4th Johore Mental Health Convention 23 - 24 August 2002 Hyatt Regency Hotel Johor Bahru Principles for the protection of persons with mental Illness and the improvement of mental health care  Adopted by General Assembly resolution 46/119 of 17 December 1991  Applications  These Principles shall be applied without discrimination of any kind such as on grounds of disability, race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, legal or social status, age, property or birth.  Definitions  In these Principles: “Counsel” means a legal or other qualified representative; “Independent authority” means a competent and independent authority prescribed by domestic law;  “Mental health care” includes analysis and diagnosis of a person’s mental condition, and treatment, care and rehabilitation for a mental illness or suspected mental illness;  “Mental health facility” means any establishment, or any unit of an establishment, which as its primary function provides mental health care;  “Mental health practitioner” means a medical doctor, clinical psychologist, nurse, social worker or other appropriately trained and qualified person with specific skills relevant to mental health care;  “Patient” means a person receiving mental health care and includes all persons who are admitted to a mental health facility;  “Personal representative” means a person charged by law with the duty of representing a patient’s interests in any specified respect or of exercising specified rights on the patient’s behalf, and includes the parent or legal guardian of a minor unless otherwise provided by domestic law;  “The review body” means the body established in accordance with Principle 17 to review the involuntary admission or retention of a patient in a mental health facility.  General limitation clause  The exercise of the rights set forth in these Principles may be subject only to such limitations as are prescribed by law and are necessary to protect the health or safety of the person concerned or of others, or otherwise to protect public safety, order, health or morals or the fundamental rights and freedoms of others.  Principle I - Fundamental freedoms and basic rights  1. All persons have the right to the best available mental health care, which shall be part of the health and social care system.  2. All persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person.  3. All persons with a mental illness, or who are being treated as such persons, have the right to protection from economic, sexual and other forms of exploitation, physical or other abuse and degrading treatment.  4. There shall be no discrimination on the grounds of mental illness. “Discrimination” means any distinction, exclusion or preference that has the effect of nullifying or impairing equal enjoyment of rights. Special measures solely to protect the rights, or secure the advancement, of persons with mental illness shall not be deemed to be discriminatory. Discrimination does not include any distinction, exclusion or preference undertaken in accordance with the provisions of these Principles and necessary to protect the human rights of a person with a mental illness or of other individuals.  5. Every person with a mental illness shall have the right to exercise all civil, political, economic, social and cultural rights as recognized in the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights, the International Covenant on Civil and Political Rights, and in other relevant instruments, such as the Declaration on the Rights of Disabled Persons and the Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment.  6. Any decision that, by reason of his or her mental illness, a person lacks legal capacity, and any decision that, in consequence of such incapacity, a personal representative shall be appointed, shall be made only after a fair hearing by an independent and impartial tribunal established by domestic law. The person whose capacity is at issue shall be entitled to be represented by a counsel. If the person whose capacity is at issue does not himself or herself secure such representation, it shall be made available without payment by that person to the extent that he or she does not have sufficient means to pay for it. The counsel shall not in the same proceedings represent a mental health facility or its personnel and shall not also represent a member of the family of the person whose capacity is at issue unless the tribunal is satisfied that there is no conflict of interest. Decisions regarding capacity and the need for a personal representative shall be reviewed at reasonable intervals prescribed by domestic law. The person whose capacity is at issue, his or her personal representative, if any, and any other interested person shall have the right to appeal to a higher court against any such decision.  7. Where a court or other competent tribunal finds that a person with mental illness is unable to manage his or her own affairs, measures shall be taken, so far as is necessary and appropriate to that person’s condition, to ensure the protection of his or her interest.  Principle 2 - Protection of minors  Special care should be given within the purposes of these Principles and within the context of domestic law relating to the protection of minors to protect the rights of minors, including, if necessary, the appointment of a personal representative other than a family member.  Principle 3 - Life in the community  Every person with a mental illness shall have the right to live and work, as far as possible, in the community.  Principle 4 - Determination of mental illness  1. A determination that a person has a mental illness shall be made in accordance with internationally accepted medical standards.  2. A determination of mental illness shall never be made on the basis of political, economic or social status, or membership of a cultural, racial or religious group, or any other reason not directly relevant to mental health status.  3. Family or professional conflict, or non-conformity with moral, social, cultural or political values or religious beliefs prevailing in a person’s community, shall never be a determining factor in diagnosing mental illness.  4. A background of past treatment or hospitalization as a patient shall not of itself justify any present or future determination of mental illness.  5. No person or authority shall classify a person as having, or otherwise indicate that a person has, a mental illness except for purposes directly relating to mental illness or the consequences of mental illness.  Principle 5 - Medical examination  No person shall be compelled to undergo medical examination with a view to determining whether or not he or she has a mental illness except in accordance with a procedure authorized by domestic law.  Principle 6 - Confidentiality  The right of confidentiality of information concerning all persons to whom these Principles apply shall be respected.  Principle 7 - Role of community and culture  1. very patient shall have the right to be treated and cared for, as far ~as possible, in the community in which he or she lives.  2. Where treatment takes place in a mental health facility, a patient shall have the right, whenever possible, to be treated near his or her home or the home of his or her relatives or friends and shall have the right to return to the community as soon as possible.  3. Every patient shall have the right to treatment suited to his or her cultural background.  Principle 8 - Standards of care  1. Every patient shall have the right to receive such health and social care as is appropriate to his or her health needs, and is entitled to care and treatment in accordance with the same standards as other ill persons.  2. Every patient shall be protected from harm, including unjustified medication, abuse by other patients, staff or others or other acts causing mental distress or physical discomfort.  Principle 9 - Treatment  1. Every patient shall have the right to be treated in• the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the. patient’s health needs and the need to protect the physical safety of others.  2.  The treatment and care of every patient shall be based on an individually prescribed plan, discussed with the patient, reviewed regularly, revised as necessary and provided by qualified professional staff.  3. Mental health care shall always be provided in accordance with applicable standards of ethics for mental health practitioners, including internationally accepted standards such as the Principles of Medical Ethics adopted by the United Nations General Assembly. Mental health knowledge and skills shall ~-never be abused.  4. The treatment of every patient shall be directed towards preserving and t. enhancing personal autonomy.  Principle 10 - Medication  1. Medication shall meet the best health needs of the patient, shall be given to a patient only for therapeutic or diagnostic purposes and shall never be administered as a punishment or for the convenience of others. Subject to the provisions of paragraph 15 of Principle 11, mental health practitioners shall only administer medication of known or demonstrated efficacy.  2. All medication shall be prescribed by a mental health practitioner authorized by law and shall be recorded in the patient’s records.  Principle 11- Consent to treatment  1. No treatment shall be given to a patient without his or her informed consent, except as provided for in paragraphs 6, 7, 8,13 and 15 below.  2.  Informed consent is consent obtained freely, without threats or improper inducements, after appropriate disclosure to the patient of adequate and understandable information in a form and language understood by the patient on:  (a) The diagnostic assessment;  (b) The purpose, method, Likely duration and expected benefit of the proposed treatment;  (c) Alternative modes of treatment, including those less intrusive; and  (d) Possible pain or discomfort, risks and side-effects of the proposed treatment.  3. A patient may request the presence of a person or persons of the patient’s choosing during the procedure for granting consent.  4. A patient has the right to refuse or stop treatment, except as provided for in paragraphs 6, 7, 8,13 and 15 below. The consequences of refusing or stopping treatment must be explained to the patient.  5. A patient shall never be invited or induced to waive the right to infomied consent. If the patient should seek to do so, it shall be explained to the patient that the treatment cannot be given without informed consent.  6. Except as provided in paragraphs 7, 8,12,13, 14 and 15 below, a proposed ~ plan of treatment may be given to a patient without a patient’s informed consent if the following conditions are satisfied:  (a) The patient is, at the relevant time, held as an involuntary patient;  (b) An independent authority, having in its possession all relevant information, including the information specified in paragraph 2 above, is satisfied that, at the relevant time, the patient lacks the capacity to give or withhold informed consent to the proposed plan of treatment or, if domestic legislation so provides, that, having regard to the patient’s own safety or the safety of others, the patient unreasonably withholds such consent; and  (c) The independent authority is satisfied that the proposed plan of treatment is in the best interest of the patient’s health needs.  7. Paragraph 6 above does not apply to a patient with a personal representative empowered by law to consent to treatment for the patient; but, except as provided in paragraphs 12, 13, 14 and 15 below, treatment maybe given to such a patient without his or her informed consent if the personal representative, having been given the information described in paragraph 2 above, consents on­the patient’s behalf.  8. Except as provided in paragraphs 12, 13, 14 and 15 below, treatment may also be given to any patient without the patient’s informed consent if a qualified mental health practitioner authorized by law determines, that it is urgently necessary in order to prevent immediate or imminent harm to the patient or to other persons. Such treatment shall not be prolonged beyond the period that is strictly necessary for this purpose.  9. Where any treatment is authorized without the patient’s informed consent, -every effort shall nevertheless be made to inform the patient about the nature of the treatment and any possible alternatives and to involve the patient as far as practicable in the development of the treatment plan.  10. All treatment shall be immediately recorded in the patient’s medical records,~, with an indication of whether involuntary or voluntary.  11. Physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others. It shall not be prolonged beyond the period which is strictly -necessary for this purpose. All instances of physical restraint or involuntary seclusion, the reasons for them and their nature and extent shall be recorded in the patient’s medical record. A patient who is restrained or secluded shall be kept under humane conditions and be under the care and close and regular supervision of qualified members of the staff. A personal representative, if any and if relevant, shall be given prompt notice of any physical restraint or involuntary seclusion of the patient.  12. Sterilization shall never be carried out as a treatment for mental illness.  13. A major medical or surgical procedure may be carried out on a person with mental illness only where it is permitted by domestic law, where it is considered that it would best serve the health needs of the patient and where the patient gives informed consent, except that, where the patient is unable to give informed consent, the procedure shall be authorized only after independent review.  14. Psychosurgery and other intrusive and irreversible treatments for mental illness shall never be carried out on a patient who is an involuntary patient in a mental health facility and, to the extent that domestic law permits them to be carried out, they may be carried out on any other patient only where the patient has given informed consent and an independent external body has satisfied itself that there is genuine informed consent and that the treatment best serves the health needs of the patient.  15. Clinical trials and experimental treatment shall never be carried out on any patient without informed consent, except that a patient who is unable to give informed consent may be admitted to a clinical trial or given experimental treatment, but only with the approval of a competent, independent review body specifically constituted for this purpose.  16. In the cases specified in paragraphs 6, 7, 8,13, 14 and 15 above, the patient or his or her personal representative, or any interested person, shall have the right to appeal to a judicial or other independent authority concerning any treatment given to him or her.  Principle 12 - Notice of rights  1. A patient in a mental health facility shall be informed as soon as possible after admission, in a form and a language which the patient understands, of all his or her rights in accordance with these Principles and under domestic law, which information shall include an explanation of those rights and how to exercise them.  2. If and for so long as a patient is unable to understand such information, the rights of the patient shall be communicated to the personal representative, if any and if appropriate, and to the person or persons best able to represent the patient’s interests and willing to do so.  3. A patient who has the necessary capacity has the right to nominate a person who should be informed on his or her behalf, as well as a person to represent his or her interests to the authorities of the facility.  Principle 13 - Rights and conditions In mental health facilities  1. Every patient in a mental health facility shall, in particular, have the right to full respect for his or her:  (a) Recognition everywhere as a person before the law;  (b) Privacy; (c) Freedom of communication, which includes freedom to communicate with other persons in the facility; freedom to send and receive uncensored private  communications; freedom to receive, in private, visits from a counsel or personal representative and, at all reasonable times, from other visitors; and freedom of access to postal and telephone services and to newspapers, radio and television; (d) Freedom of religion or belief. 2. The environment and living conditions in mental health facilities shall be as close as possible to those of the normal life of persons of similar age and in particular shall include:  (a) Facilities for recreational and leisure activities;  (b) Facilities for education;  (c) Facilities to purchase or receive items for daily living, recreation and communication;  (d) Facilities, and encouragement to use such facilities, for a patient’s engagement in active occupation suited to his or her social and cultural background, and for appropriate vocational rehabilitation measures to promote reintegration in the community. These measures -should include vocational guidance, vocational training and placement services to enable patients to secure or retain employment in the community. 3. In no circumstances shall a patient be subject to forced labour. Within the limits compatible with the needs of the patient and with the requirements of institutional administration, a patient shall be able to choose the fYpe of work he or she wishes to perform.  4. The labour of a patient in a mental health facility shall riot be exploited. Every such patient shall have the right to receive the same remuneration for any work which he or she does as would, according to domestic law or custom, be paid fo~ such work to a non-patient. Every such patient shall, in any event, have the right to receive a fair share of any remuneration which is paid to the mental health facility for his or her work.  Principle 14 - Resources for mental health facilities  1. A mental health facility shall have access to the same level of resources as any other health establishment, and in particular:  (a) Qualified medical and other appropriate professional staff in sufficient numbers and with adequate space to provide each patient with privacy and a programme of appropriate and active therapy;  (b) Diagnostic and therapeutic equipment for the patient;  (c) Appropriate professional care; and  (d) Adequate, regular and comprehensive treatment, including supplies of medication. 2. Every mental health facility shall be inspected by the competent authorities with sufficient frequency to ensure that the conditions, treatment and care of patients comply with these Principles.  Principle 15 - Admission principles  1. Where a person needs treatment in a mental health facility, every effort shall be made to avoid involuntary admission. 2.Access to a mental health facility shall be administered in the same way as access to any other facility for any other illness. 3. Every patient not admitted involuntarily shall have the right to leave the mental health facility at any time unless the criteria for his or her retention as an involuntary patient, as set forth in Principle 16, apply,- and he or she shall be informed of that right.  Principle 16 - Involuntary admission  1. A person may (a) be admitted involuntarily to a mental health facility as a patient; or (b) having already been admitted voluntarily as a patient, be retained as an involuntary patient in the mental health facility if, and only if, a qualified mental health practitioner authorized by law for that purpose determines, in accordance with Principle 4, that person has a mental illness and considers:  (a) That, because of that mental illness, there is a serious likelihood of immediate or imminent harm to that person or to other persons; or (b) That, in the case of a person whose mental illness is severe and whose judgement is impaired, failure to admit or retain that person is likely to lead to a serious deterioration in his or her condition or will prevent the giving of appropriate treatment that can only be given by admission to a mental health facility in accordance with the principle of the least restrictive alternative.  In the case referred to in subparagraph (b), a second such mental health practitioner, independent of the first, should be consulted where possible. If such consultation takes place, the involuntary admission or retention may not take place unless the second mental health practitioner concurs. 2. Involuntary admission or retention shall initially be for a short period as specified by domestic law for observation and preliminary treatment pending review of the admission or retention by the review body. The grounds of the admission shall be communicated to the patient without delay and the fact of the admission and the grounds for it shall also be communicated promptly and in detail to the review body, to the patient’s personal representative, if any, and, unless the patient objects, to the patient’s family.  3. A mental health facility may receive involuntarily admitted patients only if the facility has been designated to do so by a competent authority prescribed by domestic law.  Principle 17 - Review body  1. The review body shall be a judicial or other independent and impartial body established by domestic law and functioning in accordance with procedures laid — down by domestic law. It shall, in formulating its decisions, have the assistance of one or more qualified and independent mental health practitioners and take their advice into account.  2. The review body’s initial review, as required by paragraph 2 of Principle 16, of a decision to admit or retain a person as an involuntary patient shall take place as soon as possible after that decision and shall be conducted in accordance with simple and expeditious procedures as specified by domestic law.  3. The review body shall periodically review the cases of involuntary patients at reasonable intervals as specified by domestic law.  4. An involuntary patient may apply to the review body for release or voluntary status, at reasonable intervals as specified by domestic law.  5. At each review, the review body shall consider whether the criteria for involuntary   admission set out in paragraph I of Principle 16 are still satisfied, and, if not, the patient shall be discharged as an involuntary patient. 6. If at any time the mental health practitioner responsible for the case is satisfied that the  conditions for the retention of a person as an involuntary patient are no longer satisfied, he or she shall order the discharge of that person as such a patient.  7. A patient or his personal representative or any interested person shall have the right to appeal to a higher court against a decision that the patient be admitted to, or be retained in, a mental health facility.  Principle 18 - Procedural safeguards  1. The patient shall be entitled to choose and appoint a counsel to represent the patient as such, including representation in any complaint procedure or appeal. If the patient does not secure such services, a counsel shall be made available. without payment by the patient to the extent that the patient lacks sufficient means to pay.  2. The patient shall also be entitled to the assistance, if necessary, of the services of an interpreter. Where such services are necessary and the patient does not secure them, they shall be made available without payment by the patient to the extent that the patient lacks sufficient means to pay.  3. The patient and the patient’s counsel may request and produce at any hearing an independent mental health report and any other reports and oral, written and other evidence that are relevant and admissible.  4. Copies of the patient’s records and any reports and documents to be submitted shall be given to the patient and to the patient’s counsel, except in special cases where it is determined that a specific disclosure to the patient would cause serious harm to the patient’s health or put at risk the safety of others. As domestic law may provide, any document not given to the patient should, when this can be done in confidence, be given to the patient1s personal representative and counsel. When any part of a document is withheld from a patient, the patient or the patient’s counsel, if any, shall receive notice of the withholding and the reasons for it and shall be subject to judicial review.  5. The patient and the patient’s personal representative and counsel shall be entitled to attend, participate and be heard personally in any hearing.  6. If the patient or the patient’s personal representative or counsel requests that a particular person be present at a hearing, that person shall be admitted unless it is determined that the person’s presence could cause serious harm to the patient’s health or put at risk the safety of others.  7. Any decision whether the hearing or any part of it shall be in public or in private and may be publicly reported shall give full consideration to the patient’s own wishes, to the need to respect the privacy of the patient ‘~nd of other 4 persons and to the need to prevent serious harm to the patient’s health or to avoid putting at risk the safety of others.  8. The decision arising out of the hearing and the reasons for it shall be expressed in writing. Copies shall be given to the patient and his or her personal representative and counsel. In deciding whether the decision shall be published in whole or in part, full consideration shall be given to the patient’s own wishes, to the need to respect his or her privacy and that of other persons, to the public interest in the open administration of justice and to the need to prevent serious harm to the patient’s health or to avoid putting at risk the safety of others.  Principle 19 - Access to In formation  1. A patient (which term in this Principle includes a former patient) shall be entitled to have access to the information concerning the patient in his or her health and personal records maintained by a mental health facility. This right may be subject to restrictions in order to prevent serious harm to the patient’s health and avoid putting at risk the safety of others. As domestic law may provide, any such information not given to the patient should, when this can be done in confidence, be given to the patient’s personal representative and counsel. When any of the information is withheld from a patient, the patient or the patient’s counsel, if any, shall receive notice of the withholding and the reasons for it and it shall be subject to judicial review.  2. Any written comments by the patient or the patient’s personal representative or counsel shall, on request, be inserted in the patient’s file.  Principle 20 - Criminal offenders  1. This Principle applies to persons serving sentences of imprisonment for criminal offences, or who are otherwise detained in the course of criminal proceedings or investigations against them, and who are determined to have a mental illness or who it is believed may have such an illness.  2. All such persons should receive the best available mental health care provided in Principle 1. These Principles shall apply to them to the fullest extent possible, with only such limited modifications and exceptions as are necessary in the circumstances. No such modifications and exceptions shall prejudice the persons’ rights under the instruments noted in paragraph 5 of Principle 1.  3. Domestic law may authorize a court or other competent authority, acting on the basis of competent and independent medical advice, to order that such persons be admitted to a mental health facility.  4. Treatment of persons determined to have a mental illness shall In all ~ circumstances be consistent with Principle 11. Principle 21 - Complaints  Every patient and former patient shall have the right to make a complaint through procedures as specified by domestic law.  Principle 22 - Monitoring and remedies  States shall ensure that appropriate mechanisms are in force to promote compliance with these Principles, for the inspection of mental health facilities, for the submission, investigation and resolution of complaints and for the institution of appropriate disciplinary or judicial proceedings for professional misconduct or violation of the rights of a patient.  PrInciple 23 - Implementation  1. States should implement these Principles through appropriate legislative, judicial, administrative, educational and other measures, which they shall review periodically.