RSS 1.0Ethics and Law
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Impact of community treatment orders on inpatient bed usage in assertive outreach teamAims. To examine the impact of using Communty Treatment Orders (CTO) of the Mental Health Act on use of inpatient care in Assertive Outreach team. Background. Currently there is little evidence of the efficacy of community treatment orders (CTOs), and in particular with patients who use the Assertive Outreach service. One large randomised controlled study found no impact on use of inpatient care while a naturalistc study found significant impact. Method. Our primary outcome was the number of admissions with and without a CTO comparing each patient with themselves before CTO and under CTO( mirror-image ). Our secondary outcomes were the number of bed days, and the percentage of missed community visits post-discharge. We also looked at the potential cost savings of a reduction in inpatient bed usage. Result. All the 63 patients studied over period of 6 years had a severe and enduring mental illness. The use of a CTO was linked to a significant reduction in the number of admissions (mean difference = 0.89, 95% CI = 0.53-1.25, P < 0.0001) and bed days (mean difference = 158.65, 95% CI = 102.21-215.09, P < 0.0001) There was no significant difference in the percentage of missed community visits post-discharge. Looking at the costs, an average cost for an inpatient Assertive Outreach bed per day in the local Trust was 250, and there were 8145 bed days saved in total, making a potential saving of just over 2million, during the study period. Conclusion. This study suggests that the implementation of CTOs using clinical judgment and knowledge of patients can significantly reduce the bed usage of Assertive Outreach patients. The financial implications of CTOs need to be reviewed further, but this study does suggest that the implementation of CTOs is a cost-effective intervention and is economically advantageous to the local Trust.
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Assessing the priority of human rights and mental health: the PHRAME approachBACKGROUND: Protecting all human rights of people with mental health conditions is globally important. However, to facilitate practical implementation of rights, it is often necessary to decide which of these rights should be given priority, especially when they conflict with each other. AIMS: The aim of the Priorities of Human Rights and Mental Health (PHRAME) project is to develop a replicable approach to establish a proposed set of high-priority human rights of people with mental health conditions, to facilitate practical decision-making and implementation of such rights. METHOD: A two-stage Delphi-style study with stakeholders was conducted to generate a list of key rights of people with mental health conditions, and rank priorities among these rights in terms of feasibility, urgency and overall importance. RESULTS: The stakeholders in this study consistently ranked three rights as top priorities: (a) the right to freedom from torture, cruel inhuman treatment and punishment; (b) the right to health and access to services/treatment; and (c) the right to protection and safety in emergency situations. CONCLUSIONS: Insights from PHRAME can support decision-making about the priority to be given to human rights, to guide practical action. This approach can also be used to assess how human rights are prioritised in different settings and by different stakeholders. This study identifies the clear need for a central voice for people with lived experience in research and implementation of decisions about the priority of human rights, ensuring that action respects the opinion of people whose rights are directly affected.
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Plausible subjective experience versus fallible corroborative evidence: The formulation of insanity in Nigerian criminal courtsInsanity as a defence against criminal conduct has been known since antiquity. Going through significant reformulations across centuries, different jurisdictions across the globe, including Nigeria, have come to adopt various strains of the insanity defence, with the presence of mental disorder being the causative mechanism of the crime as their central theme. A critical ingredient in the Nigerian insanity plea is the presence of 'mental disease' or 'natural mental infirmity' as the basis for the lack of capacity in certain cognitive and behavioural domains resulting in the offence. Mental disorders, which are the biomedical formulations of this critical legal constituent are primarily subjective experiences with variable objective features. Using illustrative cases based on psycho-legal formulation as well as reform-oriented and fundamental legal research, it is shown that Nigerian courts have held that claims of insanity based on the accused person's evidence alone should be regarded as "suspect" and not to be "taken seriously." Thus, Nigerian judicial opinions rely on non-expert accounts of defendants' apparent behavioural abnormalities and reported familial vulnerability to mental illness, amongst other facts while conventionally discountenancing the defendants' plausible phenomenological experiences validated by expert psychiatric opinion in reaching a conclusion of legal insanity. While legal positivism would be supportive of the prevailing judicial attitude in entrenching the validity of the disposition in its tenuous precedential utility, legal realism invites the proponents of justice and fairness to interrogate the merit of such preferential views which are not supported by scientific evidence or philosophical reasoning. This paper argues that disregarding the subjective experience of the defendant, particularly in the presence of sustainable expert opinion when it stands unrebutted is not in the interest of justice. This judicial posturing towards mentally abnormal offenders should be reformed on the basis of current multidisciplinary knowledge. Learning from the South African legislation, formalising the involvement of mental health professionals in insanity plea cases, ensures that courts are guided by professional opinion and offers a model for reform.
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The Mental Health Act 1983 (as amended in 2007) reform – How proposed changes potentially impact personality disorder servicesAbstract: At the beginning of this year, the UK government released a White Paper on Reforms of the 1983 Mental Health Act (MHA) aiming to achieve higher quality, accessible mental health care, as well as empowering people detained under MHA during the process and continuation of detention. In this piece, we focus on the potential impact of the proposal around appropriate care, management and detention of people with Personality Disorder (PD) within the criminal justice system (CJS), psychiatric service provision and community routes. We briefly review the historical context of reforms of PD services in the UK and discuss the proposed changes and issues in relation to the criteria of least restriction, detention and therapeutic benefit. We highlight the complexity around referral routes and logistics barriers for secure PD services that might hamper speeded referral routes and raise concerns around responsibility for authorisation of transfers in the context of risk of serious harm to the public. We emphasise the complex treatment needs of individuals with PDs and how these are potentially not met. We also discuss the shift of focus from reactive care to preventative measures and early intervention in the community for individuals with mild-to-moderate levels of PD. We highlight the need for appropriate integrative services in the community to facilitate assessment across services, identification of complex needs and support options including earlier routine screening and potential digital interventions to optimise specialised care for PD.
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Mental disability, the European Convention on Human Rights and Fundamental Rights and Freedoms, and the sustainable development goalsThe Sustainable Development Goals (SDGs) arrive at an interesting time in disabilities law. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) was passed by the General Assembly (GA) in December 2006, and came into effect less than two years later. The ethos of the CRPD has notable consistencies with the SDGs, sharing objectives relating to the attainment of substantive equality for all. The intersections are at their most visible in provisions relating to economic, social and cultural rights: both contain provisions promoting rights to health, education, gender equality, employment, access to justice, and the development of inclusive societies. This chapter discusses that the CRPD is widely understood as having introduced a 'new paradigm' for disabilities law, 17 applying both to its articulation of social and economic rights and, at least as significantly, to its articulation of civil and political rights. That new paradigm is reflected in the synergies noted above between the CRPD and the SDGs, and is based on much firmer expectations of equality, non-discrimination and community integration than previously. It is unclear how far that new approach is permeating into broader human rights discourse, even at the level of other United Nations bodies. (PsycInfo Database Record (c) 2021 APA, all rights reserved) (Source: chapter)
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At the interface between paradigms: English mental capacity law and the CRPDThe United Nations Convention on the Rights of Persons with Disabilities (CRPD) is rightly seen as a break from the past in mental capacity law. At the same time, implementation will occur in the specific existing legal and administrative contexts of each State. This article uses English mental capacity law to explore these issues. The English Mental Capacity Act 2005 (MCA) can be considered the best of the "old" paradigm. The article argues that there are continuities between it and a CRPD-compliant approach. These continuities should be built upon. Further, the implementation of the MCA is still in recent memory. The lessons of that implementation will have considerable application to moves toward CRPD compliance. CRPD compliance is not just about specialist stator guardianship régimes. It is also about a myriad of law, currently capacity based, located in specific legal areas such as contract, wills and succession, and criminal law. Reform in these areas will involve not just disability law, but successful integration into those other legal areas, a matter requiring the involvement of those knowledgeable in those other areas. Since change in these areas will involve the removal of disability as a gateway criterion, they will affect the public as a whole, and the thus, determination of the degree and sort of intervention that the broader public will consider appropriate.
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Articulating future directions of law reform for compulsory mental health admission and treatment in Hong KongThis article explores and outlines four possible pathways for law reform in the area of compulsory mental health admission and treatment in Hong Kong: the (i) abolition, (ii) risk of harm, (iii) mental capacity and (iv) consensus pathways. The discussion of each pathway takes into account local challenges in implementation, as well as Hong Kong's international commitments for the protection of rights. In outlining these pathways for reform, the authors intend to also provide a blueprint for regulatory change in other jurisdictions that are in the process of reforming their mental health laws. © 2019 Elsevier Ltd
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The new mental health law in ArgentinaThe Argentinean Congreso de la Nacion (National Congress, or Parliament) approved in November 2010 a new Mental Health Law (MHL) (Law 26657, 'Salud Publica. Derecho a la Proteccion de la Salud Mental' [Public Health. The Right to Protect Mental Health]). Although it is not the first law concerning mental health - as several of the provinces and the autonomous city of Buenos Aires (Argentina's capital) have enacted their own - the MHL establishes principles for human rights and the protection of patients, and aims to develop approaches in mental health that are compatible with the most advanced views and legislation from high-income countries. In this paper we report on the most important aspects of the MHL. We highlight areas that represent a change for Argentina, such as the new arrangements for both informal and compulsory admission to hospital.
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The UK government should withdraw from the Convention on the Rights of Persons with DisabilitiesMany psychiatrists in the UK may be surprised to find that the Government ratified a convention ten years ago that suggests compulsory mental health treatment be prohibited. The Convention on the Rights of Persons with Disabilities is arguably the most important legal instrument that no one in psychiatry ever discusses, but if moved from ratification to enforcement it would have enormous effect on day-to-day practice. Here, Dr Paul Gosney argues that the convention if enforced would be damaging for the people it aims to protect, whereas Professor Peter Bartlett defends it as a necessary challenge to the inequalities in our current system.
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Capacity, consent and the lawAs health care professionals we owe a duty of care to our patients. Our patients have a right to autonomy – to make their own decisions. If we impose treatment on them against their wishes, when they have capacity to make a decision to refuse treatment, then we may be committing the tort of battery; if we fail to treat them when they lack capacity to make treatment decisions we may be found to be negligent.
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New legislation in the UK designed to increase public safety - a psychiatric viewNo abstract available
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Mental disability and the European Convention on Human RightsMental disability has come of age as a subject of concern under the European Convention on Human Rights. It was only in 1979 that the first significant decision of the ECHR was decided on the subject, and after that, cases were relatively few for many years. It is only recently that this has begun to change. This volume provides an account of where the law currently stands and speculation as to how it may develop. The initial chapters deal with substantive aspects of Convention rights (including issues of detention in institutions, conditions within institutions, medical treatment, problems associated with guardianship and others). The final two chapters move to discuss the practicalities of litigation. The book concludes with a number of appendices (primarily the primary international legal materials of relevance to mental disability rights under the ECHR, and the relevant recommendations and principles from the Council of Europe). It is hope that this volume, in addition to shedding light on where the law currently stands, will offer practical guidance to lawyers concerning the mechanics of representing people with mental disabilities.
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Reactions and consequences following judgements by the European Court of Human Rights in the UKThe Convention for the Protection of Human Rights and Fundamental Freedoms first came into force in 1953. The European Court of Human Rights was set up in 1959. In the UK, the Human Rights Act 1998 came into force in 2000 bringing the rights set out in the Convention into domestic law. Some commentators at that time feared that this would lead to an increase in cases brought by patients alleging violations of their fundamental rights, however, this did not occur. There have been a number of cases brought to the European Court of Human Rights, both prior to the Human Rights Act and subsequently after the UK courts had been exhausted. Recent relevant cases relate to voting rights for prisoners, indeterminate sentences and the sex offender register. In all these cases UK policy has been found to be incompatible with the Convention, however, subsequent change in national policy has been slow despite these rulings. In the UK, the concept of human rights has been met with increasing critcism and politicians have openly discussed the possiblity of abandoning the Human Rights Act or even leaving the Convention for the Protection of Human Rights. There is, worryingly, a view that the protection of human rights, particularly of offenders, interferes with UK policy development and that certain groups of individuals should not have the privilege of such protection.
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What informs and shapes ethical practice in intellectual disability services?Background: Theoretical literature in the intellectual disability (ID) field identified a mismatch between professional codes of practice (which assume clients to be 'autonomous') and the reality of fostering autonomy for people with ID (who at times are completely dependent on others). This research aimed to understand how professionals bridged this disjunction and actually provided ethical services with this client group. Method: Nine professionals from adult ID services who had consulted with local Ethical Advisory Groups were interviewed about their experience of addressing an ethical issue within their work. Accounts were subjected to narrative analysis. Results: Professionals' narratives featured the following themes: differing sources of conflict, professional vulnerability and seeking validation around resolution, centrality of relationships, fragility of resolutions and maintaining moral integrity. Conclusions: Findings revealed systemic pressure on professionals to find 'definitive' solutions to ethical dilemmas when the issues were not open to such resolution. Findings were reviewed in light of ethical literature that shows how professionals' work inevitably features close and enduring relationships with people with ID. We suggest professionals need to draw on ethical frameworks that can accommodate relational aspects of their practice. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
