DECODER #2: THE FRENCH NATIONAL ASSEMBLY SPECIAL COMMISSION HAS ALREADY EXTENDED THE SCOPE FOR EUTHANASIA AND ASSISTED SUICIDE
THE EVENT
From Monday 13th to Friday 17th May 2024, the members of the French National Assembly special commission started to examine the bill on the accompaniment of the sick and the aged at their end of life. They have modified the first section of the bill which concerns “accompaniment care” and the rights of the sick, in order to attempt to guarantee the development of palliative care, with no assurance however of being able to obtain ready access for all those in need. Access to “assistance in dying”, euthanasia or assisted suicide, which is the subject of the second section of the bill, has been considerably extended, in particular by the deletion of the condition of life expectancy threatened “in the short or medium term”.
THE NUMBER
A total of 2012 amendments were submitted against this bill, by the members of parliament from all parties.
SUMMARY OF THE DEBATES ON THE FIRST ARTICLES
- GUARANTEEING EQUITABLE ACCESS TO PALLIATIVE CARE
Through several amendments, the MPs began by reintroducing palliative care in the text of the bill. The notion of “accompaniment care”, which does not refer to any scientific definition, was debated at length, and considered as imprecise. Several MPs asserted that palliative care, by definition, already constitutes an overall and multidisciplinary approach of the person. As a result, the term “palliative care” was added to the title of the first section of the text which is now headed “Reinforcement of accompaniment care, palliative care and the rights of the sick”.
Several amendments were adopted against the advice of the Government in order to guarantee access to palliative care, whereas 50 % of the population who need it are not yet able to obtain access. The adoption of an amendment by Jérôme Guedj (socialist party) must now guarantee that palliative and accompaniment care must be distributed equitably throughout the land. Another amendment by Thibault Bazin (republican party) establishes an “enforceable right” to receive palliative care.
In order that adequate means be allocated to the set objectives, an amendment by Gilles Le Gendre (renaissance party) registers in the bill the additional funds required to meet the ten-year strategy on accompaniment care. Further amendments establish indicators and the submission of a yearly report on accompaniment care.
- SYSTEMIZATION OF THE USE OF ADVANCE DIRECTIVES
Several amendments were adopted to increase awareness of advance directives and the person of confidence. As a result, when elaborating or updating the “customised accompaniment plan” as defined in article 3, patients will be advised to draw up or update their advance directives and to designate a person of confidence. Advance directives will be systematically held in the shared medical records file. They will be mentioned during the medical prevention appointments at key ages, set up in 2022.
- THE SCOPE FOR “ASSISTANCE IN DYING” ALREADY EXTENDED?
On the evening of Wednesday 15th May, the members of the special commission started to examine the second section of the bill introducing “assistance in dying”, in other words assisted suicide – or euthanasia, in the event that the patient is incapable of self-administering the lethal substance.
Several MPs from all sides attempted to clarify the terms of the bill by introducing the terms “assisted suicide” and “euthanasia”, which were totally absent from the text, but their amendments were rejected. Several other amendments, which were also rejected, aimed to prevent a doctor, a nurse or a volunteer from administering the lethal substance. Finally, an amendment by the reporter was adopted to specify that the third party designated to administer the lethal substance must be of adult age and “shall not receive any payment or gratification of any kind in compensation for such designation.“
Taking up a claim by ADMD (Association pour le Droit à Mourir dans la Dignité – Association for the Right for a Dignified Death), Danielle Simonnet (LFI party) suggested that the request for “assistance in dying” could be expressed through advance directives, when the person concerned is unable to express his/herself. The Minister Catherine Vautrin then pointed out that one of the guidelines of the bill was that “the patient must be able to express his/her free and enlightened wish not only at the moment of requesting assistance in dying but must be capable of reiterating, and therefore confirming such wish throughout the procedure right up to the moment of administration of the lethal substance. The patient must always be able to change his/her mind.” The amendment was rejected. Nevertheless, an amendment to article 4 was adopted the previous day, against the advice of the Minister and the reporter, adding to the bill that “In the context of advance directives, the person can indicate his/her personal choice for the type of accompaniment for assistance in dying if the situation does not allow reiterated expression in full awareness.”
The MPs then debated at length on the conditions for access to “assistance in dying”, contained in article 6. An amendment by the ecologist MP Julie Laernoes suggested opening “assistance in dying” to minors, irrespective of their age. The Minister expressed an unfavourable opinion, explaining that “the discernment of a child develops with age, and the ability for free and enlightened expression demands full and entire maturity and discernment.” The reporter Laurence Cristol also pleaded the case of the hope for cures which are more probable when one is young. This amendment was rejected.
However, the condition of “life expectancy threatened in the short or medium term” was deleted by the adoption of an amendment by Stéphane Delautrette (socialist party), which replaces the condition of a “serious and incurable condition threatening life expectancy in the short or medium term” by “serious and incurable condition in an advanced or terminal phase.” This amendment was adopted against the advice of the Government and the President of the special commission. Oft denounced, the medium-term criterion was considered too vague, impossible to define. When questioned on the subject, the Haute Autorité de Santé (High Authority for Health) would not be able to give its recommendations until 2025. Nevertheless, this means that the very notion of threatened life expectancy was deleted, extending even further the accessibility of assisted suicide and euthanasia.
Through an amendment by Agnès Firmin Le Bodo, psychological suffering must henceforth be subordinate to physical suffering. The Minister specified that a “psychological condition pre-existing to the diagnosis of the illness, will not be sufficient to qualify for assistance in dying.”
In article 8, which describes the procedure for implementing “assistance in dying”, the MPs adopted an amendment against the advice of the reporter, to introduce the possibility of reducing the cooling off period of two days, for patients to confirm their request for assistance in dying, “if the doctor considers that it is appropriate for preserving their dignity in accordance with his/her understanding.”
In article 9, the patient now has one year from the authorisation by the doctor, to set the date for administration of the lethal substance, instead of the three months specified initially.
In article 11, the MPs adopted an amendment submitted by the Renaissance MPs to allow patients to choose euthanasia instead of assisted suicide, independently of their physical condition. Nevertheless, this amendment is in contradiction with article 5 of the bill which maintains administration of the lethal substance by a third party if the person “is not capable physically to self-administer it.
Finally, the MPs added to the bill an offence for obstructing “assistance in dying”: “Punishable by a 12-month prison sentence and 15,000 euro fine for preventing or attempting to prevent the practice or the provision of information on assistance in dying by whatever means”. On the other hand, amendments intended to penalise the inciting or encouragement of “assistance in dying” were rejected.
OUR ANALYSIS
Through various amendments, the MPs on the right and on the left sought to reinforce and to guarantee access to palliative care throughout the land. Faced with the vague notion of “accompaniment care” it was found necessary to reintroduce the notion of palliative care, whose approach is known and shared worldwide. It also seems pertinent to register in the bill the means included in the ten-year strategy for accompaniment care and thus to commit the public authorities.
Nevertheless, it must be remembered that since 1999 the law already establishes a right to palliative care for “any sick person whose condition so requires”. This bill must therefore also include a true will and corresponding means to guarantee access to palliative care for the entire French population. With an additional budget of 1.1 billion euros over ten years, the means allocated through the ten-year strategy will be inadequate. Under such conditions, several MPs (on the right and the left) identified the danger that assisted suicide becomes the default option through a lack of care, as has been reported in certain states, Canada in particular.
The debates surrounding the authorisation for “assistance in dying” revealed the difficulty in controlling euthanasia or assisted suicide. Although its opening to minors was rejected, several MPs consider it as a next stage. The deletion of “threatened life expectancy” considerably extends the scope of the bill, raising the spectre of the possibility of its availability for the handicapped. The notion of “advanced phase” is particularly vague. The President of the special commission sees this change as a breakdown of the “balance of the law”. Nevertheless, the notion of medium term was itself an opening for abuse since it is impossible to determine with any certainty, as had been expressed by many professionals during auditions. Tugdual Derville, the Alliance VITA spokesman, also denounced the vague and subjective nature of this criterion during the Alliance VITA audition.
With the deletion of life expectancy and of the cooling off period, two important safeguards have fallen.
It is of particular concern that the conditions of access are being re-written from the very outset of the examination by the special commission. It is plain to see, from the moment that assisted suicide or euthanasia are authorised, that the safeguards can rapidly dissolve away. The Minister as well as the reporters have indeed specified that assisted suicide and euthanasia must be accessible wherever there is a need, including in accompaniment homes and palliative care centres.
Moreover, the text adopted by the commission includes several contradictions.
- It is possible to register a request for assistance in dying through advance directives, but at the moment of making the request, the person must “be able to express his/her free and enlightened wish.” On the day of administration of the lethal substance, the doctor must check that “the person confirms he/she wishes to proceed with the administration.”
- There is an inconsistency between article 5 which states that administration of the lethal substance is undertaken by a third party if the person “is unable physically to proceed” and article 11 which allows the patient to choose freely between assisted suicide and euthanasia.
The text thus adopted by the commission, which is the result of different power relationships during the examination of the numerous amendments, thus lacks coherence and appears largely unsuccessful. These inconsistencies will probably give rise to new amendments during the session, but the direction to be taken by the text is far from obvious.
Finally, the introduction of an offence of obstruction against assistance in dying is extremely worrying, insofar as it could jeopardise all the work on suicide prevention and is very likely to destabilise all care workers. With the rejection of the amendments aimed at penalising the encouragement to “assistance in dying”, this bill breaches all the red lines and causes a major anthropological breakdown.
OUR FAVOURITE CONTRIBUTION
Against the advice of the reporter, an amendment by Thibault Bazin was adopted with the support of voices on the left to create an “enforceable right” to benefit from palliative care and making the regional health agencies responsible for guaranteeing the effect of such right.
OUR ALERT CALL
By her amendment, Julie Laernoes proposed opening up “assistance in dying” to minors, irrespective of their age. As a result, young children could have had access to assisted suicide or euthanasia, with the permission of their parents.
