French Families Challenge Doctors on Wrenching End-of-Life Decisions

PARIS — At least seven times, alone and in secret, Dr. Nicolas Bonnemaison prepared a lethal dose of sedative and quietly ended the life of a comatose patient in his care.

Dr. Bonnemaison, an emergency physician and palliative specialist in the city of Bayonne in southwestern France, acted without consultation of any kind — with other doctors, nurses or his dying patients’ families — and sought to conceal the procedures, keeping them unrecorded. All this he admitted freely in court, saying he was moved by a sense of duty to act outside the law, to spare his colleagues and his patients’ loved ones the strain of so weighty a choice. He was charged with the poisoning deaths of seven people.

“You wanted to protect everyone — the patients, the families, the medical personnel — out of compassion,” a state prosecutor told Dr. Bonnemaison. “To be too compassionate is to deem others disposable. It is to unburden them of a responsibility that, in fact, belongs to them.”

“I acted as a doctor,” Dr. Bonnemaison told the court in June, “through to the very end.”

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A jury acquitted him. The courtroom, filled with his supporters, erupted in applause.

Doctors in France have long held what, by American standards, might seem unthinkable discretion to make end-of-life choices for people in their care.

For patients unable to communicate, such decisions fall legally to the physician, who may withdraw treatment or administer care that will end a patient’s life so long as the stated intent is to relieve that patient’s suffering, and not to kill. The opinions of family members and fellow doctors must be heard, the law states, but by no means obeyed.

That physicians wield such expansive powers is a peculiarity born of France’s paternalistic bent, of a culture of deference to hierarchy and expertise, doctors and social scientists say [boldface emphasis by Abyssum]. Never have fears of “death panels” become a matter of public debate, as they have in the United States.

As the population ages, however, and as drawn-out hospital deaths become more the norm, patients and families increasingly say they wish to be more closely involved in end-of-life decisions. And the French doctor’s role as final arbiter of life and death is increasingly being challenged.

In June, a French high court for the first time heard a request to annul a doctor’s decision to let a patient die. A bipartisan proposal for new end-of-life legislation is to be presented to President François Hollande in the coming months. And Dr. Bonnemaison’s acquittal has been appealed by prosecutors.

“Here we’re faced with someone who, because he’s a doctor, is convinced of, inhabited by the notion that he must think in place of others, decide in place of others,” said Dr. Régis Aubry, president of France’s National Observatory on End of Life, a semiofficial organization that conducts research on end-of-life medical practices, speaking of Dr. Bonnemaison. “I find it chilling.”

That traditional conception of the doctor’s role has been undermined by an expansion in patient access to medical information, notably on the Internet, as well as technological advances and recent trends in care, doctors and researchers say. The movement to “tell the patient everything,” for instance, which took hold decades ago in the United States, began far more recently in France, said Isabelle Baszanger, a sociologist who studies end-of-life care.

New circumstances, Dr. Aubry said, “are obliging us to adopt a much broader vision of the question of responsibility.”

Demographic pressures are making end-of-life care a contentious moral, legal and economic issue in many countries. Aging populations and the growing costs of caring for them have left governments confronting trade-offs in policies affecting the closing weeks and months of life.

France’s approach, codified in a 2005 law, is distinctly ambiguous. As nations across Europe have legalized euthanasia or assisted suicide in recent years, French lawmakers have publicly refused to do the same, often citing fears of misuse. Yet by empowering doctors with broad, discretionary end-of-life rights, France has in effect quietly authorized the practice of euthanasia, doctors and officials acknowledge.

About 57 percent of the 570,000 registered deaths in France in 2012 took place in a hospital, according to the national statistics agency, a level nearly twice that in the United States. A recent report by France’s National Institute for Demographic Studies estimated that half of annual deaths were preceded by a doctor’s decision to limit treatment or raise dosages of painkillers or sedatives.

Absent a stated desire to end a patient’s suffering, the law bars doctors from intentionally ending a patient’s life, whether by withholding treatment or administering a lethal dose of a drug, but such practices account for an estimated 3 percent of total deaths, or about 17,000 each year, the report said. In only one-fifth of those cases do doctors act at the explicit request of the patient. A major report on end-of-life practices prepared in 2012 for the French presidency found a generalized “deafness” among doctors toward their patients.

Much of the current debate in France has centered on the case of Vincent Lambert, who was paralyzed in a car crash six years ago and is now in a vegetative state. With the support of Mr. Lambert’s wife, a doctor in the city of Reims has twice removed his feeding tube; twice, Mr. Lambert’s parents, Roman Catholics who believe that their son’s condition could yet improve, have won court injunctions to keep him alive.

Last month the case went before the Conseil d’État, France’s highest administrative court, which found that Mr. Lambert, now 37, could legally be allowed to die; his parents have appealed that ruling to the European Court of Human Rights.

Before his accident, Mr. Lambert, a psychiatric nurse, said he did not wish to be kept alive if ever he were gravely injured, his wife and other relatives say. Given that, and after years of unsuccessful therapies, Mr. Lambert’s medical team reasoned that to continue treating him would constitute “unreasonable obstinacy,” which is discouraged under the 2005 law, said Dr. Éric Kariger, the lead doctor.

Before removing Mr. Lambert’s feeding tube, however, Dr. Kariger failed to consult any members of the family, as required by law. Mr. Lambert’s wife was later told of the doctor’s decision; his parents discovered that the feeding tube had been removed in a visit to their son bedside. They won an injunction, and the feeding tube was reinserted.

Dr. Kariger subsequently consulted Mr. Lambert’s wife and parents, and once again removed the feeding tube.

“I told them, ‘Hold on, it’s not you making the decision — it’s me,’ ” said Dr. Kariger. “Free yourselves of any feeling of guilt.”

For many French, it is precisely because doctors are professionals, bound by medical and legal principles — not, in theory, by emotion or subjective experience — that they should be charged with making end-of-life decisions. François Lambert, Vincent’s nephew and a plaintiff in the case who would like to let his uncle die, cited the deep divisions within his own family as proof of the need for a third-party decider.

The 2005 legislation is built upon the same conclusion, said Dr. Jean Leonetti, a cardiologist and lawmaker who saw the law through Parliament. Families might be guided by “too much emotion,” Dr. Leonetti said.

The notion that patients themselves should be closely involved in medical decisions has come recently to France. Since 2002, for instance, patients have been legally entitled to gain access to their medical files without their doctor’s consent. Many doctors maintain that patients ought not to be kept fully informed.

“One must not traumatize people,” Dr. Leonetti said. “It’s not worth going to knock on the door to say, ‘You have 15 days to live’ if the patient isn’t asking for it, if he’s not insisting on it. I don’t see why one would snuff out any little lights of hope.”

At the trial of Dr. Bonnemaison, several doctors admitted they had intentionally ended patients’ lives. No charges have been brought against them.

“Traditionally, the doctor has been a man who acts alone,” Ms. Baszanger said. “We know we’re at the end of a system.”