MEDICAL AND LEGAL ISSUES OF OBSERVING THE RIGHTS OF A PERSON WITH A MENTAL ILLNESS WHO HAS BECOME A PARTICIPANT IN CRIMINAL PROCEEDINGS.

There is no health without mental health. The rich links between mind, body and the environment have been well-documented for decades. As the third decade of the millennium begins, nowhere in the world has achieved parity between mental and physical health and this remains a significant human development challenge. An important message within that collective failure is that without addressing human rights seriously, any investment in mental health will not be effective. Attacks on universal human rights principles threaten the physical, political, social, and economic environment, and actively undermine the struggle for positive mental health and well-being. Mental health systems worldwide are dominated by a reductionist biomedical model that uses medicalization to justify coercion as a systemic practice and qualifies the diverse human responses to harmful underlying and social determinants (such as inequalities, discrimination, and violence) as "disorders" that need treatment. In such a context, the main principles of the Convention on the Rights of Persons with Disabilities are actively undermined and neglected. This approach ignores evidence that effective investments should target populations, relationships, and other determinants, rather than individuals and their brains. How that dominance is overcome requires transformative human rights action. However, action that focuses only on strengthening failing mental health-care systems and institutions is not compliant with the right to health. The locus of the action must be recalibrated to strengthen communities and expand evidence-based practice that reflects a diversity of experiences. Such community-led recalibration enables the necessary social integration and connection required to promote mental health and well-being more effectively and humanely.

What About Us? Experiences of Relatives Regarding Physician-Assisted Death for Patients Suffering from Mental Illness: A Qualitative Study.

Physician-assisted death (PAD) for patients suffering from mental illness is legally permitted in the Netherlands. Although patients' relatives are not entrusted with a legal role, former research revealed that physicians take into account the patient's social context and their well-being, in deciding whether or not to grant the request. However, these studies focussed on relatives' experiences in the context of PAD concerning patients with somatic illness. To date, nothing is known on their experiences in the context of PAD concerning the mentally ill. We studied the experiences of relatives with regard to a PAD request by patients suffering from mental illness. The data for this study were collected through 12 interviews with relatives of patients who have or had a PAD request because of a mental illness. We show that relatives are ambivalent regarding the patient's request for PAD and the following trajectory. Their ambivalence is characterised by their understanding of the wish to die and at the same time hoping that the patient would make another choice. Respondents' experiences regarding the process of the PAD request varied, from positive ('intimate') to negative ('extremely hard'). Some indicated that they wished to be more involved as they believe the road towards PAD should be a joint trajectory. To leave them out during such an important event is not only painful, but also harmful to the relative as it could potentially complicate their grieving process. Professional support during or after the PAD process was wanted by some, but not by all.

Guidelines for determining restorability of competency to stand trial and recommendations for involuntary treatment.

Over 50,000 defendants are referred for competency to stand trial evaluations each year in the United States (Psychological evaluations for the courts: A handbook for mental health professionals and lawyers, New York, NY: The Guildford Press; 2018). Approximately 20% of those individuals are found by courts to be incompetent and are referred for "restoration" or remediation (Psychological evaluations for the courts: A handbook for mental health professionals and lawyers, 4th edn. New York, NY: The Guildford Press; 2018; Bull Am Acad Psychiatry Law. 1991;19:63-9). The majority of those incompetent defendants meet criteria for psychotic illnesses (J Am Acad Psychiatry Law. 2007;35:34-43). Forensic mental health professionals frequently have such patients/defendants decline recommended treatment with psychotropic medication. For a significant minority of defendants diagnosed with psychotic disorders, treatment with medication is thought to be necessary to restore their competency to stand trial. Without psychiatric intervention to restore competency, defendants may be held for lengthy and costly hospitalizations while criminal proceedings are suspended. In these situations, clinicians are guided by the Supreme Court decision, Sell v. United States (2003). The Sell opinion describes several clinical issues courts must consider when determining whether a defendant can be treated involuntarily solely for the purpose of restoring his/her competency. This paper offers some guidance to clinicians and evaluators who are faced with making recommendations or decisions about involuntary treatment. Using a question and answer format, the authors discuss data that support a decision to request, or not request, court authorization for involuntary treatment. Specifically, eight questions are posed for forensic evaluators to consider in determining the prognosis or viability of successful treatment and restoration. Finally, a clinical vignette is also presented to highlight important factors to consider in Sell-related evaluations.

A qualitative study of clinicians' perspectives on independent rights advice for involuntary psychiatric patients in British Columbia, Canada.

BACKGROUND: In British Columbia (BC), Canada, clinicians are responsible for giving involuntary psychiatric patients rights information upon admission. Yet an investigation by the BC Office of the Ombudsperson found that clinicians are not always fulfilling this responsibility. The Ombudsperson recommended that the provincial government fund an independent body to give rights advice to patients. METHODS: To understand how clinicians feel about this recommendation, focus groups of clinicians who may give psychiatric patients rights information (n = 81) were conducted in Vancouver, BC, to probe their attitudes toward independent rights advisors. The focus group transcripts were thematically analyzed. RESULTS: Most clinicians believe that giving rights information is within their scope of practice, although some acknowledge that it poses a conflict of interest when the patient wishes to challenge the treatment team's decisions. Participants' chief concerns about an independent rights-advice service were that (a) patients may experience a delay in receiving their rights information, (b) integrating rights advisors into the workflow would complicate an already chaotic admission process, and (c) more patients would be counselled to challenge their hospitalization, leading to an increased administrative workload for clinical staff. However, many participants believed that independent rights advisors would be a positive addition to the admission process, both allowing clinicians to focus on treatment and serving as a source of rights-related information. CONCLUSIONS: Participants were generally amenable to an independent rights-advice service, suggesting that the introduction of rights advisors need not result in an adversarial relationship between treatment team and patient, as opponents of the proposal fear. Clearly distinguishing between basic rights information and in-depth rights advice could address several of the clinicians' concerns about the role that independent rights advisors would play in the involuntary admission process. Clinicians' and other stakeholders' concerns should be considered as the province develops its rights-advice service.

Policing mental illness: Police use of section 136 - Perspectives from police and mental-health nurses.

Ideological shifts in mental health-care policy such as deinstitutionalisation have meant police have had to make decisions about the care of persons with a mental-health crisis. This study examines how police in five English counties respond to crisis calls when employing the powers afforded in section 136 of the Mental Health Act 1983, and the effectiveness of the national Street Triage pilot scheme. Qualitative interviews with 30 police officers and mental-health nurses were collected as data sources. The analysis shows that police have previously struggled with the significant number of crisis calls, whilst also finding mental-health services inadequately sourced, leading to some detentions in police cells as alternatives to health-based places of safety. However, the scheme has made positive changes in alleviating these issues when mental-health nurses are co-located with police, highlighting the need to strengthen their partnership by facilitating the sharing of information, responsibilities and decision making in order to ensure police cells continue to be avoided as alternative places of safety.

Knowledge and Attitudes of Psychiatrists About the Gun Rights of Persons With Mental Illness.

Individuals with mental illness have often been misperceived by the public to pose a higher risk of violence to others. Consequently, the United States government and many individual states have enacted laws barring firearm access for certain individuals with mental illness. Many of these laws allow for eventual restoration of firearm access (i.e., relief from firearm disability (RFD)). This study assesses the knowledge base and attitudes of psychiatrists practicing in South Carolina regarding these gun laws. Results of this study indicate that psychiatrists in South Carolina have significant knowledge deficits pertaining to gun laws that both restrict gun ownership and allow restoration of gun ownership rights for persons with mental illness; these deficits may apply to practitioners in other states as well. The only variable that predicted a greater knowledge about limitations on gun rights was whether a psychiatrist had a patient who was prohibited from gun ownership. South Carolina psychiatrists had more favorable attitudes about restricting gun access for persons with mental illness than about supporting the right of persons with mental illness to own a gun. Finally, if psychiatrists owned a firearm, they were more likely to support the right of persons with mental illness to own a firearm.

The ongoing discussion on termination of life on request. A review from a German/European perspective.

BACKGROUND: Interest in the topic of termination of life has been growing for 2 decades. After legalisation of active euthanasia and assisted suicide (EAS) in the Netherlands in 2002, movements to implement similar laws started in other European countries. However, many people objected to legalisation on the basis of the experiences in the Netherlands and as a matter of principal. METHODS: This selected and focussed review presents the theoretical discussions about EAS and describes the respective parliamentary discussions in Germany and the data and experiences in the Netherlands. It also considers people with mental disorders in the context of termination-of-life services. RESULTS: So far, only a few European countries have introduced legislation on EAS. Legalisation of EAS in the Netherlands resulted in an unexpectedly large increase in cases. The number of people with mental disorders who terminate their lives on request remains low. CONCLUSIONS: Experience from the Netherlands shows that widening criteria for EAS has problematic consequences.KEY POINTSTermination of life on request, which a subgroup of people support, is a matter of ongoing debate.Because of several problematic aspects, including ethical considerations, only a few countries in the world allow active euthanasia or assisted suicide.Even if euthanasia is well regulated, legalising it can have problematic consequences that are difficult to control, such as an unwanted excessive increase in euthanasia cases.The well-documented experiences with the euthanasia law in the Netherlands serve as an example of what is to be expected when euthanasia is legalised.We need to pay close attention to the relationship between suicide and suicide prevention on the one hand and euthanasia acts and promotion of euthanasia on the other.Further ethical, psychological and legal research is needed. In particular, the role of palliative medicine in societies' approach to end-of-life care must be explored in much more detail.

Mental illness and the Lebanese criminal justice system: Practices and challenges.

Forensic mental health services are a necessity for individuals involved in the criminal justice system. Such services involve two generally independent functions: assessment and treatment. A jurisdiction's legal system is a determinant of how such services are provided and to whom. In our study, we identified the Lebanese laws that address the rights and protections given to a mentally disordered defendant in the criminal justice system. We then analyzed how the Lebanese judicial system interprets and applies the written law in cases where the mental health of the defendant was brought up as an issue. We found that Lebanon's insanity test has a cognitive and a volitional component. However, there does not seem to be a uniform process regulating the use of the insanity defense: statutes do not address the procedural details and the cases we reviewed used various processes to reach their decisions. Based on our findings, we explored avenues for potential improvement in the Lebanese forensic mental health system.

The Connecticut Experience with Sell Legislation.

Since 2004, Connecticut has had two different mechanisms for involuntary medication of defendants hospitalized for restoration of competence to stand trial. In this article, we first describe the development of these two mechanisms and compare their procedural elements. The first procedure required a hearing in criminal court, in a process parallel to the subsequent U.S. Supreme Court holding in Sell v. United States; the later procedure uses a civil mechanism in probate court and was enacted in response to the dicta in Sell regarding the preferential use of alternate mechanisms for involuntary medication orders. To compare the effectiveness and efficiency of the two mechanisms, we examined 1,455 admissions to the state's secure forensic hospital for competency restoration for the calendar years 2005 through 2011. Petitions for involuntary medication of defendants were filed in five cases in criminal court (0.3%) and in 177 cases (12.2%) in probate court. The probate mechanism resulted in a significantly shorter duration of the resolution of the competence matter. Both mechanisms were effective at restoring defendants' competency (i.e., two thirds were restored by the criminal court process, and nearly 74% were restored in the civil process).

El Documento de Voluntades Anticipadas como instrumento de planificación ético-jurídico: especial atención a la salud mental / Advance Directives as an ethic-legal planning tool in a mental health context / El Document de Voluntats Anticipades com a instrument de planificació ètico-jurídic: especial atenció a la salut mental

La relación médico-paciente se encuentra en un proceso de cambio y evolución hacia un tratamiento más humano, sustentado sobre el principio de autonomía, con el objetivo de respetar los derechos del paciente y no sólo imponer la voluntad del médico. Un instrumento que salvaguarda esta situación es el Documento de Voluntades Anticipadas, como extensión del consentimiento informado. A pesar de su regulación internacional y nacional, en ciertos contextos, como el de la salud mental, el modelo hegemónico-paternalista sigue imperando y nos preguntamos por qué

The doctor-patient relations are undergoing a process of change and evolution towards a more humane approach, based on the principle of autonomy , with the aim of respecting the rights of patients and not just imposing the will of the phyisician. Advance Directives, as an extension of Informed Consent documents, can further safeguard such rights. Despite its international and national regulation, in certain contexts, such as mental health, the hegemonic-paternalistic model persists, and the authors question the underlying motive

La relació metge-pacient es troba en un procés de canvi I evolució cap a un tractament més humà basat en el principi d'autonomia, amb l'objectiu de respectar els drets del pacient I no només imposar la voluntat de metge. Un instrument que salvaguarda aquesta situació és el Document de Voluntats Anticipades, com a extensió del consentiment informat. Malgrat la seva regulació internacional I nacional, en certs contextos, com el de la salut mental, el model hegemònic-paternalista segueix imperant I ens preguntem per què

A capacidade jurídica dos doentes e deficientes mentais com o novo Código Civil e Comercial Argentino - paralelo com o Estatuto da Pessoa com Deficiência no Brasil na relação médico-paciente / La capacidad jurídica de los enfermos y deficientes mentales con el nuevo Código Civil y Comercial argentino - paralelo con el Estatuto de la Persona con Discapacidad en Brasil en la relación médico-paciente / The legal capacity of mental patients and disabilities with the new Argentinian Civil and Commercial Code - parallel with the Status of the Disabled Person in Brazil in medical-patient relationship / La capacitat jurídica dels malalts i deficients mentals amb el nou Codi Civil i Comercial argentí - paral·lel amb l'Estatut de la Persona amb Discapacitat al Brasil en la relació metge-pacient

Este artigo debate as inovações trazidas com o Código Civil e Comercial argentino, junto a um paralelo com o Estatuto da Pessoa com Deficiência no Brasil, cujas leis se adequaram à Convenção de Nova York de 2006. A pesquisa partiu da análise de documentos normativos e autores de direito civil e bioética, de forma a questionar como se efetivará a manifestação de vontade dos doentes mentais na relação médico-paciente. Para tanto, será abordado inicialmente quais mudanças ocorreram na capacidade civil no ordenamento jurídico argentino. Após, discutir-se-á a relação entre autonomia e competência e sua configuração na relação médico-paciente, para após adentrar-se no consentimento dos doentes mentais. Por fim, comparar-se-á o tratamento dado a tais indivíduos com dois países

Este artículo analiza las innovaciones del Código Civil y Comercial argentino, haciendo un paralelo con el Estatuto de la Persona con Discapacidad en Brasil, cuyas leyes se adecuaron a la Convención de Nueva York de 2006. La investigación partió del análisis de documentos normativos y autores de derecho civil y bioética, para cuestionar cómo se efectúa la manifestación de voluntad de los enfermos mentales en la relación médico-paciente. Para ello, se abordará qué cambios ocurrieron en la capacidad civil en el ordenamiento jurídico argentino. Luego se discutirá la relación entre autonomía y competencia y su configuración en la relación médico-paciente, para después adentrarse en el consentimiento de los enfermos mentales. Por último, se comparará el tratamiento dado a tales individuos en ambos países

This article discusses the innovations brought with the Argentine Civil and Commercial Code, along with a parallel with the Statute of the Person with Disabilities in Brazil, whose laws were in line with the New York Convention of 2006. The research was based on the analysis of documents normative and authors of civil law and bioethics, in order to question how the manifestation of will of the mentally ill in the doctor-patient relationship will take place. To do so, it will be initially addressed what changes have occurred in civil capacity in the Argentine legal system. Afterwards, the relationship between autonomy and competence and its configuration in the doctor-patient relationship will be discussed, after entering into the consent of the mentally ill. Finally, the treatment given to such individuals with two countries will be compared

Aquest article analitza les innovacions del Codi Civil I Comercial argentí, fent un paral·lel amb l'Estatut de la Persona amb Discapacitat al Brasil, les lleis del qual es van adequar a la Convenció de Nova York de 2006. La investigació va partir de l'anàlisi de documents normatius I autors de dret civil I bioètica per qüestionar com s'efectua la manifestació de voluntat dels malalts mentals en la relació metge-pacient. Per a això, s'abordarà quins canvis van ocórrer en la capacitat civil en l'ordenament jurídic argentí. Després es discutirà la relació entre autonomia I competència I la seva configuració en la relació metge-pacient, per després endinsar-se en el consentiment dels malalts mentals. Finalment, es compararà el tractament donat a aquests individus als dos països

Predictors of shared decision making with people who have a serious mental illness and who are under justice supervision in the community.

Shared decision making (SDM) can be an effective method for promoting service involvement among persons with serious mental illness (SMI). This survey study sought to identify predictors of positive attitudes toward the use of SDM with people with SMI who are living under probation and parole supervision. Supervising officers' (n = 291) perceptions of the capabilities of supervisees with SMI to contribute to their supervision plans, and their familiarity with recovery-oriented mental health services, were positively associated with attitudes toward using SDM. Training officers in common human goals and mental health recovery may advance SDM with supervisees with SMI.

Re: AB (Termination of Pregnancy) [2019] EWCA CIV 1215: 'Wishes and Feelings' Under the Mental Capacity Act 2005.

In Re: AB (Termination of Pregnancy), the Court of Appeal was asked to consider an assumption made about the future living arrangements of a pregnant patient, and the weight to be ascribed to her wishes and feelings when she had no real understanding of her predicament. This commentary explores the importance of taking into account the perspective of the patient, even if suffering from a mental disorder, and it will analyse the existing common law to show that the weaker the ability of the patient to form her own wishes and feelings, the more appropriate it would be to rely on the remaining evidence.

[The implementation of the law 4509/2017 in the Forensic Department of the Psychiatric Hospital of Thessaloniki].

According to the Explanatory Memorandum of the law 4509/2017, a significant change is being made to the current institutional framework of Articles 69 and 70 of the ECHR concerning the penal treatment of mentally ill offenders, in order to ensure a high level of treatment for perpetrators with mental or intellectual disorder. In application of the law, it was examined in court the abolishment, maintenance or replacement of the treatment measure of 47 patients from the Department of Forensic Psychiatry in Thessaloniki. The results were compared with the previous status quo. In 22 cases, abolishment was ordered for the patients to be discharged and return to their parent's home or to Psychosocial Rehabilitation Units. In 11 of them, their stay was in direct violation of the law due to exceeding the cap as defined by the severity of the offense. However, 7 patients remain voluntarily in the Department, as no beds are available in reintegration structures. 13 patients who have committed homicide remain with the psychiatrist's agreement beyond the overrunning the ten years of treatment due to the severity of the disease or the risk for violent behavior. The Public Prosecutor has provided solutions in many cases and has appointed lawyers for all patients as prescribed by law. However, the judiciary remains cautious and the trend towards exhaustion of the limits is clear, despite the fact that their fears are not confirmed by international bibliographic data. The application of N 4509/2017 attempts to change the landscape for this particular group of patients and allows visions for de-institutionalization, elimination of the stigma and personalized treatment, despite any ambiguities or potential problems that may arise. However, as the predominant social viewpoint, shown by the media, treats the mentally ill as dangerous, any positive changes are doomed to fail. In addition, it is necessary to develop psychiatric services for the treatment of patients which will not only treat psychotic symptoms but also antisocial and aggressive behavior in general.