Assisted Suicide not Recognized in European Law

Assisted Suicide not Recognized in European Law

by | January 6, 2023 | End of life, Euthanasia and Suicide, News, suicide

Assisted suicide: The State Council has rejected a new request by the Dignitas association.

A new attempt by the Swiss Dignitas association, has again resulted in rejection by the State Council.

Following its decision in December 2021 not to forward a PPRC (Priority Preliminary Ruling on Constitutionality) concerning the prohibition of pentobarbital, the State Council has again refused to forward to the Constitutional Council a request by the Dignitas association, submitted last September. The decision was made public on 29th December 2022. The request enjoined the Prime Minister and the Health and Solidarity Minister to rescind the provisions of a decree defining the list of psychotropic substances, and another decree defining the list of substances classified as narcotics in order to introduce an exception “to authorize anyone to be able to end their life consciously, freely and with dignity.”

As recorded in the press last September, this tactic by Dignitas consisted in an attempt to use the legal channels, considering that the parliamentary route is not progressing fast enough on the subject of the legalization of euthanasia and assisted suicide which is one of the objectives of Dignitas. The French lawyer for Dignitas considered that the situation is at a standstill and that “France refuses the principle of any accommodation of its legislation.”

The tactic used by Dignitas is also aimed at the media. Each appeal generates press coverage, and instils in the general public the concept that an unchanged situation is in itself bad, deprived of evolution. This is in fact an interpretation akin to a “ready-made idea” which is convenient but false. The accommodation of legislation is not an objective as such. Can one deplore the absence of any accommodation on the abolition of the death penalty?

Decision by the State Council concerning the Dignitas request

The decision by the State Council comes at a time when the public authorities have re-launched the debate on the end of life since last September. They motivate their refusal by noting that “Articles 2, 8 and 9 of the European convention for the safeguard of Human Rights and fundamental freedoms, relative respectively to the right to live, the right to respect for private and family life and the freedom of thought, of conscience and of religion, as interpreted by the European Court of Human Rights, …, do not inherently include the introduction of accommodation to the range of substances covered by the special policy in question requested by the association to exercise the right which it is claiming “.

The State Council has thus considered that European law and legal precedents by the European Court of Human Rights do not imply any right to the recognition of assisted suicide. The accommodation of the regulations governing toxic substances, which is intended to protect the health of the French public, does not therefore apply.

What are the Reasons and Motivations in a Request for Euthanasia?

What are the Reasons and Motivations in a Request for Euthanasia?

by | December 22, 2022 | End of life, Euthanasia and Suicide, News

Several studies conducted in hospitals on requests for euthanasia have provided an insight into the reasons and motivations of patients. These studies were able to indicate the limited number of initial requests expressed by patients (between 0.7 and 3%), and their persistence which was even less (0.3% according to one of the studies).

The analysis note released this week provides further information on the reasons for such requests and of the medical circumstances of the patients.

Medical circumstances where pain requires psychological support

In the study from 2012 conducted by Ferrand, among the 476 requests to accelerate their death, expressed by patients, many (82.4%) had consulted either a psychologist or a psychiatrist. According to carers, 13.9% of patients asking for their death to be accelerated, suffer from an active depression syndrome. The study moreover indicates that these situations may “cast doubt on the ability of the patients to take important decisions on their end of life”.

Different perceptions by patients, carers and family members

When the request is expressed by the patient, The main clinical symptoms (>40%) are controlled physical suffering (55.3%), feeding difficulties (54.6%), motor function difficulties (46%). 5% suffer uncontrollably.

The three main reasons for patients requesting an accelerated death are linked to the perception of their image and their relational quality of life:

  1. Guilt of being a burden on family and friends
  2. Fear of projecting an intolerable image of their person
  3. Useless life

The study reveals notable differences according to whether the request for an accelerated death is expressed by patients, carers or by close family members:

  • Intellectual and communication difficulties are mentioned more frequently (respectively 5 and 4 times more) by family members and medical staff than by patients as well as excretion difficulties (twice as often) and feeding difficulties (1.5 times more).
  • Uncontrollable pain is rarely mentioned by patients (5%). It is not perceived in the same way by family members and carers. The latter do not mention it at all.

A new approach based on direct interviews to allow patients who request euthanasia to express themselves

A recent study conducted in the Burgundy, Franche Comté region and released this year surveyed only patients calling for an accelerated death. On the basis of the 15 interviews conducted, the study confirmed the previous results.

Thus, the reasons given were on the one hand physical pain following acute episodes of illness, and on the other hand, a call by patients for recognition of existential suffering which they consider to be unbearable. This category includes:

  1. Psychological distress to see one’s body and functions deteriorate, loss of control of their life.
  2. A feeling of loneliness linked to the despair which they cannot share, a feeling of being of no use to others, difficulty in communicating…
  3. Projective fear of suffering in future just before death, in particular with reference to traumatic episodes experienced by family members suffering at the approach of their end of life.

The study also revealed other motivations:

  1. The desire to balance and enjoin the relations with the team of carers. The patients claimed to have noted a change of attitude by the team of carers after having made a request for euthanasia and felt reassured by the ability of the carers to manage the physical suffering and symptoms.
  2. Reaffirmation of their freedom in relation to the medical constraints.
  3. The ability to imagine a desirable future for oneself.
  4. The test of the possibility of transgressing the prohibition of euthanasia.

The study concludes that the adoption of a sympathetic attitude by the palliative care units regarding such requests establishes a platform for discussion which is able to encourage interaction with the patient rather than responding to the euthanasia request with an irreversible solution.

The apprehension of the psychological impact of painful situations experienced by patients in palliative care remains an important theme in order to ensure a better quality of life right up to their end of life.

Session #2: Citizens’ Convention on the End of Life According to Players in the Field

Session #2: Citizens’ Convention on the End of Life According to Players in the Field

by | December 22, 2022 | End of life, Euthanasia and Suicide

Following a round table devoted to the representatives of religions, the members of the Citizens’ Convention on the end of life took part, on the second day of this 2nd session, in round tables of carers and voluntary workers who told about their experience with patients in the field. They were asked about the actual problems which they have to face up to when accompanying patients during their end of life.

Doctors, psychologists, nurses, palliative care voluntary workers…In total, during several round tables, 22 carers took turn in answering the questions asked by the citizens who were meeting for the second and final week-end of the appropriation phase.

The legal framework governing the end of life appears satisfactory but the means available are inadequate

The questions concerned the state of the current law. “Have carers been confronted with gaps or limitations in the law?” as asked by Françoise. According to Doctor Clément Gakuba, a specialist in neuro-resuscitation and member of the ethics centre at Caen University Hospital, the legal framework is adequate for managing the situations met. It already includes important notions: not to abandon the patient, not to leave the patient suffering…The other carers agreed. Christophe Roman, a male nurse, reported on the advances of the law. He identified the lytic cocktails which were administered “under cover” twenty years ago. “a lysis needs to be given” was the expression used. According to him, the law has introduced a framework and safeguards for all these practices.

The law is therefore satisfactory, but what is needed, according to Professor Djilali Annane, a resuscitation doctor, is the time “to do things properly”. The time available not linked to acts of treatment has been compressed. “What is lacking, is the time to properly accompany the patients.” Apart from the time “in hours”, he later specified, there is a need to be available in spirit. “That is what is missing”, he continued, mentioning the suffering of carers, which needs to be considered. The time…a luxury, according to Emilie Quillien, a psychologist, which seems to be lacking for all carers.

Apart from time, the carers were in agreement to say that the Claeys-Leonetti law is poorly known both by citizens and the professionals. Marie-Christine Grach, a retired palliative care doctor at the Caen hospital, mentioned a survey of general practitioners in Normandy, which revealed very poor knowledge of the law.

Training is also a priority need for carers. Professor Djilali Annane denounced the current shortfall of doctors to accompany end of life patients. Elodie Cailbaut, a palliative care nurse, welcomed the introduction of palliative care courses in medical studies, which appear already to be bearing fruit. According to Emilie Quillien, training is also cruelly lacking for care-home staff to anticipate the end of life of residents.

The current inadequacy of palliative care was also denounced by carers. Elodie Cailbaut deplores that, even in Paris, it is not possible to allow patients to end their life at home, due to the lack of carers. According to Olivier de Margerie, the President of the JALMAV federation, the budget allocated to the palliative care development plan launched last year needs to be increased tenfold if anything worthwhile is to be achieved. Marie-Thérèse Leblanc-Briot, a voluntary worker in that federation, denounces the “petty measures for good conscience” but which are sorely inadequate.

For patients suffering from ALS (Charcot’s disease), providing adequate means is just as important according to Sigolène Gautier, a palliative care psychologist in Lyon. Also, according to her, in the ALS centres, there is sometimes only one psychologist for 100 patients, or more when, not only the patients, but also their families, need to be accompanied, and “at an early stage”, whereas the disease lasts for several years.

Advance directives: yes, but…

One question by the citizens regarded advance directives: “How do you know about advance directives?” asked Nathalie. Even if Professor Annane has noted that increasing numbers of people keep their advance directives on their person, resuscitation doctors are confronted, most of the time, in the case of brutal pathologies (road accidents, strokes…), with the absence of advance directives. Carers mentioned the difficulty of specifying advance directives when in good health. Even in sickness, patients have difficulty to express themselves on medical decisions and often prefer to rely on their trust in the doctor, as noted by Professor Annane. Fortunately, advance directives are “re-contextualized”. Professor Annane also observed that patients’ instructions may vary according to circumstances in their life, such as the marriage of a child, for example.

Shared refusal of “causing death”

The citizens also questioned the carers on the possible legalisation of “active assistance to die”, the expression used by the National Consultative Ethics Committee (CCNE) to designate euthanasia or assisted suicide. In answer to that question, the carers expressed a consensus on the incompatibility of “causing death” with their duties as carers. For Sigolène Gautier, “When a patient asks to die, the other person is also involved. If I can activate death, how can I possibly continue to accompany life?” In her words, that would be somehow “schizophrenic”.  Marie-Thérèse Leblanc-Briot raised the serious consequences “for a majority of the aged and fragile of any evolution of the law in that direction: “The message sent, would be: “Ultimately, it is up to you to decide whether to live or die, it is none of our business, it is a choice for you alone”. And ultimately, maybe in such case, your life is not as valuable as all that, or it is not so valuable for society”.

She also mentioned the questioning by the majority of the very aged on the meaning and value of their life for others. A little earlier during the discussions, the carers shared their experience of requests to die voiced on the wards. Anastasia Choveau, a nurse, spoke of the importance of attentive listening and understanding of patients who express such requests. “They have a right to put their request into words, they have a right to express their feelings, and merely to have such a request heard, is very important, and then, to consider what it is that motivates such a request.” Carers share a common observation: very frequently, the request changes. According to Professor Annane, the expression “I cannot bear it” is always subject to change, it expresses a suffering which is not relieved.

Finally, for doctor Julie Paquereau, if the law was to be changed to legalise euthanasia, “the risk would be the establishment of active assistance to die, through a lack of means, whereas other options may be possible, and in particular better suited accompaniment.”

10 priority themes for the coming sessions of the Citizens’ Convention on the end of life

Following these round tables, the members of the Citizens’ Convention continued their discussions during the afternoon in working groups in order to define the priority themes on which to work during the forthcoming sessions. In total 21 priority themes were defined.

At the end of the session, after a vote, the citizens agreed on the following ten priority themes, in order of importance:

  • The human and financial means required for full application of the 2016 Claeys-Leonetti law
  • The legal obligation to provide suitable and adequate human and financial means, ensure proper training and to ensure the establishment of health professionals across the entire nation and in all establishments
  • Initial and continuous training of medical, paramedical and accompanying personnel
  • Information campaigns for the general public
  • Effective and true equality of access for palliative care
  • Active assistance to die: assisted suicide and euthanasia
  • Acceptable/necessary exceptions to the Claeys-Leonetti law
  • The economics of the end of life/death
  • The limits of palliative care
  • The treatment of active assistance to die for extreme forms of psychic (psychiatric) suffering

From January, Claire Thoury, the President of the Citizens’ Convention governance committee, announced the end of the appropriation phase and the start of the deliberation and controversy phase. Several citizens stated that they still lacked some appropriation elements. Among these, was the need to hear from international players with different viewpoints, non religious spiritual approaches, and also from patients. Assurances were given that they will be able to request specific auditions …

Euthanasia: Continuous Extension in Canada and Quebec

Euthanasia: Continuous Extension in Canada and Quebec

by | December 22, 2022 | End of life, Euthanasia and Suicide, News

After extending access to euthanasia for people whose natural death is not “reasonably predictable” a mere 5 years after passing the first law in 2016, Canada intends to organise its access for people suffering from mental disease as of 17th March 2023.

Euthanasia, designated by the expression “Medical Assistance in Dying” (MAiD) in Canadian law, was made available in 2021 to any person suffering from a serious and incurable condition and who wishes to die. Since then, the media have reported troubling cases of euthanasia whereas handicapped or sick patients wished to continue to live. In particular people in situations of poverty or who are deprived of adequate health care make such requests, because they have no other options as described in a recent article.

This escalation in euthanasia requests is striking. As a comparison, in California, a State demographically comparable to Canada (40 million inhabitants) and which also legalised assisted suicide in 2016, 486 people died by assisted suicide in 2021 whereas in the same year, 10,064 people died by “MAiD” in Canada, i.e. some 3.3% of all deaths.

Controversy over the evolution on the law on euthanasia in Quebec

Quebec has not yet transposed the evolution of the Canadian federal law: a bill is due to be tabled shortly. An initial bill (C-38) which was tabled in May 2022 was the subject of considerable controversy. Apart from transposing the federal law, it is also intended to authorise an anticipated request to die “for people suffering from serious and incurable conditions leading to inaptitude”. This concerns in particular, those suffering from Alzheimer’s disease, dementia, and Parkinson’s in certain cases. Several associations reacted against the absence of discussion on the matter.

Euthanasia and mental disease

At the federal level, the 2021 law had excluded mental disease until 17th March 2023 in order to allow time for the government to evaluate the conditions for proposing euthanasia or assisted suicide with adequate safeguards. The law called for the Justice and Health Ministers to meet a group of experts “tasked with examining the protocols, the orientations and safety measures relative to MAiD in the case of people suffering from mental disorders”. This working group put forward regulatory recommendations in a report issued in the spring of 2022.

According to the experts, “Although there is a strong link between death by suicide and the existence of a diagnosed mental disorder, the vast majority of people suffering from mental disorders do not commit suicide (…). In any situation where suicidal tendencies are a concern, the doctors must consider three complementary perspectives: consider the ability of the person to provide enlightened consent or to refuse treatments, determine whether interventions to prevent suicide – including involuntary interventions – should be triggered, and propose other types of interventions which could help the person.”

These distinctions could be difficult to evaluate. And as noted by a reporter analysing the impact of the law and its extensions on the prevention of suicide “Who benefits from the prevention of suicide and who benefits from the facilitation of suicide? If death is executed on the basis of the momentary consent of a person, then where is the legitimacy of attempting to dissuade a person in distress?”

The extensions to the conditions for applying euthanasia observed in Canada show how the promises of strict control of this practice have proved to be untenable. This is a crucial reality to be considered in the debate which is opening in France on a possible evolution in the law.

Warning for the UN Committee on the Rights of the Child on the Inadequacy of the Protection of Minors from Access to Pornography

Warning for the UN Committee on the Rights of the Child on the Inadequacy of the Protection of Minors from Access to Pornography

by | December 20, 2022 | News, Pornography

Alliance VITA together with ‘Juristes pour l’Enfance’, a French association of lawyers which defends child rights, and the Evangelical Protestant Committee for Human Dignity (CPDH) sent a detailed report to the UN Committee on the Rights of the Child on 15th December 2022, denouncing the failures of the French State for the protection of minors from access to pornography.

Highlighting the highly worrying data contained in the recent report by the French Senate[1], the three associations pointed out the damaging effects of early exposure to pornography, the link between it and sexual violence committed on minors or between minors as well as with the prostitution of minors.

They recalled that the International Convention on the Rights of the Child demands that States protect children from access to pornography and contents which are inappropriate for their age.

They denounced the major contradiction between, on the one hand, the stated political will to combat the access to pornography for minors and against the violence on minors and, on the other hand, the reality of the effective laxity with respect to the international pornography lobbies.

Five recommendations for France were sent to the Children’s Rights Committee which is due to convene in Geneva at the beginning of February 2023:

  • To launch studies in order to examine the consequences of the consumption of pornography on society and particularly on children, and especially concerning the committing of sexual violence on minors or between minors.
  • Application of the law prohibiting access to pornography for minors and imposing technical solutions on pornographic sites for such prohibition to be effective and to ensure such prohibition cannot easily be circumvented by minors.
  • To enable Arcom to impose sanctions and fines directly against pornographic sites, and extend its injunctions to the social networks and to internet access providers.
  • To demand from video sharing platforms and the social networks established in France or abroad, an obligation of resultsand not merely of means to ensure effective moderation of their content.
  • To educate parents and childrenon the risks of pornography through educational programmes and communication campaigns.

 

[1] French Senate report “Pornography: The hell of the landscape, 28th September 2022, The main points… p.3. https://www.senat.fr/notice-rapport/2021/r21-900-1-notice.html