The media coverage of Vincent Lambert case keeps France breathless. Instrumentalisation or simple coincidence, whereas the Council of State (CE) will decide, by one month, about the passive euthanasia of V. Lambert, the Parliament will study the bill on euthanasia, announced by Miss Tourraine for next summer 2014. Is the Lambert case the first signs of the debate?Analysis of the case.
Vincent Lambert case
Vincent Lambert, 38 years-old, in a state called “minimal conscious state”1, is treated at the University Hospital of Reims where he has artificial feeding and hydration by enteral administration2.
How characterizing the unreasonable obstinacy? Are artificial feeding and hydration treatments which can cause it? Who does decide about stopping treatments? Does the Léonetti law related to rights of end-of-life patients apply to patients who are not ending their life? Answers to these questions raised by the case will have serious consequences.
What says Leonetti law
• The unreasonable obstinacy is characterized when “the acts of preventions, investigations or care […] seem useless, disproportionate, or with no other effect than the artificial maintenance of life”3. According to G.Le Pomellec4, the legislator did not specify expressly that artificial feeding and hydration can be qualified as treatments susceptible to be interrupted for unreasonable obstinacy. He considers that parliamentary debates “reflected this prohibition” but was not incorporated in the law, what would deprive it, for him, “from any normative value”.
• The decision to stop treatments, in France, “is made by the physician treating the patient”5, and after a collegiate procedure, the consultation of the health care surrogate, of the family, the relatives and advance directives6.
• Finally, the law states that “when a person, in advanced or terminal phase of a serious and incurable affection […] cannot express his/her will the physician can decide to limit or stop a treatment7”.But minimal conscious state patients are not at “end of life”, but in a “situation of clinical stability”, and “can, in a not exceptional way evolve more favourably than expected […] sometimes until recovering an appreciable state of consciousness, enabling them to communicate in a reliable way”.
What already judged the Council of State: controversies.
However the CS has already judged that Leonetti law should be applied to “Any person9“, and does not reserve the unreasonable obstinacy to end-of-life persons. More controversially, it has already judged that “artificial feeding and hydration [are] susceptible to be stopped” for unreasonable obstinacy, assimilating them to treatments.
For G.Le Pomellec, “The CS took the responsibility to support […] a simple intention of the legislator” which is far from being obvious for practitioners. “Overlooking the definition of the concept of ‘treatment’ [it] opened a way in the establishment of Leonetti law”.In this particular case, P-O. Arduin10 reminds that V. Lambert “breathes spontaneously, digests food naturally, and presents all the metabolic functions needed to be alive”. Artificial feeding and hydration are not intended to treat a pathology but to satisfy a basic need of the body. They are “care” intended to“prevent the patient from dying of inanition and dehydration”11.
What will judge the Council of State – worries.
We can regret that the experts designated to help the CS to decide were not questioned on this question. They are reduced to describe the current clinical state of V. Lambert, to comment the irreversible character of his brain injuries and his capacity to communicate, appreciate his reactions during care. It is to be feared that these questions generate the judgment of the quality of life of V. Lambert. Like P-O. Arduin underlines it “the risk is to consider death […] as being wanted for itself in order to kill a person of whom we judge as mediocre the “quality of life”.The UNAFTC12 insists: “Stop feeding means to comment the utility of the life”.
The opinions of specialists and relatives about minimally conscious state patients
The decision of the Council of State worries the UNAFTC13. What will be the consequences of the decision of the Council of State for the 1,500 French minimally conscious state patients? For it, “It is not normal that the question of unreasonable obstinacy arises during this phase of life when the vital functions are balanced”. It fears that “we conclude to consider, for reasons of economic rationality, to kill the useless persons”.
France Traumatisme crânien14 reminds that in the stable situation of minimally conscious state patients, “feeding and hydration […] make part of basic care due to any patient”. It warns on the“the fact that a justice decision [which] dictates medical practices constitutes a real reversal in the way to proceed”.
What already judged the Council of State is worrying. By encroaching on the role of the legislator and health professionals, is there not a risk to favor passive euthanasia and to miss the opportunity to clarify the essential aspects of Leonetti law?
1. With a serious traumatic injury, the minimally conscious state person has minimal but accurate behavioural reactions, which seem to reflect the consciousness the patient has of himself/herself or of the environment. This state has to be differentiated from a permanent vegetative state (Coma science groupe)
2. “Enteral feeding or hydration is […] [particularly] made generally with nasogastric tube, (introduced from the nose to the stomach” Larousse Médical
3. Article L1110-5 of French Public health code
4. Lawyer, wrote a paper “Affaire Vincent Lambert : The Council of State opened a breach in the Leonetti la” Le Figaro 24/02/14
5. Article R4127-37 CSP
6. Article L1111-4 CSP
7. Article L1111-13 CSP
8. Opinion of France Traumatisme Crânien – Association nationale des professionnels au service des traumatisés crâniens (National association of professionals at the service of patients with traumatic brain injuries)
9. Article L1110-5 CSP
10. P-O. Arduin, doctor in philosophy, is the Director of the Bioethics Commission of the Fréjus-Toulon Diocese
11. Vincent Lambert : Planed euthanasia? by P-O Arduin – Liberté politique 23/09/2013)
12. L’Union nationale des associations de familles de traumatisés crâniens et de cérébro-lésés
13. Press release by the UNAFTC 10/02/2014
14. L’Association nationale des professionnels au service des traumatisés crâniens.
CHRONOLOGY OF VINCENT LAMBERT CASE
September 2008: accident of Vincent Lambert.
June 2009: Treatment of Vincent Lambert at the University hospital of Reims for all the acts of daily life – artificial feeding and hydration by enteral administration15.
July 2011: the organization “Coma Science Group” of the University hospital of Lieges established a diagnostic and therapeutic assessment of Vincent Lambert : this patient is in a “minimally conscious state plus” with “perception of pain and preserved emotions”.
10th April 2013: doctor Kariger16 decided, following a collegiate procedure17 to stop artificial feeding and to reduce hydration of V. Lambert. His spouse is informed. The patient will stay 31 days without these vital contributions.
11th May 2013: the administrative court of Châlons-en-Champagne requires the recovery of artificial feeding and hydration. Motive: in the absence of advance directives and designed health care surrogate, the family in a broader sense (parents particularly) should have been informed and associated to the medical decision process.
11th January 2014: doctor Kariger decided again to stop feeding and hydration of Vincent Lambert to respect the collegiate procedure and the information to the family.
16th January 2014: The adminstrative court suspended again this decision. Main motives: Unreasonable obstinacy not characterized, inconclusive will of V. Lambert to stop treatments.
31st January 2014: Vincent Lambert’s spouse, one of his nieces, and the University hospital of Reims, appealed this judgment to the Council of State.
13th February 2013: The Council of State decided to resort to a college of three experts (Miss Marie-Germaine Bousser, Mr. Lionel Naccache, and Mr. Jacques Luauté).
The UNAFCT intervenes in the case.
15. “Enteral feeding or nutrition is useful for diseases in which the food intakes are possible, insufficient and inefficient by oral administration, but the intestine is operational […]. It is [particularly] performed with generally nasogastric tube (introduced from the nose to the stomach” Larousse Médical
16. Head of the pole Autonomy and health of the University hospital of Reims, head of the department treating Vincent Lambert
17. Six out of seven physicians included in te collegial procedure concluded to stopping feeding and diminution of hydration of Vincent Lambert