Aide active à mourir et maladie mentale : le concept d’incurabilité est-il scientifiquement acceptable et éthiquement recevable ?

Abstract

Laws granting the right to obtain active assistance in dying initially concern people suffering from incurable illnesses that cause unbearable suffering and are life-threatening in the short to medium term. But these laws are always followed by proposals and debates aimed at extending the indications for euthanasia or assisted suicide to incurable conditions, even if they are not life-threatening, as soon as they cause unbearable suffering. And so it is that some countries accept psychiatric illnesses that are declared incurable as indications for access to active assistance in dying. In Belgium and the Netherlands, for example, the press has reported on cases of people suffering from depression or post-traumatic stress disorder who have been euthanized at the end of an authorization process that involves two psychiatric opinions declaring their condition incurable, without any collegial reflection on the diagnosis or the therapeutic programs implemented. Depression and post-traumatic stress disorder, however, account for less than half of all indications for euthanasia for psychiatric illness in Belgium. That leaves us with patients labelled psychotic and with ill-defined personality and behaviour disorders. Psychiatric indications for euthanasia raise their own specific ethical issues. How can we fail to underline the uncertainty and complexity of the diagnosis, which cannot, as a rule, be supported by imaging or biology? How can we understand that indications for euthanasia are accepted for patients with several psychiatric diagnoses? From one end of the procedure to the other, the problem is to obtain the opinions of two psychiatrists declaring that the disorders are incurable, that the suffering is intolerable and that the patient's capacity for discernment is intact. The decision thus stems from a libertarian paternalism convinced of the humanist dimension of active aid in dying, and which results in an incentive (nudge) whose aim, set by the law, is only to know whether the suffering is incurable, without calling into question the diagnosis and therapeutic programs. How can we say that a mental illness is incurable? How can we distinguish between a depressed person's disgust with life and so-called existential suffering? How can we reconcile preventing suicide in cases of depression and social isolation, while at the same time encouraging assisted suicide or euthanasia for the same people? What are the criteria for verifying that the capacity for discernment has been preserved? Is there not a danger, in the name of autonomic relentlessness, of declaring that a person is autonomous when in fact he or she is subject to the heteronomy of depression, delirium or obsessive disorders? The world of psychiatry cannot avoid such questions. The American Psychiatric Association, for example, has adopted the position on medical euthanasia holding that “a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death”. Other psychiatric associations have hesitant positions. The debate must be opened. It must involve all those who treat, care for and support people of all ages whose mental health is suffering. It must also concern every citizen.