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Euthanasia and end-of-life practices in France and Germany. A comparative study

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Abstract

The objective of this paper is to understand from a sociological perspective how the moral question of euthanasia, framed as the “right to die”, emerges and is dealt with in society. It takes France and Germany as case studies, two countries in which euthanasia is prohibited and which have similar legislation on the issue. I presuppose that, and explore how, each society has its own specificities in terms of practical, social and political norms that affect the ways in which they deal with these issues. The paper thus seeks to understand how requests for the “right to die” emerge in each society, through both the debate (analysis of daily newspapers, medical and philosophical literature, legal texts) and the practices (ethnographic work in three French and two German hospitals) that elucidate the phenomenon. It does so, however, without attempting to solve the moral question of euthanasia. In spite of the differences observed between these two countries, the central issue at stake in their respective debates is the question of the individual’s autonomy to choose the conditions in which he or she wishes to die; these conditions depend, amongst others, on the doctor-patient relationship, the organisation of end-of-life care in hospital settings, and more generally, on the way autonomy is defined and handled in the public debate.

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Notes

  1. If the number of documented cases does not permit statistical comparisons, one can however suggest some particularities. Proportionally more palliative care patients died in France (21/31) than in Germany (24/52). This may relate to the fact that I spent a longer period with French teams, but also that French doctors refer patients later to palliative care teams than do German doctors. And if I reported more German than French cases, although I spent more time in France, this may be related to two reasons. First, in Germany I observed that professionals working both in palliative care units and as advisors for other units within the same hospital Secondly, in Germany patients stay for a shorter time in palliative care units than in France. German patients are often referred back to their original unit, to hospices or they return home. This suggests that German palliative care teams intervene at an earlier stage, before the patient is in an acute situation, and that they collaborate more intensively with other specialists. As we will see, in France, on the contrary, the intervention of a palliative care team is often accepted only at the “last stage”.

  2. I conducted the interviews in the first language and translated them later. There is no formal requirement in Germany or in France to have a project like this reviewed by an ethics committee. However, access was negotiated with the head of the palliative care team and appropriate standards for observation and interviews set out and observed, including guarantees of the anonymity of participants.

  3. What counts in French criminal law is the intention of the act and not the motive (article 221-6 Code Pénal). However, the jurisprundence shows that there are rarely convictions for homicide in cases where the death of a patient has been intentionally hastened. Most often, the actor is acquitted or is given a suspected sentence (see the cases of Marie Humbert and Dr Frédéric Chaussoy in the „affaire Vincent Humbert“ or the case of Chantal Chanel and Dr Laurence Tramois in the „affaire du Périgueux". TF1, 2008).

  4. This is the literal translation of the French expression “acharnement thérapeutique”. In the French end-of-life debate, this expression is currently employed when criticising a professional’s behaviour. The fact that there is no equal expression either in German or in English suggests a particularity of the French situation.

  5. In an article published January 6, 1984, in Le Monde, Patrick Verspieren, Jesuit Father and “founder” of the French palliative care movement, criticises the attitudes of “most” doctors concerning their respect of terminally ill patients. He denounces the fact that in French hospitals „euthanasia has become currently and systematically […] the usual medication at the last stage of life.

  6. If in UK as well, there are palliative care consultation teams rather than palliative care units within the hospitals, the situation cannot be compared to France. The development of the English hospice movement and the important number of hospices and their intense collaboration with hospital doctors has suggested for a long time that there is no need for development of palliative care within hospital settings. However, this does not mean that this development has not created certain problems.

  7. A study of Courtas (1991) shows that most of the members of the French association for the right-to-die (ADMD) leading the euthanasia debate did see their loved ones die under “difficult and awful conditions”.

  8. According to a Swiss report in 2006, 253 German patients have benefited of assisted suicide between 1998 and 2005 (Eidgenössisches Justiz- und Polizeidepartment, 2006, p. 33).

  9. This point is confirmed amongst others by the data from Oregon where physician assisted suicide is authorised since 1994. The principal argument for their request is losing autonomy. Furthermore, only one third of the persons who get prescriptions for lethal medications ultimately take this. These results suggest that some persons only need to be assured that there is the possibility of a quick and self-determined death (State of Oregon 2011).

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Acknowledgments

The author would like to thank Professor Simone Bateman (Centre de Recherche Sens, Ethique et Société, Paris), Professor Ruud ter Meulen and Dr Richard Huxtable (Centre for Ethics in Medicine, University of Bristol) for their constructive comments on earlier versions of this paper. This paper presents results of a PhD thesis carried out at the Ecole des Hautes Etudes en Sciences Sociales, Paris, and funded by the Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés, Paris. The author is also grateful to the European Union for funding her current post-doctoral Marie Curie fellowship which permitted writing the present paper. Finally, the author would like to thank the anonymous referees for critical comments and suggestions that led to improvements in the quality of this paper.

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Correspondence to Ruth Horn.

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This paper presents the results of my PhD: R. Horn. 2009. Le debat sur l’euthanasie et les pratiques en fin de vie en France et en Allemagne. Une étude comparative. Unpublished doctoral dissertation. Ecole des Hautes Etudes en Sciences Sociales. Paris.

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Horn, R. Euthanasia and end-of-life practices in France and Germany. A comparative study. Med Health Care and Philos 16, 197–209 (2013). https://doi.org/10.1007/s11019-011-9357-5

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