Dettagli Novembre-Dicembre 2023, Vol. 58, N. 6 Riv Psichiatr 2023;58(6):305-309 doi 10.1708/4143.41411 Scarica il PDF (108,1 kb) Citazione Bersani G, Rinaldi R, Iannitelli A. The case of Geneviève Lhermitte’s euthanasia between psychiatric evaluation, legal aspects and ethical reflection. Riv Psichiatr 2023;58(6):305-309. doi 10.1708/4143.41411 Scarica la citazione: BibTex EndNote Ris Altro dagli autori Articoli di Giuseppe BersaniArticoli di Raffaella RinaldiArticoli di Angela Iannitelli The case of Geneviève Lhermitte’s euthanasia between psychiatric evaluation, legal aspects and ethical reflection titolo - split_articolo,controlla_titolo - art_titolo The case of Geneviève Lhermitte’s euthanasia between psychiatric evaluation, legal aspects and ethical reflection autori - vau_aut_id Giuseppe Bersani1, Raffaella Rinaldi2, Angela Iannitelli3 affiliazione_autori - art_affiliazioni 1Fondazione Roma Sapienza; 2Dipartimento di Scienze anatomiche istologiche e medico legali e dell’apparato locomotore (SAIMLAL), Sapienza Università di Roma; 3Società Psicoanalitica Italiana (SPI). riassunto - art_riassunto Summary. A recent euthanasia case in Belgium has garnered attention due to its particularly dramatic aspects, sparking clinical and ethical questions about end-of-life choices in cases of mental suffering. A 56-year-old woman, convicted of the murder of her five minor children and sentenced to life imprisonment, has been granted euthanasia for “irreversible psychological suffering”. The clinical and psychodynamic aspects of the case, primarily deduced from press reports, are highly complex and give rise to numerous clinical, medico-legal, and bioethical questions. These include inquiries into the true nature of psychopathology, its actual irreversibility, its impact on the ability to express a euthanasia request with adequate awareness, the preserved capacity for self-determination, and broader issues related to end-of-life requests from patients with mental disorders. These aspects are considered in the context of the legislation in various European countries. The unique details of this case underscore the critical challenges associated with these complex issues. parolechiave - lingua - vke_key_id Key words. Euthanasia, murder of sons, psychological suffering, depression, medico-legal and ethical issues, psychoanalysis. title - controlla_titolo - art_title Il caso dell’eutanasia di Geneviève Lhermitte tra valutazione psichiatrica, aspetti giuridici e riflessione etica. abstract - art_abstract Riassunto. Un recente caso di eutanasia effettuato in Belgio, caratterizzato da aspetti di particolare drammaticità, ripropone questioni cliniche ed etiche relative alle scelte di fine vita in caso di sofferenza mentale. Una donna di 56 anni, condannata all’ergastolo per l’omicidio dei suoi 5 figli minorenni, ha ottenuto l’eutanasia per “sofferenza psicologica irreversibile”. Gli aspetti clinici e psicodinamici del caso, peraltro desumibili quasi esclusivamente da notizie di stampa, sono molto complessi e lasciano spazio a numerosi interrogativi di natura clinica, medico-legale e bioetica, in particolare sulla reale natura della psicopatologia, sulla sua reale irreversibilità, sull’influenza di questa sulla capacità di esprimere con adeguata consapevolezza la richiesta di eutanasia, sulla conservata capacità di autodeterminazione, sulle problematiche generali relative alla richiesta di fine vita da parte di pazienti con disturbi mentali, anche alla luce delle legislazioni di diversi Paesi europei. Le peculiarità del caso in questione sottolineano in modo evidente le criticità relative a tali problematiche. keyword - lingua - vke_key_id Parole chiave. Depressione, eutanasia, omicidio dei figli, problematiche medico-legali ed etiche, psicoanalisi, sofferenza psicologica. testo - art_testo Introduction The foundational principles of end-of-life legislation, observed across various countries, consistently prompt ethical and psychiatric inquiries in individual cases of application1,2. The inherent complexity of these issues often stimulates a more profound reflection on the involved matters3 occasionally leading to the reconsideration of certain paradigms underlying the concept of health as “inadequate”4. Concerning mental health matters, ethical scientific articles have primarily focused on legal aspects, such as informed consent in the presence of psychiatric pathologies, with specific implications for an individual’s capacity for self-determination5. These ethical considerations are also pertinent to health practices like Euthanasia and Assisted Suicide. The growing number of requests for these practices in countries that have regulated their use is indicative of their relevance6. This trend is also noticeable in cases involving mental disorders recognized by international nomenclatures like DSM-5 and ICD-11, encompassing psychiatric, neurocognitive, and neurodevelopmental diseases. Taking a broader perspective, detached from mental pathology considerations, the Italian Constitutional Court, in sentence no. 50 of 02/03/20227, declared the inadmissibility of proposed changes to some “lexical fragments” of art. 579 c.p.8, which sanctions the “murder of the consenting”. The Court’s decision was motivated by the fact that such changes would have allowed the killing of an individual with their consent, beyond the three cases specified in art. 579 c.p. (minor person, mentally ill person, and violation of the lawfulness of consent). The Court clarified that, in discussions involving the “supreme value of human life”, freedom of self-determination can never unconditionally prevail over the reasons for protecting this good. It always requires a balance to guarantee at least minimal protection. This rationale has sparked many ethical discussions at a national level. While not challenging the principles reaffirmed by the Constitutional Court, there is a consensus on the need for a national rule that considers the peculiarities of specific cases. This aims to prevent an increase in Euthanasia/Assisted Suicide treatments operating in legal grey areas not defined by the legislator9. In contrast to Italy, European countries such as Switzerland10,11, the Netherlands12, and Belgium13 have addressed these needs by regulating and providing data regarding the use of these practices on their national territory. Switzerland is certainly among the best known for assisted suicide, having introduced it since 1942 and carrying it out, after having ascertained conditions of extreme suffering, even on people suffering from psychiatric pathologies who represent 2.1% of the total requests of assisted suicide deemed suitable; this sample also includes dementia which represents 4.3% of these cases14. In the Netherlands, requests are evaluated by the Dutch Regional Euthanasia Review Committees, the body that evaluates requests for Euthanasia/Assisted Suicide. The reported data indicate that subjects who accessed treatment were predominantly single women who lived alone and were suffering from depression with a history of more than ten years of psychiatric treatment. Furthermore, the data also highlights the existence of another subgroup of patients who received assisted euthanasia/suicide with diagnoses that included somatic disorders, anxiety disorders, obsessive-compulsive disorders and neurocognitive disorders15. As regards the management of the execution of assisted death treatments in Belgium, since the case analyzed in this article concerns the case of Geneviève Lhermitte, a peculiar case of Euthanasia, the in-depth analysis of the current regulations and the statistics of the country will be analyzed through specifically dedicated ethical and legal reflections. The case of Geneviève Lhermitte In recent months, the case of Geneviève Lhermitte (GL), a 56-year-old Belgian woman, who obtained euthanasia in Belgium on 28 February 2023, has been widely disseminated in the media, both in print and, above all, online. The request for euthanasia was based on the presence of a condition of “irreversible psychological suffering” as foreseen by the Belgian Act on Euthanasia16, whose frequency of access to the practice for subjects suffering from psychiatric conditions does not differ from that of the countries previously mentioned (among 1 and 2% of the total requests)17. As often happens in similar situations, the data available in the press or online do not allow access to the official clinical documentation relating to the case, nor judicial documents of more specific psychiatric or criminological interest. The reflection must therefore, of necessity, be based on current information, which is limiting, if not sometimes misleading, compared to a truly in-depth knowledge of the situation; but such nevertheless, at least in the case in question, as to allow some considerations stimulated by the absolute peculiarity of the case itself. GL’s personal history was of exceptional gravity. On 28 February 2007, the woman had killed her 5 children with knives, and after various procedural and medico-legal vicissitudes, she had been recognized as capable of understanding at the time of the crime and was, at the time of the euthanasia, serving a life sentence, even if, in the last period, under house arrest. Personal history From what emerges from the available sources, GL was a woman born in Brussels, where she lived until the age of 32, then moved with her family to Nivelles, also in Belgium. Married at 24 to a man born in Morocco, she had had 5 children with him, 4 girls and a boy, aged 14, 12, 10, 8 and 3 at the time of the events. After graduating, she worked as a teacher, except for long periods of absence for health reasons or the birth of her children. A certain degree of economic difficulty and housing problems seem to emerge, as well as family tensions relating both to these and to the frequent absences of her husband, who made many trips to Morocco to maintain contact with the family, as, reported by the interested party. These issues were further complicated by the cohabitation with another older male figure, who, according to GL, had also taken on the role of the “economic protector” of the family. GL identifies this figure as significantly responsible for the relational difficulties within the family. There is insufficient information available on this potentially central aspect. But in the story following the murder, none of these problematic areas are described in such detail or emphasized to such a degree that they could have represented a recognizable or specific main causal factor for the dramatic outcome of the story. But upon careful examination some other considerations are possible. From news data, it can be reconstructed that GL is a woman who marries at the age of 24, and changes city at the age of 32, moving from the capital of Belgium to a provincial town seven times smaller than Brussels. The first daughter was born when GL was 42 years old, the second when she was 44, the third at 46 years old, the fourth at 48 years old and the last one at 53 years old. Already in this sequence, many inconsistencies can be observed, but doubts cannot be resolved because of the lack of information about GL’s story. On 28 February 2007, in an apparently lucid and certainly premeditated way, GL killed, separately her 5 children at home, cutting their throats with knives stolen for this purpose from a shop. The described modality of filicide is that of a sacrificial rite. The children are slaughtered one by one, alone, like Medea’s children, and their bodies are placed in their beds together with their toys. The episode was told by GL in a type of experience that is difficult to distinguish between the hallucinatory and the dissociative: documents report the sequence of events beginning when she heard a voice saying “the car has started”, the repetitive and seemingly automatic homicidal behaviour, a writing “JUD/Judas” with the blood of a little girl, a finally attempted suicide witout success Psychiatric aspects Before the dramatic outcome, there were some anamnestic data of psychiatric interest, these too not emphasized in their previous dimension, such as a diagnosis of “puerperal depression” in 2011, at 44 years old, after the birth of the second daughter and the event, described imprecisely, that GL has undergone outpatient psychiatric treatment since 2005, at the age of 38, six years after moving to Nivelles and four years before the birth of her first child. There are no other diagnoses issued to her either before or after the puerperal depression, nor has there been any report of the recurrence of similar episodes at the end of the three subsequent pregnancies. The regularity or frequency of psychiatric visits is not known, nor is there information on any pharmacological treatments carried out. It is possible that the family distress, mentioned several times by GL, played not only as an external reality but also in the subjective experience a central role in accentuating the condition of mental suffering, also from what emerges from a letter sent by GL to a friend immediately before the murder, in which the most relevant factors of family suffering are described. The incompleteness of the information does not allow a certain a posteriori psychiatric diagnosis. No data are available on GL’s personality structure, which was probably fragile and, based on the reconstruction of events, characterized by aspects of affective instability, sensitivity to abandonment, intense emotional reactivity, and a tendency towards dissociative experiences. Just as there is no information, certainly more difficult to obtain, on her relational modalities, in particular with her husband, and on her corresponding emotional experience. But the poor available anamnestic data and the account of the methods and subjective experience of the multiple homicides would seem indicative of a depressive disorder which arose at least in 2011, at the age of 44, in the form of a puerperal depression, on the course of which there is no certain information, if not those of more than a year of absence from work and the unspecified psychiatric treatment followed in recent years. The drama of the final gesture suggests the hypothesis of a very serious depressive flare-up, perhaps partly secondary to the experience of the husband’s repeated absences, with the consequent experience of abandonment, and to the problems of family cohabitation, the appearance of homicidal and suicidal ideation perhaps also based on a psychotic distortion of the judgment of reality, as suggested by the reported experience of auditory hallucinations at the moment of the homicides, the writing with blood following these, etc. But beyond the albeit adequate assessments of a formally psychiatric nature, some other considerations can help shed light on a case in which the obscurity of information appears to be a dominant feature. GL was objectively alone for long periods and probably felt left alone to face a life full of difficulties. The mythical figure of Medea hovers over her history and provides some hypothetical interpretations. Against the background of all this tragedy, the figure of the husband appears, who in GL’s subjective experience and story is configured based on his absence, which seems to be complemented by GL’s emotional and social loneliness. The killing of children would take on a double meaning in this sense. The first, more formally psychiatric, is often present in murder by depressed mothers, which takes on the meaning of definitive protection of their children against a hopeless life prospect. On the other hand, some aspects indicative of a dissociative alteration of the state of consciousness at the moment of the filicide leave open the hypothesis that the recrimination towards the husband for his absence may at the same time have translated into an aggressive emotionality towards him manifested itself through the killing of his children, a dynamic value that is also not uncommon in cases of murder of children. The same value that pushes Medea to kill, with a knife, the children of the absent Jason. During the trial, GL was examined by psychiatrists who indicated that she was not attributable due to mental illness, an indication not followed by the court, which sentenced her to life imprisonment. She was subsequently transferred to a psychiatric prison facility under semi-liberty and in this situation, she requested and obtained euthanasia due to “irreversible psychological suffering”. Even in this sequence, we observe an incongruity that makes us reflect a lot. The first dissonance concerns the court’s rejection of the opinion of the psychiatrists. It seems as if the horror of what happened could only be sentenced to life imprisonment, beyond what was technically observed and suggested by psychiatrists, except to subsequently recognize the infirmity and accept the request for euthanasia, almost a death penalty “consciously” chosen by the woman and supported by the Law. Legal and ethical considerations Both the ethical and medico-legal evaluation stimulate some reflections of important complexity if only due to the exceptionally tragic nature of the event and, even independently of more technical considerations, the extremely serious human suffering of the case. Ethical and medico-legal questions As already previously considered, Belgian legislation provides for euthanasia in cases of serious and irreversible suffering but does not expressly cite the assumption of a possible depressive condition underlying such suffering. With respect to the case under discussion, the first reflection concerns the admission of euthanasia for suffering even if not of a medical nature and therefore, mainly, not of a psychiatric nature, given the non-recognition by the Court of a non-attributability due to mental infirmity. Even if this is admitted by Belgian legislation, it is clear that the question immediately arises as to what the nature and intensity of this suffering must be, as well as its irreversibility, to make the end-of-life request acceptable. Only in general terms and in extreme hypotheses, one reflects that the life sentence, implicitly irreversible, allowed the adequacy and acceptance of the subsequent request for euthanasia, also implicitly irreversible, placing both decisions in a sort of a single sentence, with all the potential consequent extensions to the end-of-life request for the same single reason. It is plausible that in GL’s case the origin of the mental suffering, for which she requested euthanasia, was the feeling of guilt for killing her children. But if, as it can be hypothesized from the limited clinical data available, the murder took place in a condition of serious mental alteration, psychotic and/or dissociative, as established by the psychiatric report, the subsequent feeling of guilt would represent the result of the critical evaluation of one’s act, not consistent with the persistence of the mental alteration and therefore indicative of remission from the psychopathological condition present at the time of the facts. In other words, it would have been a request for euthanasia by a person who was healthy enough to recognize the seriousness of her conduct, not by a person still suffering from the previous mental illness that had been the basis of the murder. This would confirm the admissibility of euthanasia also for people who are certainly suffering but are currently free from particularly severe mental disorders, with all the related ethical questions considered or not, or neglected, by Belgian legislation. Unless we consider the feeling of guilt as serious and irreversible suffering and as a pathological condition, regardless of the recognition of a specific mental disorder at its basis, even in this case with a very vast range of potential extensions of requests. The second reflection instead concerns the hypothesis of the persistence at the time of the request for euthanasia of a clinical condition that is still serious and persists over time, probably, but potentially not exclusively, of a depressive nature, in the context of irreversible psychological suffering, which is also very probably based on the feeling of guilt. This evaluation would therefore frame the request for euthanasia as the request by a person suffering from a mental disorder of absolute clinical severity. If the severity of the psychopathological condition was such as to make the request for euthanasia acceptable, was the patient’s real ability to express the request in a valid way adequately assessed? Or could the same limits, linked to the severity of the mental state, which would perhaps have excluded the ability to express valid consent to the treatments, also have been recognizable concerning the request for euthanasia to invalidate its admissibility? The adequate awareness of the person requesting euthanasia represents an unavoidable condition for its acceptance. Has it been correctly verified in this case? Tertium non datur and, therefore, our reflection can only move between these two psychic situations. During the trial, GL was declared by psychiatrists who assessed her as not attributable due to mental illness, thus excluding her capacity to understand and will at the time of the murder. Was it adequately verified that this capacity had been fully recovered at the time of the euthanasia request? If the acceptance of the request was also motivated by the persistence of the morbid condition, probably depressive, sufficient therapeutic tools aimed at the remission or clinical attenuation of this were put in place, so much so that the request could, in this case, be classified with certainty in a meaning of validity? Or enough to reduce, as much as possible considering the personal, as well as clinical, history of the suffering underlying the request? Has GL been subjected to adequate pharmacological treatments, including those most effective in resistant forms of depression? Euthanasia was carried out in 2023: was treatment with hexketamine set up, the most powerful and recent active treatment in this sense? Has electroconvulsive therapy, the most powerful of the antidepressant interventions, been indicated or carried out? Has GL received adequate psychotherapeutic support? This information is not available based on what is reported in the news, but it lack leaves a shadow of profound uncertainty about the real adequacy of the clinical and medico-legal management of the matter. Considerations of the problems intrinsic to euthanasia for mental suffering These are questions that will not find an answer in the extreme case of GL, which has already reached its epilogue. But precisely the extreme aspects of the case highlight very clearly the medico-legal and ethical problems intrinsic to every request and acceptance of euthanasia in people in whom this is mainly motivated by suffering of a mental nature, whether it can be classified in a defined form of psychopathology. Problems, especially those of an ethical nature, absolutely overwhelm the principles of the respective national legislations, such as, in the case in question, the uncritical permissiveness of Belgian legislation. The presence of mental suffering does not exclude a priori the ability to freely and consciously express a request for euthanasia, in the formulation of which, in addition to the state of suffering, personal considerations of an existential, cultural, ethical, religious, etc. can contribute, as well as the same socio-cultural and legislative context in which the request is formulated. It is equally clear that cultural or ethical visions conflicting with those of the person requesting euthanasia do not in themselves have the right to contest those of the person directly concerned. But the problem of real freedom of choice is unavoidable in the case of an express request for “irreversible psychological suffering”, especially in a subject with a previously documented psychiatric pathology and recognized exclusion of this capacity at the time of the crime for which she was convicted. But paradoxically, the same reasoning would be equally, and perhaps even more, valid if the same request had been formulated by a subject without a personal history of crime, but with a simple history of serious psychopathological disorder in a condition of “irreversible psychological suffering”. Like any extreme case, that of GL, extreme on both a human and psychiatric level, contributes to presenting in a more defined light the problematic elements intrinsic to every end-of-life request and decision and should stimulate reflection on the nature of the phenomenon in general and the conceptual and operational limits of the cognitive, legal and ethical categories that are currently used. biblio_titolo - ignora References bibliografia - art_bibliografia 1. Bersani G, Rinaldi R, Iannitelli A. The Shanti De Corte case: euthanasia for mental disorder between clinic and bioethics, between law and medico-legal implications. Riv Psichiatr 2022; 57: 303-7. 2. 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