suicide
The discussion did not remain limited to the sole practice of deep and continuous sedation until death, but also addressed active assistance in dying. On that question, Régis Aubry underlined the incompatibility for health workers between caring and inducing death: “How can one dissociate from the human standpoint to the extent of being able one day to do everything possible to relieve pain and accompany suffering, and the next day inject a lethal product?”. He also recalled that requests for euthanasia may evolve with time, or even disappear. He warned in particular about the situation of aged dependent patients, who feel they are a burden on society. According to him, before making any changes in the law, there must first be a “firm, clear and constant political commitment, for our society to accompany those facing situations of vulnerability.”
Nevertheless, it is appropriate to consider the possibility of active assistance in dying when the will of the patient “appears to correspond with such request.” During his presentation, he then developed arguments to clearly distinguish between euthanasia and assisted suicide. The first does not leave any possibility for the patient to be ambivalent in requesting to die, and involves a third party (the doctor), whereas, in the case of assisted suicide, not only is the doctor not involved, but there would be a possibility for respecting the ambivalence and evolutions of the patient. Régis Aubry quoted an example in Oregon where only a small proportion of those having applied for a lethal product actually obtain it and take it.
This is the position defended in CCNE Notice No.139, for which he is a co-spokesman, pleading both for “respect for the will” of the patient and a duty of solidarity for the most vulnerable.
One may wonder however whether the acceptance of suicide for certain categories of people, in the name of respect for their own will, can be truly compatible with this duty of solidarity, at a time when the Ministry of Health on 3rd February has recently restated that suicide prevention is a major challenge for public health. Moreover, it is surely illusory to believe that it is possible to recognise, behind the expression of a request to die, an absolutely autonomous desire, free of any, even interiorised pressures.
The implementation of active assistance in dying at the heart of the agenda for this session
During the Saturday session, the citizens were asked to work on four “themes of the debate”: the possible unlocking of access to active assistance in dying, the possible procedures for access to active assistance in dying, the form of active assistance in dying (euthanasia, assisted suicide or both) and full application of the current framework and reinvented end of life accompaniment. During the debates, the citizens formed groups in order to defend the different positions. La Croix newspaper provides the figures on the distribution of the groups: On the question “Should access to active assistance in dying be unlocked?”, 27 participants chose not to support it, 41 defended unlocking it for all requests, 95 considered that its unlocking should be subject to conditions and 2 remained undecided”.
Even if, according to the comments by Claire Thoury, the President of the Governance Committee, “everyone is still free to change their mind”, this distribution nevertheless gives a first idea of the distribution of opinions within the Citizens’ Convention.
Whereas there remains only one weekend before moving on to the final conclusion phase and reporting of the results, one might question the amount of debating time devoted exclusively to active assistance in dying, and the choice of demanding that all the citizens, even those opposed to it, should debate on the possible implementation procedures. With respect to the ten priority stakes which were established by the citizens, the time devoted to this single question appears, at the very least, to be out of proportion.