Euthanasia and assisted suicide: Two distinct approaches despite appearances

Legislation in France about the end of life has been accruing since 1995, with five laws covering the development of palliative care (1995 and 1999), patients' rights (2002 and 2005), the ban of unreasonable obstinacy (2005), the development of collegiate decision-making (2005 and 2016), and finally the conditions under which a SPCMJD "deep and continuous sedation until death" may be administered when a patient's pain cannot be alleviated (2016). But despite all this progress and the ongoing development of palliative care over the past 30 years, we must acknowledge that, even today, two out of three patients who would like palliative care but are nearing the end of their lives do not have access to it. In parallel, a social movement that has been active for more than 40 years, the ADMD (Association for the right to die with dignity) is demanding that French citizens have access to an enforceable right to an elective death, as part of their freedom to dispose of their lives. Over the past year,debates on end-of-life issues in French society have been the subject of diverse and often passionate and polemical positions, between supporters and opponents of a right to "active assistance in dying". This diversity was reflected in the conclusions of a "citizens' convention", which brought together 150 French citizens chosen at random between December 2022 and April 2023 to establish a list of viewpoints supposedly representative of French citizens at large. Paradoxically, most of the voices that have been heard over the past two years have lumped together the two main options for administered death, euthanasia and assisted suicide, either condemning them uncompromisingly, or calling for both. On the other hand, few speakers in the various debates sought to distinguish analytically the differences between these two options, by addressing the details and complexities of each. This is all the more surprising given that several foreign examples now enable us to carry out a full-scale "impact study" of the two models. The following analysis, assuming that the law will move beyond the status quo and establish a new right, aims to get to the heart of this alternative by analyzing the consequences of each option from a number of perspectives. Our goal is to shed light on the underlying key facts of the debate and to avoid relying on simplistic preconceptions, moral principles and concepts. Beginning with a review of the legislation approved by the parliament and observing how it has been implemented since coming into force, we will report on what these laws of administered death have meant for all stakeholders. For both options, we will review the issues of representation of the role of the state, of personal freedom, of the impact on healthcare professionals, of repercussions on patients, of patient consent, and how these interventions are monitored. Ultimately, we will assess the quantitative impact of both paths in terms of death ratios. On the basis of some spectacular differences, which make it difficult to remain neutral in this debate, the authors finally propose a compromise that could be reached, one that will satisfy the proponents of a change of legislation, without causing a destabilizing change for all third-party stakeholders.(c) 2023 Elsevier Masson SAS. All rights reserved.