Contention des patients : « est-ce bien légal docteur ? » (Journal International de Médecine, Charles Haroche, avocat)
Le Dr Bokobza veut éveiller les consciences à l’heure où la Haute assemblée s’apprête à étudier en première lecture le Projet de loi Santé, dont l’une des dispositions décriées vise justement à définir un cadre légal à la contention.
Au-delà de la problématique de l’efficacité de la méthode, la question de la contention mérite que l’on s’y attarde d’un point de vue juridique.
En effet, pour la Constitution, il appartient à la loi de fixer les règles concernant « les garanties fondamentales » accordées à chaque citoyen (art.34) à charge pour l’autorité judiciaire « gardienne de la liberté individuelle » d’en assurer le respect (art. 66).
Il va de soi que le recours à la contention (c’est-à-dire à un procédé physique ou chimique visant à restreindre ou à rendre impossible les mouvements) est clairement de nature à porter atteinte aux droits fondamentaux du patient (liberté d’aller et de venir, droit au refus de soins…).Or, actuellement, le recours à la contention ne fait l’objet d’aucun encadrement législatif…
Pour la jurisprudence administrative, le recours à la contention est admis en cas de danger pour le patient ou pour autrui
La jurisprudence administrative a été amenée à se prononcer sur la légalité du recours à la contention dans le cadre de litiges mettant en cause la responsabilité d’hôpitaux, soit à raison d’un recours abusif à la contention (soit, au contraire, lorsque l’établissement n’y a pas eu recours avec des conséquences dommageables pour le patient).
Pour la jurisprudence, cette mesure doit être mise en œuvre uniquement dans l’hypothèse où le patient représente un risque pour lui-même ou pour les tiers.
Lorsqu’elle est exercée en dehors d’un tel cadre, la contention constituerait… un traitement inhumain et dégradant. Ainsi, la contention réalisée sur un patient non dangereux mais faisant l’objet d’un arrêté de reconduite à la frontière, constitue « un traitement inhumain » contraire à l’article 3 de la Convention européenne de sauvegarde des droits de l’homme (Cour Administrative d’Appel de Bordeaux, 1er mars 2012).
Ainsi, à l’heure actuelle, une pratique qui devrait faire l’objet d’une loi et d’un contrôle par l’autorité judiciaire, est encadré… par la jurisprudence du juge administratif.
Un recours à la contrainte qui porte atteinte aux droits des patients ?
En pratique, et en l’absence de loi et de contrôle par le juge, le risque d’atteintes aux libertés individuelles est considérable.
En 2012, le Comité européen pour la prévention de la torture s’était alarmé des conditions de recours à la mise sous contention dans les hôpitaux français. La France fut invitée à définir avec précision des protocoles de mise en place de la contention et à établir des registres permettant de retracer l’heure et la durée de la contention.
En outre, dans son rapport pour l’année 2013, le Contrôleur général des lieux de privation de liberté, Jean-Marie Delarue, s’était inquiété du fait que de nombreux établissements avaient encore recours à la contention comme une « pratique de punition » (or, en tant que tel, un tel recours à la contention est assimilable à un traitement dégradant).
En pratique (et sans attendre les recommandations du Comité Européen), de nombreux établissements de santé ont défini en interne des protocoles permettant de tracer le recours à la contention.
Dans le même temps, le Gouvernement a soigneusement pris soin d’éviter tout débat autour de la question. En 2014, le Député du Finistère Jean-Luc Bleunven (DVG) avait attiré l’attention du Ministre de la Santé sur le recours jugé abusif à la contention. En réponse, le Ministre de la Santé a souligné que les droits des patients hospitalisés d’offices avaient été renforcés par l’adoption de la loi du 5 juillet 2011 et du 27 septembre 2013 (ce qui, en l’espèce, ne répondait en rien à la question) et indiqué « qu’une mission avait été confié » au directeur de l’ARS d’Aquitaine, M.Michel Laforcade, pour répondre à cette question…
Vers un encadrement … pour la psychiatrie uniquement ?
Adopté en première lecture par l’Assemblée Nationale, l’article 13 quater du Projet de Loi Santé a précisément pour objet d’encadrer le recours à la contention. Dans l’état actuel du Projet de loi, le recours à la contention est présenté « comme une pratique de dernier recours » (terminologie qui ne manquera pas d’alimenter les débats devant les prétoires !) qui ne peut être prise que « pour une durée limitée ».
Désormais, le recours à la contention ne pourrait être envisagé qu’en cas de menace de dommage« imminent » pour le patient ou pour autrui, (ce qui semble durcir le critère retenu par la jurisprudence administrative).
L’autre nouveauté tient dans la généralisation des mécanismes de contrôle : un registre des mesures de contention et d’isolement devra être tenu dans chaque établissement psychiatrique (ce dernier devra notamment mentionner le nom du psychiatre ayant décidé de la mesure, la date et l’heure du prononcé de la mesure, sa durée, et le nom des professionnels de santé surveillant le patient).
De manière surprenante, l’amendement déposé par le Député du Loir-et-Cher Denys Robiliard (PS) n’encadre que la situation du patient hospitalisé dans un établissement de psychiatrie. Pourtant, l’on aurait tort de penser que le recours à la contention se limite aux seules hospitalisations psychiatriques (on pense, par exemple, au soin des personnes âgées ou à la prise en charge de patients agressifs aux urgences…). Dans l’état actuel du projet de loi, les contentions hors-psychiatrie ne feraient l’objet d’aucun encadrement législatif…
Un amendement consensuel… qui ne plait à personne
L’amendement proposé par le Député Denys Robiliard aurait pu apparaitre comme consensuel. Pourtant, le recours à la loi divise.
Ainsi le député de l’Aube et psychiatre Nicolas Dhuicq (UMP) n’a pas manqué de dénoncer « l’abomination » que représenterait un tel texte qui restreint la liberté d’action des médecins. D’autres spécialistes, à l’image du docteur Patrice Charbit, ont insisté sur le risque d’une « déresponsabilisation » du médecin.
Sur ce point, le passage par le législatif répond en réalité à un impératif : il est indispensable d’encadrer par la loi le recours à une pratique qui porte atteinte aux libertés des patients, qu’ils fassent l’objet de soins psychiatriques ou non.
Charles Haroche, Avocat (Paris) charlesharoche@gmail.com
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