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No sooner had France passed its law authorising euthanasia than a borderline case emerged in the press, bearing witness to the deadly spiral into which the country is being drawn. It undoubtedly illustrates the concerns of those who had been warning of a gradual shift in decision-making power towards the medical profession.
At the Pitié-Salpêtrière Hospital in Paris, Rémi, a man who emerged from a coma following a serious accident, now consistently asserts that he wishes to continue living. However, his doctors consider that the treatments keeping him alive constitute “unreasonable obstinacy” and have initiated proceedings to have them withdrawn. The Council of State has just ruled in their favour, in a decision containing a chilling phrase: “the patient’s will ends with the law.”
The case is emblematic and clashes head-on with the debates of recent weeks on consent to die. Here we are faced with the opposite scenario: when a patient is conscious, clearly expresses a desire to live and has the support of their family, who should have the final say?
Rémi’s story is extraordinary. Following an accident that caused severe neurological damage, he was left in a coma. Against all odds, he woke up but his condition remains extremely serious: he is dependent on life-support treatment and suffers from a severe disability. But he is able to communicate and states unequivocally that he wishes to continue living.
His family shares this wish and refuses to allow treatment to be withdrawn. Doctors at the Pitié-Salpêtrière Hospital nevertheless consider that continuing treatment constitutes unreasonable obstinacy within the meaning of the Claeys-Leonetti Act, which set out the medical and legal framework for patients at the end of life, until the passing of the Act of July 15th on assisted dying. In their view, continuing treatment would merely artificially prolong an existence with no prospect of significant improvement.
This disagreement led the family to launch a legal battle aimed at preventing the medical decision from being carried out. Following internal hospital procedures, the family lodged an urgent appeal with the Council of State to suspend the decision to withdraw treatment.
The appeal challenged the medical assessment that the legal criteria for “unreasonable obstinacy” had been met. In particular, the family argued that Rémi is now capable of expressing his wishes, that he is explicitly asking to live, and that this wish should take precedence.
The Council of State did not accept this argument. It upheld the doctors’ assessment and confirmed that the conditions set out in the Public Health Code had been met to authorise the withdrawal of treatment.
It is in this context that the high court states that “the patient’s wishes are subject to the law,” a phrase that sums up the philosophy adopted: the patient’s expression of will is not, in itself, sufficient if the legal criteria permitting the withdrawal of treatment are deemed to have been met.
This case highlights a paradox rarely mentioned in the debate on end-of-life care.
For months, advocates of the legalisation of euthanasia have emphasised patient autonomy and absolute respect for a patient’s wishes when they wish to die. Yet, in Rémi’s case, the opposite occurs: a patient asks to live, but this wish is not enough to prevent the withdrawal of treatment.
Under French law, the decision does indeed rest with the doctor, following a collegial procedure designed to assess whether treatment has become futile, disproportionate or serves no purpose other than the artificial prolongation of life. The family is consulted, but has no right of veto. Its role consists essentially of bearing witness to the patient’s prior wishes when the patient is no longer able to express them.
The Rémi case thus illustrates the limits of the power of relatives when faced with a medical decision. Even when they unanimously oppose the withdrawal of treatment, their opposition is not sufficient to prevent it from going ahead if the courts consider that the legal procedure has been followed.
The timing gives this decision particular political significance. Just a few days after the passing of the law establishing a right to assisted dying, many opponents are denouncing what they perceive as a growing imbalance in favour of the medical profession. In their view, the Rémi case demonstrates that the safeguards put forward during parliamentary debates do not allay all concerns. A system in which a conscious patient may have their wish to live set aside on the basis of a medical assessment reveals the extent of the power entrusted to doctors in end-of-life decisions.
Grégor Puppinck, director of the European Centre for Law and Justice, emphasises that “this is the first time that doctors have decided to withdraw treatment, against the expressed wishes of a ‘conscious’ patient, thereby causing their death.” A few years ago, the Vincent Lambert case made headlines because doctors had decided to end the life of a man in a vegetative state against his family’s wishes. But the situation, however contentious, was quite different: Vincent Lambert had not regained consciousness and, unlike Rémi, had never clearly expressed his wish to live.
What we are witnessing here is a gravely serious reversal of the principle of autonomy: individual will is invoked when it leads to a request for death but may be disregarded when it involves a request for continued care.
