24 September 1999
The ICB makes a short critical comment on the “White Paper” prepared by the Steering Committee on Bioethics of the Council of Europe (CDBI), a document dedicated to the protection of human rights and dignity of people suffering from mental disorders especially those admitted as involuntary patients in a psychiatric establishment.
The ICB adopts the following standpoints:
1) it considers both acceptable and appropriate the proposals stating that involuntary hospitalisation should only take place for therapeutic reasons and that the new legal instrument should equally apply to both involuntary hospitalisation and treatment as determined by the framework of the criminal justice system.
2) it gives assent, to the classification of mental disorders, for legislative purposes,
as mental illness stricto sensu, psychiatric handicaps and personality disorders, in coherence with the D.S.M. revising the old distinction between psychosis and neurosis, and it agrees that the medical and legal concept of “mental incapacity” plays a fundamental role in legislation both in terms of informed consent and obligatory medical treatment;
3) it consents, on abstract grounds, to making a distinction between the juridical basis for involuntary hospitalisation and involuntary treatment; however, it considers it rather utopian to believe that individuals admitted against their will could be able to choose a form of treatment; the ICB is convinced that the reasons for the forced admittance must be specified in a scientific manner, and the act itself carried out using extreme circumspection and avoiding any abuse; it is conscious of the need to strike a balance between the two principles of beneficence and autonomy, with regard to the criteria for defence of civil rights, foreseeing the possibility to utilise alternative therapies, wherever appropriate to the individual’s clinical situation (e.g. day-hospital or home treatment etc.);
4) it believes that the relevant independent authority deciding on involuntary hospitalisation and treatment should be composed of a judicial authority supported by the obligatory (but not binding) opinion of a competent psychiatrist;
5) it declares that, in emergency cases, it is ethically correct to proceed with admittance and treatment, based on the medical advice of more than one doctor and without waiting for the decision of the competent authority; which, however, will be called on to validate the decision.
6) it strongly advises against the use of neurosurgery in psychiatry, in the absence of appropriate and controlled research;
7) it insists on the protection of the personal dignity of defendants with mental disorders, the therapeutic aspect should always take precedence over penal and custodial procedures;
8) the recovery of personal and social skills and the encouragement of the actual sick person to progressively fully develop the ability to recognise and exercise civil and political rights should be among the principle objectives;
9) it states that the use of restraint and isolation must be drastically reduced and only practised in exceptional cases when there are no other alternatives or in states of emergency and should only be used for limited periods of time.
As regards the question of procreation, the ICB points out that genetic research into mental illness is still at the research stage. However the indications in several publications on both schizophrenia and depression induce the use of extreme caution.
As far as the right to communication is concerned, the ICB affirms that restrictions can only be enforced in exceptional and scrupulously motivated situations, considering the importance that communication has for mental health.
Lastly, the Committee underlines that the “White Paper” lacks any mention of the need to give support and help to the families of psychiatric patients. As the many years of experience in Italy shows, “voluntary” treatment is only effective if there is strong support from the community within the individual’s living and family environment.