Doute diagnostique et tiers compétents

Source : http://www.flickr.com/photos/thomasclaveirole/2372563326/

Critiquant le caractère inadapté du programme des études universitaires de médecine, le Professeur SEDEL ((L. Sedel, Chirurgien au bord de la crise de nerfs, p. 73, éd. Albin Michel, 2008.)) eut ce mot remarquable et plein de bon sens :

« […] Alors qu’il serait sans doute préférable d’apprendre à l’étudiant à faire des recherches sur le Net, de lui apprendre à se poser des questions et lui rappeler en permanence quelques idées simples : « Quand on ne sait pas, on demande, quand on n’écoute pas le malade, on est mauvais, quand on ne sait pas on s’abstient. » Est-ce trop demander ? »

Ce même bon sens se retrouve dans la rédaction des articles 32 et 33 du code de déontologie médicale, désormais codifiés aux articles R. 4127-32 et R. 4127-33 du code de la santé publique.

Le premier de ces textes impose au médecin qui a accepté de s’occuper d’un patient de lui prodiguer « des soins consciencieux, dévoués et fondés sur les données acquises de la science, en faisant appel, s’il y a lieu, à l’aide de tiers compétents ».

Le second exige qu’il élabore un diagnostic « avec le plus grand soin, en y consacrant le temps nécessaire, en s’aidant dans toute la mesure du possible des méthodes scientifiques les mieux adaptées, et, s’il y a lieu, de concours appropriés ».

Ces deux textes envisagent la même possibilité de recourir à des médecins en vue d’établir le diagnostic.

Par arrêt en date du 27 novembre 2008, la Cour de cassation a eu l’occasion de rappeler les règles en vigueur sus-décrites.

En l’espèce, une femme enceinte a subi une série d’échographies dont l’une au moins était spécialement justifiée par un doute du médecin radiologue, s’agissant du diagnostic. Ces examens de contrôle n’ont toutefois pas permis au praticien de lever toute incertitude. Le nouveau-né présentant à la naissance une agénésie de l’avant-bras droit et de la main droite, ses parents ont saisi le juge d’une action en réparation de leur préjudice personnel ainsi que de celui de leur enfant.

La Cour d’appel de Lyon a rejeté leur demande pour deux motifs :

  • toute réparation du préjudice de l’enfant né handicapé est exclue par application de l’article 1er de la loi n°2002-303 du 4 mars 2002,
  • l’échographie ne constitue pas un examen « fiable à 100 % » de sorte que le préjudice subi par les père et mère tient son origine dans « un aléa diagnostique inhérent à la technique utilisée » et non dans l’incompétence ou la négligence du radiologue.

Partant, l’existence d’une faute médicale n’est pas caractérisée et la responsabilité du médecin ne saurait être engagée.

La Cour de cassation a censuré ce raisonnement au visa des articles 32 et 33 du code de déontologie médicale. Elle décide que le médecin n’a pas la possibilité d’exercer un choix en présence d’un doute sur le diagnostic consécutif à un examen échographique : il a le « devoir (…) de recourir à l’aide de tiers compétents ou de concours appropriés ». Autrement dit, le médecin est responsable parce qu’il n’a pas mis en œuvre tous les moyens dont il disposait pour évacuer le doute qui avait justifié que la patiente subisse une échographie complémentaire.

Pour acquérir une certitude, le médecin est débiteur d’une obligation de moyens, issue du contrat médical conclu entre le patient et lui. Une solution somme toute classique et cohérente.

Omar YAHIA

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