The citizens’ convention is completing its work and has come out in favor of authorizing active assistance in dying. It becomes likely that a bill will be introduced in Parliament. The time for final decisions is approaching. Because there will be no turning back.
Doctor for forty years, anesthesiologist, then palliative care doctor, my opinion is based on a long experience in the field. Confronted with many end-of-life situations, with complex ethical questions, I have no lesson to teach anyone: I have changed my mind several times, taken part in decisions at the limits of the law.
In intensive care, I happened to contribute to the death of a patient who was in a medical impasse and whose life was only artificially maintained by a respirator. I was tempted to help a patient commit suicide (this happened once in thirty-five years), decided on, and then implemented terminal sedations in end-of-life patients in an emotional context sometimes upsetting.
All these decisions were made with the concern to meet the needs and expectations of patients. They have always been preceded by debates, sometimes long, involving the patient whenever possible, his family, the doctors and the teams taking care of him. There is no ethics without collegiality.
heavy decisions
Many physicians will no doubt recognize themselves in these lines. No offense to those who judge them, the weight of these decisions is heavy at the time of making them, of implementing them, and sometimes a long time afterwards.
Would our choices have been easier if the law had allowed active assistance in dying? No. The resuscitation and palliative care teams that I know did not wait for laws to institute regular ethical reflections. Palliative care teams did not wait for the 2016 law to perform deep and continuous sedation until death in end-of-life patients with refractory suffering. But I am aware that such debates are still too often lacking.
The current law makes it possible to deal with the vast majority of situations that I have accompanied. But the complexity is there and no serious team, especially in palliative care, claims to have resolved the issue of suffering at the end of life. Therefore, is the priority to radically change the law or to favor ethical debates, team reflections?
A complex reality
As we know, the decriminalization of active assistance in dying is claimed by some in the name of freedom of choice: right to freedom of self-determination, right to define oneself the limits of a dignified life . At first glance, one is tempted to subscribe to this demand, which no doubt explains the broad support for this proposal in the opinion polls. But the reality is complex and the question could be posed as follows: does a law that seems to allow freedom guarantee this freedom for all?
The benefit of such a change of law seems to concern very few patients: Belgian statistics show that only a few dozen French patients cross the border each year to benefit from euthanasia. In view of this low number, we must consider the vast majority of patients who do not ask for anything. In their long and difficult journey, some momentarily ask for assistance in dying, which is above all a call for help.
The request for euthanasia most often disappears when appropriate help is provided to them. The ambivalence is almost constant and it must be respected. The decriminalization of active assistance in dying can constitute an obstacle to the expression and respect of this ambivalence.
The warning from the Netherlands
Moreover, according to Theo Boer, professor of ethics in the Netherlands, extensions of such decriminalization would be inevitable. He was in favor of it in 2002, convinced that it struck the right balance between compassion, respect for human life and the guarantee of individual freedoms. He observes what has happened in his country in twenty years: the annual number of euthanasia cases has quadrupled.
In some places in the Netherlands, up to 15% of deaths result from an administered death, and the field of application has gradually extended: people suffering from chronic pathologies, handicapped… It predicts an identical evolution in all country legalizing active assistance in dying in the name of equal access to the law for all. He now writes: ” I was mistaken. » Will we reproduce the same scenario at the risk of making a mistake?
During team clinical ethical debates, which are our daily life, we seek a solution to a complex problem. We hope the Good solution. We often have to content ourselves with less bad. Could we, as is done in clinical ethical debates, admit that there is no ” Good ” solution to the end-of-life debate? The decriminalization of active assistance in dying, presented by some as the right answer, is it not an illusion?