Thèse Psychiatrie Palliative et Futilité Épistémique Défis Éthiques de la Prise en Charge des Dépressions Résistante au Traitement H/F - Doctorat.Gouv.Fr

Établissement : Université Paris-Saclay GS Santé publique École doctorale : Santé Publique Laboratoire de recherche : Centre de Recherche en épidémiologie et Santé des populations Direction de la thèse : Marta SPRANZI ORCID 0009000508925387 Début de la thèse : 2026-10-01 Date limite de candidature : 2026-05-08T23:59:59 Palliative psychiatry is an approach aimed at improving the quality of life of individuals living with severe and persistent mental illness (SPMI) by prioritizing the prevention and relief of suffering, reducing harm, and avoiding burdensome interventions with limited expected benefit. SPMI typically refers to chronic psychiatric conditions such as schizophrenia, bipolar disorder, major depressive disorder (MDD), anorexia nervosa, and personality disorders in adults (generally defined as individuals over 18 years old), characterized by longterm functional impairment and sustained disability despite adequate, evidencebased treatment.
Within this landscape, major depressive disorder (MDD) becomes particularly complex when symptoms persist despite adequate treatment, leading to chronic or treatmentresistant forms associated with enduring suffering, functional decline, and repeated therapeutic failures. Although MDD is not associated with imminent mortality, these situations raise difficult questions about irremediability, appropriate goals of care, and the possible relevance of palliative approaches.

Recent work has highlighted the absence of clear guidance on when further treatment should be considered futile, how irremediability should be evaluated, and under what conditions a shift from curative to palliative aims is ethically justified. In this context, the notion of epistemic futility becomes particularly important. It refers to situations in which clinicians judge further treatment as futile, not because ineffectiveness is demonstrable, but because the limits of knowledge, uncertainty, incomplete evidence, or emotional and cognitive constraints shape their interpretation of the clinical situation. These dynamics are especially visible in chronic and treatmentresistant forms of MDD, where prognostic markers are weak and clinicians' beliefs about the limits of care may influence decisions to continue, reduce, or reorient treatment, including toward harmreduction strategies or, in some jurisdictions, assisted dying.

This project examines how epistemic futility is conceptualized in the context of MDD, how clinical uncertainty shapes judgments about irremediability, and how these judgments influence decisions regarding care trajectories and goals. It investigates how psychiatrists deal with uncertainty when defining the limits of treatment, the extent to which their assessments are shaped by epistemic and contextual factors, and the ethical principles and safeguards that should guide decisions to maintain, limit, or shift the focus of care. The broader aim is to protect patient autonomy, reduce epistemic injustice, and clarify when a palliative orientation may be ethically warranted in major depressive disorder.
Treatmentresistant major depressive disorder (TRD) is increasingly recognized as a form of severe and persistent mental illness, marked by chronicity, functional impairment, and sustained suffering despite longterm, evidencebased treatment. As treatment attempts accumulate and the likelihood of remission decreases, clinicians and patients face significant uncertainty regarding prognosis, treatment sequencing, and the limits of curative care.
Clinicians face uncertainty regarding prognosis, treatment limits, and when further interventions may be futile. The lack of shared criteria for evaluating irremediability, combined with epistemic challenges, raises ethical tensions in deciding whether to continue curative approaches or shift toward palliative care. This project addresses these challenges by integrating conceptual analysis with empirical insights from psychiatric practice.
a. To explore the conceptual, ethical, and epistemological foundations of futility and irremediability in TR-MDD.
b. To analyze how psychiatrists construct and apply judgments of epistemic futility in clinical practice, and how these influence treatment decisions.
c. To examine the ethical implications of such judgments in relation to autonomy, beneficence, non-maleficence, and justice. This project adopts a hybrid theoretical-empirical methodology. It begins with a conceptual analysis of the literature on palliative psychiatry, futility, irremediability, and major depressive disorder, in order to clarify the meaning and ethical implications of epistemic futility. This theoretical work will be complemented by semistructured interviews with psychiatrists, designed to explore how they understand and apply notions of futility and irremediability in their clinical practice. Interview transcripts will be analyzed using sequential thematic analysis, progressing from case summaries to the identification of key themes and illustrative quotations.
Together, these two components will provide a rigorous and ethically informed understanding of how epistemic futility shapes decisionmaking in the care of individuals with treatmentresistant depression.

Master's degree in philosophy, applied ethics. In-depth knowledge of the context of psychiatric treatment. Knowledge and/or experience in clinical ethics and qualitative research.