Towards removing involuntary treatment

The Committee on Bioethics of the Council of Europe has been discussing, over the past few years, an additional protocol to the Oviedo Convention on Human Rights and Biomedicine on involuntary treatment of people with mental health issues.

The aim of the additional protocol (to article 7) is of course to safeguard the rights and freedoms of individuals as it was felt that the article was too broad and, “danger to oneself or to others”, could be over interpreted in some countries and abuse occurs either for political reasons or towards vulnerable people such as drug abusers, homeless and indeed people who may have certain predispositions that make us uncomfortable. Of course the latter is no reason why someone should be put inside.

I have keenly followed this argument on the committee as in Malta, no less, our mental hospital Mount Carmel, classic as the building may be, has become a landmark to label people. Dak kien ta’ Frankuni for example – everyone forgetting that the hospital was named after the owner of the property, Mr Franconi. However, unfortunately, no matter how much you do to old buildings, they remain what they are and the last time I visited the place, on a consultation, the courtyards and corridors are in the same state as they were when I was a medical student. Certainly, to be locked up under lock and key in this place under involuntary treatment is not the same as if one were to be put in the psychiatric ward at Mater Dei Hospital, where even the ergonomics of the place is so much better, and moreover, has no stigma attached to it.

The problem with treatment in these institutions is not the fact of having had a mental illness which required hospitalisation. Rather it lies in the stigma associated mostly with the institutions they are placed in. Let us not forget that Mount Carmel was indeed an institution in the past and for some people remains so. In Italy they had abolished institutions more than 40 years ago and now have only psychiatric wards in hospitals. Of course, they have the luxury of having more than one major hospital. Nevertheless, this is probably where we should be aiming.

Returning to the additional protocol, this has brought on some opposition from NGOs representing patients. A representative from Pace – the Parliamentary Assembly of the Council of Europe – was invited several times to our meetings and it seemed that she supports their cause. Indeed, we all do, but the aim of the document came under attack. Confronting this member I pointed out that it seems to me that the spirit of the additional protocol does not go in favour of article 7 but rather aims to explicitly state out the rights and to promote alternative measures in countries, and good clinical practice, so that people are not put in these places because of pressure from families or simply because they roam around the village and cause people to cringe. In no uncertain terms I decided to tell her that her problem seemed to lie with the Article 7 of the Oviedo Convention itself and not with the additional protocol. Indeed, confronting the latter would be giving more power to those who want to abuse the former. She replied that this is true but that removing the article itself would not be easy and the additional protocol would be re-enforcing, according to her, that the article remains.

Now I clearly understand these predicaments. I have seen people being abused. My students in ethics classes also bring in many cases for discussion such as those admitted because the mother could not tolerate the daughter (who had mental health issues) any longer, even though a different psychiatrist had told the daughter that he could take care of her outside hospital. An alternative measure could have been to encourage the daughter to live on her own. Cases like this only reinforce the fear of patients admitting to having mental health issues. Voluntary hospitalisation does a lot of good and we should not allow anything to taint this. But unfortunately, we do have cases when involuntary treatment is necessary. A case which I frequently relate in class comes from my own practice where, almost regularly once a year for about three years I had to admit a young man, who still lived with his parents, to hospital because he became very aggressive, agitated and delusional. Now this patient was under psychiatric care with a good consultant and sometimes he was admitted voluntarily. But it so happened that whenever he felt good, he stopped his treatment and invariably, after a month, he relapsed. No matter how much I explained to his parents to tell me when this happened, they invariably only called me when he was standing on the table threatening anyone who came close. I would call his psychiatrist and he would tell me to fill in the Schedule 2 form for sectioning and have to bring in the police for help. He would then go quietly. This was indeed unfortunate and the issue lay with the lack of education or stubbornness of the parents who let weeks go by before taking action.

On another occasion a young man, from a low socio-economic environment, went to the mental health clinic to try to get his parents into Mount Carmel hospital – one for alcoholism and one for gambling. He almost managed but luckily the doctor there decided to call me and I gave him the history that wasn’t being said. This man was their only son and knew his way around. He was boarded out from work, managed to get a disabled parking and depended on half of his parents’ pension, to pay for his renting an apartment. He saw this money being spent away and wished to lock them up. After I had explained this, the doctor of course refused to comply and I also explained to the man that they had a right to do what they liked with their money; gambling and alcohol are no reason to lock his parents up.

But there are cases when people have thanked psychiatrists for treating them, even when they did not accede. Mostly these are cases which come from low-socio economic or low-income families who do not know how to help their relatives with mental health, in time and properly, simply because they may resist. These are indeed unfortunate cases. But there are also people who due to a depression, or more often a severe form of bipolar disorder, become homeless, substance abusers and later become delusional. Their own delusions can render them dangerous to themselves and to others. Proper treatment and follow-up have helped a considerable number of people. They become productive and lead normal lives.

All the documents I have seen, from WHO, Unesco to the WMA, have held that involuntary treatment should be a last resort and that countries ought to introduce alternative measures. Conversely the CDRP – the Convention on the Rights of Persons with Disabilities, holds that this practice goes against its guidelines, that people should not be held on the grounds of the actual or perceived disability. The problem here lies in the fact that they interpret mental health as psychosocial, rather than biopsychosocial. Biological illness often needs hospitalisation. Just as the heart can have pathology, so can the brain, which is an organ as well. Our law states that one cannot hold some for more than a specific time and the psychiatrist must apply again if this is really necessary. The aim of the DH-BIO is to provide a more holistic approach to mental health and reduce involuntary treatment to when all other alternative measures have been exhausted.

The NGOs were always invited to meetings but failed to suggest other alternative measures than were already put forward by the committee, failing to see perhaps, and I say this with an utmost sense of responsibility as a person who hold a position of Family Medicine and Patients’ Rights at University, that collaboration is much better than confrontation. We need to increase community mental health professionals including doctors, nurses, psychologists and social workers if we are to control involuntary measures.

Pierre Mallia is Professor of Family Medicine and Patients’ Rights and teaches at the University of Malta. He chairs the Bioethics Research Programme of the Faculty of Medicine and Surgery. He also chairs the Bioethics Consultative Committee. This article is his personal opinion and does not represent the opinion of any committee or Board he serves on.