10 May 2013

Global psychiatry: stop deploying human rights rhetoric to justify forced psychiatric treatment

On Wednesday I gave a lecture at the University of Leeds. It was about human rights and the Movement for Global Mental Health. Let me outline one of the main points which I made. OliverTalks posts next week will cover the other points.

The Movement has two “specific goals of scaling up services for and protecting the human rights of people living with mental disorders.” (Patel et al, Lancet 2008). I argue that for all the good things it is doing, the Movement’s flirtatious relationship to human rights is unhelpful because like the best flirts, one doesn’t know what it means or how one should react.

For many in the Movement, human rights means being a nice doctor. For others, human rights are more threatening because rights concern the distribution of power and status. Psychiatrists wield immense power over the individual and have significant status in policy circles and the media.

Rights are used as a way of navigating our way through competing claims. But in psychiatry the conflict is in-built because in most jurisdictions in the world, a psychiatrist has the legal power to override someone’s refusal of treatment. Psychiatrists make the claim for treatment, sometimes couching this in the right to health and non-discrimination terms. Patients sometimes have a competing claim to bodily and mental integrity, freedom from torture and other forms of ill-treatment and to freedom from abuse and exploitation: they have the right to say no. The language and practice of rights heightens the sense of conflict.

For some doctors, human rights boil down to imposing treatment whether the patient likes it or not. This is an idiosyncratic and intolerant view that is contradicted by firmly-established human rights law. For example, Norman Sartorius (former president of the world and European psychiatric associations and former director of the WHO’s mental health division) gave a speech on human rights at a conference organised by the Movement in London in March 2013. He said that, “advocates for the human rights of the mentally ill neglect to highlight the importance of fulfilling human duties which contribute to self-stigmatisation.” I think this coded message means: a mad person has the duty to accept treatment for his madness because by not accepting treatment, the mad person will bring stigma onto himself by being mad and/or doing mad things. Sartorius then dismissed a recent report on torture in healthcare by the UN Special Rapporteur on Torture as “an obstacle to care” which should be “thrown out.” I urge psychiatrists to join the discourse about human rights implementation, on the understanding that they (like human rights people such as me) may not hold all the answers.

This fantasy utopia of sanity exemplifies a medical model of disability hell-bent on fixing the individual. A social model of disability was pioneered at the Centre for Disability Studies at the University of Leeds. It rejects this approach. The very treaty which Norman Sartorius deploys to defend his views does also. One need only read until Article 3 of the UN Convention on the Rights of Persons with Disabilities to find the principle of “[r]espect for difference and acceptance of persons with disabilities as part of human diversity and humanity.”

Sartorius’s views are aligned to those of the World Psychiatric Association whose former president wrote in The Lancet in 2011 that “The first indisputable right of a person with a mental disorder is to find in the public health system a professional who is able to understand the nature of that disorder.” Not the right to life, or freedom from torture, but the right to find knowledgeable psychiatrists. The second “unquestionable” right “is to receive an intervention for that disorder that accords with available research evidence, within the limitations of the local context.” It’s also a right for this disorder to be “managed in a setting that is decent, humane, and non-abusive” and for the person’s mental illness not to prevent him from having “a full affective and social life”.

This ranking is rank. It relies on no research asking users and survivors of psychiatry about their views but rather unconvincingly relies on the author’s authority. The views perpetuate an approach that the disordered mind (or brain?) is a machine which needs to be fixed; fixed before one could countenance leading a fulfilling life.

What are the stated views of the he World Psychiatric Association? Its document most relevant to human rights is the “Madrid Declaration on Ethical Standards of Psychiatric Practice”, written in 1996 and revised in 1999, 2002 and 2011 (remember the CRPD was adopted in 2006).

Does this document ensure that psychiatrists’ practices comply with established international human rights law? Not at all.

We learn that, “[e]thical practice is based on the psychiatrist’s individual sense of responsibility to the patient and judgment in determining what is correct and appropriate conduct.” It continues: “[e]xternal standards and influences such as professional codes of conduct, the study of ethics, or the rule of law by themselves will not guarantee the ethical practice of medicine.” It says that nothing should get in the way of the patient’s “right” to receive best treatment possible.

In a section entitled “Protection of the rights of psychiatrists” (my emphasis), we are told that “psychiatrists ought to have the right to [… institute] effective treatment and management protocols in accordance to best practices and evidence-based medicine.” That is an interesting deployment of the word “right”.

These idiosyncratic and intolerant views are contradicted by human rights standards. Those who speak on behalf of the Global Movement for Mental Health should cease and desist using the rhetoric of human rights to legitimise forced treatment. As we know, such treatment – however well intentioned – can amount to torture, inhuman and degrading treatment and punishment which enjoy an absolute prohibition under international law.