Des lois de soins sans consentement à l’évolution de la responsabilité en psychiatrie

Abstract

A reform of the French mental health legislation has been due for a long time, but has been continually postponed. The entry into force of the Act of July 5th 2011 finally allowed France to comply with the European recommendations and showed that, following this, the Constitutional Council would provide encouragement to legislative reform through the procedure known as the “Question Prioritaire de Constitutionnalité” (an application for a preliminary ruling on whether a legislative provision is constitutional). The search for balance and the emergency context within which this reform has been developed both show its fragility, which explains why a partial reform was adopted in September 2013 in order to introduce legislative corrections. One of the main provisions of the Act of July 5th 2011 is the encroachment of the judiciary on daily psychiatric practice, since provision is made for the systematic control of all hospitalizations without consent lasting more than 15 days by the “judge ruling on civil detention cases” (“juge des libertés et de la détention”). This judicial review imposes greater rigour on the issue of medical certificates, since the prospect of legal inspection must now be taken into account. This underlines the importance of training in forensic psychiatry for psychiatric residents and practitioners. More generally mental health professionals should in the future be more involved in the drafting of the law. Current legal developments reflect the divided expectations of society and make the issue of the psychiatrist's responsibility more prevalent. The backdrop to this is a society in which the precautionary principle has gradually become a legal principle in its own right, in an overall context determined by the debate between those defending individual freedoms and those who subordinate these to safety. At the same time, we are witnessing a paradigm shift of law and the transition from the post-war welfare state model to a neoliberal approach. This is based on the principle that responsibility should be vested in the individual and that s/he is presumed to be rational. The outcome is a governmentalist attitude, based on the need to leave nothing to chance and entailing an extensive concept of the precautionary principle – in other words, giving priority to the principle of foresight, in order to ensure optimisation of the ability to pre-empt « the worst ». This concept has obviously implications in terms of individual responsibility, since responsibility for an act lies with those who should have foreseen it. In the field of medical practice, this responsibility can be questioned through the items noted in the medical file (history, diagnosis, consistency between medical and nursing records). It can also be questioned in relation to the means available to protect the patient (from himself), family members or any third party. This responsibility can also be related to prescriptions for medication, which can sometimes be interpreted as reflecting underestimation of the risk.