National Bioethics Committee
Psychiatry and Mental Health: Bioethical Guidelines
Outline and Recommendations
(24 November 2000)
1. Protection of the right to health, which in Italy has
the status of constitutional right and must be interpreted as
including mental health, entails, from the bioethical standpoint,
a preliminary reflection on the actual definition of equitable
treatment and access to treatment in accordance with the
principles of human dignity. Nevertheless, defining (or
redefining) the criteria governing the equitable treatment of
psychiatric patients itself necessarily involves a complex
approach in which respect of the patient's rights can be
reconciled with the security of the community. While reference to
these rights places this issue in a strictly regulatory
dimension, the understanding of the context in which they arise
may draw upon such fundamental, wide-ranging ethical principles
as the principle of justice (defined as the obligation imposed on
the physician, clinical psychologist and other qualified
practitioners, to take into account the social consequences for
third parties of each healthcare action and to reconcile the good
of the individual with the collective good, avoiding any
imbalance and respecting equity in the distribution of resources
and services), the principle of beneficence (defined as the duty
of the physician, the clinical psychologist and of the other
qualified practitioners to pursue the welfare of the patient,
protecting his life and health also in the field of preventive
care), the principle of autonomy (defined as the duty of the
physician, the clinical psychologist and of the other qualified
practitioners to respect the free and responsible will of the
patient, who enjoys the right to receive diagnostic and
therapeutic information and to express consent, including the
right of refusal).
Generally speaking there has been a radical change in the
cultural paradigm of the physician-patient relationship. The
traditional model based exclusively on the principle of
beneficence is being replaced and flanked by one based
essentially on the principle of autonomy, thus introducing the
primacy of the self-determination of the person in the case of
illness together with a therapeutic alliance including, in
addition to the treatment, also looking after the patient. Care
must nevertheless be exercised to avoid underestimating the
asymmetric nature of the contract and the purely legal and
ethical nature of the equality between the parties thereto with
regard to personal rights, without however any prejudice to the
unbridgeable difference in their respective knowledge. While it
is undeniable that any objectivizing subordination of the patient
is ethically unacceptable insofar as it is detrimental to human
dignity, this cannot be used to legitimate a reversal of the
relationship as the price paid would be not only a questionable
undervaluation of the scientific and professional skills but also
detrimental to the objective priority interest of the protection
of life and health. The principle of guarantee is thus an
essential point of reference in contemporary medical ethics.
2. In contemporary medical ethics, the protection of
the patient's subjectivity thus takes on a paradigmatic value
insofar as it is an essential condition for the construction and
development of freedom, which is essentially defined as a process
of liberation arising out of a fundamental ethical need of the
person. The protection of the mental patient's subjectivity thus
has an ethical connotation insofar as it consists of educating to
feel and to want to be free and thus of promoting true freedom. A
concept of freedom thus defined is closely related to the
principle of autonomy, which is related to the absolute respect
of the person. But in order to avoid any dangerous
misunderstanding it must be pointed out that protection of the
patient's subjectivity does not consist in believing that he is
free (despite the evidence of pathological conditioning of a
cognitive and/or affective nature) but rather in helping him to
become free.
It is aimed at restoring communication which has been impaired
or interrupted by the mental disorder and thus makes listening
possible. Above and beyond the diagnostic and clinical methods
used in the anamnesis, the fact of listening and being a good
listener has also a high ethical value as it means accepting and
acknowledging the patient not as someone other than myself but as
another self that gives meaning to relating to him- and thus to
my-self. The ethical value of listening thus consists in a
deliberate act of self-limitation that the psychiatrist, clinical
psychologist and the other qualified practitioners perform by
shunning the recurrent temptation towards narcisism and feelings
of omnipotence in order to adjust to the real dimension of the
encounter.
Lastly, as far as the complex question of the intrinsic limits
imposed on the informed consent given by psychiatric patients is
concerned, it is first necessary to clarify the progressive and
variable nature of sanity/insanity. Also in the case of
schizophrenia it must be borne in mind that the path trodden is
extremely variable and differentiated: between the two extremes
of a chronic state with serious cognitive deterioration and
substantial impairment, on the one hand, and the attainment of
acceptable conditions of health on the other, there is a wide
range of intermediate states in which phases of relapse and
remission alternate, or an acceptable degree of well-controlled
stabilization is achieved. From this emerges a radical criticism
of two extreme approaches: one aimed at excluding always and in
any case the mental patient's capacity to correctly perceive the
information and express valid consent; the other is characterized
by naive optimism in the opposite direction. In actual fact it
must above all be pointed out that between the absolute lack of
discernment characterizing madness and "normality" there is an
infinite series of intermediate steps, in which cognitive
deficits and affective alterations can lead to the reduction of
the latter but not its total absence. This does not in any case
justify withholding the information but involves the ethical (but
also clinical) criterion of caution in evaluating in each case
if, how, when to provide the information and above all a pondered
choice of the ways and means suitable for each individual patient
with reference to his or her situation and bio-psycho-physical
and existential context. To this end, for the purpose of
reconciling the principle of beneficence with the principle of
autonomy, and to avoid any sidetracking and naivety, it is
essential to adopt the criterion that "informing means in the
first instance communicating inside the relationship".
3. To the extent to which it is possible to find any
correspondence between the ethical plane and the purely
regulatory plane, these criteria and ethical guidelines must be
considered in the light of several fundamental human rights. It
is indeed necessary to stress the fact that persons affected by
mental/affective disorders/problems must be guaranteed the same
rights as all the other members of the community, regardless of
the concrete opportunity they may have to exercize them. The
particular vulnerability of these subjects actually entails
ensuring a strengthening of the acknowledgment of their full
citizenship which must be concretely defended and promoted, in
the first instance through the respect of certain rights and/or
by the fulfilment of certain fundamental duties, such as:
- right to treatment without any coercion and in full respect
of human dignity with access to the most suitable techniques of
medical, psychological, ethical and social action;
- right to the elimination of any kind of discrimination
(sexual, cultural, religious, political, economic, social,
ethnic) in the form of treatment, even when the latter is
restrictive of their freedom;
- right to rehabilitation and reinsertion, also through access
to housing and employment;
- right not to be subjected to any form of physical and/or
psychological abuse;
- duty to protect from the consequences of forms of
self-destructiveness (self-accusation, declarations of
unworthiness, etc.) versus the family, employers, judicial
authorities;
- duty to attain optimal conditions of hospitalization and
communication with the exterior;
- duty to defend parenthood, to be implemented in full respect
of the prevailing interest of children under the age. To this end
it is necessary to arrive at a trade-off between the duty of
beneficence versus patients and the right of the under-the-age
child to a healthy and balanced development.
4. As far as the question of the assistance to
psychiatric patients in Italy is more specifically concerned,
general consideration must be given to law no. 180 of 1978,
subsequently transposed into arts. 33, 34 and 35 of the National
Health Service (SSN) statutes. Law no. 180 definitely represents
a scientific, cultural and civil milestone as it abolished the
mental asylum institution and opened up new horizons for the
organization of a healthcare system without asylums and
established the conditions for the restoration of full
citizenship to psychiatric patients. The Italian model, backed by
the World Health Organization, has influenced mental health
policy in many other countries seeking to replace the asylums
with more effective and efficient local forms of care.
Nevertheless, more than twenty years after its introduction, it
is now more than ever necessary to make a serious examination of
its concrete application above and beyond the admittedly
important completion of the shutdown of the Psychiatric
Hospitals. This closure, as a result of the absence or
inefficient functioning of the alternative structures, such as
psychiatric diagnosis and treatment services of the hospitals (as
structures intermediate between the local district and the
hospitals) runs the risk of causing new problems, in the first
instance for the individual's health, but also for the
equilibrium, the economy and even the health of the family, who
has to bear most of the, often unsustainable, cost of supporting
the sick member. Indeed in those cases in which the service fails
to provide truly effective therapeutic and rehabilitation
programmes at the local level involving a strong commitment to
the patient, it is the families that remain the main referents of
the care, something that often leads to abandonment or even
triggers violent reactions often leading to the serious episodes
reported by the media. This type of phenomena awakens dormant
prejudices regarding mental illness and the stigmatization of
psychiatric patients. These prejudices readily lend themselves to
being instrumentalized in such a way as to increase the fear of
the 'social dangerousness' of the mental patient in public
opinion and the political world and increase the demand for
greater control which might again be implemented coercively and
thus not in a therapeutic way respecting the patient's
rights.
Several fundamentally important questions emerge from this
scenario which are directly related to the responsibility of the
institutions in the implementation of law no. 180. These
questions are centered in particular around:
- improved training of psychosocial workers and GPs;
- establishment of rehabilitation structures at different
protection levels;
- greater attention concentrated on psychiatric care of minors,
in particular on the mental problems that emerge at the
adolescent stage;
- the establishment of rehabilitation structures for
minors;
- stronger preventive and earlier diagnostic action;
- care of the seriously ill who refuse both medical and
psychiatric care and are prone to violent behaviour;
- information and public debate to combat prejudice towards the
mentally ill.
In this connection it is recommended that the 1998-2000
"Protection of Mental Health" objective project be implemented.
This measure, if properly applied, could contribute to solving
many of the psychiatric healthcare problems and to raising the
level of service effectiveness and quality. It could thus make a
decisive contribution to the further development of the "Italian
laboratory" in the mental health field that has aroused so much
interest and appreciation in many different countries. More
specifically, the 1998-2000 mental health objective project has
the advantage of making a correct approach to the issue of groups
at risk regarding both mental health and possible suicidal
outcomes, mental health education and early intervention. As far
as children's mental health in particular is concerned, the
objective project has the merit of having acknowledged that the
individual's development from childhood to adulthood is a
continuum, although it does not make any clear distinction
between the areas of psychiatry, psychology, neuropsychology and
rehabilitation, in particular with reference to the differences
in objectives, methods and organization in the action taken,
which has negative repercussions also on psychiatric healthcare.
Lastly, mention must be made of the positive emergence of a
health pact aimed at coordinating and integrating the formal and
informal agencies that, each in their own way, can contribute to
constructing a community mental health project. The Objective
Project also calls for research to be undertaken by the Superior
Health Institute to evaluate the effectiveness of primary
preventive action. It also entails the University psychiatric
institutes taking operational responsibility for all the district
and hospital structures involved in providing mental health
services for a community of about 150,000 inhabitants. This
measure is the only one that guarantees high quality training for
psychiatric practitioners and is capable of linking together
research carried out in the observational field provided by the
local district with practical trials of the effectiveness of the
action. In view of their objective importance, these acquisitions
are bound to change the physiognomy of psychiatric healthcare in
the years to come.
5. In view of the foregoing, the National Bioethics
Committee has formulated the following more specific
recommendations:
- allocate to national and regional institutions, and allow them
to spend, the national and regional health funds required to
establish at least all the services envisaged in the Objective
Project, also in view of the importance attributed by the WHO to
mental health;
- give greater publicity to simple and correct information
concerning mental illness also in schools and avoid the risk of
reductionist interpretations of mental illness. More generally,
it is recommended that balance and understanding be maintained
when dealing with the bio-psycho-social complexities of mental
illness;
- promote periodic national campaigns against the
stigmatization of and prejudice towards persons affected by
mental disorders and problems in order to render effective the
respect of equality, the right to information and the fight
against discrimination;
- re-examine the concept of "incapacity", situating it inside
the continuum that runs from the extremes of normality to the
total loss of all cognitive ability. Also from the legal point of
view it should be noted that the majority of psychiatric
disorders reduce but do not eliminate sanity completely. It is
thus recommended that a reappraisal be made of the civil law
institutions of interdizione and inabilitazione
(disqualification) and to introduce more flexible forms of
safeguarding than the existing ones which take into account the
new needs of protection of those suffering from mental disorders
and which avoid stigmatizing them. It is emphasized in
particular, in view of the experiences of other European
countries, that the figure of 'support manager' should be
introduced also into the Italian legal system;
- bring to completion the process of closing down the public
and private mental hospitals. In each single case, however, it is
necessary to ensure that the alternatives introduced to cope with
the emergency do not actually retain their previous mental
hospital characteristics. It must also be considered that there
are still 9 private mental homes with some two thousand inmates
that, after twenty years since the beginning of the
de-asylumization process provided for by law no. 180, are
completely unjustified from the ethical and clinical point of
view;
- guarantee that the family receives adequate support and,
whenever necessary, in collaboration with the therapeutic team,
take on an active role in the therapeutic/rehabilitation
programme of the sick member, pursuing the objective of the
latter's autonomization. Guarantee a reference emergency
organization also providing night-time and holiday service.
- carry on a constant primary and secondary prevention
activity versus the mental/affective disorder or problem starting
from the biological and affective-relational aspects going back
to the perinatal period and covering the entire life span, by
ensuring the best educational, employment, social security and
healthcare conditions; formulate an early diagnosis and ensure
that young people are taken on board at the first significant
symptoms; introduce special programmes in schools in
collaboration with the families and, without arousing any
unjustified alarm and risk of "psychiatrization", help recognize
and prevent mental problems and disorders. The psychiatric
pathologies of the adult are actually always rooted in the period
of development and the extent of the psychiatric problems of
adults will be dependent on the quality of the treatment received
at the earlier stages of life. This kind of initiative is thus
essential for the concrete attainment of the right to health
(which is implemented also by means of prevention), and access to
treatment, and to sustain and promote solidarity with subjects at
risk;
- guarantee that special attention is paid to the direct and
indirect signals of mental distress in subjects during the period
of development in order to determine the underlying distress;
guarantee different care levels for acute situations and
rehabilitation for consolidated conditions. During the period of
development, encourage day hospital and outpatient healthcare
activities, and reduce hospitalization. Unfortunately, it is
necessary to guarantee an adequate number of hospital beds for
psychiatric emergencies and for acute forms requiring continuous
care and extended observation in structures other than the
psychiatric diagnosis and treatment services that can satisfy not
only healthcare and protection needs but also the needs and
rights specific to this age group;
- guarantee and maintain the acceptance of responsibility in
the more serious and difficult cases even when the treatment is
not accepted by those directly concerned. Reference is made in
this case to the general principles of protection of the mental
patient, the risk/benefit parameter as the general rule for
treatment avoiding the extremes of using disproportionate medical
measures and abandonment;
- lay down national parameters for the accreditation of mental
health structures. Quality control of the services is actually
itself a criterion of guaranteed equitable treatment and fair
allocation of resources earmarked for health. The 65
neuropsychiatric care centres (with 7149 authorized beds, 6144 of
which accredited or covered by conventions, that is, funded by
the Regions) must be aimed at avoiding rendering the patients'
condition chronic and to be converted, as far as possible, into
open residential rehabilitation structures that, if possible,
have an operating relationship with one or two mental health
departments;
- involve and support "family doctors" in view of the fact
that many patients go to them for mental health problems of
varying degrees of seriousness. The GP must be trained to
recognize conditions of mental distress, to be able to evaluate
its nature and seriousness, and to know how to use the
psychiatric services both for consultancy and to identify the
more serious situations requiring specialist intervention at an
early stage;
- ensure the training of physicians, general paediatricians,
psychosocial practitioners, professional nurses, social
assistants and professional and voluntary educators. For this
purpose it is necessary to extend all the practitioners'
bioethical knowledge and to lay down several minimum objectives
so that training may be effective and ethically grounded. These
include: greater attention paid to the users' health needs than
to the practitioners' needs; an open attitude must be displayed
to the skills and contributions of the different professional
figures; suitable tools must be provided for the management by
the practitioners of the various dimensions of the individual,
the family, the group and the community, as well as for the
promotion of mental health in the community, such as the
development and implementation of specific mental health
programmes; special attention must also be focused on research
and training concerning bioethical problems related to the
protection of mental health;
- acknowledge the right of psychiatric patients to a sex life
although it is advisable at the same time to investigate ways and
means of informing them properly and getting them to take
responsibility for their sex life;
- revise the pharmaceutical 'ticket' system in order to ensure
that new generation drugs (such as atypical antipsychotics) that
have proved more effective and to have fewer side effects are
accessible to all;
- review the nature and tasks of the "Judiciary Psychiatric
Hospital" and the relevant legislation and to promote action by
the Ministry of Justice to institute a convention with specific
structures for minors having committed offences and who suffer
from psychiatric disorders. More specifically, it should be
pointed out that the existing Judiciary Psychiatric Hospitals
are, both from the institutional and the medical standpoints, in
clear contradiction with law no. 180 and with any modern approach
to mental health action;
- by means of suitable structures to prevent the risk of the
psychiatric diagnosis and treatment services becoming a mere
repetition of mental hospital practices and consequently
increasing the proneness to chronic conditions rather than
recovery from the illness. More specifically, all forms of
mechanical restraint must be done away with as they are
detrimental to the patient's dignity;
- ensure that the mental health departments, as laid down in
the recent DGL 239/99, perform healthcare services in the
prisons. The protection of the psycho-physical integrity of
convicts is indeed an elementary duty of justice and also an
indispensable prerequisite for any rehabilitation. The prisons
must become places in which everyday life is no longer itself a
cause of mental distress and disorder and which allow psychiatric
assistance to be provided. It must also be observed that the
alternatives to prison - including admission to mental health
departments - have proved to be extremely effective in the
countries having adopted them, for example, Sweden, as measures
to replace prison detainment.
Conclusions
The laws of the Republic, from the Constitution down to the
"Protection of Mental Health objective projects" state that the
State guarantees the exercise of the "right to health" and thus
of the right to mental health. However, the experience of the
reform and, even before that, of the law establishing the mental
hospitals, shows how laws by themselves are not enough to ensure
effectiveness in the mental health field. This is because
exercizing the right to mental health is strongly dependent on
the culture and on the state of the social relations in the local
conditions, on the level of professional training and skills
possessed by individual practitioners and groups of
practitioners, as well as on the policies of the local
administrators and managers. As can be seen from the preceding
treatment, it emerges that the majority of problems related to
mental health are laboriously managed by persons who suffer alone
in the family, with their peers, with GPs, within the private
physician and psychologist circuit and the dimension of popular
religious feeling where the search for salvation is also
accompanied by the hope of regaining health. The public health
service is addressed in the case of situations defined as
serious, which are the more dramatic ones from the point of view
of individual and family distress, more alarming from the social
point of view and more liable to lead to isolation and
marginalization. It often happens that the DSMs (Mental Health
Departments) fail to take on board in all their complexity and
for their full duration situations that we have defined as
"serious" and ultimately abandon them either to the families or
to a healthcare circuit with inadequate resources when it is not
openly a continuation of the mental hospital approach.
It was precisely to answer this kind of question that, also in
Italy, it was decided that an organization of services based on
Community Psychiatry would be more effective and respectful of
the person's dignity than the mental hospital. Community
Psychiatry involves the work of a multiprofessional team
operating in a given district and in a position to intervene
within 24 hours at the patient's home, in the surgery, the
hospital, and homes offering various degrees of protection aimed
at rehabilitation; it has links with the municipalities and the
other health services, works in close collaboration with the
users and the family associations, and has access to the
available opportunities of vocational training, employment,
culture, assistance, leisure time. Treatment is provided at the
biological, psychological, social, pedagogic and cultural
level.
To remedy the conditions of abandonment in serious situations
and in general on the topic of psychiatric assistance and its
chronic shortage of human, structural and financial resources,
strong action by the Regions is essential to ensure a renewed
commitment regarding the crucial aspect of the distress, and to
give a positive signal to the families and to public opinion.
On the expectation, but not taking for granted, that all the
Local Health Services (Aziende Sanitarie) have released resources
to support the activities of the multiprofessional teams of the
Mental Health Departments and that they have the necessary scope
and instruments for their work, the most important condition for
what we have defined as the most serious situations to be managed
in a way in which the rights and dignity of the person and the
families are respected is that the managers and practitioners
should take responsibility for caring. This is because
psychiatric assistance has to cope daily with high levels of
distress of the persons and families involved, their strong
social stigmatization, the problems of protection, of the freedom
of choice and consent to treatment even to the limit of coercion,
with the need for continuity in longterm "caring" in
psycho-social rehabilitation processes, with the singularity and
multiplicity of the world views of the persons, groups and
cultures. As a result of these peculiarities and of the objective
of ensuring that the mentally ill receive available optimal
treatments, local health authorities, professional organizations
and scientific gatherings must guarantee continuity of training,
the verification of the quality of the services provided by all
practitioners and the evaluation of the outcomes at the level of
Mental Health Departments and of District Medicine. We are thus
referring not only to physicians and psychologists, but also to
professional nurses, professional educators, social assistants,
social health and social welfare practitioners. Fresh objectives
to be pursued by the Regions and the Health Centres consist of
information and training aimed at users and their families in
support of self-help and of increasingly authoritative and
competent associations and voluntary organizations.
In the context of these reasons, the terms federalism,
regionalism and localism mean the assumption of full
responsibility by the administrators and managers of the Local
Health Services vis-à-vis the guarantees to be provided
for mental health activities in all the local communities,
without exception.
