Caring for persons with mental illness: some bioethical issues

21 September 2017


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Within the complex and differentiated context of mental illness, the opinion intends to examine from the bioethical point of view the persistent critical issues in psychiatric care in
the territory, as well as the prospects offered by the recent closure of Judicial Psychiatric Hospitals (OPG ).
The bioethical perspective underlying the analysis is the treatment of those suffering from mental illness through the integration of “cure” that is centred on the neurobiological
components at the basis of the disease, and “care”, which deals with the suffering, subjectivity and needs of the actual person. 
This involves calling into question both the principles of clinical bioethics and social responsibility towards the enduring phenomenon of stigma and discrimination, insufficient
inclusion, lack of full recognition of fundamental human rights.
In the wake of the paradigm shift, with the closure of mental asylums, from the custodial to the therapeutic model, the opinion emphasises the bioethical tension towards
the treatment of those affected by mental illness oriented to the maintaining, as far as possible, of independence: a tension already present in the earlier opinions of the NBC
dedicated to the topic of mental health, and which is repeated here in the light of relevant international documents, such as the Helsinki Declaration on Mental Health in 2005 and
the UN Convention on the Rights of Persons with Disabilities 2007, but also in the light of analysis, comments and resolutions that, at international level, highlight the criticalities in the concrete realization of enshrined rights.
There is still a distance to be bridged between the ideal model of treatment of persons affected by mental illness that emerges in all its centrality, even from the Health
Action Plans for mental health proposed by the World Health Organization at various levels, and the concreteness of the practice.
The opinion focuses on the one and the other level: on the theoretical level, the references, declarations, conventions and international plans are accompanied by an analysis of the legal protection measures that our legal system provides for the protection of persons affected by mental illness; on the practical level, it analyzes the studies carried out in Italy on the mental health system, both as regards the services for acutely ill patients, as well as on residential facilities and district units.
These analyzes, the comparison between theory and practice, as well as the voices of Patient and Family Associations, have given rise to a list of priorities for a more effective
system of care which respects the rights of persons with mental illness by:
• overcoming the existing variability in the approach of services;
• increasing the capacity of residential facilities to discharge patients and let them
return home;
• identifying service quality indices;
• bridging the shortage of social interventions. which constitute one of the most
important barriers to reintegration
• increasing research;
• verifying the appropriateness of pharmacological intervention;
• giving effect to the right of patients to timely diagnosis and increasing the taking
into care of growing children and adolescents.
Regarding the closure of Judicial Psychiatric Hospitals and the new system of treatment - provided for by Law 81 of 2014 - for offenders deemed to be of unsound mind at the time of committing the offence and therefore acquitted, the opinion expresses appreciation for the principles underlying the new system and the establishment of REMS.
(Residences for the Execution of Security Measures)
In particular, it is recommended that the inspiration behind the law providing for individual rehabilitation projects within the territory for the acquitted, should be respected,
as a rule the execution of the custodial measure in REMS is to be considered the exception to be resorted to when no valid alternatives provide adequate therapeutic
This requires the strong commitment of the territorial services for the taking into care of those acquitted.
As regards the persistence of delays, shortcomings in assistance, stigma and discrimination, the NBC, in order to improve the living conditions of persons affected by
mental illness, makes the following recommendations to:
 initiate and support social communication campaigns;
 develop integration between “cure” and “care” in compliance with the principles of
the three Es, (Ethics, Evidence, Experience);
 establish a system for evaluating the quality of service provision;
 promote research, both on the pharmacological and psycho-social level;
 avoid inequalities between the various regions, ensuring that everyone living in our
country has the same standards of mental health care;
 counteract the decline in the staffing of territorial services by increasing resources
to reach the standards of spending of the most advanced European countries;
 support the families of people with mental illness, enhancing the support not only
of psychiatric services, but of the entire network of health and social services on
the territory;
 activate continuous training opportunities for operators;
 promote greater attention to mental health in childhood and adolescence;
 monitor the implementation of the new system of treatment after the closure of the
 ensure the rights of people with mental illness, in accordance with the UN
Convention on the Rights of Persons with Disabilities, with particular regard to freedom, equality before the law, social inclusion.

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