we explain the debate on the vital prognosis engaged “in the short or medium term”

The examination of the bill on the end of life continues in the National Assembly, with the sensitive question of the criteria for access to assisted suicide or euthanasia.

Assisted dying, for whom? The deputies are preparing to debate, Tuesday June 4, one of the most sensitive questions of the examination of the bill on the end of life, which continues all week in the National Assembly with a view to a vote at first reading on June 11. Since the government’s text was modified in committee in mid-May, discussions have focused on one of the five criteria determining access to assisted suicide or euthanasia: must the vital prognosis of the patient is engaged “short or medium term”as the executive wishes, or should we demand that the disease be “in advanced or terminal phase”, as some parliamentarians defend? Behind this battle of words, the issue is very concrete for some patients.

What did the initial bill provide for?

In the text presented on April 10 by the government, article 6 listed five conditions for access to assisted dying: the person must be an adult, of French nationality or residence, able to express their wishes, in a state of strong suffering and “to be suffering from a serious and incurable condition with a short or medium-term vital prognosis”.

With this last criterion, the executive intended to mean, firstly, that the patient must be affected by an illness “which is life-threatening (serious illness) and which cannot be cured (incurable illness)”. The mention of “short or medium term” came to introduce a temporal limit, to condition access to assistance in dying on a life expectancy in hours or days (short term) or “weekdays or months” (middle term). Objective: reserve the device for end-of-life patients, excluding those who may still live for many years.

In practice, to define whether or not a patient falls under the “middle term”, each doctor would be responsible for assessing the time remaining for their patient to live. In its opinion of April 4, the Council of State validated this system, with two clarifications: the medium term should not exceed “twelve months” and the High Authority for Health (HAS) could formulate “recommendations” on the assessment of the medium-term horizon. The Minister of Health, Catherine Vautrin, contacted the body, which promised the first elements of a response at the end of 2024 and a formal recommendation “by the second quarter of 2025”.

2 Why was the text changed?

During the hearings conducted by the special commission on the end of life, many elected officials, doctors and experts warned of the difficulty of determining the life expectancy of a patient beyond a few days, or even a few weeks. “Regarding the notion of the medium term, it seems urgent to me to remain in the dark”pleaded the president of the National Consultative Ethics Council, Jean-François Delfraissy, inviting each medical team to decide “case by case”. The president of the HAS, Lionel Collet, himself recognized the “difficulty” to understand the middle term, a notion which does not exist in any law “at the International scale”.

Supporters of assisted dying have expressed concern that patients, particularly those suffering from Charcot’s disease, could be excluded from the system on the grounds that their life expectancy would still be greater than a year. “We cannot be the only country in the world to speak of a ‘vital prognosis committed in the short or medium term’, which cannot be defined and which would exclude people suffering from neurodegenerative diseases from the next law”argued Jonathan Denis, president of the Association for the Right to Die with Dignity (ADMD).

Rather than waiting for a definition of “middle term” by the HAS, the parliamentarians of the commission therefore reformulated this criterion: the person must “to be suffering from a serious and incurable illness in the advanced or terminal phase”. From then on, there is no longer any question for the doctor to hazard a numerical prognosis. The notion of “advanced or terminal phase” East “perfectly defined” in the Public Health Code and “raises fewer doubts”defended several elected officials, while recognizing that they also wanted “to broaden” access to assisted dying for other categories of patients.

3 How could the text evolve?

Judging that “the balance” Bill “was broken”, the government opposed the commission’s rewrite. The expression “advanced phase” would be “too big” And “would amount to integrating inflammatory diseases (severe progressive rheumatoid arthritis for example) and a number of neurodegenerative diseases (for example the so-called ‘advanced’ stage of Parkinson’s disease)”, estimates the executive. The latter therefore warned that he intended to take advantage of the examination of the text in the hemicycle to return to the initial criterion of vital prognosis engaged “short or medium term”. He even tabled an amendment to this effect.

Elected officials from all sides have proposed similar adjustments, or even amendments limiting the use of assistance in dying to the short term or to the terminal phase. With the wording voted in committee, “u“No one presenting with metastasized cancer, despite a life expectancy of several years, could ‘benefit’ from assisted dying.”, estimates LR deputy and emergency doctor Philippe Juvin. Other parliamentarians suggested setting in the law a deadline associated with the medium term, six months for example. Conversely, elected officials from the majority or the left have tabled amendments aimed at removing any temporal criteria to integrate patients at an early stage and accident victims with a long-term horizon, “like Vincent Humbert in his time”.

The supporters of the commission’s text intend to defend their vision. Elected officials from the majority and La France insoumise have thus tabled amendments “compromise”in which they propose to keep the reference to the “advanced or terminal phase” while explicitly reintegrating the notion of “vital prognosis”, without specification of duration. The examination of these various amendments in the hemicycle could therefore give rise to a new version of the text.