French MPs will on Tuesday vote on two landmark bills on palliative care and assisted dying. They're the result of months of debate shaped by a rare democratic experiment that brought together 184 randomly selected citizens to grapple with one of society’s most intimate and divisive questions: how should we die?
Marc-Olivier Strauss-Kahn was on a high-speed train in November 2022 when his phone rang. The 71-year-old retired economist had no idea he was about to join what he would later describe as "the best social experience of my life".
The caller invited him to join France's citizens' convention on end-of-life care – President Emmanuel Macron's bid to involve the public in a national conversation about assisted dying.
France’s current 2016 law allows for “deep and continuous sedation" for terminally ill patients, but assisted suicide – where a patient takes a lethal drug themselves – and euthanasia – where a third party administers it – remain illegal.
The convention was asked to answer one question: “Is the way we accompany those approaching the end of life adapted to the different situations which emerge, or do we need to introduce changes?”
Strauss-Kahn was curious to explore a topic that concerns everyone. “We’re all going to die at some stage,” he says.
He was also intrigued by the novel format. “How can you make so many people work together when they don’t know each other and they have so many different backgrounds?”
What followed was an intensive four-month process spanning 27 days of deliberation across nine weekends – backed up by online chats and virtual meetings. The participants – diverse in age, gender, region, and education level – were united by their willingness to engage.
"I met people that I might never have met or talked to before," the retired economist and senior civil servant explains. He sat alongside people who "had difficulties understanding all the words" and needed help with some concepts.
Rather than creating division, the range of backgrounds became a strength. “The importance, the intimacy of the topic helped us to respect the views of the other, because there is no right or wrong,” he says.
Listen to a conversation with Marc-Olivier Strauss-Kahn in the Spotlight on France podcast
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For and against
Another participant was 35-year-old Soline Castel, who runs a day centre for people with mental disabilities in rural Sarthe. Unlike Strauss-Kahn, who came in broadly in favour of assisted dying, Castel’s family background meant she leaned more towards opposing it.
Still, she was determined not to make up her mind in advance. "I let myself be guided by the convention to form an opinion," she says.
Over the four months, the 184 participants sat through 60 hearings with health professionals, philosophers, lawyers and religious figures. They also heard from terminally ill patients and workers in palliative care.
By the end, their positions had crystallised in opposite directions. Strauss-Kahn became more supportive of assisted dying, calling it "the ultimate freedom".
His conviction was strengthened by discovering the "many obstacles to be overcome", including a lack of medicine, knowledge and information, and poor training for healthcare professionals.
"I have to confess that several times I cried," Strauss-Kahn admits, reflecting on the testimonies he heard.
He remembers a particularly striking moment during a hearing with religious leaders from six different faiths, who all referred to the commandments "you shall not kill" and "you shall not steal".
"A philosopher said in response: 'When it's your own money, you are not robbing yourself; when it's your own life you're not killing. It's your own liberty to decide what you want.' That helped me understand better the differences of views."
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Castel, however, emerged "firmly opposed to any form of active assistance in dying", believing it would be impossible to guarantee protection for vulnerable people.
"It's extremely difficult to put sufficient safeguards in place to guarantee the safety of my fellow citizens, especially those who may be vulnerable," she explains. "I work in the field of disability, and I'm also thinking of the elderly."
Castel was raised a Catholic, though she does not believe faith should influence a country's laws. However, she said the testimonies raised serious concerns about subtle pressure on elderly people from their families. They may have been influenced, she says, "but no one will know".
Despite the 2016 law, 19 of France's 101 administrative departments still do not have palliative care units, according to a health ministry report. Castel argues that if the existing law were properly applied, most cases would be resolved.
"Studies have shown that people who ask for help dying often do so because they are alone or in pain," Castel says. These two factors can be resolved, she adds, while conceding there are also rare cases where no pain relief is possible.
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Respecting diversity of opinion
The convention's final recommendations reflected the range of views in the room.
A large majority – 95 percent – backed expanded palliative care. Some 76 percent supported medical assistance in dying, but only as a last resort and in strictly defined cases. Those in the 23 percent minority who opposed any form of assisted dying were given equal time to speak – a courtesy that stood in stark contrast to debates in parliament.
"At the same time, the so-called representative democracy, our elected members in parliament, were shouting and the contrast made us very proud of our respect for each other," Strauss-Kahn notes.
He says the convention has already had an impact. A 10-year strategy for palliative care is being implemented, bringing total investment in the sector to around €6 billion by 2034. Arguments from the citizen panel – both for and against assisted dying – are now often cited by MPs and in the media.
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In a country like France, where political compromise is rare, the convention showed that deliberative democracy can handle divisive issues with nuance and respect.
Rather than seeking false consensus, the participants focused on clearly stating the arguments on both sides.
"We realised it was better to clarify any consensus, express the arguments for and against and assess how many were in favour," Strauss-Kahn says. "We're living through a crisis of representative democracy and the idea is not to replace representative democracy by deliberative democracy, but just to involve the citizens more as a complementary approach."
Castel says of her minority stance: "I really felt I'd been heard. The arguments of those who were against were said, reiterated and written down."
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Life after the assembly
Strauss-Kahn and Castel are now part of a broader group known as "The 184", created after the convention to promote deliberative democracy and better end-of-life care. Although they disagree on assisted dying, they continue to work together to ensure the convention's work stays part of the national debate.
The idea was also to ensure a life after the assembly. "I like to say that we thought about end of life but not the end of life of the convention," Strauss-Kahn says. "For some people it really was a form of social inclusion."
They are also advising the next citizens’ assembly – which will focus on school hours and children’s wellbeing – on what could be improved.
Strauss-Kahn says they are trying to improve ties with parliament, since some MPs viewed the convention as a threat. He also warns about the need to fight misinformation.
"Some were saying that up to a million people would be able to access assisted dying, this is false. We encourage the new convention to do fact-checking from the very beginning."
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Whether France's lawmakers follow the convention's recommendations or not remains to be seen, but both Strauss-Kahn and Castel are convinced the process was important.
Strauss-Kahn encourages anyone who can to take part.
"If there's a phone call that is not clearly a commercial, take it and try to participate because it's a unique chance in your life," he says.
