International Journal of Science Annals, Vol. 7, No. 1, 2024 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa SOCIAL AND BEHAVIORAL SCIENCES. Health Care Sciences REVIEW ARTICLE Choosing to Die with the Help or by the Hand of a Doctor (Medically-Assisted Death): Limitations and Safety Profiles –––– Authors’ Contribution: A – Study design; Cembrani F.1 ABDEF , De Leo D.2 ADEF B – Data collection; C – Statistical analysis; 1 University of Verona, Italy D – Data interpretation; 2 Griffith University, Australia E – Manuscript preparation; F – Literature search; Received: 07.01.2024; Accepted: 27.02.2024; Published: 30.06.2024 G – Funds collection Abstract Background and Depression severity can be profoundly impacting the life of individuals, while its Aim of Study: persistence can provoke the conviction that recovery is unattainable. One of the extreme consequences is the request for euthanasia. However, during major depression cognition can be significantly impaired. In this study, we comment on the exemplar case of a Belgian lady, Mrs. Godelieva de Troyer, who made that request and obtained the desired outcome. The aim of the study: to consider a specific case of a patient with major depressive disorder and the role of doctors in informing the decision about medically assisted death. Material and Methods: The history of the request made by Mrs. Godelieva is described. The procedure was followed by the reactive initiatives of the son of the lady, who made a formal complaint against the procedure that brought his mother to death and appealed the European Court of Justice. Results: A description of what happened is briefly reported, including considerations on the clinical treatments received by Mrs. Godelieva, the roles interpreted by the doctors she consulted and, finally, the appropriateness of the decision taken. Conclusions: In revisiting this case, the decision-making process during major depression episodes and the authenticity and robustness of end-of-life choices in similar cases are critically examined. Comments are made on the frequency of cognitive impairments during major depressive episodes and the need to provide depressed people the necessary support during their important choices. Keywords: Major depression, chronic persistent depression, euthanasia, medically assisted suicide, care for depressed people, psychological support, European Court of Justice Copyright: © 2024 Cembrani F., De Leo D. Published by Archives of International Journal of Science Annals DOI: https://doi.org/10.26697/ijsa.2024.1.1 Conflict of interests: The authors declare that there is no conflict of interests Peer review: Double-blind review Source of support: This research did not receive any outside funding or support Information about Cembrani Fabio (Corresponding Author) – https://orcid.org/0009-0007-6214- the authors: 6557; f.cembrani@gmail.com; Coroner, Contract Professor, University of Verona, Verona, Italy. De Leo Diego – https://orcid.org/0000-0001-8255-6480; Doctor of Medical Sciences, MD, Emeritus Professor of Psychiatry, Griffith University, Brisbane, Australia. Introduction Depression and Bio-Legal Issues: General Framework disability globally, as confirmed by the Global Burden of Depression is a clinical reality frequently encountered in Disease study (GBD) which calculated, for 2019, the psychogeriatric clinics; it is the leading cause of disability adjusted life years (sum of years of life lost in 60 International Journal of Science Annals, Vol. 7, No. 1, 2024 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa the world due to premature mortality and years of life progressive increase in cases of euthanasia (from 259 in lived in conditions of suboptimal health) estimated at 2003 to 2,790 in 2021) to which people mainly over 70 46.9 million years (GBD 2019 Diseases and Injuries years old resorted (in 67.1% of cases), and those mostly Collaborators, 2020). Following the statistical indicators affected by a neoplastic pathology (63.4% of cases), provided by the World Health Organization (WHO), mainly through administration of barbiturates (99.6% of there would be over 300 million depressed people in the cases). Very small, but present, mental and behavioral world (World Health Organization, 2022) with a disorders: this happened in 94 cases in 2021 (1.9% of the prevalence that can affect one in five people in the total); in 45 cases (equal to 0.9% of the total) this general population, increasing with age; 31.74% of old occurred due to a personality disorder, a depressive people (65+ years of age) would, in fact, be affected by a picture and schizophrenia; in 49 cases (1.0% of the total) depressive disorder and its prevalence would be higher due to the existence of a cognitive disorder produced by (40.8%) in developing countries (Zenebe et al., 2021), Alzheimer’s disease, vascular dementia or Lewy bodies’ with peaks recorded in Africa – 43.1% (Bedaso et al., dementia. In most patients, different types of suffering, 2022) and in India – 34.4% (Pilania et al., 2019). In both physical and psychic, were present simultaneously. nursing homes, 18.9% of older adults reportedly suffer The suffering has been described as constant, unbearable, from major depressive disorder (MDD), as indicated by and unrelievable. Among the most often mentioned a recent meta-analysis of 32 observational studies physical sufferings are air hunger, digestive obstruction (Fornaro et al., 2020). with vomiting, constant pain. Among the most frequent Also in Italy, depression is the most widespread mental causes of psychological suffering, are dependence on disorder: about 5-6% of the population is affected by it, others, loss of dignity, loneliness, social isolation and while 10-15% of it would have experienced a depressive despair. episode at least once in life even if these indicators vary In this article we would like to try to give an answer to according to the sources and diagnostic methodologies the many problematic questions that the principle of self- used. Recent studies indicate that MDD could affect over determination raises in the event that the holder of the 7.5 million people (11.4% of the population), mainly right is a particularly fragile, vulnerable, influenced or women with low schooling and poor economic status (de otherwise suggestible person, and what is the support that Girolamo et al., 2005). these people must be guaranteed by whoever has the Not only because of its frequency, depression raises responsibility of care, especially in situations where the many (complex) practical questions, including juridical good put at risk is the protection of life protected by the ones (as in the case of patient suicide) (Cupelli, 2013) European Convention on Human Rights (Council of and, more generally, bioethical ones, often faced with a Europe, 2002). feeble voice by psychiatrists “whose opinion is only The aim of the study. To consider the exemplary case of rarely sought but, above all, even more rarely expressed” a Belgian lady, Mrs. Godelieva de Troyer, with a major (Bersani et al., 2020, p. 57). It is therefore necessary to depressive disorder and the role of doctors in informing reflect on the impact of depression and the possible the decision about medically assisted death. impact of cognitive impairment, especially in cases of severe (major) depression, when important decisions are Materials and Methods to be taken by the individual affected by it. This is what The Death through Euthanasia of Mrs. Godelieva de we are meant to do in this short essay, in which we Troyer, which Came before the Examination of the propose to address the quality and robustness of end-of- European Court of Justice Following the Complaint life choices given the relationship that exists, especially Presented by Her Son in old age, among depression, cognitive decline and risk At the material time, Mrs. Godelieva de Troyer was a 64- of progression from mild cognitive impairment (MCI) to year-old Belgian woman, suffering for over 40 years frank dementia (Rosenberg et al., 2013). from a depressive disorder generally considered as We would do so starting from a public matter that has “major” and unresponsive to the pharmacological recently come under examination by the European Court treatments prescribed by the numerous psychiatrists near of Human Rights (Judgment n. 78017 of 4 October 2022, whom she was in therapy. She herself had decided to die Mortier vs. Belgique), immediately acknowledging that by resorting to euthanasia, a practice permitted in that the regulatory framework which Belgium has adopted for country due to the effects of the law of 28 May 2002, then the non-punish ability of euthanasia is very liberal modified by the law of 28 February 2014, which (Cembrani et al., 2014; Dentamaro, 2019): it also allows extended this option to minors with the consent of parents minors capable of discernment and people affected by a or legal representatives without setting any age limit, mental pathology who find themselves “in a useless however, as instead requested by the Dutch legislation. condition of physical or psychological suffering, Dr. G. T., her general practitioner, was informed of the unbearable and incurable” to access it if adults (Mehlum decision, but declined the woman’s invitation to start the et al., 2020) provided they are capable of understanding procedure. He advised her to contact Prof. W. D., a and wanting, with limitations that have however proved Belgian oncologist well known in his country for being a to be completely insufficient in the face of the strong supporter of euthanasia. exponential growth of cases. In this regard, the latest According to the reconstruction of the events made by the Report from the Commission Fédérale de Contrôle et judges of Strasbourg, on 29 September 2011 Prof. W. D. D’evaluation de L’euthanasie (2023) – documents the spoke to Mrs. de Troyer, learning that she was at that time 61 International Journal of Science Annals, Vol. 7, No. 1, 2024 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa being followed by a psychiatrist, that her depressive with dignity. The son did not reply to her letter, while the disorder had started very early (at the age of 19 years) daughter replied: although very saddened by the decision, and that the many pharmacological approaches had never she respected her mother’s will. resulted in full recovery, even if there was a break in 2006 On February 7, 2012, Prof. W. D. contacted another when the woman, after the suicide of her husband, had psychiatrist, Dr. B., who stated that the woman’s health embarked on a new relationship, then abruptly problem was chronic and no longer treatable on a interrupted. therapeutic level. The same Dr. B., on the following 10 For the last two years, Mrs. Godelieva de Troyer had February, sent a letter to Dr. T. informing her that he had decided to sever ties with her children and her previously met the woman (in 1996) due to a very serious grandchildren, for reasons that were not explored at the psychopathology probably related to a childhood time by Prof. W. D. This physician came anyway to the traumatic experience, highlighting that the prognosis was conclusion that the woman was suffering from a serious extremely uncertain and obscure. personality disorder, associated with a chronic mood On February 14, the patient formalized her euthanasia disorder, and that she no longer believed in her functional request in writing, indicating in Prof. W. D. her attending recovery and in the success of any pharmacological physician. On the same day, Dr. T. signed a report option. He therefore agreed to become her attending acknowledging that the patient had consulted her several physician in the path aimed at euthanasia, instructing her times to inform her of her decision to die in order to put to consult a second psychiatrist (Dr. V.), as required by an end to her unbearable and hopeless suffering. In that Belgian law. report, the woman was described as lucid and reasonable The meeting between the woman and Dr. V. took place even after she had been provided with information on on 17 December 2011: on that occasion, the specialist possible therapeutic options, and then concluded that the confirmed the chronic depressive picture from which the conditions established by the Belgian law permitted to patient was suffering, albeit with “ups and downs”, help her die. The same conclusion was reached on the concluding that the request for euthanasia was premature, following February 17 by Dr. V. D., who confirmed the suggesting that she go to another psychiatrist to reset the serious social isolation of the woman and her refusal to drug treatment plan. undergo any further drug therapy. On December 23, 2011, Prof. W. D. met again the On February 27, 2012, the patient signed a handwritten woman who expressed her deep concern of being declaration acknowledging her intention to donate her abandoned and seeing not accepted her request to die body to science; two days later, on February 29, 2012, with euthanasia while admitting that she was ready to see she made a donation of 2,500 euros to Leif (Levenseinde another psychiatrist (Dr. V. D.), as requested by Dr. V. Informathieforum), a non-profit association led by On that occasion, Mrs. de Troyer spoke about the reasons Prof. W. D., which also had among its members Drs. T. that had motivated her to break off relations with her two and V. D. children, in particular with her eldest son, described by On 8 and 12 March 2012, Prof. W. D spoke again with the woman as a person she was afraid of due to his the woman concluding that there were no more prospects aggressiveness. In a subsequent meeting, which took for continuing her life. place on January 12, 2012, Mrs. Godelieva de Troyer told On March 20, 2012, Mrs. de Troyer met P. D., a person Prof. W. D. she was feeling deeply exhausted, she trusted, confiding to her that she intended to write a confirming her decision not to see her children anymore, farewell letter to her children. specifying that she had yet to be visited by Dr. V .D. On April 13, 2012, Prof. W. D. and P. D. met again because not reachable. Prof. W. D. thus advised her to Mrs. Godelieva de Troyer who accepted the idea of consult another psychiatrist, Dr. T. writing a letter addressed to her children with the The meeting with the latter took place on January 17, assistance of P. D. At the end of the conversation, 2012, and during the meeting the woman specified that Prof. W. D. came to the conclusion that the only her daughter, with whom all contact had been interrupted reasonable option was euthanasia and set the date for for two years, knew of her request to die by euthanasia April 19, 2012. specifying that she no longer had anyone in her life, that On April 10, 2022, two telephone consultations took she was alone, that she felt incurably ill, that she no place between the woman and the same Prof. W. D. who longer had the stamina to do anything and that she wanted reassured her regarding her will: the euthanasia act was to die as soon as possible. Although she was never practiced on the following April 19 by the same hospitalized in a psychiatric environment (this Prof. W. D. in the UZ Brussels University Hospital, in opportunity was never raised by any doctor), Mrs. de the presence of Mr. Samuel Vinck (an attorney) and some Troyer added that she had no faith in psychiatric science. friends of the woman. On 20 January 2012, there was a new consultation with Information of her death was given to her children on the Prof. W. D., who agreed to accompany her personally to following 20 April, before the opinion expressed by the Dr. V. D. This psychiatrist suggested her to inform the federal control commission provided for by Belgian law, children of her decision to die, so that they could co-chaired by the same Prof. W. D., who ascertained the accompany her and be present during the euthanasia regularity of the euthanasia procedure and the observance procedure. Thus, on 31 January 2012, the woman sent an of all the criteria established by Belgian law verified by email to her two children to inform them of her decision, “deux médecins indépendants, qui confirmaient la the endless severity of her suffering and her desire to die capacité de la patiente, l’incurabilité de sa pathologie et 62 International Journal of Science Annals, Vol. 7, No. 1, 2024 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa l’existence d’une souffrance psychique extrême, (existence of a serious pathology and incurable, insupportable et unapaisable”. producing constant and unbearable suffering) but little or The subsequent complaints expressed to the Judicial nothing was done to offer her that support which could Authority by the patient’s son T. M., a university control or contain her suffering. In addition, it seems that professor, accusing of non-compliance with Belgian law her daughter’s affection could probably be recovered, and of not having been informed of what had been and that there was a network of friends and trust on which authorized by the two Belgian doctors, were not followed the woman could still count. up; in May 2017 he was informed of the filing of his Without questioning the seriousness of the suffering criminal complaint due to insufficient evidence. Hence, caused by the psycho-pathological condition from which his decision to appeal to the European Court of Justice Mrs. Godelieva de Troyer was affected, her protracted for the violation of articles 2 and 8 of the European state of suffering (albeit between the ups and downs that Convention on Human Rights (ECHR). are normally recorded in these clinical situations), the Going into the merits of the matter, the Strasbourg incomplete control of the depressive symptomatology judges, without declaring the existence of a conflict despite the prolonged pharmacological and psycho- between art. 2 of the ECHR and the Belgian law (which, behavioral therapies, the distrust gained towards under certain conditions, decriminalized euthanasia), psychiatric treatments, her social isolation and loss of recognized that the strictness of the procedure envisaged hope, what appears indisputable is that the robustness of by Belgian internal legislation had not been respected her decision was not subjected to any particular because the same Prof. W. D., having personally verification and that some of the doctors she interviewed supervised the euthanasia procedure from the initial politely declined the invitation or temporarily suspended request of the woman, could not have expressed any it, believing that the decision to die at the hands of a judgment on the merits of his work, and would therefore doctor required a more complete maturation. have had to abstain for reasons of independence and Trying to give a practical answer to these questions, we competence. hypothesized to transfer the human story of Thus sanctioning Belgium, but without however Mrs. Godelieva de Troyer to the Italian context (where addressing the compliance of Belgian law with art. 2 of euthanasia is forbidden) asking ourselves what could the ECHR (Bucalo, 2023) and without discussing the have happened if she had asked Italian doctors to help her robustness of the woman’s decision as had been done, to die with assisted suicide, a practice permitted within however, by the same judges in the Haas sentence against limits and the guarantees provided by the Constitutional Switzerland (Butturini, 2011) whose protagonist had Judge in sentence no. 242/2019; sentence with which the been a patient suffering from bipolar disorder who had art. 580 of the penal code (“Instigating and assisting in resorted to the Court complaining about the inertia of the suicide”) makes the actor no longer punishable in the country to supply a drug lethal for his assisted suicide, hypothesis in which the execution of the intention of which should have put an end to his unbearable suffering. suicide, autonomously and freely formed, of the adult person has been facilitated provided that the person is Results and Discussion affected by an irreversible pathology, kept in life from The Choice to Die with the Help or by the Hand of the life-sustaining treatments, the condition is a source of Doctor (Medically Assisted Death): Limitations and physical or psychological suffering that the person Safety Profiles in Italy considers as intolerable, while remaining fully capable of Beyond the complexity of the case, as it has been making free and informed decisions. reconstructed by the Judges of the European Court of These conditions and the methods of execution of Justice, the human story of Mrs. Godelieva de Troyer assisted suicide must then be verified by a public raises many questions. Two in particular, for what structure of the national health service, subject to the concerns us here, having to ask what it was: opinion of the territorially competent ethics committee, (1) the robustness of her decision to die by euthanasia as thus identifying a whole series of constraints – not only scientific evidence demonstrates that cognitive deficits procedural but above all substantial – which have set, and can represent an important component of MDD (Douglas they continue to pose, problematic questions, not yet & Porter, 2009) proving capable of compromising fully resolved. memory, attentional functions and learning (Kriesche et For example, it is much debated which Ethics Committee al., 2023) with a worsening of the deficits caused by is properly required to express its opinion in these cases. repeated relapses (Semkovska et al., 2019) and aging In response to the specific question posed by the Minister (Dotson et al., 2020); of Health, on 24 February 2023 the National Bioethics (2) the support (medical, psychological, pharmacological Committee considered that the responsibility should be and human) that should have been guaranteed to the attributed to the CETs (Territorial Ethics Committees), woman and with what possible precautions (or guarantee referred to in the Decree of 26 January 2023 rules) could and should have brought to maturity the (“Identification of forty territorial ethics committees”), decision of the same to put an early end to life her. uniformly present in the country. The general impression that emerges from the analysis of Another important topic of debate concerns life support, this sad story is that the doctors consulted by Mrs. de on which there are frankly antithetical ideas, there being Troyer were particularly attentive to the formal aspects those who indicate it in those measures that require the required by Belgian law to finalize the euthanasia request use of artificial means and the support given by machines 63 International Journal of Science Annals, Vol. 7, No. 1, 2024 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa and those who, on the contrary, extend it to the entire Depressive Disorder, Authenticity and Robustness of therapeutic weaponry available to doctors. End-of-Life Choices Different positions also exist on the validity of the Nonetheless, the Italian legislator, precisely regarding the treatment decision, there being those who subordinate it end of life (law n. 219/2017), has subordinated the to the person’s ability to understand and want, and those legitimacy of the choice of treatment to the integrity of who, on the contrary, value the cognitive, affective and the person’s ability to understand and want without hint emotional aspects of decision making, believing that at what his judgment parameters are in order to reduce mental disability can never be neither a valid nor a the evaluative suggestions often present, even among reasonable reason to discriminate against people (Grahek experts, in the courtrooms (Foucault, 2020). et al., 2018), with all that it entails on a practical level for The question is particularly complex, and some very the rupture of the presumed ability/incapacity dichotomy, useful indications have been proposed at an international and of that still dominant paradigm which sees legal level in this regard (American Psychiatric Association, incapacity as the instrument to give support to those 2012; Appelbaum, 2007) to correct trivializing people. professional styles without generalizing the complexity The controversy that exists on the capacity, which is a of situations. broad and complex philosophical-political construct, In Italy, the Italian Psychogeriatric Association, AIP whose polysemy – already verifiable in ordinary (Cembrani et al., 2019), and the Istituto Superiore di language – becomes even more evident in the juridical Sanità, ISS, did so in relatively recent times which, in an vocabulary due to the plurality and heterogeneity of the extensive document approved by the Conference of contexts, makes impossible to relate to each other by Regions and Autonomous Provinces (Istituto Superiore finding a common cross matrix. di Sanita’, 2020), gave a definition of the decision- Legal capacity (UN Convention on the Rights of Persons making capacity specifying that its evaluation falls with Disabilities, art. 12), ability to act (law n. 219/2017, within the sphere of responsibility entrusted to clinicians. art. 1, paragraph 5), ability to understand and want (law These are required to fulfill it with the traditional tools of n. 219/2017, art. 1, paragraph 1 and art. 5, paragraph 1), neuropsychological investigation combined with a inability to look after one's own interests (art. 404 of the careful functional evaluation of what the person can do civil code), ability to make a will (art. 591 of the civil in real life situations. The evaluation is therefore code), ability to consciously participate in the process multidimensional: after the clinical-anamnestic (art. 70 criminal procedure code), procedural capacity interview, it focuses on the neurological/geriatric (art. 75 civil procedure code) and ability to make a free dimensions completed by the neuropsychological and informed decision (Constitutional Court, ordinance evaluation and by the diagnostic-instrumental tests aimed n. 207/2018 and sentence n. 242/2019) are, thus, the so at excluding treatable secondary pathological forms. many known and formalized faces of the capacity present The assessment involves the use of some international in the places of law that confirm its eclectic polysemy, scales, which would allow for the selection of two probably exacerbated by the vague links and the cohorts of patients: overlapping of meanings that infer from the different a) those with scores on the Mini Mental State expressions. Examination (MMSE) between 20 and 30 (Clinical In this way, capacity has become a juridical abstraction Dementia Rating – CDR 0.5-1.5) who would have very that is not easy to classify, also due to the extraordinary mild to mild cognitive limitations; resistance that it shows every time one tries to give it a b) those with MMSE scores below 20 (CDR equal to or unitary classification, fading – depending on the place – greater than 2.0, i.e. moderate to severe cognitive in juridical capacity, in imputability, in ability to act, in impairments) who would not be able to give valid that of standing in court, in the ability to make a will and consent and who could be further evaluated by the in the ability to understand and want, to quote some of its administration of other neurocognitive tests, such as the explanations of dubious significance. Mac Arthur Competence Assessment Tool-Treatment However, it is on the ability to understand and want that (MacCAT-7), a 21-item scale (which takes 15-20 refers the law n. 219 of 2017 (Cappelli, 2021). minutes to administer) or with simpler analytical “Regulations on informed consent and advance treatment methods such as the University of California San Diego provisions”, whilst the Constitutional Court, in more Brief Assessment of Capacity to Consent (UBACC) appropriate terms, has repeatedly referred to the person’s (Jeste et al., 2007). ability to make a free and informed decision, without Naturally, one wonders, as AIP did, whether these tests however entering into the merits of how this should be are really able of selecting people capable of giving their explored. consent from those unable to do so, who therefore should This is an area on which discussion continues, as there be initiated towards their legal incapacity, as are doubts as to whether the rationality of the scientific recommended by the ISS. It should be considered that the model is capable of exploring the quality, authenticity MMSE is not a diagnostic tool created for this specific and robustness of decision making, with the rigor purpose and that the more sophisticated evaluation envisaged by the method of experimental science, as a scales, such as the MacCAT-7, while exploring the reproducible and unquestionable final judgment because domains of reasoning, planning, choice and control it is formulated on the basis of the criteria established by (complex cognitive processes), elude other important a universal scientific law. aspects (e.g., the social, relational, affective and 64 International Journal of Science Annals, Vol. 7, No. 1, 2024 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa emotional ones) which certainly affect every choice of coping with her loneliness, loss of hope and unbearable life. suffering. In fact, rationality is an extraordinarily complex process, Her contacts with the Belgian doctors, as confirmed by often fallible because it can be influenced by many choice the procedural reconstruction of the affair, were repeated alternatives, which are in turn influenced by not only – this cannot be denied – but what seems to emerge is cognitive but also emotional, social and environmental their ritual formality with the apparent renunciation of processes. making any useful attempt to give the woman the support At this point, we should ask ourselves if the selection of and comfort she needed. those who are able to make a treatment decision from This could have been achieved not only by setting up a those who are not can be operated with these diagnostic new therapeutic plan which, probably, would not have tools and if the traditional scientific model, with its had the desired effect (due to the patient’s weak logical spectrum with a hypothetical-deductive matrix, is compliance, also testified by her most complete distrust a tool suitable for achieving this specific purpose and in psychiatric care), but above all by providing her with whether or not it complies with the provisions of art. 12 the psychological support that the Italian law of 2017 of the UN Convention on the Rights of Persons with confirmed to be indispensable in all cases of therapeutic Disabilities (CRPD) (Cembrani et al., 2022) and the need refusal. not to discriminate against people in the exercise of their Support that could have strengthened relationships with freedom rights. friends and recovered the family affections that However, the question remains open, even if what is Mrs. de Troyer had interrupted for little-investigated beyond dispute is that the decision to die of Madame de reasons, even admitting that her inner feeling could be Troyer was not targeted by any particular verification, influenced by the aggressive behavior of her son, who whose robustness was taken for granted by the two later became the true and only protagonist of the judicial doctors who finalized her euthanasia, without dispute initiated for the alleged violation of Belgian law, considering that major depressive disorder is capable of: which was then examined by the Supreme Court of a) interfering with the generative process of emotional Justice. responses (Joorman & Stanton, 2016) due to a frequent Moreover, her relationship with her daughter was not distortion of information caused by cognitive biases in completely severed by the latter, given her reply to her interpretation and memory processes; mother’s email in which she declared that she accepted b) to compromise – more or less severely – the domains her decision to die, albeit with great pain. This confirms of memory, attention and executive functions (Marazziti that an attempt should have been made in re-establishing et al., 2010) with overall cognitive dysfunction emerging family relations, if only for a better accompaniment of in demanding rather than automatic processes (Hartlage the woman in her last life project. et al., 2018). However, friends (who therefore existed) took part in it. The result is impaired executive functions and a Mr. P. D., met on 20 March 2012, and described as a dysregulation of emotion control (Vazquez & trusted person, was the one the woman confided the inner Hernangómez, 2009). need to write a farewell letter addressed to her children. The result is also a reduced cognitive control over the cognitive biases that make depressive symptoms chronic Conclusions and dysregulation in the control of negative emotions Formulating definitive conclusions from cases that have (Grahek et al., 2018) the neurobiological cause of which reached trial in the courtrooms is almost always a could be identified in the reduced functioning of the gamble, not only because the procedural reconstruction anterior cingulate cortex, of the ventral prefrontal cortex of events usually shows profiles of incompleteness but (Beevers, 2005) and the dorsolateral one (Li et al., 2010). above all because the decision taken in sentence by the What really were the cognitive impairments of Judges is a confounding factor that may influence the Mrs. Godelieva de Troyer is evident from the final comment. reconstruction of the facts carried out by the Judges of Nonetheless, news stories are an extraordinary training the European Court of Justice: the robustness of her ground that motivates and trains reflection. decision-making capacity has been only partially In the story here described, we wanted to try our hand investigated. without the ambition of arriving at an absolute truth. Only by Dr. T. the woman was described as lucid and The case of Mrs. de Troyer raises many questions reasonable, even if it is not known whether these general concerning the robustness of the decision-making notes have been confirmed by a more in-depth test capacity of people suffering from major depressive evaluation so as to investigate those cognitive and disorder, which – in our opinion – must always be careful emotional domains (and, with them, suggestibility) that and in-depth, considering that their management cannot may be negatively affected by major depressive disorder. be limited to the pharmacological approach alone. On the Need to Also Give Depressed People the This assumes particular importance when the legal asset Necessary Support for the Maturation of Life Choices put at risk is the defence of life. In addition to evaluating the robustness of Mrs. de To all effects – even in the Italian legislation – this is the Troyer’s decision-making capacity, we still have to ask cornerstone of democratic life, which opens up to all the ourselves in what concrete ways her taking charge could other rights and freedoms inscribed in the human person. and should have been strengthened with the aim of 65 International Journal of Science Annals, Vol. 7, No. 1, 2024 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Ethical Approval situazioni di vulnerabilità, di debolezza e di The case involved is a public case (European Court of razionalità limitata: Iniziali riflessioni a margine Human Rights Judgment n. 78017 of 4 October 2022, della sentenza n. 50 del 15 febbraio 2022 della Mortier vs. Belgique). 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International Journal of Science Annals, 7(1), 60–68. https://doi.org/10.26697/ijsa.2024.1.1 The electronic version of this article is complete. It can be found online in the IJSA Archive https://ijsa.culturehealth.org/en/arhiv This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/deed.en). 68