End of life bill : Opening of a counter for assisted suicide and euthanasia
The end of life bill has been submitted to the French State Council for examination, prior to its presentation to the French Cabinet on 10th April.
A bill which has been “tied-up” for months
A version dated October 2023 had already been circulated. Alliance VITA, through its spokesperson had provided an analysis. At the time, many associations of carers had denounced its terms. The version circulating today picks up on all the characteristics of the previous version and adds the criterion of psychological suffering:
- “assistance in dying” would be conducted in the form of assisted suicide or euthanasia if the patient is unable to self-administer including with a close relation.
- A single doctor has the final say as to whether the patient’s request meets the eligibility criteria.
- Life expectancy must be threatened in the short or medium term without any definition of the term.
- The decision time is relatively short: the decision may be put to execution in less than 3 weeks.
- Close relations and family members have no role in the process established.
- The conscience clause included does not cover pharmacists who have to prepare and provide the lethal substance, nor does it cover the institutions accommodating the patients.
- Checks will only be conducted in retrospect.
This virtual absence of any modifications since October throws suspicion on the reasons for the time delay for the official announcement, made by Emmanuel Macron during an interview on 10th March. Especially as the bill does not include any constraining objectives with respect to palliative care which have been renamed as “accompaniment care”.
The content of the bill
- Presentation of the motives
The presentation of motives strives to position the bill in continuity with the previous laws: Access to palliative care, refusal of unreasonable therapeutic obstinacy, possibility of ending or refusing a treatment, deep and continuous sedation until death in the event of life expectancy threatened in the short term etc.
The word dignity, which is never defined, comes up several times in the presentation. When reading the text, it is understood that dignity refers to the subjective feeling of the patient, and not the intrinsic dignity of any human being. This represents a first semantic sliding with heavy consequences.
With this bill, the break-away is confirmed with the search for a “French way” for the end of life. Put forward in 2005, this “French way” rejected therapeutic obstinacy and euthanasia. In its discussions with the members of the Citizens’ Convention on the end of life in April 2023, Emmanuel Macron spoke of “establishing a new waypoint towards this new French model for the end of life”. The process being established is in fact a foreign import.
The bill refers to a “request by society”: “to be able to choose one’s death”. However, as far as we are aware, no survey, or Citizens’ Convention has ever asked the direct question “Do you wish to be able to decide on your own death?”. The CCNE (National Consultative Ethics Committee), consulted for the bill, indicated in its controversial advice on the question (advice 139):
“The call for active assistance in dying concerns in particular the fear of a bad death: suffering from isolation, loneliness, incapacitation, dependence or the absence of access to palliative care. Finally, requests to die may also be the expression of a deep anxio-depressive syndrome (which should be evaluated and treated) in a situation where the loss of certain functions and autonomy build up, leading to a loss of self-esteem. These fears may explain the call for a legislative evolution towards the authorisation for active assistance in dying.”
How can one speak of a free and enlightened will for a decision, in such a context?
And if suicide is considered as an “ultimate freedom”, as is suggested in the presentation of motives, or even a “right”, for what reason would there be any need for prevention?
- The first section of the bill is devoted to “accompaniment care and the rights of patients.”
The first articles are intended to redefine such care as a broader approach than palliative care. The notion of “palliative care” is included in the more general term of “accompaniment care”. The bill claims that such care includes “support care” (psychological and nutritional accompaniment etc.), “comfort care” (massage, music therapy etc.), such accompaniment becoming a “palliative approach initiated early including at home and regularly re-evaluated to improve the quality of life of the patient until death.”
That definition is in fact exactly that of palliative care according to the WHO!
Its web site specifies that: “Palliative care represents an approach to improve the quality of life of patients (adults and minors) and their families, confronted with problems associated with potentially fatal diseases. They prevent and relieve suffering through early recognition, correct evaluation and treatment of pain and other problems, whether they be physical, psychosocial or spiritual.”
The reality on the ground seems unknown in this bill. Music therapy is practiced in palliative care units, as well as psychological accompaniment. Jacques Ricot, the philosopher, recalls in an ancient article that the first palliative care unit in France, which opened in 1987, included a psychologist within its team. Claire Oppert, the cellist, has written a fine testimony on music therapy for people at their end of life. None of this is new, therefore, contrary to what is being claimed.
A new term has enriched the sanitary lexicon namely “accompaniment houses”, which are intermediate structures intended to accommodate patients for this general cover.
No promise of means has been given in the bill under “care”. The “accompaniment houses” will be under budgetary funding constraints (so-called ONDAM national objective for health insurance expenditure) which is already managing a health system in crisis.
The bill introduces a right to visit hospitalised patients and residents of medico-social establishments. Called for in the aftermath of the severe restrictions experienced during the sanitary crisis, this right “must however be reconciled with the organisational constraints of the establishment.”
- The second section of the bill details the “assistance in dying” process.
This consists of self-administration of the lethal substance by the patient, or its administration by a health-worker or a close relation if the patient is physically incapable of doing so.
Apparently strict conditions are mentioned:
The patient must be an adult, capable of expressing their free and enlightened will, suffering from a serious and incurable condition threatening their life expectancy in the short or medium term and subject to persistent or unbearable physical or psychological suffering associated with their condition.
In an interview during which President Macron revealed the broad lines of the bill, he indicated that it would be “up to a medical team to decide, collectively and transparently, the response to be given to such requests.”
In the text submitted to the State Council, a single doctor would take the decision. The doctor consulted would seek advice from a doctor who does not know the patient, a specialist in the pathology which the patient is suffering from and a professional paramedic.
Such advice does not in any way constitute a “collective decision”. The process adopted thus establishes medical omnipotence. There is some concern that a channel may be created since the patient will be able to choose the doctor to receive the request. No link with the patient’s doctor is required. In the same conversation with the La Croix and Libération journalists, Emmanuel Macron stated that “Family members who may well be advised to act will be able to appeal against the decision”. No information to or consultation of close relations or family members is however included in the process.
The time required for implementation is relatively short: the doctor consulted has 15 days to respond to the patient, then the patient has 2 days to confirm the request.
Finally, for this so-called “French model” whose Minister in charge, Catherine Vautrin, has specified that it is “neither euthanasia, nor assisted suicide” whereas it is in fact legalising both, the bill will modify the code of insurance and the mutual insurance system which exclude suicide cases from life insurance claims during the first year of the contract.
“The frontiers of my language are the frontiers of my world”, according to Ludgig Wittgenstein, the philosopher. One can therefore understand the importance afforded by this bill to the use of its own language, manipulating new definitions of existing realities.
The world modelled by this bill is resolutely individualistic. It constitutes a total upheaval by lifting the prohibition to kill and it establishes a medical omnipotence, the first victims of which will be the most vulnerable.
