Who could apply for assisted suicide were the law to be finally adopted ?
Law for exceptions or creation of a wide-open counter? The question is being raised to know who could apply for assisted suicide were the law to be finally adopted.
Article 4 of the bill adopted at its first reading by the National Assembly establishes a set of five criteria. The supporters of assisted suicide regularly describe them in the media as 5 strict criteria.
The first two criteria are obviously not restrictive by nature:
The applicant must be at least 18 years old and French or living in France stably, that would apply to around 54.5 million people (calculated according to INSEE sources).
In order to estimate the number of people eligible for assisted suicide – and euthanasia “if he/she is physically incapable of so doing” – the last three criteria are the ones which need to be evaluated. They are worded as follows:
- The patient must be suffering from a serious and incurable disease, whatever the cause, affecting life expectancy, in an advanced phase, characterised by the entry into an irreversible process marked by the deterioration of the health of the patient, affecting his/her quality of life, or in its terminal phase;
- The patient must be subject to constant physical or psychological suffering associated with the disease, which is either refractory to treatments, or unbearable according to the patient if he/she chooses not to receive or to terminate receiving treatment. Psychological suffering only does not under any circumstances provide eligibility for assistance in dying;
- The patient must be capable of expressing his/her free and enlightened will.
Criteria which are devoid of any scientific or objective approach
The wording of these criteria introduces numerous notions: “serious and incurable disease”, “life expectancy”, “advanced phase”, “constant physical or psychological suffering”… These notions are not however clearly defined.
For example, the term “advanced phase” is not a medically precise notion. The High Authority for Health (HAS) recently published a report on the notions of “life expectancy threatened in the medium term” and “advanced phase” and its conclusion is unequivocal:
“The result of the above is that the two notions mentioned in the submission do not appear appropriate as a basis for an approach on an individual temporal life expectancy. The college notes, more generally, that the work by the HAS did not enable identification of the alternative criterion liable to guide such an approach under more satisfactory conditions”. As recalled by the nephrologist Bruno Dallaporta in an article for Le Figaro: “It is not clear what exactly is meant by the advanced phase of a disease.”
Concerning the criterion of suffering, there indeed exist evaluation scales for pain. The question is regularly put to patients: “On a scale of 1 to 10, how do you rate your level of pain?”. The basis is therefore declarative. The experience of medical teams shows incidentally that for identical diagnoses, patients may feel pain more or less strongly according to their history, their situation, their overall care… Moreover, in establishing this criterion, the judgement of the patient is central: “Unbearable according to the patient”. It is definite that the statement by the patient on his/her pain must be listened to: considered by the medical team, the patient’s family and entourage. Everything must be done in order to relieve it, without suggesting death as the only desirable solution.
Another subjective item: the notion “affecting quality of life”. A theoretically clear expression, quality of life is a vague notion. When in good health, many people will claim that a loss of mobility has a serious effect on their quality of life. However, many people who have experienced serious accidents have reported their ability for recovering their will to live. Here is a striking example: in a study of tens of patients suffering from the locked-in syndrome, 72% claim to be happy.
Serious disease, advanced phase: who might be concerned?
In view of the lack of medical rigour in the definition of the criteria, an estimate can be based upon the patients categorised by the administration as long-term diseased (ALD). According to the health service web site, “Long-term disease (ALD) concerns a disease whose gravity and/or chronic nature require long-term treatment“. The definition of ALD diseases therefore contains notions of gravity and duration which are close to the notions of serious disease in an advanced phase, with an impact on quality of life due to the “extended treatment”.
According to a report by the IGAS (General Inspectorate for Social Affairs) published in the autumn of 2024, and based on the health system statistics, there were 13.7 million people recognised as ALD in 2021. Among the ALD categories, there are categories qualified as chronic and serious. For example, 501,000 patients affected by a disabling stroke, 1,436,000 patients suffering from serious cardiac insufficiency, 340,000 patients suffering from serious chronic respiratory insufficiency, 150,000 people suffering from Parkinson’s disease. Among the patients suffering from serious kidney disease, 258,000 patients are registered as ALD. As underlined by MP Philippe Juvin (LR) several times during the parliamentary debates: “chronic kidney insufficiency, which is treated by dialysis, is a terminal kidney condition. It is its definition. Therefore, the criteria are met. However, there is a remaining life expectancy of 20 years.
The absence of a well-defined and strict criterion therefore opens the door to a very broad definition of the people liable to resort to assisted suicide if the bill were to be finally adopted. All the patients categorised as ALD would not, fortunately, meet the criteria of the text. But one can reasonably estimate that between 5 and 10% of the categories labelled as “serious” would be eligible, their quality of life being degraded and their incurability established. That equates to a minimum of several hundred thousand people concerned directly. The French Society for Accompaniment and Palliative Care (SFAP) has published a very plausible estimate of around 1 million patients.
The intention stated at the outset, by the CCNE, the citizens’ convention, Emmanuel Macron, was to meet the needs of exceptional “medium term” end-of-life situations. Catherine Vautrin, the Minister, repeated as much when the debate started in the Parliament. It concerns “precise situations”. Faced with the reality of the figures, the intentions and declarations do not hold up. The text does not concern the end of life. In fact, it includes the very numerous cases of serious and disabling diseases. In the context of the health system crisis, and at a time when pessimistic forecasts on its funding are building up, the irresponsibility of this legislative procedure is patent.
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