The draft law on aid in dying, the broad outlines of which were presented by French President Emmanuel Macron in March, will be presented to the Council of Ministers on Wednesday, April 10. According to the current text, aid in dying will only be a possibility for those who simultaneously meet these five conditions:
- be at least 18 years old;
- be of French nationality or reside in France;
- be capable of expressing their will "in a free and informed manner";
- have declared a serious and incurable disease involving life-threatening condition in the short or medium term;
- present "resistant or unbearable" physical or psychological suffering.
The patient must make their request to a doctor who, after obtaining the opinion of a specialist and one of the applicant's caregivers, will make a decision within 15 days. The bill stipulates that the patient must administer the lethal substance themselves if they are capable of doing so or, failing this, ask a person of their choice to do it. The doctor or nurse in charge of verifying the patient's wishes may also perform this task.
What's included in the French bill?
Two important questions arise from the conditions set out in this bill: How do we define what is a medium-term life-threatening condition, and what about advance directives, which are not taken into account?
The definition of a medium-term life-threatening illness is central to the precise definition of the scope of this system. Depending on whether the deadline is set at a few months or several years, the diseases giving rise to the right to aid in dying are not the same.
Mélanie Heard, head of the health department at think tank Terra Nova, and Martine Lombard, professor emeritus of law, expressed concern in an op-ed published in Le Monde that the ambiguity of the wording would "deprive the future law on the end of life of a large part of its practical scope," leaving the responsibility for interpretation to doctors, who are likely to be very cautious. Others, such as the Association for the Right to Die with Dignity (ADMD), condemn this notion, which "condemns patients suffering, for example, from Lou Gehrig's disease, to experience the drama of the final stages of the disease's evolution," which is slow but inescapable. Professionals are also campaigning for a change in the law: "So that those who don't want to suffer physical or psychological decay can be supported toward death," argued neurologist Valérie Mesnage at the end of 2023 in Le Monde.
Another unresolved issue is that of advance healthcare directives. The 2005 Leonetti law enables every adult to express his or her wishes concerning "the end of his or her life, as regards the conditions for continuing, limiting, stopping or refusing medical treatment or procedures." However, under the current bill any person who is unable to formulate his or her own request directly to a doctor, even if he or she has done so in an advance directive that may have been reaffirmed and supplemented as his or her illness progressed, will not be able to request aid in dying.
How would French law respond to cases encountered in countries that allow euthanasia?
Two European countries legalized euthanasia more than 20 years ago: the Netherlands in 2001 and Belgium in 2002. These are the countries where euthanasia is most widely practiced: 8,720 cases were recorded by the Dutch in 2022, and 3,423 on the Belgian side in 2023. The other countries are smaller (Luxembourg legalized the practice in 2009, but only recorded 34 cases in 2022) or have changed their legislation more recently: Spain in 2021 (with 288 cases in 2022) and Portugal in 2023.
Assisted suicide has been decriminalized in Austria since 2022, in Germany since 2020 and in Italy since 2019. In Switzerland, active euthanasia is prohibited, while assisted suicide is fully integrated into the law. While access and procedures vary from country to country, the US state of Oregon's example is the one that comes closest to the French bill (this state recorded 367 assisted suicides in 2023).
Based on reports published in the Netherlands and Belgium (countries with the highest number of euthanized patients, and which are also experiencing significant historical hindsight), we have listed the most frequent pathologies among euthanized patients, in order to anticipate the French legislative response. These are general guidelines, not answers that apply to individual cases or patients.
Advanced cancers
Cancerous tumors are the leading cause of conditions leading to euthanasia. In Belgium, they account for more than half (55.5%) of life terminations: 1,899 cases in 2023. In the Netherlands, this proportion reaches 57.8% of the 8,720 euthanasia performed in 2022 (5,046 cases).
Based on Belgian figures, malignant tumors of the digestive (pancreas, colon, esophagus and stomach), respiratory (mainly lung) and breast organs alone accounted for 60% of cancer-related life terminations.
What would the French bill allow?
It will be possible to request assistance in dying for these advanced, incurable types of cancers: They meet the conditions set out in the bill, because they are life-threatening in the short or medium term, and are associated with unbearable physical or psychological suffering.
Multiple chronic pathologies
They account for 16.4% of euthanasia cases in the Netherlands (1,429 cases) and 23.2% of those carried out in Belgium (793 cases).
The accumulation of chronic diseases, including geriatric ones, can also be the cause of unbearable suffering with no prospect of improvement, since some of them are age-related and degenerative. The combination of disorders caused by these different conditions is a source of both physical and psychological suffering: loss of autonomy, loss of quality of life, sensory impairment and depression.
What would the French bill allow?
How the future law on aid in dying will deal with these cumulative chronic diseases will depend on the definition of "medium term." In Belgium, 421 of the 793 people with combinations of several refractory chronic conditions in 2023 were diagnosed with a "short" foreseeable time to death (in the coming days, weeks or months). Conversely, 372 people were diagnosed with a foreseeable time to "non-short" death; such a situation would deviate from the possibilities envisaged by French legislation.
Diseases of the nervous system
Nervous system illnesses – Parkinson's disease, Lou Gehrig's disease, multiple sclerosis, for example – are the third major type of condition for which patients have the most recourse to euthanasia: 9.6% in Belgium and 7% in the Netherlands.
These neurodegenerative diseases cause motor and cognitive disturbances for which there is no cure. Treatments can slow the progression of these diseases, reduce symptoms and improve quality of life, but over the longer term, disorders can progress and lead to irreversible disability.
What would the French bill allow?
In the case of such diseases, the requirement that the patient's prognosis be "short- or medium-term" may rule out the possibility of seeking such help at the stage when suffering becomes unbearable, as the patient's days are generally still far from numbered.
Diseases of the circulatory system
They represent 3.2% of the pathologies at the origin of euthanasia performed in Belgium, and 4.1% of those performed in the Netherlands.
Diseases of the circulatory system are mainly related to the after-effects of a stroke, which can lead to sudden and severe loss of autonomy and complete dependence. The main consequences are mild to pronounced hemiplegia, speech disorders, sensory disturbances and pain.
What would the French bill allow?
End-of-life requests from these patients will largely be excluded from the current bill, particularly in cases where the prognosis is neither short nor medium-term.
Diseases of the respiratory system
These illnesses prompted 3% of euthanized patients in Belgium, and 3.2% of those euthanized in the Netherlands, to request euthanasia.
Pulmonary fibrosis is one of the main chronic respiratory diseases affecting euthanized people. It is incurable and progressive, and treatments can only slow its development.
What would the French bill allow?
The progressive nature of the disease, which implies a more or less rapid deterioration in the patient's condition, makes it possible to envisage recourse to aid in dying under the conditions set out in the bill, when the vital prognosis may be engaged in the "medium term" – and depending on how this condition is interpreted.
Neurodegenerative diseases
Dementia cases account for 1.2% of euthanized patients in Belgium and 2.5% of those euthanized in the Netherlands.
These neurodegenerative diseases, such as Alzheimer's, are characterized by increasing impairment of memory and cognitive functions, as well as behavioral disorders. The process is irreversible, and in the absence of curative treatment, the disease leads to a progressive loss of autonomy.
What would the French bill allow?
These conditions clearly fall outside the legal spectrum: The person requesting help to die would have to be able to express his or her request in an "informed manner," and even in this case, his or her vital prognosis would probably not yet be committed in the medium term. Even if the person had left advance directives, asking to die when the dementia starts to cause unbearable suffering, these could not be taken into account under the future law.
Legislation in Belgium and the Netherlands incorporates these requests, based on advance directives and the wishes expressed by patients during their moments of lucidity. When patients are no longer capable of expressing their wishes, the medical team makes the decision under a very strict procedure (which is very rare: 6 cases out of 282 in the Netherlands).
Mental illnesses
Mental disorders account for 1.3% of euthanasia performed in the Netherlands and 1.4% of those performed in Belgium.
What would the French bill allow?
At this stage, these illnesses will also be excluded from the scope of the bill, as they are not life-threatening. The bill's explanatory memorandum, a version of which has leaked, is explicit in its wording: "which excludes suffering exclusively linked to mental or psychological disorders."
Alongside the most common pathologies covered by the legislation of our European neighbors, other emblematic cases have fueled the public debate on euthanasia in France. For example, young Vincent Humbert, quadriplegic, blind and mute after a car accident, who asked President Chirac for the right to die in 2002, would not find an answer in the future law.