 Introduction: Notes on the evolution of patient rights
The development of the rights of mental patients is the result of a confluence of social and political forces at precise historical moments. The process generally starts with a public awareness of the issues, which is fed into the political system, which in turn creates legislation to enact mechanisms for the protection and safeguard of the rights of mental patients.
In the 19th century in the Western world and countries with similar legislation the perception of the public and government alike of mental patients was centred on their "dangerousness", or risk to public harm, and the legislation was directed to the protection of the public. The detention of the patient required the signature of a physician or magistrate and the period of detention was indefinite. Limitations to this detention began to appear gradually in the first half of the 20th century. The criterion remained largely "danger" but the requirement for detention included the signature of one or more physicians or magistrates and was limited to a period of one or two years with mandatory review by a physician or government officials. It was not until the Second World War that the public concern with civil liberties and human rights in general found expression in national and international legislation. The landmark of this movement was the Universal Declaration of Human Rights of the United Nations of 1948.
Consequently, the UN developed legal instruments for the protection of groups vulnerable to human rights abuse, namely: (Power point image 1)
· Racial, religious and ethnic minorities
· Victims of political persecution
· Women, children and the elderly
· Family, marriage an youth
· Indigenous and tribal people in independent countries
· Prisoners of War (POWs)
· Civilians in times of war
· Civil prisoners
· Refugees, asylum seekers and stateless persons
· The labour force
· The unemployed
· The poor and economically disadvantaged individuals and nations.
· The physically disabled
· The mentally ill
· The mentally retarded
· Victims of torture and Cruel, Inhuman or Degrading Treatment or Punishment
National and Regional legislations constantly expand this list to include
· Victims of domestic violence
· Gays and lesbians
· People infected with HIV
· Others
Each one of these groups has had relevant UN legislation to protect their rights (UN, 1994).
The enactment of those rights has very much depended on the capacity of each group to advocate on their own behalf. Thus the civil rights movement in North America in the 1960s and 70s, for example, was responsible for major advances in federal and state or provincial legislation. The difference between the majority of the vulnerable groups and the mentally ill is that the mentally ill persons find more difficult advocate for themselves. Their capacity is changing slowly but are still largely dependent on their family, the state, or the health professions to speak or act on their behalf. One such example was the mental health movement of the late 1950s and 60s.
UN legislation
The Universal Declaration of Human Rights of the United Nations (UN, 1948) states:
Article 9, "No one shall be subjected to arbitrary arrest, detention or exile."
At a level specific for the mentally ill the UN proclaimed the "Principles for the protection of persons with mental illness and improvement of mental health care", 1991 and the Declaration on the Rights of the Mentally Retarded Persons, 1971. The "Principles for the protection of persons with mental illness and improvement of mental health care", 1991, declare:
Principle 1, on Fundamental freedoms and basic rights, Article 6: "Any decision that by reason of his or her mental illness, a person lacks legal capacity, and any decision that, in consequence of such incapacity, a personal representative shall be appointed, shall be made only after a fair hearing by an independent and impartial tribunal established by domestic law. The person whose capacity is at issue shall be entitled to be represented by counsel". "Decisions regarding capacity and the need of a personal representative shall be reviewed at reasonable interviews prescribed by domestic law. The person whose capacity is at issue, his or her personal representative, if any, and any other interested person shall have the right to appeal to a higher court against any such decision."
Principle 4, on Determination of mental illness, Article 2: "A determination of mental illness shall never be made on the basis of political, economic or social status, of membership of a cultural, racial or religious group, or any other reason not directly relevant to mental illness."
Principle 9, on Treatment, Article 1: "Every person shall have the right to be treated in the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the patient"s health needs and the need to protect the physical safety of others."
Principle 11, on Consent to treatment, Article 1: "No treatment shall be given to a patient without his or her informed consent except as provided for in [other] paragraphs."
Principle 12, on Notice of rights, Article 1: "A person in a mental health facility shall be informed as soon as possible after admission, in a form and language which the patient understands, of his or her rights according to this principle and domestic law."
Principle 16 relates to involuntary admission.
Principle 17 refers to an independent and impartial Review Body to which an involuntary patient may apply to review her detention and for the purpose of release or change to voluntary status at reasonable intervals as specified by domestic law.
Principle 18 refers to procedural safeguards such as the patient"s right to choose and appoint a counsel to represent the patient as such and if necessary to the services of an interpreter.
Persons with mental illness have also rights related to privacy, confidentiality, freedom of communication and access to information. (Principles 6, 13, 19)
The Principles apply to all persons admitted to a mental health facility, regardless of whether they are in fact mentally ill. (Principle 24)
The above legislation and its implicit spirit have found their way, more or less successfully, into the legislation of many countries.
Overview of the international legislation
A very cursory review of the legislation for the protection of rights of the mentally ill would have to distinguish between countries whose legislation is based on British common law, in fact English speaking countries (England and Wales, Australia, New Zeeland, USA and Canada and some other countries member of the British Commonwealth) and civil law countries, mostly Continental Europe ( France, Spain, Germany, Netherlands, Italy, etc.) and most of their former colonies in Africa, Asia and Latin America.
Recent reviews of mental health and forensic services in a number of countries do indeed show a very uneven development and rarely, outside a handful of countries, mention in their reports on patient rights and safeguards for their detention and forceful treatment. The main concerns in those countries reviewed are services, training, research, ethical issues in medical practice, low status of psychiatry with respect to other specialties, and the resources required for a fair balance between inpatient care and community services, but seldom, if ever, are patient rights mentioned. This may be in some cases due to the focus or interest of the reviewer. (International Journal of Law and Psychiatry, 2000)
In England and Wales the Mental Health Act 1983 spells out safety procedures for admission, detention and appeal. There is no provision for outpatient or community involuntary treatment, a practice that we shall see quite developed in North America. There is a new mental health act being drafted with considerable controversy as to the admission and treatment of personality disorders to mental institutions.
In New Zealand the Mental Health Act introduced in 1992 contains a number of innovations when compared with previous acts. Among others noted are the creation of comprehensive procedures for review and appeals of decisions about the patient"s condition and legal status, the specifications of the rights of the patients subject to involuntary and treatment and the establishment of a legal framework for community treatment orders. (Brinded, 2000. In Special Issue: International Perspectives on Forensic Mental Health Systems)
In Australia the Burdekin Report, 1993, outlines the needed balance between the rights of the public and those of the patient (International Psychiatry. Bulletin of the Board of International Affairs of the Royal College of Psychiatrists, Oct. 6 issue, 2004).
In Poland in 1994 a mental health act appeared for the first time. The Parliamentary Act of 1999, promoted the expansion of mental health services. Safeguards for the detention of patients depend on a second consultation by a psychiatrist.
(International Psychiatry. Bulletin of the Board of International Affairs of the Royal College of Psychiatrists, Oct. 6 issue, 2004).
In Russia legislation dating from 1992 facilitated more democratic and humanistic detention procedures. After 48 hours the case is reviewed by other psychiatrists, which is mandatory every six months with provision for appeals to tribunals and courts.
In Italy the mental health reform of 1978 (Law 180) represented a radical change from custodial practices to community treatment with major general steps towards patients" autonomy and rights. (International Journal of Law and Psychiatry, 2000)
In Spain in 1985 a mental health reform updated legislation to modern community mental health care standards. The specific legislation for involuntary detention was enacted in 2001. Evaluation reports are beginning to appear.
In Buenos Aires, Argentina, detention is largely by judiciary procedure with the next of kin and the public guardian required to consent to the involuntary admission.
In many Latin American countries no procedural reviews are in place. (International Psychiatry. Bulletin of the Board of International Affairs of the Royal College of Psychiatrists, Oct. 6 issue, 2004).
In the Philippines there is no mental health act.
In Japan the law of 1988, amended in 1999, established psychiatric review boards for the protection of patients.
European countries as a group deserve special attention. In 1950 they adopted the Convention for the Protection of Human Rights and Fundamental Freedoms in which Article 5 states: Everyone has the right to liberty and security of the person. Article 19 establishes a European commission of human rights and European court of human rights (UN, 1997; Kingdon et al., 2004). The Commission was merged into the European Court by the 11th Protocol of the ECHR, in force since No. 1, 1998.
The Council of Europe, representing 45 states, in 1994 in the Parliamentary Assembly accepted Recommendation 1235 on Psychiatry and Human Rights (Council of Europe, 1994) which was much more specific about the rights of people with mental disorder. The Convention provides, on Involuntary Admissions and Detention:
Article 5(1)(e) of the ECHR as interpreted by the European Court of Human Rights places the following limitations on involuntary detention of persons on grounds of mental illness:
1) government must comply with domestic law by following all democratically imposed criteria and procedures.
2) government must act consistently with the purpose of confinement, which is to provide care and treatment in the person"s best interests. This means that authorities may not act arbitrarily and that the circumstances and conditions of confinement must be compatible with treatment rather than punishment.
3) the person must be suffering from a mental illness sufficient to justify confinement and must continue to suffer from such a mental illness. Government, moreover, must produce independent evidence that reliably diagnoses the person as mentally ill within internationally accepted medical standards.
4) Government may not detain persons for an unreasonable period when they are subject to conditional release into the community.
Psychosurgery and electroconvulsive therapy are addressed specifically. Mechanical restraint is forbidden as is the use of isolation cells. Pharmaceutical restraint should be limited and in proportion to the perceived risk. New recommendations include the obligation to immediately inform people of their rights, further direction on ethical research and the provision of "sociotherapy programs" for detained individuals with personality disorders. This Recommendation has been further developed by a Working Party on Human Rights in Psychiatry, 1996, to "ensure the protection of the human rights and dignity of people with mental disorder, specifically those placed as involuntary patients in a psychiatric establishment." It defines the right to be informed of their rights as patients, to have treatment discussed, reviewed and revised regularly by trained and qualified staff, in the least restrictive environment and with adequate satisfaction of other physical and social needs. (Kingdon et al. 2004)
In June 7, 1999, the Organization of American States adopted the Inter-American Convention on the Elimination of All Forms of Discrimination Against Persons with Disabilities. This Convention aims to eliminate all forms of discrimination against
persons with disabilities, including those with mental disabilities, and
encourages states to make efforts toward completely integrating persons with
disabilities into society. The Convention has not yet gone into effect. (http://www.cidh.oas.org/basicos/disability.htm.)
It should be noted at this point that the Declaration of Hawaii by the World Psychiatric Association, 1977, was the first general agreement by the psychiatric community on minimal ethical standards and acknowledged the conflicts that can exist between the physician (specially the psychiatrist), the patient and society and provided specific guidelines as needed. It was a necessary step to deal with reports of widespread political abuse of psychiatry. The World Psychiatric Association followed with a charter on the rights of people with mental illness, Madrid Declaration on Ethical Standards for Psychiatric Practice, of 1996, amended in 1999 and 2002-2005, to protect psychiatric patients from discrimination and ill treatment with ethical guidelines for psychiatrists. (WPA, 2002)
Canadian Mental Health Legislation
The Canadian Charter of Rights and Freedoms, Articles 7, 9 and 10 (Part 1 of Canadian Constitutional Act, 1982) reflects international human rights standards as elaborated by the UN and other international bodies:
"Article 7. Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice".
Article 10. Everybody has the right on arrest or detention to: a) be informed promptly of the reasons thereof; b) retain and instruct counsel without delay and to be informed of that right; c) have the validity of the detention determined by way of habeas corpus (written command to have the person brought to a court to investigate the lawfulness of the detention) and to be released if the detention is not lawful."
Just like the Universal Declaration was incorporated into de Canadian Charter specific, this and others UN legal instruments found there expression in the Canadian and Ontario mental health legislation. In fact, they read like the forerunner of the Mental Health of Ontario and other Canadian provinces, as they should, since Canada is a charter member of the UN obliged to enact its declarations, covenants and agreements.
In Canada, the federal government legislates health care by means of the Canadian Health Act. Provinces issue their own statutes and acts regulating practice. All provinces, including the Province of Quebec, which has a legal system based on civil law (as opposed to British common law tradition), have basically the same procedures and criteria for commitment, safeguards and appeal. The provinces of British Columbia, Saskatchewan and Ontario have exemplary though not flawless mechanisms for the protection of patient rights while they are involuntarily detained in mental hospitals or admitted to other health care facilities. Procedural safeguards are instituted for treatment with consent and more recently for the provision of community or outpatient involuntary treatment called community treatment orders (CTOs).
This paper will review in some detail the Ontario mental health legislation with its procedures and safeguards for patient rights as an example of a well-developed system to protect psychiatric patients" rights. Another reason for presenting this legislation is because it is the one I know best and with which I have direct experience. I shall review the legislation, first as it refers to involuntary patient admission and then to treatment consent and to community treatment orders. As we shall see this legislation reads like a replica of the legal instrument provided by the United Nations, the Council of Europe and compares well to any of the most progressive states.
Involuntary Detention and Admission
In Ontario, mental health legislation is mainly defined by the Mental Health Act, the Health Care Consent Act, 1996, and the Substitute Decisions Act, 1992. This legislation is the centre of attention in this paper. (Government of Ontario, 2004)
The reason for the parsimony in the presentation of this legal background to the rights of patients is to make obvious to all of us the awesome responsibility of the doctor who deprives a person of the right to freedom without having committed any criminal offence. The legislation aims at protecting the rights of patients and persons with a mental illness, including the right to treatment and care, while at the same time ensuring the public rights and safety. The doctor is obliged to make sure that these persons have all their inherent rights respected, which are the right to information and reason for their detention, the right to counsel and the right to appear in front of an independent and competent tribunal to determine the validity of their detention, and to be released if the detention is not lawful.
Those powers and responsibilities are granted to the psychiatrist by virtue of those Acts. Most frequently the psychiatrist is called to invoke the Mental Health Act in the detention and admission of a person to a mental institution. This is the purpose is obliged to fill a number of basic documents, in fact legally prescribed statutory forms or certificates . Forms 1, 3, 4 and 5 of the Act: Form 1 Application by Physician for psychiatric assessment, (Section 15 MH Act); forms 3 and 4, Certificate of Involuntary Admission, (Section 20 of the Mental Health Act).
Forms 1, 3 and 4 stipulate that the person is mentally ill, is not suitable for voluntary admission and that he or she meets a number of criteria, pin pointed in specific paragraph or for boxes A and B. The following are the criteria for Box A and Box B (slides).
Form 1 (certificate) contains in as of the recommendation by the doctor to detain this person for assessment for 72 hours; in Form 3 the doctor certifies that the patient should be admitted and detained involuntarily for two weeks; and subsequently in its renewals (Form 4s), which permit the involuntary detention for longer periods of time up to three months.
After listing the relevant criteria in Box A and Box B the of forms 3 and 4 "the signing physician must: 1) give the patient a properly executed Form 30; 2) notice notify a rights adviser."; 3) send this form forthwith to the "officer in charge" for review; and inform the patient the grounds for the detention and of his or her right to challenge the certificate at a hearing of the Board and to counsel.
Form 30, in fact, gives notice to the patient of the reasons for his o her detention, literary "To inform you that you have been detained under the authority of a certificate of involuntary admission (Form 3) or certificate of renewal (Form 4). It also informs the patient that "if you wish to challenge your detention, you have a right to a hearing before the Board. You may apply for a hearing by completing a Form 16". This application by the patient is what triggers the hearing before the Board and gives the Board jurisdiction. Form 30 also includes notice to the rights advisor that the patient has been admitted involuntarily. Form 30, however, does not specify that this form "must be sent to the officer in charge for review", although this is a requirement under Section 20 (A) of the MHA. It requires that "following completion and filing of a certificate of involuntary admission or renewal the officer in charge (defined as the highest administrative authority of the institution) or its delegate shall review the documents to ascertain whether or not they are filled in compliance with the criteria outlined in the Act." The OIC shall inform the attending physician that upon review the documents are correct. There is no statutory form for the OIC/delegate to inform the MD, but it must be documented in some way that it has been done. This is done, most frequently by countersigning and dating Forms 3/4). The requirement to file Form 3 or 4 with the OIC is also listed as a duty of the attending physician in Section 20 (1) (c) of the Act.
Capacity to consent
This legislation is based on the following principles:
· No treatment without consent
· In principle, all persons are considered capable (there is no age limit to consent)
· A person is capable, if
a) is able to understand the information that is relevant to making a decision about treatment, and
b) is able to appreciate the reasonable foreseeable consequences of a decision or lack of a decision. There some discussion as to the meaning of "able". Most people think that "able" in this Act refers the capacity to understand not only in an abstract sense but in the patient current context and circumstances. A patient may understand the meaning of mental illness and the particular treatment, but, lacking insight or judgement, not that the diagnosis or treatment are applicable to him or herself. Contrariwise, a person may be able to understand the information on the treatment proposed and the benefits and risks as they pertain to his case, and still reason in his estimation the risks are not worth the benefits and choose not to have the treatment. (Case Starson vs. Swayze)
People who are able to make their own decision for their own treatment have the right to make foolish, silly or even fatal decisions. If the person is incapable, a Substitute Decision Maker must be found according to ranking criteria under the Act. People making decisions for other people have clear restrictions and must follow a set of rules:
A. Prior wishes expressed by the patient, if known, must be followed and
B. best interests are applicable when previous wishes are absent. They must be determined according to values and beliefs of the patient and to whether the treatment will likely result in improvement of the condition or delay or prevent deterioration, the benefits outweigh the risk of harm and whether a less restrictive or intensive treatment would be just as beneficial as the treatment proposed.
The forms and documents required in the assessment of capacity are basically two: Form A or the application by the patient to the Board to review a finding of incapacity by the doctor under Section 32(1), 50(1) and 65(1) of the Health Care Consent Act of 1996; and Form 33, of notice to the patient under Section 38(4), 15(1) of the Mental Health Act, that he or she has been found
1. not mentally competent to examine your own clinical records.
2. not mentally competent to consent to disclosure of your own clinical records.
3. not mentally competent to manage property.
4. not mentally capable to consent to treatment of a mental disorder, as defined under the Health Care Consent Act.
Community Treatment Orders
In December 2000, the amendment to the Mental Health Act 1987 and 1989 introduced the concept of Community Treatment Order (CTO) and its clinical application. Beside the criteria of dangerousness or risk to the self or other it added the criterion of likelihood or risk of "physical or mental deterioration" of the patient. CTOs have been a controversial innovation with important challenges as to their compatibility with the Charter of Rights. It is also argued that it is a slippery slope to forced treatment in the community and that its effectiveness is still to be proven. (O"Reilly, 2004)
This concept and practice is not limited to Ontario but is already employed in a few other countries, including the United States under the term of Mandatory Treatment Orders or Involuntary Outpatient Treatment, and with minor variations in other Canadian provinces, including British Columbia and Saskatchewan. In various states of the U.S., namely North Carolina, and in Saskatchewan evaluation studies show that effectiveness is related to the length under CTOs (longer than six months) and very much depends on the CTO plan of treatment and services available. The criteria for effectiveness are prevention of re-hospitalization, community tenure and improvement in the quality of life.(Swartz, 2004)
The purpose of CTOs is to provide a person who suffers from a serious mental disorder with a comprehensive plan of community-based treatment that is less restrictive than being detained in a psychiatric facility. The CTO criteria are listed on Form 45 under Section 33(1) 33(3) (2). This form is the main instrument that the psychiatrist must fill to initiate the CTO. The criteria are as follows:
· in the last three years the person has been a patient in a psychiatric facility on two or more separate occasions or for a cumulative period of 30 days in that three year period
· it is the least restrictive, because the person has shown non-compliance after discharge and will likely be non-compliant with the likelihood of subsequent deterioration and readmission under form 1.
· Is not capable or competent to consent to treatment.
Besides the filling of form 45, the psychiatrist is also responsible for discussing the Treatment Plan with the other participants in the treatment and assuring that the treatment is available in the community.
Principles and Guidelines for Psychiatrists to Present at the Hearings of Review Boards and Tribunals
As for the psychiatric profession, a number of observations and recommendations are appropriate at this point. It is not the first time that psychiatry and psychiatrists in most of the world were required to go through profound changes in their conceptual paradigms and practices. Since World War II new models of thinking and treating patients erupted into the field of psychiatry. After a critical period of change, impact and adjustment the profession took the best of those ideas that other professions had to offer and incorporated them into an evolving medical and psychiatric model. Consider the arrival of psychoanalysis and other psychological schools in the 1940s and 50s, epidemiology and sociology in the 1960s, the community mental health model and legislation of the 1960s and 70s, the anthropologists with their emphasis on specific cultural context, and more recently the biomedical theories and research with their powerful impact on the psychopharmacological approach to treatment, the corporate and market economy model in management and clinical practice, and finally, the current and growing human rights movements as applicable to psychiatric treatment and care. Psychiatry and psychiatrists adapted and survived those changes. The profession became much richer for it. The same challenge is in front of us: How do we integrate into our own thinking and practice the best that the human rights movement can offer us for the benefit of our patients and our profession.
Below is a list of practical guidelines for the psychiatrists and other medical practitioners to facilitate our compliance with the requirements of the law and provide the clinical reasoning that will satisfy appeal boards or review tribunals of the validity of the treatment we may have recommended. I am using as an example the presentation of psychiatrists at the hearings of a particular mental health review tribunal, the Consent and Capacity Board of Ontario.
1. The hearings of the Consent and Capacity Board of Ontario (CCB) are primarily a medico-legal procedure, not a medical procedure. At the hearings the Board administers mainly the Mental Health Act of 1990 as amended in 2004, the Health Care Consent Act, 1996, and the Substitute Decisions Act, 1992, of the province of Ontario
2. The psychiatrist is there to pursue the best treatment interests of the patient.
3. The role of the patient"s counsel is to advance the legal interests of his or her client.
4. The Board is not there to look after the best interests of the patient, but to assure that clinical practice meet the requirements of the law. Therefore
5. The presentation of the psychiatrist at the hearing is a clinical presentation with specific treatment and care recommendations, be it involuntary admission, incapacity to consent to treatment or to manage property, etc.
6. Since it is the psychiatrist, not the hospital nor any other witness, who signed the documents with the prescribed care and treatment which have been appealed, it is her or his responsibility to produce the evidence and reasons for such recommendations.
7. The psychiatrist"s testimony consists of a clinical history and observations made directly by her or himself or by other witnesses. He or she may submit other selected documents to support his/her case. As a party to the hearing the psychiatrist has the right to call witnesses. As the hearings are open to the public, medical students and other trainees may be present as observers.
8. Unless represented by counsel, the psychiatrist will direct his or her own presentation and the testimony of his or her witnesses.
9. The purpose of calling witnesses is to support the psychiatrist"s medico-legal recommendations by asking them questions that may yield evidence on specific points on which they posses direct and expert information. (Open-ended questions, global narratives or questions beyond their direct observation or expertise tend to be repetitious and to lengthen the hearing. Precise and pointed questioning of witness will support the psychiatrist"s recommendations and make the hearing more efficient). Witnesses can be cross-examined. Collateral or hearsay evidence can be sufficient but at the Board hearings will give to it less weight than to directly observed evidence.
10. Proper preparation of the hearing will considerably reduce time and cost. A brief clinical history in a traditional format should emphasize those points which will support the psychiatrist"s recommendations by meeting the requirements of the Statutes.
11. This Clinical Summary and recommendations preferably should be prepared and typed the day before the hearing and handed over to the patient"s counsel and the Board before the hearing to give them time to read it. (In other countries a written psychiatric report is required, as is also the case in Ontario when a doctor has to appear in front of the Review Board to defend a treatment recommendation for the mentally ill offender. The Summary or report could be introduced as an exhibit and therefore need not be read completely by the doctor at the hearing, although certain passages may be highlighted and given orally. (Among other advantages of the clinical summary are that it protects the patient-doctor relationship from the strain of revealing openly private information, and that the patient"s counsel is also less likely to cross-examine the doctor).
12. Copies of the selected documents or notes from medical records can be attached to the Clinical Summary as exhibits.
13. As a Summary or as a Final Submission of the presentation, it is advisable that the psychiatrist reviews, keeps in mind, refers to the specific sections of the various acts, point by point if necessary, and bring to bear upon them the pertinent clinical information which constitute the criteria or grounds for his/her recommendations. The submissions are an explanation by the parties (in most cases the doctor and legal counsel) of what the evidence means and how the Board should respond to it.
14. The hearings, though informal, are nevertheless quasi-judicial procedures. They are an enquiry, not a trial with adversarial dynamics.
15. If the presenting doctor is concerned with the manner or line of questioning of the patient"s counsel, he/she should ask the Chairman or Presiding Member of the Board for advise on how to respond to such questioning.
16. In the same vein the doctor should display due courtesy and professional conduct at all times. Failure to do so may result in the Board reporting the doctor to the College of Physicians and Surgeons of Ontario, or in other jurisdictions to the pertinent professional disciplinary body.
Summary and conclusions
The psychiatrists called to an appeal tribunal, review board or hearing to explain and justify her or his treatment recommendations is presented, in fact, with a number of important opportunities:
1. To enhance the treatment of their patients by adding to the treatment the authority and support of the law.
2. To promote the role of the psychiatrist as a leading member of the mental health treatment team.
3. To gain recognition and support from the hospital administration for the services provided by the institution and its programs.
4. Maintain and enhance the tradition of the psychiatrist"s humane concern the respect for the rights and dignity of psychiatric patients.
5. Finally, to lobby the government, as the insurer of services, or the client as the context may call for recognition or payment for the time invested in the preparation and at the hearings as a service provided.
With many thanks for your attention
Federico Allodi, MD
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References
Bindman, J., Maingay, S., and Szmuckler. (2003) The Human Rights Act and mental health legislation. British Journal of Psychiatry. 182, 9194
Brinded, PMJ (2000). In Special Issue: International Perspectives on Forensic Mental Health Systems. Op cit.
Council of Europe (2000) White Paper regarding a Draft Recommendation on Legal Protection of Persons Suffering from Mental Disorder Especially Those Placed as Involuntary Patients. Strasburg: Council of Europe
Government of Canada (1982) Canadian Charter of Rights and Freedoms, Articles 7, 9 and 10 of the Legal Rights (Part 1 of Canadian Constitutional Act). Ottawa
Government of Ontario (2004) Ontario Consent and Capacity Legislation, 2004-2005 Edition. An Unofficial Publishers Compilation. Aurora, Ontario, Canada: Canada Law Book Inc.
International Journal of Law and Psychiatry (2000) Special Issue: International Perspectives on Forensic Mental Health Systems, Vol. 23 (No. 5-6), September/October-November/December. Pergamon Press
International Psychiatry. Bulletin of the Board of International Affairs of the Royal College of Psychiatrists (2004) Oct. 6 issue.
Kingdon, D., Jones, C.R., and Lonnqvist, J. (2004) Protecting the human rights of people with mental disorder: New recommendations emerging from the Council of Europe. British Journal of Psychiatry, Vol. 185, p. 277-279
O"Reilly, R. (2004) Why are community treatment orders controversial? Review. Canadian Journal of Psychiatry, Vol. 49, p. 579-584
Swartz, MS and Swanson, JW (2004) Involuntary outpatient commitment, community treatment orders, and assisted outpatient treatment: What"s in the data? Review. Canadian Journal of Psychiatry, Vol. 49, p.585-591
United Nations (1994) Human Rights. A Compilation of International Instruments, Vol. I and II. New York and Geneva: United Nations.
United Nations (1994) Universal Declaration of Human Rights (1948). Op. cit.
United Nations (1991) Principles for the protection of persons with mental illness and improvement of mental health care. Op. cit.
United Nations (1971) Declaration on the Rights of the Mentally Retarded Persons. Op. cit.
United Nations (1997)Compilation of International Instruments, Vol. II, Regional Instruments., New York, Geneva: United Nations
World Psychiatric Association Charter on the rights of people with mental illness, Madrid Declaration on Ethical Standards for psychiatric Practice, of 1996, amended in 1999 and 2002-2005
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