Dignity, human rights and the limits of mental health legislation

Involuntary status and mental capacity for treatment decisions under Sections 4, 3, and 57 of Ireland's Mental Health Act, 2001: analysis and recommendations for reform

Although significant progress has been made in Irish mental health law in recent decades, the Mental Health Act, 2001 still falls short of properly protecting human rights. A consideration of human rights developments, both domestically and internationally, highlights the urgent need for reform. In this paper we consider Sections 4 ('Best interests'), 3 ('Mental disorder') and 57 ('Treatment not requiring consent') of the 2001 Act and related recommendations in the 2015 Report of the Expert Group on the Review of the Mental Health Act, 2001, and suggest specific areas for reform. Just as medicine evolves over time, so too does our understanding of human rights and law. While embracing a human rights-based approach to the extent suggested here might be seen as aspirational, it is important to balance achievable goals with higher ideals if progress is to be made and rights are to be respected.

Human rights in mental healthcare; A review of current global situation

The relationship between mental health and human rights is complex and bidirectional. Global mental health movements have been emphasizing the promotion of human rights in mental health care in accordance with the UN Convention on the Rights of Persons with Disabilities and the WHO QualityRights Initiative. The main objective of this review is to have an overview of the current global situation of human rights in mental health services by performing a review of scientific literature. The literature search and elimination process yielded a total of 26 articles focussing on human rights-related reports and tools. Further assessment of these articles clearly shows that despite significant improvements in mental health service delivery in the past decade, there is still substantial reporting of the continuing prominence of stigmatizing attitudes, and human rights violations and abuses in mental health settings. The human rights perspective requires society, particularly policymakers, to actively promote necessary conditions for all individuals to fully realize their rights. We suggest developing a more comprehensive model in mental health that integrates human rights into existing services and approaches. A model that recognizes that all people with mental health conditions and psychosocial disabilities are rights holders.

Dignity, coercion and involuntary psychiatric care: a study of involuntary and voluntary psychiatry inpatients in Dublin

OBJECTIVES

There is a paucity of research about psychiatric inpatients' experience of dignity. Most of the limited literature on this topic is qualitative. Our study provides quantitative data about self-rated dignity among involuntary and voluntary psychiatry inpatients. We explore relationships between perceived dignity and legal status, coercion, level of insight, diagnosis, and therapeutic alliance, among other parameters.

METHODS

We recruited 107 participants aged 18 years or over from two inpatient psychiatric units in Dublin, Ireland over a 30-month period. Interviews consisted of structured, validated assessment tools. Demographic and clinical data were obtained from patient charts.

RESULTS

Patient Dignity Inventory (PDI) score was non-normally distributed (skewed to the right), with a median score of 63.0 out of 125 (inter-quartile range: 40.0-80.0). On multi-variable testing, lower self-rated dignity was associated with higher perceived coercion, better insight and more negative symptoms. There was no association between dignity and gender, employment status, marital status, ethnicity, age, admission status, diagnosis, working alliance, positive symptoms or cognition.

CONCLUSIONS

Lack of dignity is linked with perceived coercion and negative symptoms, and is seen in patients with better insight. These links merit further study if we are to understand patient dignity in a more nuanced and useful way.KEYPOINTSWe interviewed psychiatric inpatients using the Patient Dignity Inventory and other structured assessment tools.There was no significant difference between voluntary and involuntary patient groups' self-rated dignity.Less self-rated dignity was seen in patients with higher levels of perceived coercion.Patients with better insight reported lower dignity.Dignity scores were not significantly associated with age, gender, ethnicity, diagnosis or length of stay in hospital.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Reconsidering the ethics of compulsive treatment under the light of clinical psychiatry

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It focuses on how patients experience CT and its impact on their mental health and treatment programs, the reasons for the use of CT versus voluntary treatment and what efforts have been made to reduce, replace and refine the presence of CT in psychiatry.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

The role of Mental Health Care Act status in dignity-related complaints by psychiatric inpatients: A cross-sectional analytical study

Background

Globally interest has grown in promoting the rights of patients, especially psychiatric patients. Two core elements of patients’ rights are the rights to be treated in a dignified manner and to give feedback about services. Psychiatric patients may feel treated in an undignified manner, especially during involuntary hospital admissions.

Aim

We explored the relationship between Mental Health Care Act 17 of 2002 (MHCA) status and dignity-related complaints.

Setting

The study was conducted at a specialist state psychiatric hospital.

Methods

We reviewed 120 registered complaints by psychiatric inpatients, retrieved the clinical files, and analysed 70 complaints. Fisher’s exact tests described the relationship between patients’ MHCA status and the frequency of dignity-related or other categories of complaints. Logistic regression analyses were adjusted for potential covariates.

Results

Most complaints were from single, literate male patients, aged 30–39 years, with mood disorders. Most complainants were admitted involuntarily (60%). Dignity-related complaints (n = 41; 58%) outnumbered nondignity-related complaints (n = 29; 41%). The proportion of dignity-related complaints was higher in involuntary (64%) and assisted (60%) patients than in voluntary patients (44%). Dignity-related complaints were not significantly associated with MHCA status (χ² = 2.03 and p = 0.36). Involuntary patients were more than twice as likely as assisted and voluntary patients to complain about dignity-related matters (Odds ratio [OR]: 2.25; 95% confidence interval [CI] [0.71; 7.13]; p = 0.16).

Conclusion

Involuntary patients are more likely to complain about dignity-related matters. Qualitative research is recommended for a deeper understanding of patients’ experiences during admission.

Articulating future directions of law reform for compulsory mental health admission and treatment in Hong Kong

This article explores and outlines four possible pathways for law reform in the area of compulsory mental health admission and treatment in Hong Kong: the (i) abolition, (ii) risk of harm, (iii) mental capacity and (iv) consensus pathways. The discussion of each pathway takes into account local challenges in implementation, as well as Hong Kong's international commitments for the protection of rights. In outlining these pathways for reform, the authors intend to also provide a blueprint for regulatory change in other jurisdictions that are in the process of reforming their mental health laws.

Gendered denials: Vulnerability created by barriers to legal capacity for women and disabled women

This article explores the vulnerability that is created when legal capacity is denied to women and disabled women. It argues that vulnerability is largely contingent on social constructs - as opposed to being an inherent quality of disability or gender. It discusses barriers to the exercise of legal capacity that women and disabled women experience - such as limitations on reproductive choice, higher rates of substituted decision-making, and unique experiences with forced mental health treatment. It then explores evidence that such barriers are disempowering and can leave women and disabled women vulnerable to abuse and marginalisation. It explores financial, physical and sexual abuse that can occur as a result of this vulnerability. Finally, it concludes that autonomy and power are inextricably linked and can be essential for minimising vulnerability.

A human rights foundation for ethical mental health practice

There are close links between clinical ethics, human rights and the lived experience of mental illness and mental health care. Principles of professional ethics, national mental health legislation and international human rights conventions all address these themes in various ways. Even so, there are substantial deviations from acceptable standards at certain times, resulting in significant violations of rights in the developing and developed worlds. An explicitly human rights-based approach has improved matters in, for example, Scotland. External drivers of change, such as legislation, standards, codes of practice, inspections and sanctions for violations, are all needed. Attitudes and culture are also critical drivers of change. Most importantly, the principles and values of ethical, human rights-based professional practice need be taught and modelled throughout professional careers. Ongoing training in this area should form a central element of programmes of continuing professional development, delivered by people with expertise and understanding, including service users.

Best interests and the raison d’être of health care

The report of the expert group on the review of the Mental Health Act has recommended that the requirement to consider the best interests of the person be replaced by a list of guiding principles, which focus on the autonomy of the individual. The implied rationale for this is that acting in our patients’ best interests may be a violation of their human rights. Dignity is being proposed as an alternative way of capturing ‘the positive aspects associated with best interests’, but it is not clear how dignity is preferable to best interests. Both approaches may help protect the most vulnerable from exploitation. However, unlike best interests, dignity can be used as a synonym for autonomy. Valuing autonomy as a means to an end (instrumental value) should be distinguished from valuing autonomy as an end in itself (intrinsic value). As the ultimate end of instrumental autonomy is invariably the person’s best interests, abandoning that principle renders instrumental autonomy obsolete, leaving intrinsic autonomy as the supreme value. As best interest, dignity and autonomy rarely conflict, the proposed changes may appear minor, but they are not. When such values do conflict, acting against our patients’ interests may become inevitable.

Human rights in psychiatric practice: an overview for clinicians

Matters relating to human rights arise in almost every area of psychiatric practice. Although some statements of rights are non-binding declarations (e.g. the United Nations' Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care), others are legally binding (e.g. the European Convention on Human Rights) and actively shape national laws. Persons with mental illness commonly experience violations of rights, including their economic and social rights. Psychiatrists can promote human rights through high-quality, evidence-based clinical practice; patient-centred service management; social awareness and engagement; and international activism to enhance protection and promotion of the rights of people with mental illnesses at global level.