By Audrey Lebret
There are few cases as publicized in France as the story of Vincent Lambert, a patient in a vegetative state whose fate deeply divided his family. On June 28, 2019, the Cour de Cassation signed the last substantial decision of the Vincent Lambert case, after six years of proceedings. The patient died on July 11, 2019.
In 2008, Vincent Lambert was involved in a traffic accident that left him in a quadriplegic state and suffering from massive brain trauma. In 2011, a medical evaluation described his state as minimally conscious. Doctors tried to establish a code of communication to which he was never responsive. Nonetheless, doctors tracked some behaviors that they interpreted as an opposition to treatments and a refusal to live (Conseil d’Etat judgement, at 20). In 2013, his doctor initiated a procedure with the agreement of Mr. Lambert’s wife in order to interrupt the treatments. That initiated a lengthy court battle.
French law does not authorize euthanasia or assisted suicide. However, following the case of Vincent Humbert, the legislature adopted the Léonetti Act in 2005 for patients in “an advanced or terminal stage of a serious and incurable disease.” The Act provides that treatments shall not be implemented or continued if “they result from an unreasonable obstinacy.” A 2016 legislative amendment specified that artificial nutrition and hydration constitute a treatment. The 2005 legislation allowed doctors to interrupt or limit “futile” and/or “disproportionate” treatments and/or with “no other object than sustaining life artificially” (article L.1111-13 of the Public Health Code, abrogated). The 2016 statute softened the former legislation, stating that those treatments must “appear” futile or disproportionate and/or having no other “effect” (replacing “object”) then artificially sustaining life (article L.1110-5-1 of the Public Health Code). In such circumstances, the patient’s consent is required, but in case he/she cannot express it, a collegiate procedure must take place.
Mr. Lambert’s doctor considered that continuing life support would be an unreasonable obstinacy. He reached that conclusion relying on the unanimous agreement of experts on the irreversibility of Mr. Lambert’s severe brain damage — but also on his wishes, as expressed to his wife and confirmed by his brother. Hence, the doctor took the decision to withdraw the patient’s nutrition and reduce his hydration. Mr. Lambert’s parents and two of his siblings challenged that decision and the case eventually reached the Conseil d’Etat, the highest administrative jurisdiction. Based on the doctor’s arguments, and on an expert panel’s evaluation of Mr. Lambert’s status as permanently vegetative, the judge decided in 2014 that the doctor had scrupulously followed the procedure.
The parents and two of Vincent Lambert’s siblings immediately made an application to the European Court of Human rights alleging in particular a violation of article 2, the right to life. In 2015, the Court unsurprisingly afforded a broad margin of appreciation to the country. When faced with ethical issues, it regularly uses this doctrine in order to respect the principle of subsidiarity. Therefore, the Court analyzed the respect of article 2 through procedural rather than substantial obligations. It found that the French Act, as interpreted by the Conseil d’Etat, did not lack clarity and provided safeguards. Besides, it noted that the decision making-process was “lengthy and meticulous, exceeding the requirements laid down by the law” (at 168) and respected article 2. Despite the dissenters’ arguments, according to which the Court made a “retrograde step” in the protection of vulnerable persons, the Court found by 12 votes against five that there would not be any violation of the Convention if the doctors were to implement the Conseil d’Etat judgement of 2014.
While a new doctor initiated another medical procedure, he interrupted it shortly after because of threats on the medical team. The procedure only ended in 2018 with a decision to withdraw the treatments with continuous deep sedation. A new team of experts confirmed Lambert’s irreversible vegetative state. Despite their attempt to discredit the experts, the parents’ new application was rejected. In April 2019, the Conseil d’Etat confirmed the “unreasonable obstinacy.” The other applications to the European Court of Human Rights on alternative legal basis were rejected. Their last application to the UN Committee on the Rights of Persons with Disabilities did not succeed, since it ordered an interim measure that the government and judges did not implement. Vincent Lambert died one week after the enforcement of the decision to withdraw the treatments.
It is likely that the case had more institutional consequences than substantial impacts for patients in a vegetative state.
Institutional impacts in France
Institutional impacts are the consequence of the multiple instances solicited to arbiter the conflict. The parents of Vincent Lambert made use of every right of petition they could. At the international level, the case could have been the occasion to analyze the interactions and dialogues of the UN Committee on the Rights of Persons with Disabilities and the European Court of Human Rights. However, the French government’s refusal to implement the Committee’s order deprived the UN body of the occasion to scrutinize the case. The respect of this interim measure was actually a source of conflict between French judges, since a judicial judge ordered the French government its implementation before being contradicted by the highest judicial Court. Indeed, the Lambert case did no less than question France’s division of jurisdictional power between the administrative and the judicial orders and the relevance of this persistent division. This opened intense legal discussions at the national level, until the strong decision of the Cour de Cassation stated that the judicial judge did not have jurisdiction over that decision.
Substantial impacts for patients in a vegetative state?
Concerning the substantial impacts of the Lambert case, most of the issues raised by the French National Council on Ethics (CCNE) in 2014, on the difficulty of objectively defining consciousness or the interpretation of the legal criteria remain unresolved. Central to the Lambert case was the determination of the patient’s wishes. In this regard, the Act of 2016 made advanced directives legally binding. In the past months, encouraged by politicians and discussions on social networks, the registration of advanced directives increased in France. Importantly, people engaged in discussions on the subject. On the other hand, the case highlighted the difficulty to deal with family disagreements, despite a real effort of mediation. At this stage, the case teaches that doctors do not need to received a unanimous agreement of relatives in order to proceed. Nonetheless, to avoid the risk of such lengthy proceedings reappearing, a member of the Parliament argued for ranking priority among the relatives, in favor of the spouse. However, had the wife opposed to the withdrawal of treatments in this case, it is not sure it would have prevented the long-running conflict. On a broader perspective, Israël Nisand, doctor and President of the European Forum on Bioethics denounced the hypocrisy and cruelty of the legislation: “Nobody wants to die of thirst and hunger. […] I do not see the moral advantage to die slowly compared to dying fast.” The debate on assisted suicide is ongoing.