He wanted to be kept alive; doctors could still stop treatment

(CN) — A French man had made his wishes clear in advance — keep him alive, even if he never regained consciousness — but Europe’s human rights court said Thursday France had not violated the right to life after doctors later withdrew life-sustaining treatment.

In a unanimous judgment, the European Court of Human Rights said France’s end-of-life rules pass muster not because they guarantee a particular outcome, but because of how the decisions are made. What mattered to the judges was the process. French law, the court said, is designed to protect patients by forcing doctors to slow down, consult widely and justify their choices, instead of leaving an irreversible decision to a single clinician.

The ruling also spells out the limits of patient autonomy. Written wishes and advance directives carry real weight, the judges said, but they are not untouchable instructions that apply in every possible situation.

When a patient’s condition has fundamentally changed and treatment no longer offers real medical benefit, doctors may depart from those wishes. But they can do so only after an exacting process that includes repeated medical evaluations, collective decision-making within a care team, input from outside specialists, ongoing communication with family members and the possibility of swift court oversight.

As long as those safeguards are genuinely respected, the court made clear, human rights law does not require life-sustaining treatment to continue at all costs.

A.M., the patient at the center of the dispute, was 44 when a routine repair job in May 2022 suddenly turned into a medical crisis. He was struck by a utility vehicle and rushed to intensive care in Valenciennes with devastating injuries. After cardiac arrest and a prolonged loss of oxygen to the brain, doctors found no signs of brain activity. He never woke up, surviving only with the help of a ventilator and other invasive life-support.

Within days, his medical team began a formal collective review triggered when treatment risks losing any real medical purpose. The family pushed back, pointing to handwritten advance directives A.M. had prepared in June 2020.

As the Strasbourg judges later summarized, he had written that he wanted “that he continue to be kept alive even artificially in the event that he were to lose consciousness permanently and be unable to communicate with his loved ones.”

An initial attempt in early June 2022 to withdraw treatment was halted by an emergency judge in Lille, who found doctors had not given those wishes enough weight.

The decision sent the case back to the hospital. Doctors ordered further neurological tests, sought advice from outside specialists and convened a series of multidisciplinary and ethical meetings, keeping the family informed as they reassessed A.M.’s condition step by step.

By mid-July, the medical team reached the same conclusion again, eventually deciding to withdraw life-sustaining treatment.

This time, courts declined to intervene. Emergency judges found the legal process had been followed, and France’s highest administrative court later agreed, with backing from the Constitutional Council.

Life support was withdrawn later that year, and A.M. died in December 2022. With domestic remedies exhausted, his relatives took the case to the Strasbourg court, arguing France had breached his right to life by allowing doctors to set aside wishes he had clearly expressed in advance.

The European court disagreed. Judges said countries have room to regulate end-of-life decisions, especially in a field where there is no single European approach. What counts, they said, is whether the law puts meaningful safeguards in place and whether decisions are reached through a process that genuinely protects life.

On that point, France passed the test. Judges pointed to the extended review, repeated medical assessments, input from outside specialists and ethics bodies, continuous dialogue with the family and the availability of fast, layered court oversight.

The judges wrote, “nothing allows calling into question the assessment of the domestic judges that the patient’s interest was constantly at the heart of the decision-making process, and that the final decision not to follow Mr. A.M.’s advance directives and to stop the treatments keeping him alive was motivated by the preservation of that interest.”

The ruling draws a narrow but deliberate line. Advance directives, the court emphasized, remain a central guide in medical decision-making and should normally be respected.

That distinction is familiar territory in medical ethics. Roberto Andorno, an associate professor of bioethics and biomedical law at the University of Zurich, said advance directives are usually meant to draw clear lines around what patients do not want done to them in the future.

When those documents are used to ask for specific treatment instead, he said doctors are not automatically bound to comply.

“Doctors cannot be obliged to provide treatments that, after careful consideration, are deemed to constitute therapeutic obstinacy,” Andorno said.

Judges accepted that no written instruction can account for every medical turn. Where treatment offers no realistic prospect of benefit, continuing it may conflict with the duty to avoid artificially prolonging life. The court also rejected claims that the decision was rushed or lacked oversight.

For legal scholars, the ruling marks a clear step beyond the court’s earlier end-of-life cases.

Audrey Lebret, a law professor in health law and bioethics, said the court’s judgment marks a significant step in its end-of-life jurisprudence. The court confirmed that states enjoy wide leeway in regulating the withdrawal of life-sustaining treatment, provided laws are clear, foreseeable and accompanied by procedural safeguards.

What is new is the court’s explicit recognition that advance directives opposing the withdrawal of treatment are not absolute, and that limitations may be compatible with states’ positive obligations under the right to life. The right to consent to treatment, as well as the right not to consent to its discontinuation, may be limited within the framework of a law that ensures a fair balance of interests and is subject to judicial oversight.

That debate is particularly acute here, said Ralf Jox, a professor of medical ethics at the University of Lausanne, because the case sits in one of medicine’s most contested areas: Chronic disorders of consciousness, including what is now called unresponsive wakefulness syndrome.

He said doctors themselves disagree if there is any medical reason to continue treatment once loss of consciousness is irreversible, or whether “the mere continuation of biological life of the organism” can still count as a goal of care.

Amel Alghrani, a law professor at the University of Liverpool and a visiting professor at the University of Oxford, said the judgment reinforces that boundary in legal terms.

Patient autonomy remains central, she said, but it does not create an enforceable right to insist on life-sustaining treatment when clinicians, acting within a robust legal and ethical framework, conclude care has become medically inappropriate.

Lawyers for the applicants and representatives of the French government did not immediately respond to requests for comment.

The judgment is not immediately final. Under the court’s rules, the parties have three months to ask for the case to be referred to the Grand Chamber, a step granted only in exceptional circumstances. If no referral is requested — or if such a request is refused — the ruling will become final and binding on France, closing the case at the European level.

Courthouse News reporter Eunseo Hong is based in the Netherlands.