Society

Euthanasia Du Jour? Doctors' Hidden Truth On End-Of-Life Care

Amid an ongoing public debate in France on end-of-life palliative care, doctors tell Le Monde how they secretly help their patients die.

“I assist until death”
“I assist until death”
Laetitia Clavreul

PARIS — As the president of a doctor’s union says of treating the chronically ill, “We’ve all pushed the syringe” at some point in their careers.

Death is a topic that doctors rarely discuss among themselves. Too heavy, too personal. Instead, these things tend to be between attending physicians and their patients, who they follow until their very last minutes.

French President François Hollande has promised a draft bill on end-of-life assistance, and the role doctors play for chronically ill patients is at the heart of the debates. Some have agreed to tell us about their practice, whether anonymously or using their names.

“Doctor, will you help me?” The question is sometimes asked when the end of life is not that near. “I tell them that I am not the right doctor for that,” says doctor O., who has been a general practitioner in the west of France for the past 30 years. “I don’t claim to be the one to decide.”

But when the final moments truly have arrived, it’s a different story. He helps patients “go” when they are in pain, when life has become unbearable. Often, he says, “They do not voice any request. But when we touch their forehead with our hand and they are looking straight at us, they tell us with their eyes: ‘I’m ready.’”

He recalls a Saturday night at 11.30 p.m., when an entire family was holding vigil for a mother in pain and asked him to “do something,” because that was what she wanted. He repeated that he was not allowed to, that he could only increase the morphine dosage. “But I knew what the outcome was going to be,” he says.

Dr. Stéphane Pertuet, from the northern French town of Barentin, says a patient once asked him, “You’ll do what’s necessary, won’t you?” The patient was telling him he was scared. The doctor comforted the dying man, and said that he would.

Pertuet remembers a former military man, who made him promise not to hospitalize him “at the end,” and to do “what’s necessary” so he could die “in a dignified” manner. One day, when he was in a state of shock, he told the doctor, “Finish me.” “Of course, I didn’t do it,” Pertuet says. “But I made sure that he wouldn’t suffer by setting up a graded treatment, aware that it could kill him. If he felt that I was hesitant, it would have been a fiasco.”

Doctors use various drugs, all of them legal, to help ease a dying patient’s pain and usher them peacefully into death. Curare or potassium chloride would immediately lead to the death of the patient. But using those drugs would be a crime. What doctors can legally do is prescribe sedation to relieve suffering and agony. They can mix anxiolytics, morphine or other analgesics, leading to respiratory depression and death a few hours or days later. What the law forbids is “intentionally” causing death.

In the patient’s shoes

Words are important, says Dr. G., a general practitioner in southeast France. “Yes, I help people die,” he says. “Killing is different. It’s an immediate action. Increasing the dosage has nothing to do with euthanasia.”

When Pertuet arrives at the home of a patient he is treating, he doesn’t necessarily have a preconceived idea of what he is going to do, he says. “I suppose I sense that I will lead the patient to death, but I have no other choice. Otherwise, the patient suffers.” He tries to step into the patient’s shoes, taking into account his personality, culture and religion.

Bernard Senet, a retired physician working as a medical officer at an association advocating legalizing euthanasia, has worked in private practice and also in a palliative care environment. When patients are suffering agonizing pain, Senet says it is his duty to help them.

“When the patient is uncomfortable despite the morphine, we open up the automatic syringe and it all goes,” he says. Once or twice a year over the course of his career, he has found himself in this kind of situation, and it is no doubt the case for other physicians too.

In fact, he knows it is because he often receives calls from fellow doctors asking for his advice. “I’m not an exception,” he says. “For fear of judges, the others don’t want to say that we do it, in appropriate conditions, and that it’s never easy,” he admits. “But from the moment you stop the treatments, you know you are sentencing the patient to death. From the moment you dispense Hypnovel at the hospital, you know you will cause a respiratory arrest.”

“I assist until death”

Not every doctor is willing to assist their patients in death, but for the ones who do, they regard it as part of their job. “I remember my first assistance very clearly,” Pertuet says. “It is the quintessence of our commitment. It is then very important to be a good technician and a very good psychologist. But it always leaves a mark.”

Dr. R., a general practitioner specializing in palliative care near Paris, says he assists “until death, because death is part of life.” But recently, a seriously ill patient under 70 years old asked him if he would agree to give him “an injection.” Even if the law changes, the doctor says he would never go that far.

The law, in fact, is not necessarily at the heart of everyone’s concerns. Pertuet hasn’t really altered his handling of these cases over the years, he says. “I watch the debates between experts with amusement. They hide behind religious beliefs, sacrosanct ethics and palliative care. But for me, the more I think about it, the less sure I am.” What is important “is what they never talk about: humanity, technique, the doctor-patient bond.”

The French Leonetti legislation, passed in 2005, has made doctor G. more relaxed. “We used to be limited on a legal basis,” he says. “We couldn’t handle therapies when we knew we were at a lethal level.” Even the French medical college, which he characterizes as typically “quite retrograde,” last year announced its support of terminal sedation for patients with insurmountable pain, calling it “a duty of humanity.”

“It’s not a step towards euthanasia,” insists Dr. Jean-Marie Faroudja, ethics head of the national medical college council, pointing out the necessary commitment to the Hippocratic Oath. “Killing must remain prohibited.” He acknowledges that “between causing death and putting the patient to sleep until it arrives, the difference is narrow.” But it exists.

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Geopolitics

How Thailand's Lèse-Majesté Law Is Used To Stifle All Protest

Once meant to protect the royal family, the century-old law has become a tool for the military-led government in Bangkok to stamp out all dissent. A new report outlines the abuses.

Pro-Democracy protest at The Criminal Court in Bangkok, Thailand

Laura Valentina Cortés Sierra

"We need to reform the institution of the monarchy in Thailand. It is the root of the problem." Those words, from Thai student activist Juthatip Sirikan, are a clear expression of the growing youth-led movement that is challenging the legitimacy of the government and demanding deep political changes in the Southeast Asian nation. Yet those very same words could also send Sirikan to jail.

Thailand's Criminal Code 'Lèse-Majesté' Article 112 imposes jail terms for defaming, insulting, or threatening the monarchy, with sentences of three to 15 years. This law has been present in Thai politics since 1908, though applied sparingly, only when direct verbal or written attacks against members of the royal family.


But after the May 2014 military coup d'état, Thailand experienced the first wave of lèse-majesté arrests, prosecutions, and detentions of at least 127 individuals arrested in a much wider interpretation of the law.

The recent report 'Second Wave: The Return of Lèse-Majesté in Thailand', documents how the Thai government has "used and abused Article 112 of the Criminal Code to target pro-democracy activists and protesters in relation to their online political expression and participation in peaceful pro-democracy demonstrations."

Criticism of any 'royal project'

The investigation shows 124 individuals, including at least eight minors, have been charged with lèse-majesté between November 2020 and August 2021. Nineteen of them served jail time. The new wave of charges is cited as a response to the rising pro-democracy protests across Thailand over the past year.

Juthatip Sirikan explains that the law is now being applied in such a broad way that people are not allowed to question government budgets and expenditure if they have any relationship with the royal family, which stifles criticism of the most basic government decision-making since there are an estimated 5,000 ongoing "royal" projects. "Article 112 of lèse-majesté could be the key (factor) in Thailand's political problems" the young activist argues.

In 2020 the Move Forward opposition party questioned royal spending paid by government departments, including nearly 3 billion baht (89,874,174 USD) from the Defense Ministry and Thai police for royal security, and 7 billion baht budgeted for royal development projects, as well as 38 planes and helicopters for the monarchy. Previously, on June 16, 2018, it was revealed that Thailand's Crown Property Bureau transferred its entire portfolio to the new King Maha Vajiralongkorn.

photo of graffiti of 112 crossed out on sidewalk

Protestors In Bangkok Call For Political Prisoner Release

Peerapon Boonyakiat/SOPA Images via ZUMA Wire

Freedom of speech at stake

"Article 112 shuts down all freedom of speech in this country", says Sirikan. "Even the political parties fear to touch the subject, so it blocks most things. This country cannot move anywhere if we still have this law."

The student activist herself was charged with lèse-majesté in September 2020, after simply citing a list of public documents that refer to royal family expenditure. Sirikan comes from a family that has faced the consequences of decades of political repression. Her grandfather, Tiang Sirikhan was a journalist and politician who openly protested against Thailand's involvement in World War II. He was accused of being a Communist and abducted in 1952. According to Sirikhan's family, he was killed by the state.

The new report was conducted by The International Federation for Human Rights (FIDH), Thai Lawyer for Human Rights (TLHR), and Internet Law Reform Dialogue (iLaw). It accuses Thai authorities of an increasingly broad interpretation of Article 112, to the point of "absurdity," including charges against people for criticizing the government's COVID-19 vaccine management, wearing crop tops, insulting the previous monarch, or quoting a United Nations statement about Article 112.

Juthatip Sirikan speaks in front of democracy monument.

Shift to social media

While in the past the Article was only used against people who spoke about the royals, it's now being used as an alibi for more general political repression — which has also spurred more open campaigning to abolish it. Sirikan recounts recent cases of police charging people for spreading paint near the picture of the king during a protest, or even just for having a picture of the king as phone wallpaper.

The more than a century-old law is now largely playing out online, where much of today's protest takes place in Thailand. Sirikan says people are willing to go further on social media to expose information such as how the king intervenes in politics and the monarchy's accumulation of wealth, information the mainstream media rarely reports on them.

Not surprisingly, however, social media is heavily monitored and the military is involved in Intelligence operations and cyber attacks against human rights defenders and critics of any kind. In October 2020, Twitter took down 926 accounts, linked to the army and the government, which promoted themselves and attacked political opposition, and this June, Google removed two Maps with pictures, names, and addresses, of more than 400 people who were accused of insulting the Thai monarchy. "They are trying to control the internet as well," Sirikan says. "They are trying to censor every content that they find a threat".

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