2024-04-10 03:32:30
The bill on “assisted dying”, the broad outlines of which were revealed by Emmanuel Macron in March, will be presented to the Council of Ministers on Wednesday April 10 and will arrive at first reading in the National Assembly on May 27. According to the text, transmitted to the Council of State, assistance in dying may strictly benefit people who simultaneously meet these five conditions:
be at least 18 years old; be of French nationality or reside in France; be able to express their will “in a free and informed manner” ;have declared a serious and incurable illness affecting their vital prognosis in the short term or medium term;present physical or psychological suffering “refractory or unbearable”.
The patient must make his request to a doctor who, following having obtained the opinion of a specialist and the applicant’s caregiver, will render his decision within fifteen days. The text provides that the patient administers the lethal substance himself when he is capable of doing so or, failing that, that he asks a person of his choice. The doctor or nurse present, responsible for verifying the patient’s wishes, can also accomplish this task.
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What are the specific issues of the French bill?
Two important questions arise from the conditions provided for by this bill: how to define the end of the medium-term vital prognosis, and what regarding advance directives, which are not taken into account?
The definition of the medium-term vital prognosis commitment is central to precisely drawing the contours of this system. Depending on whether the deadline is a few weeks or several months, the pathologies giving rise to the right to assisted dying are not the same.
Read also: End of life: words to better understand the debate
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Mélanie Heard, head of the health center at Terra Nova, and Martine Lombard, professor emeritus of law, expressed concern in a forum at Monde that the ambiguity of the wording does not empty “the future law on the end of life of a large part of its practical scope”, leaving the responsibility for interpretation to doctors, who will probably be very careful. Others, like the Association for the Right to Die with Dignity (ADMD), denounce this notion, which “condemns patients suffering, for example, from Charcot’s disease, to experience the tragedies of the final stages of the disease’s evolution”, whose evolution is slow but inevitable. Professionals are also campaigning for changes to the law: “So that those who do not want to suffer physical or psychological decline can have support towards death”argued at the end of 2023 in The world neurologist Valérie Mesnage.
Another unresolved question is that of advance directives. The Leonetti law of 2005 allows each adult to express their wishes on “their end of life with regard to the conditions for the continuation, limitation, cessation or refusal of medical treatment or procedures”. Or, according to the current bill, any person finding themselves unable to formulate their request directly to a doctor, even if they have done so in an advance directive which might be reaffirmed and supplemented gradually as his illness progresses, will not be able to request assistance in dying.
How would French law respond to cases encountered in countries that authorize euthanasia?
Two European countries have legalized euthanasia for more than twenty years: the Netherlands in 2001 and Belgium in 2002. These are the States which practice it the most: 8,720 cases were recorded by the Dutch in 2022, and 3 423 on the Belgian side in 2023. The other countries are smaller (Luxembourg legalized the practice in 2009, but only records 34 cases in 2022) or have changed their legislation more recently, Spain in 2021 (which has 288 cases in 2022) and Portugal in 2023.
Assisted suicide has been decriminalized in Austria since 2022, in Germany since 2020 and in Italy since 2019. In Switzerland, active euthanasia is prohibited while assisted suicide is fully integrated into the law. If the access modalities and procedures vary in each country, it is the example of the American state of Oregon which is closest to the French bill (this state recorded 367 assisted suicides in 2023) .
Based on reports published in the Netherlands and Belgium (countries with the highest number of patients affected, with figures decreasing in recent years), we have identified the most common pathologies of people who have asked to die. For each of these diseases, we tried to define whether they would be affected by the future French law. This is a theoretical reflection, at a stage where the text is still far from being voted on.
Advanced stage cancers
Tumors of cancerous origin constitute the first source of conditions leading to euthanasia. In Belgium, they represent more than half (55.5%) of life interruptions: 1,899 cases in 2023. In the Netherlands, this proportion reaches 57.8% of the 8,720 situations recorded in 2022 (5,046 cases) .
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Based on Belgian figures, malignant tumors of the digestive organs (pancreas, colon, esophagus and stomach), respiratory (mainly of the lung) and breast were the cause, alone, of 60% of cases of interruption of life linked to a cancerous tumor.
What would the French bill allow?
It will be possible to request assistance in dying for these incurable cancerous conditions at advanced stages: they meet the conditions of the bill, because they involve the vital prognosis of patients in the short or medium term, and are associated with unbearable physical or psychological suffering.
Les polypathologies
They constitute 16.4% of cases in the Netherlands (1,429 cases) and 23.2% in Belgium (793 cases).
The accumulation of chronic pathologies, including geriatric, can also be the cause of unbearable suffering with no prospect of improvement since some of them are degenerative, linked to age. The combination of disorders induced by different conditions is a source of physical but also psychological suffering: loss of autonomy, alteration of quality of life, sensory deficiency, depression, etc.
What would the French bill allow?
The management of these polypathologies by the future law on assisted dying will depend on the definition that will be given to the “medium term”. In Belgium, 421 people, out of the 793 who presented combinations of several refractory chronic conditions in 2023, were diagnosed with a foreseeable outcome of so-called “brief” death (in the coming days, weeks or months). Conversely, 372 people were diagnosed with a foreseeable “non-brief” death term; such a situation would deviate from the possibilities envisaged by French legislation.
Diseases of the nervous system
Pathologies of the nervous system – Parkinson’s disease, Charcot’s disease, multiple sclerosis, for example – are the third major type of conditions for which patients most resort to euthanasia: 9.6% in Belgium and 7%. in the Nederlands.
These neurodegenerative diseases cause motor and cognitive disturbances for which any cure is excluded. Treatments make it possible to slow the progression of these diseases, reduce their symptoms and improve quality of life, but in the more or less long term the disorders can progress and develop into irreversible disabilities.
What would the French bill allow?
For such diseases, the condition of life-threatening involvement “short or medium term” risks ruling out the possibility for the patient to resort to this help at the stage where the suffering becomes unbearable, his days generally still being far from being numbered.
Diseases of the circulatory system
They represent 3.2% of the pathologies at the origin of assisted dying carried out in Belgium, and 4.1% of those carried out in the Netherlands.
Diseases of the circulatory systems are mainly linked to the following-effects of a stroke, which can cause a sudden and severe loss of autonomy and complete dependence. The main following-effects are hemiplegia, mild to pronounced, speech disorders, sensory disorders and pain, etc.
What would the French bill allow?
The end-of-life requests of these patients will be largely excluded from the current bill, particularly in cases for which the vital prognosis is not threatened in the short or medium term.
Diseases of the respiratory system
These illnesses pushed 3% of patients in Belgium, and 3.2% in the Netherlands, to request assistance in dying.
Pulmonary fibrosis is one of the main chronic respiratory diseases of euthanized people. It is incurable and progressive; treatments only slow its development.
What would the French bill allow?
The progressive nature of the disease, which implies a more or less rapid deterioration in the condition of patients, makes it possible to consider recourse to assisted dying under the conditions provided for by the bill, when the vital prognosis may be committed to ” middle term “ – and according to the interpretation that will be made of this condition.
Neurodegenerative diseases
Dementia situations represent 1.2% of cases in Belgium and 2.5% of those in the Netherlands.
These neurodegenerative diseases, such as Alzheimer’s for example, are characterized by an increasing impairment of memory and cognitive functions, as well as behavioral disorders. The process is irreversible, and, in the absence of curative treatment, the disease leads to a progressive loss of autonomy.
What would the French bill allow?
These conditions clearly fall outside the scope of the bill: the person requesting assistance in dying would need to be able to express their request in an “informed manner”, and even in this case, their vital prognosis would probably not yet be engaged in the medium term. . Even if the person had left advance directives, to ask to die when dementia would cause them unbearable suffering, these might not be taken into account within the framework of the future law.
Belgian and Dutch legislation incorporates these requests, relying on advance directives and the wishes expressed by patients during their moments of lucidity. When they are no longer able to express themselves, the medical team makes the decision with a very supervised procedure (which is very rare, 6 cases out of 282 in the Netherlands).
Diseases psychiatric
Psychiatric disorders are rare among requests for assistance in dying: 1.3% of cases in the Netherlands and 1.4% in Belgium.
What would the French bill allow?
These diseases will, at the current stage, also be excluded from the scope of this bill, because they do not threaten the vital prognosis of patients. The explanatory memorandum of the text, a version of which has leaked, is explicit in its wording: “which excludes suffering exclusively linked to mental or psychological disorders”.
In addition to these most common pathologies covered by the legislation of our European neighbors, other emblematic cases have fueled the public debate around euthanasia in France. Thus, the young Vincent Humbert, quadriplegic, blind and mute following a road accident, who had requested the right to die from President Chirac in 2002, would not find a response in the future law.
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