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Euthanasia: the difficult debate on active assistance in dying

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Euthanasia: what definition?

Euthanasia consists in administering a lethal substance to a patient who requests it, with the aim of causing his death. This practice is currently illegal in France. In the eyes of the law, it is assimilated to murder or assassination.

In countries where it is authorized (see below), euthanasia responds to the voluntary request of a patient suffering from a serious and incurable illness, causing unbearable suffering.

The scope varies by country. In most cases, euthanasia is limited to adults, but Belgium and the Netherlands allow it for children under certain conditions. The diseases concerned can go as far as psychiatric disorders, as in Belgium where, in March 2023, euthanasia was granted to a woman victim of rape, in view of the psychological suffering endured.

What is the difference between euthanasia and assisted suicide?

In euthanasia, it is a doctor who performs the lethal injection.

In assisted suicide, the gesture is performed by the patient himself: either he swallows a lethal product, or he triggers an infusion.

In both cases, the lethal substance is prescribed by a doctor.

This assisted suicide is currently authorized in Switzerland (director Jean-Luc Godard resorted to it in September 2022), in Belgium, in Austria and in 10 American states.

Assisted suicide is, like euthanasia, currently illegal in France. In an opinion delivered in September 2022the National Ethics Advisory Committee opened the door ajar, considering that it “there is a way for an ethical application of active assistance in dying, under certain strict conditions (…)”

What is the difference with deep and continuous sedation until death?

Unlike active assistance in dying (euthanasia or assisted suicide), deep and continuous sedation until death has been authorized in France since the Claeys-Leonetti law of February 2, 2016. It concerns end-of-life patients, whose vital prognosis is committed in the short term (a few hours to a few days, according to the High Health Authority).

Concretely, the person is plunged into a deep and irreversible coma. To put him to sleep, a powerful sedative (usually midazolam) is administered as a continuous infusion. The law obliges to associate a treatment against pain, most often morphine.

This deep and continuous sedation is strictly supervised. It can only be implemented (in hospital, at home or in a medico-social establishment) after a collegial decision-making procedure involving the care team.

It is allowed in three situations:

– A patient – incurable and at the end of life – asks to be put to sleep so that he no longer suffers unrelievable suffering, “suffering which can be physical, psychic or existential”, says Dr. Valérie Mesnage, doctor at the APHP Clinical Ethics Center and hospital neurologist.

– A patient suffering from an incurable pathology asks for treatment to be stopped, which will accelerate his end of life. In this context, he can benefit from deep and continuous sedation until death.

– A patient – incurable and kept alive by active treatment – finds himself unable to express himself. “At the end of a collegial procedure, the referring doctor decides on a limitation or a cessation of this treatment under the refusal of unreasonable obstinacy, which will jeopardize his vital prognosis. It must be associated with deep and continuous sedation until death so that the patient does not suffer. A possible refusal must be sought beforehand through the advance directivesnear trusted person or, failing that, of his relatives, explains Dr. Mesnage.

How is it different from euthanasia?

In 2018, the High Authority for Health (HAS) answered this question by emphasizing two points: intention and temporality.

In deep sedation, the doctor who puts the patient to sleep does not intend to cause his death. The death results from “the natural evolution of the disease”, according to the expression of the HAS. In contrast, in euthanasia, death is deliberately caused.

Another difference: the death of a patient under deep and continuous sedation will occur, depending on the state of the person, in a few minutes, days or weeks – which can be painful to bear for the entourage. In euthanasia, death is instantaneous.

What about requests for euthanasia in France?

A french study published in 2014, based on 2,000 medical records of patients admitted to palliative care, estimates euthanasia requests at around 3%.

In her practice, Dr. Valérie Mesnage is faced with these situations: “There are requests for euthanasia today in France. However, we must distinguish on the one hand the frequent wish to hasten death; on the other hand, the request for active assistance in dying, which is much rarer”, she explains.

For this neurologist, deep and continuous sedation until death does not respond to all situations. It underlines the particular case of certain patients suffering from an incurable disease and who gradually lose all autonomy (mobility, speech, swallowing ability, etc.). These people condemned by their illness to stay “locked in their body” are currently unresolved. “We offer them to do everything possible to make their addiction as painless as possible, home help for example. But some of these patients refuse: they no longer want to depend on others,” notes the neurologist. And yet, in such situations, sedation cannot be implemented: “Given that these patients are not at the end of their life, it would be ethically unacceptable to put them in a deep coma until they die”, explains Valérie Mesnage.

Which countries allow euthanasia?

In 2022, the National Center for Palliative and End of Life Care published Panorama of legislation on active assistance in dying around the world, written by a project manager, Perrine Galmiche. This document draws up an inventory. What are these countries?

– Belgium since 2002

The law allows euthanasia for patients, adults or minors (unspecified age, but on condition of having a certain discernment), incurable and at the end of life; but also for physical or psychological suffering that is unbearable and impossible to relieve. In Belgium, assisted suicide is also tolerated.

– The Netherlands since 2001

The law authorizes euthanasia and assisted suicide, including for adolescents aged 12 to 16, with the essential consent of the parents. After 16 years, their opinion is advisory.

– Luxembourg since 2009

Access to euthanasia and assisted suicide is authorized, only for adults.

– Spain since 2021

The law authorizes euthanasia and assisted suicide only for adults.

Euthanasia and assisted suicide are accessible to adults. In 2023, the law should evolve to include psychiatric patients.

– Australia since 2017

Euthanasia and assisted suicide are possible for adults only.

– New Zealand since 2019

Euthanasia and assisted suicide are authorized for adults

Who can perform euthanasia?

In countries that allow it, euthanasia is a medical act performed by a doctor regardless of his specialty. In general, palliative care specialists are strongly opposed to it, as is currently the case in France. In reality, “In these countries, euthanasia is rarely practiced by palliative care physicians. Most of the time, it is the family doctor or a doctor specializing in the disease. They mostly work at home. observes Perrine Galmiche, now project manager at the APHP’s Clinical Ethics Center.

Whatever the country, doctors have the right to refuse to participate in euthanasia by asserting their conscience clause.

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