Right to life and right to respect for private life
II. RELEVANT DOMESTIC LAW AND PRACTICE A. Public Health Code 52. Under Article L. 1110 ‑ 1 of the Public Health Code (“the Code”), all available means must be used to secure to each individual the fundamental right to protection of health. Article L. 1110 ‑ 2 of the Code provides that the patient has the right to respect for his or her dignity, while Article L. 1110 ‑ 9 guarantees to everyone whose condition requires it the right to palliative care. This is defined in Article L. 1110 ‑ 10 as active and ongoing care intended to relieve pain, ease psychological suffering, preserve the patient ’ s dignity and support those close to him or her. 53. The Law of 22 April 2005 on patients ’ rights and end ‑ of ‑ life issues, known as the “ Leonetti Act ” after its rapporteur, Mr Jean Leonetti (see paragraph 44 above), amended a number of Articles of the Code. The Act was passed following the work of a parliamentary commission chaired by Mr Leonetti and tasked with exploring the full range of end ‑ of ‑ life issues and considering possible legislative or regulatory amendments. In the course of its work the parliamentary commission heard evidence from a great many individuals. It submitted its report on 30 June 2004. The Act was passed unanimously by the National Assembly on 30 November 2004 and by the Senate on 12 April 2005. The Act does not authorise either euthanasia or assisted suicide. It allows doctors, in accordance with a prescribed procedure, to discontinue treatment only if continuing it would demonstrate unreasonable obstinacy (in other words, if it would mean taking it to unreasonable lengths ( acharnement thérapeutique ) ). The relevant Articles of the Code, as amended by the Act, read as follows. Article L. 1110-5 “Every individual, regard being had to his or her state of health and the urgency of the treatment required, shall be entitled to receive the most appropriate care and to be given the safest treatment known to medical science at the time to be effective. Preventive or exploratory acts or care must not, as far as medical science can guarantee, subject the patient to disproportionate risks in relation to the anticipated benefits. Such acts must not be continued with unreasonable obstinacy. Where they appear to be futile or disproportionate or to have no other effect than to sustain life artificially, they may be discontinued or withheld. In such cases, the doctor shall preserve the dignity of the dying patient and ensure his or her quality of life by dispensing the care referred to in Article L. 1110-10 ... Everyone shall be entitled to receive care intended to relieve pain. That pain must in all cases be prevented, assessed, taken into account and treated. Health - care professionals shall take all the measures available to them to allow each individual to live a life of dignity until his or her death ... ” Article L. 1111-4 “Each individual shall, together with the health - care professional and in the light of the information provided and the recommendations made by the latter, take the decisions concerning his or her own health. The doctor must respect the individual ’ s wishes after informing him or her of the consequences of the choices made ... No medical act or treatment may be administered without the free and informed consent of the patient, which may be withdrawn at any time. Where the individual is unable to express his or her wishes, no intervention or examination may be carried out, except in cases of urgency or impossibility, without the person of trust referred to in Article L. 1111-6, the family or, failing this, a person close to the patient having been consulted. Where the individual is unable to express his or her wishes, no decision to limit or withdraw treatment, where such a measure would endanger the patient ’ s life, may be taken without the collective procedure defined in the Code of Medical Ethics having been followed and without the person of trust referred to in Article L. 1111-6, the family or, failing this, a person close to the patient having been consulted, and without any advance directives issued by the patient having been examined. The decision to limit or withdraw treatment, together with the reasons for it, shall be recorded in the patient ’ s file ... ” Article L. 1111-6 “ All adults may designate a person of trust, who may be a relative, another person close to the adult, or his or her usual doctor, and who will be consulted in the event that the patient is unable to express his or her wishes and to receive the necessary information for that purpose. The designation shall be made in writing and may be revoked at any time. Should the patient so wish, the person of trust may provide support and attend medical consultations with the patient in order to assist him or her in making decisions. Whenever he or she is admitted to a health - care establishment, the patient shall be offered the possibility of designating a person of trust in the conditions laid down in the preceding paragraph. The designation shall be valid for the duration of the patient ’ s hospitalisation, unless he or she decides otherwise ... ” Article L. 1111-11 “ All adults may draw up advance directives in case they should become unable to express their wishes. These shall indicate the wishes of the individual concerned as regards the conditions in which treatment may be limited or withdrawn in an end ‑ of ‑ life situation. They may be revoked at any time. Provided they were drawn up less than three years before the individual became unconscious, the doctor shall take them into account in any decision to carry out examinations, interventions or treatment in respect of the person concerned ... ” 54. The collective procedure provided for in the fifth paragraph of Article L. 1111 ‑ 4 of the Code is described in detail in Article R. 4127 ‑ 37, which forms part of the Code of Medical Ethics and reads as follows: “I. The doctor shall at all times endeavour to alleviate suffering by the means most appropriate to the patient ’ s condition, and provide moral support. He or she shall refrain from any unreasonable obstinacy in carrying out examinations or treatment and may decide to withhold or discontinue treatment which appears futile or disproportionate or the only purpose or effect of which is to sustain life artificially. IV. COMPARATIVE LAW A. Legislation and practice in Council of Europe member States 72. According to the information available to the Court concerning thirty-nine of the forty-seven Council of Europe member States, no consensus exists in practice in favour of authorising the withdrawal of treatment designed only to prolong life artificially. In the majority of countries, treatment may be withdrawn subject to certain conditions. In other countries the legislation prohibits withdrawal or is silent on the subject. 73. In those countries which permit it, this possibility is provided for either in legislation or in non-binding instruments, most often in a code of medical ethics. In Italy, in the absence of a legal framework, the withdrawal of treatment has been recognised in the courts ’ case-law. 74. Although the detailed arrangements for the withdrawal of treatment vary from one country to another, there is consensus as to the paramount importance of the patient ’ s wishes in the decision-making process. As the principle of consent to medical care is one of the aspects of the right to respect for private life, States have put in place different procedures to ensure that consent is expressed or to verify its existence. 75. All the legislation allowing treatment to be withdrawn makes provision for patients to issue advance directives. In the absence of such directives, the decision lies with a third party, whether it be the doctor treating the patient, persons close to the patient or his or her legal representative, or even the courts. In all cases, the involvement of those close to the patient is possible, although the legislation does not choose between them in the event of disagreement. However, some countries operate a hierarchy among persons close to the patient and give priority to the spouse ’ s wishes. 76. In addition to the requirement to seek the patient ’ s consent, the withdrawal of treatment is also subject to other conditions. Depending on the country, the patient must be dying or be suffering from a condition with serious and irreversible medical consequences, the treatment must no longer be in the patient ’ s best interests, it must be futile, or withdrawal must be preceded by an observation phase of sufficient duration and by a review of the patient ’ s condition. B. Observations of the Human Rights Clinic 77. The Human Rights Clinic, third-party intervener ( see paragraph 8 above ), presented an overview of national legislation and practice concerning active and passive euthanasia and assisted suicide in Europe and America. 78. The survey concludes that no consensus currently exists among the member States of the Council of Europe, or in the other countries surveyed, regarding the authorisation of assisted suicide or euthanasia. 79. However, there is consensus on the need for passive euthanasia to be tightly regulated in those countries which permit it. In that connection each country lays down criteria in its legislation for determining the point at which euthanasia may be performed, in the light of the patient ’ s condition and in order to make sure that he or she has consented to the measure. Nevertheless, these criteria vary appreciably from one country to another. THE LAW I. STANDING TO ACT IN THE NAME AND ON BEHALF OF VINCENT LAMBERT 80. The applicants submitted that the withdrawal of Vincent Lambert ’ s artificial nutrition and hydration would be in breach of the State ’ s obligations under Article 2 of the Convention. In their view, depriving him of nutrition and hydration would constitute ill-treatment amounting to torture within the meaning of Article 3 of the Convention. They further argued that the lack of physiotherapy since October 2012 and the lack of therapy to restore the swallowing reflex amounted to inhuman and degrading treatment in breach of that provision. Lastly, they submitted that the withdrawal of nutrition and hydration would also infringe Vincent Lambert ’ s physical integrity, in breach of Article 8 of the Convention. 81. Articles 2, 3 and 8 of the Convention read as follows. Article 2 “1. Everyone ’ s right to life shall be protected by law. No one shall be deprived of his life intentionally ... ” Article 3 “No one shall be subjected to torture or to inhuman or degrading treatment or punishment.” Article 8 “1. Everyone has the right to respect for his private and family life, his home and his correspondence. 2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.” A. The applicants ’ standing to act in the name and on behalf of Vincent Lambert 1. The parties ’ submissions (a) The Government 82. The Government observed that the applicants had not stated that they wished to act on Vincent Lambert ’ s behalf, and considered the question whether they could apply to the Court on his behalf to be devoid of purpose. ( b) The applicants 83. The applicants submitted that any individual, irrespective of his or her disability, should be able to benefit from the guarantees afforded by the Convention, including where he or she had no representative. They stressed that their standing or interest in bringing proceedings had never been challenged before the domestic courts, as French law gave the family of a person whose treatment it was proposed to withdraw the right to express a view on the measure in question. This necessarily entailed standing to act in court proceedings not only on their own behalf but also on behalf of the patient. 84. Citing the criteria established by the Court in Koch v. Germany (no. 497/09, §§ 43 et seq., 19 July 2012), the applicants submitted that those criteria were satisfied in the present case because the case concerned a matter of general interest and because of their close family ties and their personal interest in the proceedings. They stressed that they had applied to the domestic courts and then to the Court in order to assert Vincent Lambert ’ s fundamental rights under Articles 2 and 3 which he himself was unable to do and which his wife could not either since she had accepted the medical decision in issue. ( c) The individual third-party interveners 85. Rachel Lambert, Vincent Lambert ’ s wife, submitted that the applicants did not have standing to act on behalf of Vincent Lambert. She pointed out that the Court had been prepared to recognise the standing of a relative either when the complaints raised an issue of general interest pertaining to “respect for human rights” and the person concerned, as heir, had a legitimate interest in pursuing the application, or on the basis of the direct effect on the applicant ’ s own rights. However, in Sanles Sanles v. Spain ((dec.), no. 48335/99, ECHR 2000 ‑ XI), the Court had found that the rights asserted by the applicant under Articles 2, 3, 5 and 8 of the Convention belonged to the category of non ‑ transferable rights and had held that the applicant, who was the sister-in-law and legitimate heir of the deceased, could not claim to be the victim of a violation on her late brother ‑ in ‑ law ’ s behalf. 86. On the issue of representation, she observed that it was essential for representatives to demonstrate that they had received specific and explicit instructions from the alleged victim. This was not the case of the applicants, who had received no specific and explicit instructions from Vincent Lambert, whereas the examination of the case by the Conseil d ’ État had highlighted the fact that she herself had been taken into her husband ’ s confidence and informed of his wishes, as corroborated by statements produced before the domestic courts. 87. François Lambert and Marie ‑ Geneviève Lambert, Vincent Lambert ’ s nephew and half ‑ sister, submitted that the applicants lacked standing to act on his behalf. Firstly, the violations of Articles 2, 3 and 8 of the Convention alleged by the applicants concerned non ‑ transferable rights to which they could not lay claim on their own behalf; secondly, the applicants were not the legal representatives of Vincent Lambert, who was an adult born in 1976; and, thirdly, their application contravened Vincent Lambert ’ s freedom of conscience and his own right to life and infringed his privacy. François Lambert and Marie ‑ Geneviève Lambert observed that, although the Court had, by way of an exception, accepted that parents might act on behalf and in the place of a victim in arguing a breach of Article 3 of the Convention, this was only in the case of the victim ’ s disappearance or death and in certain specific circumstances. Those conditions were not met in the present case, making the application inadmissible. They argued that the Court had had occasion to reaffirm this inadmissibility in end-of-life cases similar to the present one (they referred to Sanles Sanles, cited above, and Ada Rossi and Others v. Italy (dec.), nos. 55185/08, 55483/08, 55516/08, 55519/08, 56010/08, 56278/08 and 58424/08, 16 December 2008). 88. Lastly, they argued that the applicants could not in fact “legitimately” challenge the Conseil d ’ État ’ s judgment, since the position they defended was directly opposed to Vincent Lambert ’ s beliefs. The doctors and the judges had taken account of the latter ’ s wishes, which he had confided to his wife – with whom he had had a very close relationship – in full knowledge of the facts, in view of his professional experience as a nurse. 2. The Court ’ s assessment ( a) Recapitulation of the principles 89. In the recent cases of Nencheva and Others v. Bulgaria ( no. 48609/06, 18 June 2013) and Centre for Legal Resources on behalf of Valentin Câmpeanu v. Romania ( [GC], no. 47848/08, ECHR 2014), the Court reiterated the following principles. In order to rely on Article 34 of the Convention, an applicant must be able to claim to be a victim of a violation of the Convention. According to the Court ’ s established case - law, the concept of “victim” must be interpreted autonomously and irrespective of domestic concepts such as those concerning an interest or capacity to act ( see Nencheva and Others, cited above, § 88). The individual concerned must be able to show that he or she was “directly affected” by the measure complained of ( see Centre for Legal Resources on behalf of Valentin Câmpeanu, cited above, § 96, with further references ). 90. An exception is made to this principle where the alleged violation or violations of the Convention are closely linked to a death or disappearance in circumstances allegedly engaging the responsibility of the State. In such cases the Court has recognised the standing of the victim ’ s next-of-kin to submit an application ( see Nencheva and Others, cited above, § 89, and Centre for Legal Resources on behalf of Valentin Câmpeanu, cited above, §§ 98-99, with further references ). 91. Where the application is not lodged by the victims themselves, Rule 45 § 3 of the Rules of Court requires a written authority to act, duly signed, to be produced. It is essential for representatives to demonstrate that they have received specific and explicit instructions from the alleged victim on whose behalf they purport to act before the Court (see Post v. the Netherlands (dec.), no. 21727/08, 20 January 2009; Nencheva and Others, cited above, § 83; and Centre for Legal Resources on behalf of Valentin Câmpeanu, cited above, § 102). However, the Convention institutions have held that special considerations may arise in the case of victims of alleged breaches of Articles 2, 3 and 8 of the Convention at the hands of the national authorities. Applications lodged by individuals on behalf of the victim or victims, even though no valid form of authority was presented, have thus been declared admissible ( see Centre for Legal Resources on behalf of Valentin Câmpeanu, cited above, § 103). 92. Particular consideration has been shown with regard to the victims ’ vulnerability on account of their age, sex or disability, which rendered them unable to lodge a complaint on the matter with the Court, due regard also being paid to the connections between the person lodging the application and the victim (ibid .). 93. For instance, in S.P., D.P. and A.T. v. the United Kingdom (no. 23715/94, Commission decision of 20 May 1996, unreported ), which concerned, inter alia, Article 8 of the Convention, the Commission declared admissible an application lodged by a solicitor on behalf of children whom he had represented in the domestic proceedings, in which he had been instructed by the guardian ad litem, after noting in particular that their mother had displayed no interest, that the local authorities had been criticised in the application and that there was no conflict of interests between the solicitor and the children. In İlhan v. Turkey ([GC], no. 22277/93, §§ 54-55, ECHR 2000 ‑ VII), where the direct victim, Abdüllatif İlhan, had suffered severe injuries as a result of ill-treatment at the hands of the security forces, the Court held that his brother could be regarded as having validly introduced the application, based on Articles 2 and 3 of the Convention, since it was clear from the facts that Abdüllatif İlhan had consented to the proceedings, there was no conflict of interests between himself and his brother, who had been closely concerned with the incident, and he was in a particularly vulnerable position because of his injuries. In Y.F. v. Turkey ( no. 24209/94, § 31, ECHR 2003 ‑ IX), in which a husband alleged under Article 8 of the Convention that his wife had been forced to undergo a gynaecological examination following her detention in police custody, the Court found that it was open to the applicant, as a close relative of the victim, to make a complaint concerning allegations by her of violations of the Convention, in particular having regard to her vulnerable position in the special circumstances of the case. 94. Still in the context of Article 8 of the Convention, the Court has also accepted on several occasions that parents who did not have parental rights could apply to it on behalf of their minor children (see, in particular, Scozzari and Giunta v. Italy [GC], nos. 39221/98 and 41963/98, §§ 138 ‑ 39, ECHR 2000 ‑ VIII; Šneersone and Kampanella v. Italy, no. 14737/09, § 61, 12 July 2011; Diamante and Pelliccioni v. San Marino, no. 32250/08, §§ 146-47, 27 September 2011; A.K. and L. v. Croatia, no. 37956/11, §§ 48-50, 8 January 2013; and Raw and Others v. France, no. 10131/11, §§ 51-52, 7 March 2013). The key criterion for the Court in these cases was the risk that some of the children ’ s interests might not be brought to its attention and that they would be denied effective protection of their Convention rights. 95. Lastly, the Court recently adopted a similar approach in Centre for Legal Resources on behalf of Valentin Câmpeanu, cited above, concerning a young man of Roma origin, seriously disabled and HIV positive, who died in hospital before the application was lodged and had no known next-of-kin and no State-appointed representative. In view of the exceptional circumstances of the case and the seriousness of the allegations, the Court recognised that the Centre for Legal Resources had standing to represent Valentin Câmpeanu. The Court emphasised that to find otherwise would amount to preventing such serious allegations of a violation of the Convention from being examined at an international level ( ibid., § 112). ( b) Application to the present case 96. The applicants alleged on Vincent Lambert ’ s behalf a violation of Articles 2, 3 and 8 of the Convention ( see paragraph 80 above ). 97. The Court considers at the outset that the case-law concerning applications lodged on behalf of deceased persons is not applicable in the present case, since Vincent Lambert is not dead but is in a state described by the expert medical report as vegetative (see paragraph 40 above). The Court must therefore ascertain whether the circumstances before it are of the kind in which it has previously held that an application could be lodged in the name and on behalf of a vulnerable person without him or her having issued either a valid authority to act or instructions to the person purporting to act for him or her ( see paragraphs 93-95 above ). 98. It notes that none of the cases in which it has accepted, by way of an exception, that an individual may act on behalf of another is comparable to the present case. The case in Centre for Legal Resources on behalf of Valentin Câmpeanu, cited above, is to be distinguished from the present case in so far as the direct victim was dead and had no one to represent him. In the present case, while the direct victim is unable to express his wishes, several members of his close family wish to express themselves on his behalf, while defending diametrically opposed points of view. The applicants mainly rely on the right to life protected by Article 2, the “sanctity” of which was stressed by the Court in Pretty v. the United Kingdom (no. 2346/02, § 65, ECHR 2002 ‑ III), whereas the individual third ‑ party interveners (Rachel Lambert, François Lambert and Marie ‑ Geneviève Lambert) rely on the right to respect for private life and in particular the right of each individual, encompassed in the notion of personal autonomy ( ibid., § 61), to decide in which way and at which time his or her life should end (ibid. , § 67; see also Haas v. Switzerland, no. 31322/07, § 51, ECHR 2011, and Koch, cited above, § 52). 99. The applicants propose that the Court should apply the criteria set forth in Koch (cited above, § 44), which, in their submission, they satisfy on account of their close family ties, the fact that they have a sufficient personal or legal interest in the outcome of the proceedings and the fact that they have previously expressed an interest in the case. 100. However, the Court observes that in Koch, cited above, the applicant argued that his wife ’ s suffering and the circumstances of her death had affected him to the extent of constituting a violation of his own rights under Article 8 of the Convention (§ 43). Thus, it was on that point that the Court was required to rule, and it was against that background that it considered that account should also be taken of the criteria developed in its case-law allowing a relative or heir to bring an action before it on the deceased person ’ s behalf (§ 44). 101. In the Court ’ s view, these criteria are not applicable in the present case since Vincent Lambert is not dead and the applicants are seeking to raise complaints on his behalf. 102. A review of the cases in which the Convention institutions have accepted that a third party may, in exceptional circumstances, act in the name and on behalf of a vulnerable person (see paragraphs 93-95 above ) reveals the following two main criteria: the risk that the direct victim will be deprived of effective protection of his or her rights, and the absence of a conflict of interests between the victim and the applicant. 103. Applying these criteria to the present case, the Court does not discern any risk, firstly, that Vincent Lambert will be deprived of effective protection of his rights since, in accordance with its consistent case-law ( see paragraphs 90 above and 115 below ), it is open to the applicants, as Vincent Lambert ’ s close relatives, to rely before the Court, on their own behalf, on the right to life protected by Article 2. 104. As regards the second criterion, the Court must next ascertain whether there is a convergence of interests between the applicants and Vincent Lambert. In that connection it notes that one of the key aspects of the domestic proceedings consisted precisely in determining Vincent Lambert ’ s wishes, given that Dr Kariger ’ s decision of 11 January 2014 was based on the certainty that Vincent Lambert “ had not wished, before his accident, to live under such conditions” (see paragraph 22 above). In its judgment of 24 June 2014, the Conseil d ’ État found, in the light of the testimony of Vincent Lambert ’ s wife and one of his brothers and the statements of several of his other siblings, that in basing his decision on that ground, Dr Kariger “[could not] be regarded as having incorrectly interpreted the wishes expressed by the patient before his accident” (see paragraph 50 above). Accordingly, the Court does not consider it established that there is a convergence of interests between the applicants ’ assertions and what Vincent Lambert would have wished. 105. The Court concludes that the applicants do not have standing to raise the complaints under Articles 2, 3 and 8 of the Convention in the name and on behalf of Vincent Lambert. 106. It follows that these complaints are incompatible ratione personae with the provisions of the Convention within the meaning of Article 35 § 3 ( a) and must be rejected pursuant to Article 35 § 4. B. Rachel Lambert ’ s standing to act in the name and on behalf of Vincent Lambert 1. The parties ’ submissions 107. In a letter from her lawyer dated 9 July 2014, Rachel Lambert requested leave to represent her husband Vincent Lambert as a third-party intervener in the procedure. In support of her request she furnished a judgment of the Châlons ‑ en ‑ Champagne guardianship judge, dated 17 December 2008, giving her authority to represent her husband in matters arising out of their matrimonial regime, as well as two statements from a sister and half-brother of Vincent Lambert. According to those statements, Vincent Lambert would not have wished a decision in his case to be taken by his parents, from whom he was morally and physically estranged, but rather by his wife, who was his person of trust. She also produced a statement by her stepmother, who said that she had accompanied Rachel Lambert in July 2012 to a consultation with a professor of medicine at Liège University Hospital which was also attended by the first two applicants. During the consultation she and Rachel Lambert had stated Vincent Lambert ’ s wish not to live in an incapacitated state if such a situation should arise, and the second applicant had reportedly said that, if the question of euthanasia should arise, she would leave the decision to Rachel Lambert. In her observations, Rachel Lambert submitted that, since she was informed of her husband ’ s wishes, as corroborated by the statements she had produced, she alone had legal standing to act on behalf of Vincent Lambert and to represent him. 108. The Government did not make any submissions on this point. 109. The applicants submitted that the ruling of the guardianship judge produced by Rachel Lambert did not give her general authority to represent her husband, but merely authority to represent him in property-related matters. She could not therefore claim to be the only person to represent her husband before the Court. The applicants further maintained that the statements she had produced had no legal value; they also disputed the content of the statement by Rachel Lambert ’ s stepmother. They noted that Vincent Lambert had not designated a person of trust, and concluded that, as French law currently stood and in the absence of a full or partial guardianship order, Vincent Lambert was not represented by anyone in proceedings concerning him personally. 2. The Court ’ s assessment 110. The Court notes that no provision of the Convention permits a third-party intervener to represent another person before the Court. Furthermore, according to Rule 44 § 3 (a) of the Rules of Court, a third ‑ party intervener is any person concerned “ who is not the applicant”. 111. Accordingly, the Court cannot but refuse Rachel Lambert ’ s request. C. Conclusion 112. The Court has found that the applicants lacked standing to allege a violation of Articles 2, 3 and 8 of the Convention in the name and on behalf of Vincent Lambert (see paragraphs 105 ‑ 06 above), and has also rejected Rachel Lambert ’ s request to represent her husband as a third-party intervener (see paragraphs 110 ‑ 11 above). Nevertheless, the Court emphasises that, notwithstanding the findings it has just made regarding admissibility, it will examine below all the substantive issues arising in the present case under Article 2 of the Convention, given that they were raised by the applicants on their own behalf. II. ALLEGED VIOLATION OF ARTICLE 2 OF THE CONVENTION 113. The applicants submitted that the withdrawal of Vincent Lambert ’ s artificial nutrition and hydration would be in breach of the State ’ s obligations under Article 2 of the Convention. They maintained that the Leonetti Act lacked clarity and precision, and complained of the process culminating in the doctor ’ s decision of 11 January 2014. 114. The Government contested that argument. A. Admissibility 115. The Court reiterates its case-law to the effect that the next-of-kin of a person whose death allegedly engages the responsibility of the State may claim to be victims of a violation of Article 2 of the Convention (see paragraph 90 above). Although Vincent Lambert is still alive, there is no doubt that if artificial nutrition and hydration were withdrawn, his death would occur within a short time. Accordingly, even if the violation is a potential or future one (see Tauira and 18 Others v. France, no. 28204/95, Commission decision of 4 December 1995, Decisions and Reports 83 ‑ B, p. 112, at p. 131), the Court considers that the applicants, in their capacity as Vincent Lambert ’ s close relatives, may rely on Article 2. 116. The Court notes that this complaint is not manifestly ill-founded within the meaning of Article 35 § 3 (a) of the Convention. It further notes that it is not inadmissible on any other ground. The complaint must therefore be declared admissible. B. Merits 1. The applicable rule 117. The Court reiterates that the first sentence of Article 2, which ranks as one of the most fundamental provisions in the Convention and enshrines one of the basic values of the democratic societies making up the Council of Europe ( see McCann and Others v. the United Kingdom, 27 September 1995, §§ 1 4 6 ‑ 4 7, Series A no. 324), enjoins the State not only to refrain from the “intentional” taking of life (negative obligations), but also to take appropriate steps to safeguard the lives of those within its jurisdiction (positive obligations) (see L.C.B. v. the United Kingdom, 9 June 1998, § 36, Reports of Judgments and Decisions 1998 ‑ III). 118. The Court will address these two aspects in turn and will begin by examining whether the present case involves the State ’ s negative obligations under Article 2. 119. While the applicants acknowledged that the withdrawal of nutrition and hydration might be legitimate in cases of unreasonable obstinacy, and accepted that a legitimate distinction existed between, on the one hand, euthanasia and assisted suicide and, on the other hand, “ therapeutic abstention”, consisting in withdrawing or withholding treatment that had become unreasonable, they nevertheless argued repeatedly in their observations that, since these criteria were not met in their view, the present case concerned the intentional taking of life; they referred in this regard to the notion of “euthanasia”. 120. The Government stressed that the aim of the medical decision was not to put an end to life, but to discontinue a form of treatment which had been refused by the patient or – where the patient was unable to express his or her wishes – which constituted, in the doctor ’ s view based on medical and non-medical factors, unreasonable obstinacy. They quoted the public rapporteur before the Conseil d ’ État, who in his submissions of 20 June 2014 had noted that, in discontinuing treatment, a doctor was not taking the patient ’ s life but was resolving to withdraw when there was nothing more to be done (see paragraph 45 above). 121. The Court observes that the Leonetti Act does not authorise either euthanasia or assisted suicide. It allows doctors, in accordance with a prescribed procedure, to discontinue treatment only if continuing it demonstrates unreasonable obstinacy. In its observations to the Conseil d ’ État, the National Medical Academy reiterated the fundamental prohibition barring doctors from deliberately taking another ’ s life, which formed the basis for the relationship of trust between doctor and patient. That prohibition is laid down in Article R. 4127-38 of the Public Health Code, which states that doctors may not take life intentionally (see paragraph 55 above). 122. At the hearing of 14 February 2014 before the Conseil d ’ État, the public rapporteur cited the remarks made by the Minister of Health to the members of the Senate examining the Leonetti Bill: “While the act of withdrawing treatment ... results in death, the intention behind the act [is not to kill; it is] to allow death to resume its natural course and to relieve suffering. This is particularly important for care staff, whose role is not to take life.” 123. In the case of Glass v. the United Kingdom ((dec.), no. 61827/00, 18 March 2003), the applicants complained under Article 2 of the Convention that a potentially lethal dose of diamorphine had been administered to their son, without their consent, by doctors in the hospital where he was being treated. The Court noted that the doctors had not deliberately sought to kill the child or to hasten his death, and examined the parents ’ complaints from the standpoint of the authorities ’ positive obligations (see also Powell v. the United Kingdom (dec.), no. 45305/99, ECHR 2000 ‑ V). 124. The Court notes that both the applicants and the Government make a distinction between the intentional taking of life and “therapeutic abstention” (see paragraphs 119-20 above), and stresses the importance of that distinction. In the context of the French legislation, which prohibits the intentional taking of life and permits life-sustaining treatment to be withdrawn or withheld only in certain specific circumstances, the Court considers that the present case does not involve the State ’ s negative obligations under Article 2, and will examine the applicants ’ complaints solely from the standpoint of the State ’ s positive obligations. 2. Whether the State complied with its positive obligations ( a) The submissions of the parties and the third-party interveners ( i) The applicants 125. The applicants submitted first of all that the Leonetti Act was not applicable to Vincent Lambert, who, in their view, was neither sick nor at the end of life, but was severely disabled. They complained of the “confusion” arising from the Act on the following points: the notion of unreasonable obstinacy (and in particular the criterion concerning treatment having “ no other effect than to sustain life artificially”, which they considered to be extremely imprecise), and the classification of artificial nutrition and hydration as treatment rather than care. In their submission, Vincent Lambert ’ s enteral feeding was not a form of treatment that could be withdrawn, and the notion of unreasonable obstinacy did not apply to his medical situation. 126. They argued that the process leading to the doctor ’ s decision of 11 January 2014 was incompatible with the State ’ s obligations flowing from Article 2 of the Convention. In their view, the procedure was not truly collective as it involved seeking opinions on a purely consultative basis, with the doctor alone taking the decision. They maintained that alternative systems were possible which would allow other doctors or the members of the family, in the absence of a person of trust, to participate in the decision ‑ making process. Lastly, they argued that the legislation should take into account the possibility of disagreement between family members and make provision at the very least for mediation. ( ii) The Government 127. The Government submitted that the Leonetti Act struck a balance between the right to respect for life and patients ’ right to consent to or refuse treatment. The definition of unreasonable obstinacy was based on the ethical principles of beneficence and non ‑ maleficence reiterated in the Council of Europe ’ s “Guide on the decision-making process regarding medical treatment in end-of-life situations”. In accordance with those principles, health-care professionals had an obligation to deliver only appropriate treatment and had to be guided solely by the benefit to the patient, which was to be assessed in overall terms. In that regard both medical and non ‑ medical factors, and in particular the patient ’ s wishes, were to be taken into account. They pointed out that when the bill had been debated in Parliament, an amendment seeking to exclude artificial nutrition and hydration from the scope of treatment had been rejected. They stressed that treatment also encompassed methods and interventions responding to a functional deficiency in the patient and involving the use of intrusive medical techniques. 128. The Government emphasised that the French legislation provided for a number of procedural safeguards: consideration of the patient ’ s wishes and of the views of the person of trust, the family or those close to the patient and implementation of a collective procedure in which the family and those close to the patient were involved. Lastly, the doctor ’ s decision was subject to review by a judge. ( iii) The third-party interveners ( α ) Rachel Lambert 129. Rachel Lambert submitted that the Leonetti Act subjected the doctor ’ s decision to numerous safeguards and balanced each individual ’ s right to receive the most suitable care with the right not to undergo treatment in circumstances amounting to unreasonable obstinacy. She stressed that the legislature had not sought to limit the recognition of patients ’ previously expressed wishes to cases in which they had designated a person of trust or drawn up advance directives; where this was not the case, the views of the family were sought in order, first and foremost, to establish what the patient would have wanted. 130. Referring to the collective procedure implemented in the present case, she pointed out that Dr Kariger had consulted six doctors (three of them from outside the hospital), had convened a meeting with virtually all the care staff and all the doctors and had held two meetings with the family. His decision had been reasoned at length and bore witness to the professionalism of his approach. ( β ) François Lambert and Marie-Geneviève Lambert 131. François Lambert and Marie-Geneviève Lambert submitted that the doctor ’ s decision had been taken in accordance with the Leonetti Act, referred to above, the provisions of which they recapitulated. They stressed that the data emerging from the expert medical report ordered by the Conseil d ’ État were fully consistent with the notion of treatment serving solely to sustain life artificially, observing that it was Vincent Lambert ’ s inability to eat and drink by himself, without medical assistance in the form of enteral nutrition and hydration, that would cause his death. 132. They submitted that the decision ‑ making process in the present case had been particularly lengthy, meticulous and respectful of the rights of all concerned, of the medical and paramedical opinions sought and of the views of the family members who had been invited to participate (especially the applicants, who had been assisted by a doctor of their choosing throughout the process) and who had been kept fully informed at every stage. In their view, the final decision had been taken in accordance with the process required by law and by the Convention, as set out in the Council of Europe ’ s “Guide on the decision-making process regarding medical treatment in end ‑ of ‑ life situations”. ( γ) National Union of Associations of Head Injury and Brain Damage Victims ’ Families ( UNAFTC ) 133. UNAFTC echoed the concerns of the families and establishments it represented, and argued that patients in a chronic vegetative or minimally conscious state were not in an end-of-life situation and were not being kept alive artificially, and that where a person ’ s condition was not life ‑ threatening, artificial feeding and hydration could not be deemed to constitute treatment that could be withdrawn. UNAFTC submitted that a patient ’ s wishes could not be established on the basis of spoken remarks reported by some of the family members, and when in doubt, life should take precedence. At all events, in the absence of advance directives and of a person of trust, no decision to withdraw treatment could be taken in the absence of consensus within the family. ( δ) Amréso-Bethel 134. The association Amréso ‑ Bethel, which runs a care unit for patients in a minimally conscious or chronic vegetative state, provided details of the care dispensed to its patients. ( ε) Human Rights Clinic 135. In view of the multitude of approaches across the world to end ‑ of ‑ life issues and the differences regarding the circumstances in which passive euthanasia was permitted, the Human Rights Clinic submitted that States should be allowed a margin of appreciation in striking a balance between patients ’ personal autonomy and the protection of their lives. ( b) The Court ’ s assessment ( i) General considerations ( α ) Existing case-law 136. The Court has never ruled on the question which is the subject of the present application, but it has examined a number of cases concerning related issues. 137. In a first group of cases, the applicants or their relatives invoked the right to die, relying on various Articles of the Convention. In Sanles Sanles, cited above, the applicant asserted, on behalf of her brother-in-law, who was tetraplegic and wished to end his life with the assistance of third parties and who died before the application was lodged, the right to die with dignity, relying on Articles 2, 3, 5, 6, 8, 9 and 14 of the Convention. The Court rejected the application as being incompatible ratione personae with the provisions of the Convention. In Pretty, cited above, the applicant was in the terminal stages of an incurable neurodegenerative disease and complained, relying on Articles 2, 3, 8, 9 and 14 of the Convention, that her husband could not help her to commit suicide without facing prosecution by the United Kingdom authorities. The Court found no violation of the provisions in question. Haas and Koch, cited above, concerned assisted suicide, and the applicants relied on Article 8 of the Convention. In Haas, the applicant, who had been suffering for a long time from a serious bipolar affective disorder, wished to end his life and complained of being unable to obtain the lethal substance required for that purpose without a medical prescription; the Court held that there had been no violation of Article 8. In Koch, the applicant alleged that the refusal to allow his wife (who was paralysed and needed artificial ventilation) to acquire a lethal dose of medication so that she could take her own life had breached her right, and his, to respect for their private and family life. He also complained of the domestic courts ’ refusal to examine his complaints on the merits, and the Court found a violation of Article 8 on that point only. 138. In a second group of cases, the applicants took issue with the administering or withdrawal of treatment. In Glass, cited above, the applicants complained that diamorphine had been administered to their sick child by hospital doctors without their consent, and of the “ do not resuscitate ” order entered in his medical notes. In its decision of 18 March 2003, cited above, the Court found that their complaint under Article 2 of the Convention was manifestly ill-founded; in its judgment of 9 March 2004 it held that there had been a violation of Article 8 of the Convention. In Burke v. the United Kingdom ((dec.), no. 19807/06, 11 July 2006), the applicant suffered from an incurable degenerative brain condition and feared that the guidance applicable in the United Kingdom could lead in due course to the withdrawal of his artificial nutrition and hydration. The Court declared his application, lodged under Articles 2, 3 and 8 of the Convention, inadmissible as being manifestly ill-founded. Lastly, in its decision in Ada Rossi and Others, cited above, the Court declared incompatible ratione personae an application lodged by individuals and associations complaining, under Articles 2 and 3 of the Convention, of the potentially adverse effects for them of execution of a judgment of the Italian Court of Cassation authorising the discontinuation of the artificial nutrition and hydration of a young girl in a vegetative state. [1] 139. The Court observes that, with the exception of the violations of Article 8 in Glass and Koch, cited above, it did not find a violation of the Convention in any of these cases. [2] ( β ) The context 140. Article 2 requires the State to take appropriate steps to safeguard the lives of those within its jurisdiction ( see L.C.B. v. the United Kingdom, cited above, § 36, and the decision in Powell, cited above); in the public-health sphere, these positive obligations require States to make regulations compelling hospitals, whether private or public, to adopt appropriate measures for the protection of patients ’ lives (see Calvelli and Ciglio v. Italy [GC], no. 32967/96, § 49, ECHR 2002 ‑ I; Glass, cited above; Vo v. France [GC], no. 53924/00, § 89, ECHR 2004 ‑ VIII; and Centre for Legal Resources on behalf of Valentin Câmpeanu, cited above, § 130). 141. The Court stresses that the issue before it in the present case is not that of euthanasia, but rather the withdrawal of life ‑ sustaining treatment (see paragraph 124 above). 142. In Haas ( cited above, § 54), the Court reiterated that the Convention had to be read as a whole (see, mutatis mutandis, Verein gegen Tierfabriken Schweiz (VgT) v. Switzerland (no. 2) [GC], no. 32772/02, § 83, ECHR 2009). In Haas (cited above, § 54) the Court considered that it was appropriate, in the context of examining a possible violation of Article 8, to refer to Article 2 of the Convention. The Court considers that the converse also applies : in a case such as the present one reference should be made, in examining a possible violation of Article 2, to Article 8 of the Convention and to the right to respect for private life and the notion of personal autonomy which it encompasses. In Pretty ( cited above, § 67) the Court was not prepared to exclude that preventing the applicant by law from exercising her choice to avoid what she considered would be an undignified and distressing end to her life constituted an interference with her right to respect for her private life as guaranteed under Article 8 § 1 of the Convention. In Haas ( cited above, § 51), it asserted that an individual ’ s right to decide in which way and at which time his or her life should end was one of the aspects of the right to respect for private life. The Court refers in particular to paragraphs 63 and 65 of the judgment in Pretty, where it stated as follows. “ ... In the sphere of medical treatment, the refusal to accept a particular treatment might, inevitably, lead to a fatal outcome, yet the imposition of medical treatment, without the consent of a mentally competent adult patient, would interfere with a person ’ s physical integrity in a manner capable of engaging the rights protected under Article 8 § 1 of the Convention. As recognised in domestic case-law, a person may claim to exercise a choice to die by declining to consent to treatment which might have the effect of prolonging his life ... The very essence of the Convention is respect for human dignity and human freedom. Without in any way negating the principle of sanctity of life protected under the Convention, the Court considers that it is under Article 8 that notions of the quality of life take on significance. In an era of growing medical sophistication combined with longer life expectancies, many people are concerned that they should not be forced to linger on in old age or in states of advanced physical or mental decrepitude which conflict with strongly held ideas of self and personal identity.” 143. The Court will take these considerations into account in examining whether the State complied with its positive obligations flowing from Article 2. It further observes that, in addressing the question of the administering or withdrawal of medical treatment in Glass and Burke, cited above, it took into account the following factors : (a) the existence in domestic law and practice of a regulatory framework compatible with the requirements of Article 2 ( see Glass, cited above); (b) whether account had been taken of the applicant ’ s previously expressed wishes and those of the persons close to him or her, as well as the opinions of other medical personnel ( see Burke, cited above); (c) the possibility to approach the courts in the event of doubts as to the best decision to take in the patient ’ s interests (ibid.). The Court will take these factors into consideration in examining the present case. It will also take account of the criteria laid down in the Council of Europe ’ s “ Guide on the decision ‑ making process regarding medical treatment in end-of-life situations ” (see paragraphs 60-68 above). ( γ ) The margin of appreciation 144. The Court reiterates that Article 2 ranks as one of the most fundamental provisions in the Convention, one which, in peace time, admits of no derogation under Article 15, and that it construes strictly the exceptions defined therein (see, among other authorities, Giuliani and Gaggio v. Italy [GC], no. 23458/02, §§ 174-77, ECHR 2011 ). However, in the context of the State ’ s positive obligations, when addressing complex scientific, legal and ethical issues concerning in particular the beginning or the end of life, and in the absence of consensus among the member States, the Court has recognised that the latter have a certain margin of appreciation. First of all the Court observes that in Vo (which concerned the acquittal on a charge of unintentional homicide of the doctor responsible for the death of the applicant ’ s unborn child), in examining the point at which life begins from the standpoint of Article 2 of the Convention, it concluded that this matter came within the States ’ margin of appreciation in this sphere. It took into consideration the absence of a common approach among the Contracting States and of a European consensus on the scientific and legal definition of the beginning of life ( cited above, § 82). The Court reiterated this approach in, inter alia, Evans v. the United Kingdom ([GC], no. 6339/05, §§ 54-56, ECHR 2007 ‑ I, concerning the fact that domestic law permitted the applicant ’ s former partner to withdraw his consent to the storage and use of embryos created jointly by them) and in A, B and C v. Ireland ([GC], no. 25579/05, § 237, ECHR 2010, in which the applicants essentially complained under Article 8 of the Convention of the prohibition on abortion in Ireland for health and well ‑ being reasons). 145. On the question of assisted suicide the Court noted, in the context of Article 8 of the Convention, that there was no consensus among the member States of the Council of Europe as to an individual ’ s right to decide in which way and at which time his or her life should end, and therefore concluded that the States ’ margin of appreciation in this area was “considerable” ( see Haas, cited above, § 55, and Koch, cited above, § 70). 146. The Court also stated, in general terms, in Ciechońska v. Poland ( no. 19776/04, § 65, 14 June 2011), concerning the authorities ’ responsibility for the accidental death of the applicant ’ s husband, that the choice of means for ensuring the positive obligations under Article 2 was in principle a matter that fell within the State ’ s margin of appreciation. 147. The Court notes that no consensus exists among the Council of Europe member States in favour of permitting the withdrawal of artificial life-sustaining treatment, although the majority of States appear to allow it. While the detailed arrangements governing the withdrawal of treatment vary from one country to another, there is nevertheless consensus as to the paramount importance of the patient ’ s wishes in the decision-making process, however those wishes are expressed (see paragraphs 74 ‑ 7 5 above). 148. Accordingly, the Court considers that in this sphere concerning the end of life, as in that concerning the beginning of life, States must be afforded a margin of appreciation, not just as to whether or not to permit the withdrawal of artificial life ‑ sustaining treatment and the detailed arrangements governing such withdrawal, but also as regards the means of striking a balance between the protection of patients ’ right to life and the protection of their right to respect for their private life and their personal autonomy (see, mutatis mutandis, A, B and C v. Ireland, cited above, § 237). However, this margin of appreciation is not unlimited (ibid. , § 238) and the Court reserves the power to review whether or not the State has complied with its obligations under Article 2. ( ii) Application to the present case 149. The applicants alleged that the Leonetti Act lacked clarity and precision, and complained of the process culminating in the doctor ’ s decision of 11 January 2014. In their view, these shortcomings were the result of the national authorities ’ failure to fulfil their duty of protection under Article 2 of the Convention. ( α ) The legislative framework 150. The applicants complained of a lack of precision and clarity in the legislation, which, in their submission, was not applicable to the case of Vincent Lambert, who was neither sick nor at the end of his life. They further maintained that the legislation did not define with sufficient precision the concepts of unreasonable obstinacy and treatment that could be withdrawn. 151. The Court has regard to the legislative framework established by the Public Health Code (hereinafter “the Code”) as amended by the Leonetti Act (see paragraphs 52 ‑ 54 above). It further reiterates that interpretation is inherent in the work of the judiciary ( see, among other authorities, Nejdet Şahin and Perihan Şahin v. Turkey [GC], no. 13279/05, § 85, 20 October 2011). It observes that, prior to the rulings given in the present case, the French courts had never been called upon to interpret the provisions of the Leonetti Act, although it had been in force for nine years. In the present case the Conseil d ’ État had the task of clarifying the scope of application of the Act and defining the concepts of “treatment” and “unreasonable obstinacy” (see below). The scope of application of the Act 152. In its ruling of 14 February 2014, the Conseil d ’ État determined the scope of application of the Act. It held that it was clear from the very wording of the applicable provisions, and from the parliamentary proceedings prior to enactment of the legislation, that the provisions in question were general in scope and were applicable to all users of the health system, whether or not the patient was in an end - of - life situation (see paragraph 33 above). 153. The Court notes that in his observations to the Conseil d ’ État Mr Jean Leonetti, the rapporteur for the Act, stated in his capacity as amicus curiae that it was applicable to patients who had brain damage and thus suffered from a serious condition that was incurable in the advanced stages, but who were not necessarily “at the end of life”. For that reason the legislature, in the title of the Act, had referred to “patients ’ rights and end-of-life issues” rather than “patients ’ rights in end ‑ of ‑ life situations ” (see, to similar effect, the observations of the National Medical Academy, paragraph 44 above). The concept of treatment 154. The Conseil d ’ État, in its ruling of 14 February 2014, interpreted the concept of treatment that could be withdrawn or limited. It held, in the light of Articles L. 1110 ‑ 5 and 1111 ‑ 4 of the Code, cited above, and of the parliamentary proceedings, that the legislature had intended to include among such forms of treatment all acts seeking to maintain the patient ’ s vital functions artificially, and that artificial nutrition and hydration fell into that category of acts. The amicus curiae submissions to the Conseil d ’ État agreed on this point. 155. The Court notes that the Council of Europe ’s “Guide on the decision ‑ making process regarding medical treatment in end ‑ of ‑ life situations” addresses these issues. The Guide specifies that treatment covers not only interventions whose aim is to improve a patient ’ s state of health by acting on the causes of the illness, but also interventions which have a bearing only on the symptoms and not on the aetiology of the illness, or which are responses to an organ dysfunction. According to the Guide, artificial nutrition and hydration are given to a patient following a medical indication and imply choices concerning medical procedures and devices (perfusion, feeding tubes). The Guide observes that differences in approach exist between countries. Some regard artificial nutrition and hydration as a form of treatment that may be limited or withdrawn in the circumstances and in accordance with the guarantees provided for in domestic law. The considerations to be taken into account in this regard are the patient ’ s wishes and whether or not the treatment is appropriate in the situation in question. In other countries they are regarded as a form of care meeting the individual ’ s basic needs which cannot be withdrawn unless the patient, in the terminal phase of an end ‑ of ‑ life situation, has expressed a wish to that effect (see paragraph 61 above). The concept of unreasonable obstinacy 156. Under the terms of Article L. 1110 ‑ 5 of the Code, treatment will amount to unreasonable obstinacy if it is futile or disproportionate or has “no other effect than to sustain life artificially” (see paragraph 53 above). It is this last criterion which was applied in the present case and which the applicants consider to be imprecise. 157. In his observations to the Conseil d ’ État in an amicus curiae capacity, Mr Leonetti stated that this wording, which was stricter than the wording originally envisaged ( treatment “which prolongs life artificially”) was more restrictive and referred to artificially sustaining life “in the purely biological sense, in circumstances where, firstly, the patient has major irreversible brain damage and, secondly, his or her condition offers no prospect of a return to awareness of self or relationships with others” (see paragraph 44 above). In the same vein, the National Medical Council emphasised the importance of the notion of temporality, observing that where a pathological condition had become chronic, resulting in the person ’ s physiological deterioration and the loss of his or her cognitive and relational faculties, obstinacy in administering treatment could be regarded as unreasonable if no signs of improvement were apparent (ibid.) 158. In its judgment of 24 June 2014, the Conseil d ’ État detailed the factors to be taken into account by the doctor in assessing whether the criteria for unreasonable obstinacy were met, while making clear that each situation had to be considered on its own merits. These were: the medical factors (which had to cover a sufficiently long period, be assessed collectively and relate in particular to the patient ’ s current condition, the change in that condition, his or her degree of suffering and the clinical prognosis) and the non ‑ medical factors, namely the patient ’ s wishes, however expressed, to which the doctor had to “attach particular importance”, and the views of the person of trust, the family or those close to the patient. 159. The Court notes that the Conseil d ’ État established two important safeguards in that judgment. Firstly, it stated that “the sole fact that a person is in an irreversible state of unconsciousness or, a fortiori, has lost his or her autonomy irreversibly and is thus dependent on such a form of nutrition and hydration, does not by itself amount to a situation in which the continuation of treatment would appear unjustified on grounds of unreasonable obstinacy”. Secondly, it stressed that where a patient ’ s wishes were not known, they could not be assumed to consist in a refusal to be kept alive ( see paragraph 48 above ). 160. On the basis of this analysis, the Court cannot subscribe to the applicants ’ arguments. It considers that the provisions of the Leonetti Act, as interpreted by the Conseil d ’ État, constitute a legal framework which is sufficiently clear, for the purposes of Article 2 of the Convention, to regulate with precision the decisions taken by doctors in situations such as that in the present case. The Court therefore concludes that the State put in place a regulatory framework apt to ensure the protection of patients ’ lives ( see paragraph 14 0 above ). ( β ) The decision-making process 161. The applicants complained of the decision-making process, which, in their view, should have been genuinely collective or at the very least have provided for mediation in the event of disagreement. 162. The Court notes at the outset that neither Article 2 nor its case-law can be interpreted as imposing any requirements as to the procedure to be followed with a view to securing a possible agreement. It points out that in Burke, cited above, it found the procedure consisting in determining the patient ’ s wishes and consulting those close to him or her as well as other medical personnel to be compatible with Article 2 (see paragraph 143 above). 163. The Court observes that, although the procedure under French law is described as “collective” and includes several consultation phases (with the care team, at least one other doctor, the person of trust, the family or those close to the patient), it is the doctor in charge of the patient alone who takes the decision. The patient ’ s wishes must be taken into account and the decision itself must be accompanied by reasons and is added to the patient ’ s medical file. 164. In his observations as amicus curiae, Mr Jean Leonetti pointed out that the Act gave the doctor sole responsibility for the decision to withdraw treatment and that it had been decided not to pass that responsibility on to the family, in order to avoid any feelings of guilt and to ensure that the person who took the decision was identified. 165. It is clear from the comparative-law materials available to the Court that in those countries which authorise the withdrawal of treatment, and where the patient has not drawn up any advance directives, there exists a great variety of arrangements governing the taking of the final decision to withdraw treatment. It may be taken by the doctor (this is the most common situation), jointly by the doctor and the family, by the family or legal representative, or by the courts ( see paragraph 75 above ). 166. The Court observes that the collective procedure in the present case lasted from September 2013 to January 2014 and that, at every stage of its implementation, it exceeded the requirements laid down by law. Whereas the procedure provides for the consultation of one other doctor and, where appropriate, a second one, Dr Kariger consulted six doctors, one of whom was designated by the applicants. He convened a meeting of virtually the entire care team and held two meetings with the family which were attended by Vincent Lambert ’ s wife, his parents and his eight siblings. Following those meetings Vincent Lambert ’ s wife and six of his brothers and sisters argued in favour of withdrawing treatment, as did five of the six doctors consulted, while the applicants opposed such a move. The doctor also held discussions with François Lambert, Vincent Lambert ’ s nephew. His decision, which ran to thirteen pages (an abridged seven-page version of which was read out to the family) provided very detailed reasons. The Conseil d ’ État held in its judgment of 24 June 2014 that it was not tainted by any irregularity (see paragraph 50 above). 167. The Conseil d ’ État found that the doctor had complied with the requirement to consult the family and that it had been lawful for him to take his decision in the absence of unanimity among the family members. The Court notes that French law as it currently stands provides for the family to be consulted (and not for it to participate in taking the decision), but does not make provision for mediation in the event of disagreement between family members. Likewise, it does not specify the order in which family members ’ views should be taken into account, unlike in some other countries. 168. The Court notes the absence of consensus on this subject ( see paragraph 16 5 above ) and considers that the organisation of the decision ‑ making process, including the designation of the person who takes the final decision to withdraw treatment and the detailed arrangements for the taking of the decision, fall within the State ’ s margin of appreciation. It notes that the procedure in the present case was lengthy and meticulous, exceeding the requirements laid down by the law, and considers that, although the applicants disagree with the outcome, that procedure satisfied the requirements flowing from Article 2 of the Convention (see paragraph 143 above). ( γ ) Judicial remedies 169. Lastly, the Court will examine the remedies that were available to the applicants in the present case. It observes that the Conseil d ’ État, called upon for the first time to rule on an appeal against a decision to withdraw treatment under the Leonetti Act, provided some important clarifications in its rulings of 14 February and 24 June 2014 concerning the scope of the review carried out by the urgent-applications judge of the administrative court in cases such as the present one. 170. The applicants had lodged an urgent application with the administrative court for protection of a fundamental freedom under Article L. 521-2 of the Administrative Courts Code. This Article provides that the judge, “when hearing an application of this kind justified by particular urgency, may order any measures necessary to safeguard a fundamental freedom allegedly breached in a serious and manifestly unlawful manner by an administrative authority”. When dealing with an application on this basis, the urgent ‑ applications judge of the administrative court normally rules alone and as a matter of urgency, and may order interim measures on the basis of a “plain and obvious” test ( manifest unlawfulness). 171. The Court notes that, as defined by the Conseil d ’ État (see paragraph 32 above), the role of the urgent-applications judge entails the power not only to suspend implementation of the doctor ’ s decision but also to conduct a full review of its lawfulness (and not just apply the test of manifest unlawfulness), if necessary sitting as a member of a bench of judges and, if needs be, after ordering an expert medical report and seeking the opinions of persons acting in an amicus curiae capacity. 172. The Conseil d ’ État also specified in its judgment of 24 June 2014 that the particular role of the judge in such cases meant that he or she had to examine – in addition to the arguments alleging that the decision in question was unlawful – any arguments to the effect that the legislative provisions that had been applied were incompatible with the Convention. 173. The Court notes that the Conseil d ’ État examined the case sitting as a full court (the seventeen-member Judicial Assembly), which is highly unusual in injunction proceedings. In its ruling of 14 February 2014, it stated that the assessment carried out at Liège University Hospital dated from two and a half years previously, and considered it necessary to have the fullest information possible on Vincent Lambert ’ s state of health. It therefore ordered an expert medical report, which it entrusted to three recognised specialists in neuroscience. Furthermore, in view of the scale and difficulty of the issues raised by the case, it requested the National Medical Academy, the National Ethics Advisory Committee, the National Medical Council and Mr Jean Leonetti to submit general observations to it as amici curiae, in order to clarify in particular the concepts of unreasonable obstinacy and sustaining life artificially. 174. The Court notes that the expert report was prepared in great depth. The experts examined Vincent Lambert on nine occasions, conducted a series of tests and familiarised themselves with the entire medical file and with all the items in the judicial file of relevance for their report. Between 24 March and 23 April 2014 they also met all the parties concerned (the family, the medical and care team, the medical consultants and representatives of UNAFTC and the hospital). 175. In its judgment of 24 June 2014, the Conseil d ’ État began by examining the compatibility of the relevant provisions of the Public Health Code with Articles 2, 8, 6 and 7 of the Convention (see paragraph 47 above), before assessing the conformity of Dr Kariger ’ s decision with the provisions of the Code (see paragraphs 48 ‑ 50 above). Its review encompassed the lawfulness of the collective procedure and compliance with the substantive conditions laid down by law, which it considered – particularly in the light of the findings of the expert report – to have been satisfied. It noted in particular that it was clear from the experts ’ findings that Vincent Lambert ’ s clinical condition corresponded to a chronic vegetative state, that he had sustained serious and extensive injuries whose severity, coupled with the period of five and a half years that had passed since the accident, led to the conclusion that it was irreversible and that there was a “poor clinical prognosis”. In the view of the Conseil d ’ État, these findings confirmed those made by Dr Kariger. 176. The Court further observes that the Conseil d ’ État, after stressing “the particular importance” which the doctor must attach to the patient ’ s wishes (see paragraph 48 above), sought to ascertain what Vincent Lambert ’ s wishes had been. As the latter had not drawn up any advance directives or designated a person of trust, the Conseil d ’ État took into consideration the testimony of his wife, Rachel Lambert. It noted that she and her husband, who were both nurses with experience of patients in resuscitation and those with multiple disabilities, had often discussed their professional experiences and that on several such occasions Vincent Lambert had voiced the wish not to be kept alive artificially in a highly dependent state (see paragraph 50 above). The Conseil d ’ État found that those remarks – the tenor of which was confirmed by one of Vincent Lambert ’ s brothers – had been reported by Rachel Lambert in precise detail and with the corresponding dates. It also took account of the fact that several of Vincent Lambert ’ s other siblings had stated that these remarks were in keeping with their brother ’ s personality, past experience and views, and noted that the applicants did not claim that he would have expressed remarks to the contrary. The Conseil d ’ État observed, lastly, that the consultation of the family, prescribed by law, had taken place (ibid.). 177. The applicants submitted, relying on Article 8 of the Convention, that the Conseil d ’ État should not have taken into consideration Vincent Lambert ’ s spoken remarks, which they considered to be too general. 178. The Court points out first of all that it is the patient who is the principal party in the decision-making process and whose consent must remain at its heart; this is true even where the patient is unable to express his or her wishes. The Council of Europe ’ s “Guide on the decision ‑ making process regarding medical treatment in end-of-life situations” recommends that the patient should be involved in the decision-making process by means of any previously expressed wishes, which may have been confided orally to a family member or close friend (see paragraph 63 above). 179. The Court also observes that, according to the comparative ‑ law materials available to it, in the absence of advance directives or of a “living will”, a number of countries require that efforts be made to ascertain the patient ’ s presumed wishes, by a variety of means (statements of the legal representative or the family, other factors testifying to the patient ’ s personality and beliefs, and so forth ). 180. Lastly, the Court points out that in its judgment in Pretty ( cited above, § 63), it recognised the right of each individual to decline to consent to treatment which might have the effect of prolonging his or her life. Accordingly, it takes the view that the Conseil d ’ État was entitled to consider that the testimony submitted to it was sufficiently precise to establish what Vincent Lambert ’ s wishes had been with regard to the withdrawal or continuation of his treatment. ( δ ) Final considerations 181. The Court is keenly aware of the importance of the issues raised by the present case, which concerns extremely complex medical, legal and ethical matters. In the circumstances of the case, the Court reiterates that it was primarily for the domestic authorities to verify whether the decision to withdraw treatment was compatible with the domestic legislation and the Convention, and to establish the patient ’ s wishes in accordance with national law. The Court ’ s role consisted in ascertaining whether the State had fulfilled its positive obligations under Article 2 of the Convention. On the basis of that approach, the Court has found both the legislative framework laid down by domestic law, as interpreted by the Conseil d ’ État, and the decision-making process, which was conducted in meticulous fashion in the present case, to be compatible with the requirements of Article 2. As to the judicial remedies that were available to the applicants, the Court has reached the conclusion that the present case was the subject of an in ‑ depth examination in the course of which all points of view could be expressed and all aspects were carefully considered, in the light of both a detailed expert medical report and general observations from the highest ‑ ranking medical and ethical bodies. Consequently, the Court concludes that the domestic authorities complied with their positive obligations flowing from Article 2 of the Convention, in view of the margin of appreciation left to them in the present case. (ε ) Conclusion 182. It follows that there would be no violation of Article 2 of the Convention in the event of implementation of the Conseil d ’ État judgment of 24 June 2014. III. ALLEGED VIOLATION OF ARTICLE 8 OF THE CONVENTION 183. The applicants maintained that they were potentially victims of a violation of their right to respect for their family life with their son and brother, in breach of Article 8 of the Convention. 184. The Court is of the view that this complaint is absorbed by those raised by the applicants under Article 2 of the Convention. In view of its finding concerning that Article (see paragraph 18 2 above), the Court considers that it is not necessary to rule separately on this complaint. IV. ALLEGED VIOLATION OF ARTICLE 6 OF THE CONVENTION 185. The applicants further complained that the doctor who took the decision of 11 January 2014 was not impartial, as he had previously taken the same decision, and that the expert medical report ordered by the Conseil d ’ État had not been fully adversarial. They relied on Article 6 § 1 of the Convention, the relevant parts of which provide : “In the determination of his civil rights and obligations ... everyone is entitled to a fair ... hearing ... by an independent and impartial tribunal established by law.” 186. Even assuming Article 6 § 1 to be applicable to the procedure resulting in the doctor ’ s decision of 11 January 2014, the Court considers that these complaints, to the extent that they have not been dealt with already under Article 2 of the Convention (see paragraphs 150 ‑ 1 81 above), are manifestly ill ‑ founded. 187. It follows that this aspect of the application must be rejected pursuant to Article 35 §§ 3 ( a) and 4 of the Convention.
The Court held that there would be no violation of Article 2 (right to life) of the European Convention on Human Rights in the event of implementation of the Conseil d’État judgment of 24 June 2014.  It observed in particular that there was no consensus among the Council of Europe member States in favour of permitting the withdrawal of life-sustaining treatment. In that sphere, which concerned the end of life, States must be afforded a margin of appreciation. The Court considered that the provisions of the Act of 22 April 2005, as interpreted by the Conseil d’Etat, constituted a legal framework which was sufficiently clear to regulate with precision the decisions taken by doctors in situations such as that in the present case. The Court was further keenly aware of the importance of the issues raised by the present case, which concerned extremely complex medical, legal and ethical matters. In the circumstances of the case, the Court reiterated that it was primarily for the domestic authorities to verify whether the decision to withdraw treatment was compatible with the domestic legislation and the Convention, and to establish the patient’s wishes in accordance with national law. The Court’s role consisted in examining the State’s compliance with its positive obligations flowing from Article 2 of the Convention. The Court found the legislative framework laid down by domestic law, as interpreted by the Conseil d’État, and the decision-making process, which had been conducted in meticulous fashion, to be compatible with the requirements of Article 2. The Court reached the conclusion that the present case had been the subject of an in-depth examination in the course of which all points of view could be expressed and that all aspects had been carefully considered, in the light of both a detailed expert medical report and general observations from the highest-ranking medical and ethical bodies2.