The heated debate over French bill to legalize 'assistance for dying'

InIn an interview published jointly by French dailies Libération and La Croix on March 10th, Emmanuel Macron sketched the broad lines of draft legislation to legalize, under a set of conditions, medically assisted death for terminally ill patients.

Until now, voluntary euthanasia and assisted suicide are outlawed in France, although legislation introduced in 2016, called the Claeys-Leonetti law, allows for the right of a patient to receive “deep and continuous sedation” leading to death when their medical condition is severe and incurable in the short-term, defined as being at an “advanced and terminal stage”.  

While the French president’s announcement follows months of prevarication – the details of the bill were originally expected to be presented at the end of September – the timetable is now set, and Macron has established the framework for several months of debate on the issue.  

The proposed legislation will first be submitted within “eight to ten days” for legal approval by the Council of State, before then being presented before a government cabinet meeting in April, and subsequently for debate within the National Assembly, parliament’s lower house, as of May 27th.

In careful wording, the French president said the legislation was to legalize “assistance for dying”, which would be made available to adults “capable of full and complete discernment” about their situation. It therefore excludes what he called “patients afflicted with psychiatric or neurodegenerative illnesses which alter discernment, such as Alzheimer’s [disease]”. The patients eligible to receive the lethal medication must be evaluated as reaching the terminal stage of their illness – and therefore their lives – in “the short- or medium-term”, and that their “physical or psychological sufferance” is “stubborn”.

While the future debates in parliament will inevitably involve heated debate between those in favour and those against the legalization of “assistance for dying”, they will also centre on the very concrete proposals regarding the circumstances and criteria surrounding that assistance, and which are fundamental for the effectiveness of such legislation. Among the crucial questions is what exactly does a “short- or medium-term” prognosis mean, and who would be qualified to authorise the administration of lethal medication.    

Regarding the latter, the French president spoke in vague terms of “a medical team” that would be required to decide the matter “collegially and with transparency”. Macron’s entourage have indicated that a body of some sort would be tasked with overseeing the follow-up of such a decision. In Spain, after an assisted death is first approved by two doctors, a commission of evaluation is required to give its approval. In practice, the administration of euthanasia or assisted suicide, both legalized in the country in 2021, is very rarely authorised because of the complexity of the procedure.

The draft legislation proposed in France would, in its current form, require doctors to pronounce on a case within a maximum of 15 days. But for the patient seeking assisted death, the process could in theory take much longer if they meet with a refusal and subsequently submit their case to a different medical team.

It appears likely that a majority of lawmakers at the National Assembly would approve the draft legislation. In 2021, the first article of a private member’s bill in favour of assisted suicide drew the support of 83% of the Assembly, before it was scuppered by five Members of Parliament (MPs) from the conservative Les Républicains party who filed 2,500 amendments, choking the debating procedure and rendering it unmanageable. Meanwhile, the conservative majority in the Senate, the upper and less powerful house, is firmly opposed to legalizing assisted suicide.

On March 9th, Emmanuel Macron met with representatives of the principal religions in France (the Christian, Muslim and Jewish faiths), who are all openly hostile to euthanasia and assisted suicide. In October 2022, he travelled to the Vatican to discuss the issue with Pope Francis, who underlined the Catholic Church’s view that euthanasia is a “crime against human life”, and that assisted suicide is a “sin”.

But the French president nevertheless has pressed on with the bill, while sources in the presidential office, the Élysée Palace said his interview with Libération and La Croix had been very closely “weighed” beforehand. It was perhaps to assuage those most opposed to the bill among religious and medical circles that he made the somewhat intriguing comment that legalizing assistance to die would be “neither a new law nor a freedom”.

However, the draft legislation as proposed by Macron does contain two fundamental new rights for the severely ill seeking to end their lives, and who has been authorised to do so. One is that they can obtain a prescription for lethal medication to swallow, and the other is that euthanasia can be proposed to those physically incapable of doing so. The bill sets out that the latter would be performed either by a designated volunteer, or by the patient’s doctor or nurse.

In his interview, Macron underlined that the proposed legislation follows on the consultations on the issue by a so-called “citizens’ convention”, a panel of close to 200 people chosen at random, which, after three months of debates and with a massive majority, pronounced in favour of allowing the terminally ill “access to active assistance” to end their lives. The bill clearly draws from the advice issued in 2022 by France’s national consultative committee on ethics, the CCNE, which in a surprising U-turn from its previous positions, found in favour of legalizing assisted suicide, although it came out against euthanasia for those patients physically incapable of such an act. 

The French medical association, the ordre des Médecins, which serves to regulate the profession, has positioned itself against the participation of doctors in both euthanasia and assisted suicide. The French association representing the palliative care sector, the SFAP, has been particularly active in opposing the legalisation of euthanasia, to the point of financing a campaign entitled “Let’s dare to live” and, following Macron’s interview, it issued a statement voicing its “consternation, anger and sadness” at what he said, and what it called a “contempt for the work of carers”.    

The bill however also allows for an extra 1 billion euros of public funding for palliative care over the next ten years, on top of the 1.6 billion euros already allocated, which the SFAP said was “derisory”. The financing is notably designated for the creation of palliative care units in the 21 French départements (counties) which have none (out of a total of 101 départements), and also for investment in paediatric palliative care.

There is no recent opinion survey or study which offers a true idea of the views among doctors in France. Some have spoken out publicly against the bill, and others have explained that their position has evolved. One of the latter is Régis Aubry, head of the “pain and palliative care” unit at the teaching hospital (CHU) in Besançon, in eastern France, and who was a co-rapporteur of the CCNE working group which found in favour of assisted suicide in 2022. “I am less sure of myself than in the past,” he told Mediapart.    

The French medical association, the ordre des Médecins, which serves to regulate the profession, has positioned itself against the participation of doctors in both euthanasia and assisted suicide. The French association representing the palliative care sector, the SFAP, has been particularly active in opposing the legalisation of euthanasia, to the point of financing a campaign entitled “Let’s dare to live” and, following Macron’s interview, it issued a statement voicing its “consternation, anger and sadness” at what he said, and what it called a “contempt for the work of carers”.    

The bill however also allows for an extra 1 billion euros of public funding for palliative care over the next ten years, on top of the 1.6 billion euros already allocated, which the SFAP said was “derisory”. The financing is notably designated for the creation of palliative care units in the 21 French départements (counties) which have none (out of a total of 101 départements), and also for investment in paediatric palliative care.

There is no recent opinion survey or study which offers a true idea of the views among doctors in France. Some have spoken out publicly against the bill, and others have explained that their position has evolved. One of the latter is Régis Aubry, head of the “pain and palliative care” unit at the teaching hospital (CHU) in Besançon, in eastern France, and who was a co-rapporteur of the CCNE working group which found in favour of assisted suicide in 2022. “I am less sure of myself than in the past,” he told Mediapart.

While hardline Catholic organisations, such as CIVITAS and the Jérôme Lejeune Foundation, have for long expressed their firm opposition to euthanasia and assisted suicide, the French association for the right to die in dignity, the ADMD, gave a cautious welcome to the drafting of what it called “the law of ultimate freedom”. It questioned what exactly was meant by a prognostic that a patient would die of their illness in the “short- to medium-term”. In a statement, it warned that this would “condemn patients afflicted, for example, with motor neurone disease, to suffer the dramas of the last stages of the evolution of the illness”.

The ADMD also regretted that under the bill, euthanasia would not be accessible for those who are capable of committing assisted suicide but who do not want to carry it out by themselves. “Could one die all alone, with a medical prescription that is valid for three months?” asked the association’s chairman, Jonathan Denis. “That’s contrary to the principle of solidarity expressed by the [French] president.”

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• The original French version of this report can be found here.

English version by Graham Tearse