From the expression of the request to the administration of the lethal substance, franceinfo presents the scenario envisaged by the executive, which must still submit its bill to the Council of State and unveil it in the Council of Ministers.
He wants “draw a path” towards a “possibility of requesting assistance in dying under certain strict conditions”. Emmanuel Macron unveiled, on Sunday March 10, the outlines of the long-awaited end-of-life bill. Advancing with caution, the head of state presented the “frame” envisaged, which does not create, according to him, “neither a new right nor a freedom”no more than one “automatic assistance” of the medical profession. “The new framework offers a possible path, in a specific situation, with precise criteria, where the medical decision has its role to play”he insisted, in an interview given to The cross And Release.
For the first time, the President of the Republic detailed the route that could be presented to applicants for assistance in dying. Franceinfo details the different stages envisaged at this stage, while keeping in mind that the text is likely to evolve in the coming months, during its examination before the Council of State, then in the Assembly national and in the Senate.
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1 A request made by the patient and subject to five conditions
The journey presented by Emmanuel Macron begins at the initiative of the main interested party, the patient. To qualify for assistance in dying, the person must meet five criteria:
- Be aged 18 or over. “This support will be reserved for adults, as the Citizens’ Convention had recommended”, says the head of state. In reality, in spring 2023, this body had only recorded the opinions “very shared” of its members on this point, without recommendation one way or the other. With this criterion, the executive therefore opts for caution, even if it means creating inequality in the face of the law between a 17-year-old patient and another 18-year-old.
- Being “capable of full and complete discernment”. The president thus intends to exclude from the procedure “patients with psychiatric illnesses or neurodegenerative diseases that impair discernment, such as Alzheimer’s”. The objective is to ensure the free and informed will of the person who expresses the wish to die, even if this means ruling out the approach of patients who make an advance request at a still early stage of their pathology.
- Being suffering from an incurable illness. This criterion refers to any pathology which, in the current state of knowledge, cannot or can no longer be cured. This concerns, for example, patients with terminal cancer. The “assisted death” envisaged by the executive therefore does not concern patients at an early stage, for whom there is still hope of remission.
- Have a vital prognosis engaged in the short or medium term. If the notion of short term generally refers to an expected death in a few days, or even a few weeks, this criterion remains vague regarding the medium term. The Elysée put forward, on Monday, a horizon of “several weeks, several months”while specifying that no threshold would be included in the law, and that this criterion would be left to the appreciation of the medical community.
- Feeling “refractory” suffering. The last eligibility criterion is the existence of suffering “physical or psychological” that “we cannot relieve”, explains Emmanuel Macron. This notion of suffering refractory to treatment already exists in the Public Health Code and can concern very diverse situations, whether pain, breathing difficulties or existential anxieties. According to a source close to the matter, the bill, however, excludes psychological suffering alone.
2 Confirmation of the request after a reflection period
Once the initial request has been made, a period of“a minimum of two days of waiting” opens “to test the strength of the determination” of the patient, says Emmanuel Macron. “It happens that people want to end it, but then reconsider this request, because we have been able to relieve their pain in the meantime”justifies the Elysée. “The first question that will be asked [au patient demandeur], is to offer him palliative care”which he will be free to refuse, clarified the Minister of Health, Catherine Vautrin, Monday evening on France 2. It is only at the end of this two-day reflection period that the request assistance in dying may be repeated, in order to move on to the next stage.
3 A phase of assessment of the patient’s situation
Confirmation of the request opens a deadline “maximum fifteen days” allowing health professionals to examine the file. A team composed of at least two doctors is formed to “ensure that the access criteria are met”if necessary by collecting “specialist opinion” and requesting “doctors, psychologists, nurses or caregivers who are used to accompanying the person”, according to the head of state. At any time during the procedure, doctors can exercise their conscience clause and withdraw from it. To deal with this eventuality, the Elysée says it is considering a “list” of volunteer professionals to whom refractory doctors could refer the patient.
4 A medical decision that may be subject to appeal
At the end of the evaluation phase, the patient must obtain a response. “It is up to a medical team to decide, collectively and transparently, what action it takes on this request”, advocates Emmanuel Macron. In the event of a unanimous green light, the procedure continues. But what happens if there are divergent opinions among professionals? “Collegiality does not mean unanimity”recognizes the head of state. “The medical profession knows how to manage disagreements ethically. I have confidence in the ability of medical and paramedical staff to deal with these situations humanely.” Asked on this point by franceinfo, the presidency mentions “a decision made by one person in the end, because there is only one doctor who prescribes”.
If his request is rejected, the patient has “the right to see another medical team or to seek recourse” – without knowing, at this stage, what the terms or deadlines would be. A provisional version of the bill dated October, consulted by franceinfo, mentioned a referral to judicial or administrative justice, “if applicable in the context of an emergency procedure”. In his interview, the Head of State also mentions a possible appeal initiated by “family members” of the patient, who could therefore contest the medical decision, whether favorable or unfavorable.
5 Implementation of assisted dying
Once the patient’s request is approved, “we ask him to think for a minimum of two days”, detailed Catherine Vautrin on Monday. Once this new reflection period has passed, he is issued a prescription, “valid for three months”, “period during which the patient can, of course, withdraw at any time”, according to Emmanuel Macron. Support by health professionals continues in order to define, “in a dialogue with the patient”, the terms and conditions for providing assistance in dying. Load on them “to recommend the presence or absence of medical personnel or the most appropriate location”whether at home, in a nursing home or in hospital.
In the event that the patient decides to go through with it, the product must be collected from the pharmacy 24 hours before the procedure, according to a source close to the matter. The nature of the final gesture depends on the state of health of the patient. If his physical abilities allow it, “the administration of the lethal substance is carried out by the person himself”, according to the text of the bill, cited by Emmanuel Macron in his interview. Otherwise, the person can ask to be assisted by a third party, responsible for example for holding the cup containing the product or injecting it. This speaker can be a doctor or a nurse, or even any other “willing person” designated by the patient, as long as she is technically able to provide the last gesture. Throughout the procedure, relatives will be able to benefit from specific support, particularly if they are required to “perform the gesture”assures the Elysée.