ASSISTED SUICIDE EUTHANASIA

DOES THE END OF LIFE BELONG TO US ?

"The day after the adoption of the report of the citizens' convention on this subject, which considers it "necessary" to authorize assisted suicide and euthanasia, Emmanuel Macron spoke on Monday, April 3, in front of the 184 participants gathered at the Elysée Palace. He recalled in particular that a "citizen convention never replaces parliamentary deliberation".

This extremely sensitive subject, which refers each person to their own vulnerability, indeed calls upon medical, societal, legal, ethical, philosophical and, of course, political dimensions and requires time to think about them.

Red lines not to cross

"I ask the government, in conjunction with parliamentarians, to carry out a work of co-construction on the basis of this solid reference which is that of the citizens' convention", continued the Head of State, while setting "red lines" not to be crossed. Among these, the need to "guarantee the expression of the free and enlightened will", of the "reiteration of the choice", "the incurability of refractory, psychic and physical suffering, even the commitment of the vital prognosis".

"You insist, rightly, that active assistance in dying should never be carried out for a social reason, to respond to the isolation which sometimes can make a patient who knows he is condemned feel guilty", added Emmanuel Macron, who also closed the door to any assistance in dying for minors. "These few red lines seem to me to frame the hypothesis of a French model of the end of life", he further underlined.

Better application of the existing framework, namely the Claeys-Leonetti law of 2016

Legislation on the end of life in France has been able to reinvent itself since the first milestones laid by the Kouchner law of 1999 which guaranteed access to palliative care. The Leonetti law of 2005, then the Claeys-Leonetti law of 2016 opened up rights for people at the end of life. Beyond the cessation of treatment, they frame the appointment of a person of trust and the drafting of advance directives, a written declaration that can be made by any adult person to specify their wishes concerning their end of life.

Current legislation allows caregivers to irreversibly sedate patients near death, whose suffering is intolerable. But it does not go so far as to authorize assisted suicide or euthanasia, as proposed by the citizens' convention.

These provisions are seen as effective means of removing uncertainties related to end-of-life conditions. However, they are ineffective.

This is why the "first pillar of the response" that Emmanuel Macron intends to bring to the conclusions of the citizens' convention and the various works on the subject is "perhaps the least spectacular response": that of the best application of the framework existing, namely the Claeys-Leonetti law of 2016, which "we need to better enforce".

Indeed, it is clear that advance directives are difficult to apply

A team of researchers has analyzed the ability of people of trust to make decisions corresponding to the wishes of their loved one. Based on nearly 20,000 pairs of patient-trustee responses on hypothetical end-of-life scenarios, they came to a worrying conclusion: in a third of cases, the trustee is wrong about treatment preference of his loved one and does not make the decision that he would like.

Even more alarming: this figure remains the same when discussions on these issues have already taken place. Indeed, people of trust can prioritize their own values ​​over those of their loved ones.

Moreover, asking an elderly person to make a decision about their end of life is not easy, including when the family and the caregivers seem to have reached an agreement. They may in particular be confronted with moral dilemmas: should one consider not having one's life extended under certain conditions? Is it possible to agree to let others decide for oneself if it is no longer possible to express oneself?

The question is particularly complex in the case of elderly people living in institutions. According to a study conducted in 2013-2014 in 78 retirement homes in France, questions relating to the end of life were discussed with a maximum of 21.7% of residents.

In another exploratory study, British health researchers highlighted older people's concerns when asked to think about palliative care and euthanasia (and in particular the terms of their implementation). Thus, even if advance directives have been drafted in anticipation of hypothetical future difficulties, the elderly will not necessarily be able to adhere to them when they are really confronted with the end of their existence, as described in an article by two researchers Stéphane Alvarez and Emmanuel Monfort published in The Conversation.

Not only is drafting advance directives not a simple exercise for the patient, but he must also be supported by an efficient and responsive healthcare system.

Exceed the current limits?

However, the High Authority for Health clarified in 2020 that the Claeys-Leonetti law is not sufficiently applied by health professionals: an improvement is necessary in the dialogue between health professionals and patients, even the oldest. Progress is also needed in supporting them and their loved ones.

Then, will the decision-makers introduce active assistance in dying while the palliative care system is criticized for its unequal aspect (26 departments have no palliative care units) and more generally for an obvious lack of means? ?

And the Head of State to point to a "fundamental inequality" in access to palliative care on the territory. The president thus confirmed “a ten-year national plan for the management of pain and the development of palliative care, with the necessary investments”. Without giving figures on the financing of this plan, the Head of State undertook to "develop the management of palliative care", including in the pediatric sector, "to better integrate it into the hospital in the course of care, to set a threshold of beds per territory and to continue their development at home". An essential prerequisite before considering going further than the current provisions.

Be that as it may, the Order of Physicians, the first concerned if any, said it was "unfavourable" to doctors being able to participate in "a process which would lead to euthanasia, the doctor not being able to deliberately provoke the death by the administration of a lethal product" in the event of a change in the legislation on the end of life.

In addition, the LR deputy for Bas-Rhin Patrick Hetzel denounces in his column in Figarovox a biased debate: to pilot the citizens' convention on the end of life, in conjunction with consulting firms, the executive has indeed chosen the Economic Council and social (CESE), which in 2018 advocated the legalization of euthanasia and assisted suicide. And to conclude: "The debate on the end of life deserves better than amateurism and manipulation".

Faced with these non-exhaustive findings, it seems legitimate to ask the question of a real political will to introduce the notion of assisted dying into the law, a development that has been refused until now. Many questions remain...