The rights of psychiatric patients in the light of the principles announced by the United Nations: A recognition of the right to consent to treatment?

International Journal of Law and Psychiatry

Volumn 20, Issue 2, 1997, Pages 259-278

  Gendreau, Caroline ^a  

^a UNIVERSITÉ DE MONTRÉAL   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HUMAN; INFORMED CONSENT; PATIENT CARE; PATIENT RIGHT; UNITED NATIONS;

PROFESSIONAL PATIENT RELATIONSHIP;

COMMITMENT OF MENTALLY ILL; HUMANS; INFORMED CONSENT; MENTAL COMPETENCY; MENTAL DISORDERS; PATIENT ADVOCACY; UNITED NATIONS;

EID: 0030961692     PISSN: 01602527     EISSN: None     Source Type: Journal    
DOI: 10.1016/S0160-2527(97)00007-1     Document Type: Article

References (110)

1. e session ordinaire (1977) and Recommandation sur la protection juridique des personnes atteintes de troubles mentaux et placées comme patients involontaires, Rec. R (83) 2 Comité des Ministres (1983). Moreover, a covenant for the prevention of torture was adopted. This Covenant is designed to protect, notably, patients detained in psychiatric hospitals. See Convention pour la prévention de la torture, des peines ou traitements inhumains ou dégradants. Conseil de l'Europe, Série de Traités Européens, no. 126.
2. e session ordinaire (1977) and Recommandation sur la protection juridique des personnes atteintes de troubles mentaux et placées comme patients involontaires, Rec. R (83) 2 Comité des Ministres (1983). Moreover, a covenant for the prevention of torture was adopted. This Covenant is designed to protect, notably, patients detained in psychiatric hospitals. See Convention pour la prévention de la torture, des peines ou traitements inhumains ou dégradants. Conseil de l'Europe, Série de Traités Européens, no. 126.
3. e session ordinaire (1977) and Recommandation sur la protection juridique des personnes atteintes de troubles mentaux et placées comme patients involontaires, Rec. R (83) 2 Comité des Ministres (1983). Moreover, a covenant for the prevention of torture was adopted. This Covenant is designed to protect, notably, patients detained in psychiatric hospitals. See Convention pour la prévention de la torture, des peines ou traitements inhumains ou dégradants. Conseil de l'Europe, Série de Traités Européens, no. 126.
4. Larry Gostin, Human Rights in Mental Health: A Proposal for Five International Standards Based upon the Japanese Experience, 10 INT'L J. L. & PSYCHIATRY 353 (1987). See also Richard J. Bonnie, Soviet Psychiatry and Human Rights: Reflexions on the Report of the U.S. Delegation in Alexandre Capron & Larry Gostin, London '89, Proceedings of the Second International Conference on Health Law and Ethics, 18 LAW, MED. & HEALTH CARE 123 (1990).
5. Larry Gostin, Human Rights in Mental Health: A Proposal for Five International Standards Based upon the Japanese Experience, 10 INT'L J. L. & PSYCHIATRY 353 (1987). See also Richard J. Bonnie, Soviet Psychiatry and Human Rights: Reflexions on the Report of the U.S. Delegation in Alexandre Capron & Larry Gostin, London '89, Proceedings of the Second International Conference on Health Law and Ethics, 18 LAW, MED. & HEALTH CARE 123 (1990).
6. Larry Gostin, Human Rights in Mental Health, in Martin Roth & Robert Bluglass (eds.), PSYCHIATRY, HUMAN RIGHTS AND THE LAW 148, at 154 (1985).
7. U.N. Doc. G.A. Res. 46/119 (1991) [hereinafter U.N. Principles]. The complete text of the General Assembly Resolution was reproduced in this Journal, in: Rosenthal & Rubenstein, International Human Rights Advocacy under the "Principles for the Protection of Persons with Mental Illness," 16 INT'L J. L. & PSYCHIATRY 257, 291-300 (1993).
8. See Report of the Sub-Commission on Prevention of Discrimination and Protection of Minorities, [hereinafter Sub-Commission] prepared by the Special Rapporteur Erica-Irene A. Daes, U.N., Principles, guidelines and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder. U.N. Doc. E/CN/4/Sub.2/1983/17 (1983) [hereinafter Daes report]. This report comprises a Draft of Principles and Guidelines [hereinafter the Daes Draft].
9. Universal Declaration of Human Rights, G.A. Res. 217 A (III) (1948).
10. See U.N. Doc. H.R.C. Res. 10 A (XXXIII) (1977).
11. Hereinafter Sub-Commission. 9 See U.N. Doc. H.R.C. Res. 10 A (XXXIII) (1977).
12. See U.N. Doc. Medical measures that may properly be employed in the treatment of persons detained on grounds of mental ill-health, U.N. Doc. E/CN.4/Sub.2/446 (1980). This report was submitted pursuant to U.N. Doc. Sub-Commission Res. 6 (XXXII) (1979).
13. See U.N. Doc. Medical measures that may properly be employed in the treatment of persons detained on grounds of mental ill-health, U.N. Doc. E/CN.4/Sub.2/446 (1980). This report was submitted pursuant to U.N. Doc. Sub-Commission Res. 6 (XXXII) (1979).
14. See U.N. Doc. Sub-Commission Res. 11 (XXXIII) (1980).
15. Id.
16. See Daes report, supra note 5, and U.N. Doc. E/CN.4/Sub.2/1983/17/Add.1 (1983). See also the preliminary report by the Special Rapporteur, Mrs. Erica-Irene Daes, U.N. Doc. E/CN.4/Sub.2/474 (1981) and her temporary report U.N. Doc. E/CN.4/Sub.2/1982/16 (1982).
17. See Daes report, supra note 5, and U.N. Doc. E/CN.4/Sub.2/1983/17/Add.1 (1983). See also the preliminary report by the Special Rapporteur, Mrs. Erica-Irene Daes, U.N. Doc. E/CN.4/Sub.2/474 (1981) and her temporary report U.N. Doc. E/CN.4/Sub.2/1982/16 (1982).
18. See Daes report, supra note 5, and U.N. Doc. E/CN.4/Sub.2/1983/17/Add.1 (1983). See also the preliminary report by the Special Rapporteur, Mrs. Erica-Irene Daes, U.N. Doc. E/CN.4/Sub.2/474 (1981) and her temporary report U.N. Doc. E/CN.4/Sub.2/1982/16 (1982).
19. See U.N. Doc. E/CN.4/Sub.2/1983/SR.29 (1983) par. 26 at 7.
20. See U.N. Doc. H.R.C. Res. 1989/40 (1989). It is also important to note that four main revisions were made by the Sub-Commission Working Group. See, chronologically, U.N., Sessional Working Group on the question of persons detained on the grounds of mental ill-health or suffering from mental disorder; U.N. Doc. D/CN.4/Sub.2/1984/19 (1984); U.N. Doc. E/CN.4/Sub.2/1985/20 (1985); U.N. Doc. E/CN.4/Sub.2/1987/ WG.3/WP.1, (1987); U.N. Doc. E/CN.4/Sub.2/1987/32 (1987); U.N. Doc. E/CN.4/Sub.2/1988/23 (1988)
21. See U.N. Doc. H.R.C. Res. 1989/40 (1989). It is also important to note that four main revisions were made by the Sub-Commission Working Group. See, chronologically, U.N., Sessional Working Group on the question of persons detained on the grounds of mental ill-health or suffering from mental disorder; U.N. Doc. D/CN.4/Sub.2/1984/19 (1984); U.N. Doc. E/CN.4/Sub.2/1985/20 (1985); U.N. Doc. E/CN.4/Sub.2/1987/ WG.3/WP.1, (1987); U.N. Doc. E/CN.4/Sub.2/1987/32 (1987); U.N. Doc. E/CN.4/Sub.2/1988/23 (1988)
22. See U.N. Doc. H.R.C. Res. 1989/40 (1989). It is also important to note that four main revisions were made by the Sub-Commission Working Group. See, chronologically, U.N., Sessional Working Group on the question of persons detained on the grounds of mental ill-health or suffering from mental disorder; U.N. Doc. D/CN.4/Sub.2/1984/19 (1984); U.N. Doc. E/CN.4/Sub.2/1985/20 (1985); U.N. Doc. E/CN.4/Sub.2/1987/ WG.3/WP.1, (1987); U.N. Doc. E/CN.4/Sub.2/1987/32 (1987); U.N. Doc. E/CN.4/Sub.2/1988/23 (1988)
23. See U.N. Doc. H.R.C. Res. 1989/40 (1989). It is also important to note that four main revisions were made by the Sub-Commission Working Group. See, chronologically, U.N., Sessional Working Group on the question of persons detained on the grounds of mental ill-health or suffering from mental disorder; U.N. Doc. D/CN.4/Sub.2/1984/19 (1984); U.N. Doc. E/CN.4/Sub.2/1985/20 (1985); U.N. Doc. E/CN.4/Sub.2/1987/ WG.3/WP.1, (1987); U.N. Doc. E/CN.4/Sub.2/1987/32 (1987); U.N. Doc. E/CN.4/Sub.2/1988/23 (1988)
24. See U.N. Doc. H.R.C. Res. 1989/40 (1989). It is also important to note that four main revisions were made by the Sub-Commission Working Group. See, chronologically, U.N., Sessional Working Group on the question of persons detained on the grounds of mental ill-health or suffering from mental disorder; U.N. Doc. D/CN.4/Sub.2/1984/19 (1984); U.N. Doc. E/CN.4/Sub.2/1985/20 (1985); U.N. Doc. E/CN.4/Sub.2/1987/ WG.3/WP.1, (1987); U.N. Doc. E/CN.4/Sub.2/1987/32 (1987); U.N. Doc. E/CN.4/Sub.2/1988/23 (1988)
25. See U.N. Doc. H.R.C. Res. 1989/40 (1989). It is also important to note that four main revisions were made by the Sub-Commission Working Group. See, chronologically, U.N., Sessional Working Group on the question of persons detained on the grounds of mental ill-health or suffering from mental disorder; U.N. Doc. D/CN.4/Sub.2/1984/19 (1984); U.N. Doc. E/CN.4/Sub.2/1985/20 (1985); U.N. Doc. E/CN.4/Sub.2/1987/ WG.3/WP.1, (1987); U.N. Doc. E/CN.4/Sub.2/1987/32 (1987); U.N. Doc. E/CN.4/Sub.2/1988/23 (1988)
26. and U.N. Rapport du groupe de travail sur le projet d'ensemble de principes et de garanties pour la protection des malades mentaux et l'amélioration des soins de santé mentale. U.N. Doc. E/CN.4/1990/31 (1990).
27. Many differences of opinion were expressed over those two Drafts about patient's rights, which were substantially altered in the second version. "However, the relativistic nature of human rights in mental health can be illustrated by the fact that the two working parties took irreconcilable positions on certain key features of the Declaration, including the concept of treatability." Gostin, supra note 2. See the U.N., Written statement submitted by the International Association of Penal Law and the International Commission of Jurists, nongovernmental organizations in consultative status, category II. U.N. Doc. E/ CN.4/Sub.2/NGO/81 (1980) and U.N. Doc. E/CN.4/Sub.2/NGO/85 (1981). For a detailed discussion on these Drafts, see the proceedings in Association internationale de droit pénal, THE PROTECTION OF THE PERSONS SUFFERING FROM MENTAL DISORDER (1980).
28. Many differences of opinion were expressed over those two Drafts about patient's rights, which were substantially altered in the second version. "However, the relativistic nature of human rights in mental health can be illustrated by the fact that the two working parties took irreconcilable positions on certain key features of the Declaration, including the concept of treatability." Gostin, supra note 2. See the U.N., Written statement submitted by the International Association of Penal Law and the International Commission of Jurists, nongovernmental organizations in consultative status, category II. U.N. Doc. E/ CN.4/Sub.2/NGO/81 (1980) and U.N. Doc. E/CN.4/Sub.2/NGO/85 (1981). For a detailed discussion on these Drafts, see the proceedings in Association internationale de droit pénal, THE PROTECTION OF THE PERSONS SUFFERING FROM MENTAL DISORDER (1980).
29. Many differences of opinion were expressed over those two Drafts about patient's rights, which were substantially altered in the second version. "However, the relativistic nature of human rights in mental health can be illustrated by the fact that the two working parties took irreconcilable positions on certain key features of the Declaration, including the concept of treatability." Gostin, supra note 2. See the U.N., Written statement submitted by the International Association of Penal Law and the International Commission of Jurists, nongovernmental organizations in consultative status, category II. U.N. Doc. E/ CN.4/Sub.2/NGO/81 (1980) and U.N. Doc. E/CN.4/Sub.2/NGO/85 (1981). For a detailed discussion on these Drafts, see the proceedings in Association internationale de droit pénal, THE PROTECTION OF THE PERSONS SUFFERING FROM MENTAL DISORDER (1980).
30. See U.N. Doc. G.A. Res. 33/53 (1978).
31. See U.N., Communication écrite soumise par l'Organisation mondiale de la santé à la Commission des droits de l'homme au sujet de la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux, U.N. Doc. E/CN/4/1988/66, (1988) at 4: U.N., Renseignements fournis par l'O.M.S. sur la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux. U.N. Doc. E/ CN.4/Sub.2/1987/WG.3/WP.2 (1987) at 2
32. See U.N., Communication écrite soumise par l'Organisation mondiale de la santé à la Commission des droits de l'homme au sujet de la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux, U.N. Doc. E/CN/4/1988/66, (1988) at 4: U.N., Renseignements fournis par l'O.M.S. sur la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux. U.N. Doc. E/ CN.4/Sub.2/1987/WG.3/WP.2 (1987) at 2
33. and U.N., Communication soumise par l'Organisation mondiale de la santé, U.N. Doc. E/CN.4/Sub.2/1988/WG.3/WP.3 (1988) at 2:
34. U.N., Principles and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder - Report from the Secretary-General. U.N. Doc. E/CN.4/1990/53/Add.3 (1990) at 9 and U.N., Report of the working Group on the mentally ill, Intervention by Niall MacDermot, Secretary-General of the International Commission of Jurists (1987).
35. The introductory document for the U.N. Principles was adopted by the Working Group, but is not part of the General Assembly Resolution. See U.N., Report of the Working Group on the Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care. U.N. Doc. E/ CN.4/1991/39 (1991) at paras. 2 and 3.
36. Id. The expression "minimal standards" is not reproduced in the U.N. Principles. It is worth noting that some governments, in particular the Government of Japan, were reluctant to adopt this expression. See U.N., Principles and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder - Report from the Secretary-General. U.N. Doc. E/CN.4/1990/53/Add.3 (1990) at 2.
37. Id. The expression "minimal standards" is not reproduced in the U.N. Principles. It is worth noting that some governments, in particular the Government of Japan, were reluctant to adopt this expression. See U.N., Principles and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder - Report from the Secretary-General. U.N. Doc. E/CN.4/1990/53/Add.3 (1990) at 2.
38. Universal Declaration of Human Rights, supra, note 6; International Covenant on Economic, Social and Cultural Rights, 1976, 993 U. N. T. S. 13; International Covenant on Civil and Political Rights, 1976, 999 U. N. T. S. 187; Optional Protocol to International Covenant on Civil and Political Rights, 999 U. N. T. S. 1976, 306.
39. In this regard, it is relevant to reproduce an extract from the Preamble of the Universal Declaration, id.: Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world, . . . , Whereas the people of the United Nations have in the Charter reaffirmed their faith in fundamental human rights, in the dignity and worth of the human person and in the equal rights of men and women and have determined to promote social progress and better standards of life in larger freedom, . . .
40. Introduction of the U.N. Principles, supra note 19.
41. John Orley, Report by John Orley (W.H.O.) on the recent meeting of the Working Group of the United Nations Commission on Human Rights (20 October-9 November), dealing with the right of the mentally ill, in INNOVATIONS IN MENTAL HEALTH LEGISLATION AND GOVERNMENT POLICY: A EUROPEAN PERSPECTIVE, organised by the Ministry of justice of LaHaye, Netherlands, November 19-22, 1990, 36 (emphasis added). See also U.N., Communication soumise par l'Organisation mondiale de la santé, U.N. Doc. E/CN.4/Sub.2/1988/WG.3/WP.3 (1988) at 2 and 7. The title adopted prior to this modification was: Principles, guidelines and guarantees for the protection of the mentally ill or persons suffering from mental disorder.
42. John Orley, Report by John Orley (W.H.O.) on the recent meeting of the Working Group of the United Nations Commission on Human Rights (20 October-9 November), dealing with the right of the mentally ill, in INNOVATIONS IN MENTAL HEALTH LEGISLATION AND GOVERNMENT POLICY: A EUROPEAN PERSPECTIVE, organised by the Ministry of justice of LaHaye, Netherlands, November 19-22, 1990, 36 (emphasis added). See also U.N., Communication soumise par l'Organisation mondiale de la santé, U.N. Doc. E/CN.4/Sub.2/1988/WG.3/WP.3 (1988) at 2 and 7. The title adopted prior to this modification was: Principles, guidelines and guarantees for the protection of the mentally ill or persons suffering from mental disorder.
43. See Daes Draft, supra note 2, s. 7 and 8. The Special Rapporteur proposed. Daes report, supra note 5, at 50, 58, 59, that the Sub-Commission consider making basic recommendations to the Commission of Human Rights for consideration by Governments, namely, she states that the Governments should: Elaborate and implement programs for social and community care of the patient and allocate adequate resources for the improvement, if necessary, of medical services and mental institutions. . . . ; Recognize the rights of patients to receive treatment, and to refuse treatment, the rights to rehabilitation. . . ; Establish modern and suitable mental institutions and develop adequate medical services, which should call for good quality mental health workers and produce more and better teachers and teaching in mental health centers.
44. This is a question of great importance. It would need a much longer development with the "travaux préparatoires" in support. For further discussion, see Caroline Gendreau, LE DROIT DU PATIENT PSYCHIATRIQUE DE CONSENTIR À UN TRAITMENT: ÉLABORATION D'UNE NORME INTERNATIONALE (1996) at 77-88. See also Rosenthal & Rubenstein, supra note 4, at 260-62.
45. U.N. Principles, supra note 4, Principle 1(4). For a comment on this Principle, see the conclusion of this article.
46. Christopher C. Joyner recalls the distinction, between a declaration and a recommendation, made by the Human Rights Commission in Memorandum by the Office of Legal Affairs on the use of term "declaration" and "recommendation," 34 U.N. ESCOR, Supp. (No. 8) 15, U.N. Doc. E/CN.4/L.610, reprinted in Commission of Human Rights Report. U.N. ECOSOC Council Off. Rec., Supp. (No. 8) 15, U.N. Doc. E/3616/Rev.1 (1962), as referred in C.C. Joyner, U.N. General Assembly resolutions and international law: rethinking the contemporary dynamics of norm-creation, 11 CAL. W. INT'L L. J. 445, 456 (1981).
47. Christopher C. Joyner recalls the distinction, between a declaration and a recommendation, made by the Human Rights Commission in Memorandum by the Office of Legal Affairs on the use of term "declaration" and "recommendation," 34 U.N. ESCOR, Supp. (No. 8) 15, U.N. Doc. E/CN.4/L.610, reprinted in Commission of Human Rights Report. U.N. ECOSOC Council Off. Rec., Supp. (No. 8) 15, U.N. Doc. E/3616/Rev.1 (1962), as referred in C.C. Joyner, U.N. General Assembly resolutions and international law: rethinking the contemporary dynamics of norm-creation, 11 CAL. W. INT'L L. J. 445, 456 (1981).
48. Christopher C. Joyner recalls the distinction, between a declaration and a recommendation, made by the Human Rights Commission in Memorandum by the Office of Legal Affairs on the use of term "declaration" and "recommendation," 34 U.N. ESCOR, Supp. (No. 8) 15, U.N. Doc. E/CN.4/L.610, reprinted in Commission of Human Rights Report. U.N. ECOSOC Council Off. Rec., Supp. (No. 8) 15, U.N. Doc. E/3616/Rev.1 (1962), as referred in C.C. Joyner, U.N. General Assembly resolutions and international law: rethinking the contemporary dynamics of norm-creation, 11 CAL. W. INT'L L. J. 445, 456 (1981).
49. Christopher C. Joyner recalls the distinction, between a declaration and a recommendation, made by the Human Rights Commission in Memorandum by the Office of Legal Affairs on the use of term "declaration" and "recommendation," 34 U.N. ESCOR, Supp. (No. 8) 15, U.N. Doc. E/CN.4/L.610, reprinted in Commission of Human Rights Report. U.N. ECOSOC Council Off. Rec., Supp. (No. 8) 15, U.N. Doc. E/3616/Rev.1 (1962), as referred in C.C. Joyner, U.N. General Assembly resolutions and international law: rethinking the contemporary dynamics of norm-creation, 11 CAL. W. INT'L L. J. 445, 456 (1981).
50. Christopher C. Joyner recalls the distinction, between a declaration and a recommendation, made by the Human Rights Commission in Memorandum by the Office of Legal Affairs on the use of term "declaration" and "recommendation," 34 U.N. ESCOR, Supp. (No. 8) 15, U.N. Doc. E/CN.4/L.610, reprinted in Commission of Human Rights Report. U.N. ECOSOC Council Off. Rec., Supp. (No. 8) 15, U.N. Doc. E/3616/Rev.1 (1962), as referred in C.C. Joyner, U.N. General Assembly resolutions and international law: rethinking the contemporary dynamics of norm-creation, 11 CAL. W. INT'L L. J. 445, 456 (1981).
51. See Paul Sieghart. THE INTERNATIONAL LAW OF HUMAN RIGHTS 16 (1983).
52. Rosenthal & Rubenstein, supra note 4, at 287.
53. E.g., we observe that the World Association for Psychosocial Rehabilitation sought the creation of a United Nations annual reporting system pursuant to the application of the U.N. Principles. See U.N., Principes et garanties pour la protection des personnes détenues pour maladie mentale ou atteintes de troubles mentaux. Rapport de secrétaire général, U.N. Doc. E/CN.4/1990/53/Add.2 (1990) para. 6.
54. The penultimate Draft, U.N., Rapport du Groupe de travail de session sur la questin des personnes détenues pour maladie mentale ou atteintes de troubles mentaux, U.N. Doc. D/CN.4/Sub.2/1988/23 (1988) s. 22, at 14, provided the following clause: Il est recommandé aux États de créer une commission pluridisciplinaire indépendante, chargée de promouvoir le respect des Principes et garanties tels qu'ils sont consacrés par la législation nationale, de procéder à des inspections afin de suivre les méthodes utilisées à l'égard des patients et les conditions dans lesquelles ces derniers sont traités, et d'enquêter et de formuler des recommandations au sujet des plaintes déposées par les patients ou leurs représentants. The N.G.O. Disabled Peoples' International argued in favor of such a measure of international control on an annual basis. See U.N., Principes et garanties pour la protection des personnes détenues pour maladie mentale ou atteintes de troubles mentaux. Rapport du secrétaire général, U.N. Doc. E/CN.4/1990/53/Add.2 (1990) para. 6. See also Rosenthal & Rubenstein, supra note 4, at 287.
55. The penultimate Draft, U.N., Rapport du Groupe de travail de session sur la questin des personnes détenues pour maladie mentale ou atteintes de troubles mentaux, U.N. Doc. D/CN.4/Sub.2/1988/23 (1988) s. 22, at 14, provided the following clause: Il est recommandé aux États de créer une commission pluridisciplinaire indépendante, chargée de promouvoir le respect des Principes et garanties tels qu'ils sont consacrés par la législation nationale, de procéder à des inspections afin de suivre les méthodes utilisées à l'égard des patients et les conditions dans lesquelles ces derniers sont traités, et d'enquêter et de formuler des recommandations au sujet des plaintes déposées par les patients ou leurs représentants. The N.G.O. Disabled Peoples' International argued in favor of such a measure of international control on an annual basis. See U.N., Principes et garanties pour la protection des personnes détenues pour maladie mentale ou atteintes de troubles mentaux. Rapport du secrétaire général, U.N. Doc. E/CN.4/1990/53/Add.2 (1990) para. 6. See also Rosenthal & Rubenstein, supra note 4, at 287.
56. Rosenthal & Rubenstein, supra note 4, at 267-84. These authors offer an interesting study of the ways that the U.N. Principles, as an international instrument of human rights, can gain "legal significance" by different implementation strategies. See also Michel Virally. La distinction entre textes internationaux ayant une portée juridique dans les relations mutuelles entre leurs auterus et textes qui en sont dépourvus, 60-I ANNUAIRE DE L'INSTITUT DE DROIT INTERNATIONAL 328, at 350 (1983).
57. See Australian Human Rights and Equal Opportunity Commission, HUMAN RIGHTS AND MENTAL ILLNESS, REPORT OF THE NATIONAL INQUIRY INTO THE HUMAN RIGHTS OF PEOPLE WITH MENTAL ILLNESS 31 (1993); International Commission of Jurists, International Commission of Jurists Mission to Japan, April 1988, Preliminary report and recommendations, 37 I.C.J. Newsletter, 10-11 and 28-44 (1988): International Commission of Jurists, Mission to study human rights of psychiatric patients, conclusion and recommendations. April 1992, (unpublished). See also Saleem Shah, People's Republic of China. Second National Workshop on Mental Health, 3 INT'L BULL. LAW & MENTAL HEALTH 17 (1991).
58. See Australian Human Rights and Equal Opportunity Commission, HUMAN RIGHTS AND MENTAL ILLNESS, REPORT OF THE NATIONAL INQUIRY INTO THE HUMAN RIGHTS OF PEOPLE WITH MENTAL ILLNESS 31 (1993); International Commission of Jurists, International Commission of Jurists Mission to Japan, April 1988, Preliminary report and recommendations, 37 I.C.J. Newsletter, 10-11 and 28-44 (1988): International Commission of Jurists, Mission to study human rights of psychiatric patients, conclusion and recommendations. April 1992, (unpublished). See also Saleem Shah, People's Republic of China. Second National Workshop on Mental Health, 3 INT'L BULL. LAW & MENTAL HEALTH 17 (1991).
59. See Australian Human Rights and Equal Opportunity Commission, HUMAN RIGHTS AND MENTAL ILLNESS, REPORT OF THE NATIONAL INQUIRY INTO THE HUMAN RIGHTS OF PEOPLE WITH MENTAL ILLNESS 31 (1993); International Commission of Jurists, International Commission of Jurists Mission to Japan, April 1988, Preliminary report and recommendations, 37 I.C.J. Newsletter, 10-11 and 28-44 (1988): International Commission of Jurists, Mission to study human rights of psychiatric patients, conclusion and recommendations. April 1992, (unpublished). See also Saleem Shah, People's Republic of China. Second National Workshop on Mental Health, 3 INT'L BULL. LAW & MENTAL HEALTH 17 (1991).
60. Rosenthal & Rubenstein, supra note 4, and Stanley S. Herr, Rights of Disabled Persons: International Principles and American Experiences. 1 COLUM. HUM. RTS. L. REV. 1, 12 (1980).
61. Canadian Charter of Rights and Freedoms, Constitution Act. 1982, Canada Act. 1982, 1982, c. 11 (U.K.) Sch. B in R.S.C., 1985, App. II, no. 44, Sch. B. See William Schabas, International Human Rights Law, Use in Canadian Charter, (1991); Anne F. Bayefsky, INTERNATIONAL HUMAN RIGHTS LAW, USE IN CANADIAN CHARTER OF RIGHTS AND FREEDOMS LITIGATION (1992); Daniel Turp, Le recours au droit international aux fins de l'interprétation de la Charte canadienne des droits et libertés: un bilan jurisprudentiel, in LA CHARTE CANADIENNE DES DROITS ET LIBERTÉS: CONCEPTS ET IMPACTS (1985).
62. Canadian Charter of Rights and Freedoms, Constitution Act. 1982, Canada Act. 1982, 1982, c. 11 (U.K.) Sch. B in R.S.C., 1985, App. II, no. 44, Sch. B. See William Schabas, International Human Rights Law, Use in Canadian Charter, (1991); Anne F. Bayefsky, INTERNATIONAL HUMAN RIGHTS LAW, USE IN CANADIAN CHARTER OF RIGHTS AND FREEDOMS LITIGATION (1992); Daniel Turp, Le recours au droit international aux fins de l'interprétation de la Charte canadienne des droits et libertés: un bilan jurisprudentiel, in LA CHARTE CANADIENNE DES DROITS ET LIBERTÉS: CONCEPTS ET IMPACTS (1985).
63. Canadian Charter of Rights and Freedoms, Constitution Act. 1982, Canada Act. 1982, 1982, c. 11 (U.K.) Sch. B in R.S.C., 1985, App. II, no. 44, Sch. B. See William Schabas, International Human Rights Law, Use in Canadian Charter, (1991); Anne F. Bayefsky, INTERNATIONAL HUMAN RIGHTS LAW, USE IN CANADIAN CHARTER OF RIGHTS AND FREEDOMS LITIGATION (1992); Daniel Turp, Le recours au droit international aux fins de l'interprétation de la Charte canadienne des droits et libertés: un bilan jurisprudentiel, in LA CHARTE CANADIENNE DES DROITS ET LIBERTÉS: CONCEPTS ET IMPACTS (1985).
64. Charte des droits et libertés de la personne, L.R.Q., c. C-12. As an example among others, see Commission des droits de la personne du Québec et Commission scolarie de St-Jean-sur-Richelieu, [1991] R.J.Q. 3003 (T.D.P.Q.). In this case, the Tribunal referred to the Declaration of the Rights of Mentally Retarded Persons, G. A. Res. 2856 (XXXVI) (1971) and to the Declaration on the Rights of Disabled Persons, G.A. Res. 3447 (XXX) (1971). See also Madeleine Caron, L'utilisation du droit international aux fins d'interprétation et d'application de la Charte des droits et libertés de la personne du Québec, REVUE QUÉBÉCOISE DE DROIT INTERNATIONAL 308 (1984).
65. Charte des droits et libertés de la personne, L.R.Q., c. C-12. As an example among others, see Commission des droits de la personne du Québec et Commission scolarie de St-Jean-sur-Richelieu, [1991] R.J.Q. 3003 (T.D.P.Q.). In this case, the Tribunal referred to the Declaration of the Rights of Mentally Retarded Persons, G. A. Res. 2856 (XXXVI) (1971) and to the Declaration on the Rights of Disabled Persons, G.A. Res. 3447 (XXX) (1971). See also Madeleine Caron, L'utilisation du droit international aux fins d'interprétation et d'application de la Charte des droits et libertés de la personne du Québec, REVUE QUÉBÉCOISE DE DROIT INTERNATIONAL 308 (1984).
66. Charte des droits et libertés de la personne, L.R.Q., c. C-12. As an example among others, see Commission des droits de la personne du Québec et Commission scolarie de St-Jean-sur-Richelieu, [1991] R.J.Q. 3003 (T.D.P.Q.). In this case, the Tribunal referred to the Declaration of the Rights of Mentally Retarded Persons, G. A. Res. 2856 (XXXVI) (1971) and to the Declaration on the Rights of Disabled Persons, G.A. Res. 3447 (XXX) (1971). See also Madeleine Caron, L'utilisation du droit international aux fins d'interprétation et d'application de la Charte des droits et libertés de la personne du Québec, REVUE QUÉBÉCOISE DE DROIT INTERNATIONAL 308 (1984).
67. Charte des droits et libertés de la personne, L.R.Q., c. C-12. As an example among others, see Commission des droits de la personne du Québec et Commission scolarie de St-Jean-sur-Richelieu, [1991] R.J.Q. 3003 (T.D.P.Q.). In this case, the Tribunal referred to the Declaration of the Rights of Mentally Retarded Persons, G. A. Res. 2856 (XXXVI) (1971) and to the Declaration on the Rights of Disabled Persons, G.A. Res. 3447 (XXX) (1971). See also Madeleine Caron, L'utilisation du droit international aux fins d'interprétation et d'application de la Charte des droits et libertés de la personne du Québec, REVUE QUÉBÉCOISE DE DROIT INTERNATIONAL 308 (1984).
68. 38 Rosenthal & Rubenstein, supra note 4.
69. See Caroline Gendreau, The United Nations Principles for the Protection of Human Rights in the Field of Mental Health, communication presented at the International Conference titled Human Rights, Mental Health and Therapy in a Radically Changing World and held under the auspices of W.H.O., Banff, Alberta, Canada, 28 January 1993.
70. Paul S. Appelbaum, Informed Consent, in David Weisstub (dir.), LAW AND MENTAL HEALTH. INTERNATIONAL PERSPECTIVES 45-69 (1984): Although it is asserted that informed consent in psychiatric practice raises different issues than in the rest of medicine, and by implication that the doctrine should be modified to address these issues, the similarities between the informed consent process in psychiatry and in general medicine vastly outweigh the differences. There is little question that informed consent law is generally relevant to psychiatric practice.
71. Michael Bay, Implementing Competency Legislation for Health Care, 14 HEALTH L. CANADA 35 (1993). The author explains how psychiatric practices at the hospital are often stronger than law provisions formally adopted by the legislature.
72. The criteria of involuntary admission to a mental health facility can have a considerable incidence on the right to consent to treatment when the involuntary admission is, itself, formulated as a criterion of incapacity to exercise the right. Also, the refusal of treatment, if not a legal criterion, is still used in practice to limit the right to consent to treatment. See Mary-BethValentine, Duff Warning and David Giuffrida. Capacité mentale et refus de traitement dans les hôpitaux psychiatriques, SANTÉ MENTALE AU CANADA 21 (1992). For a jurisprudential discussion on these matters, see the Appeal Court of Quebec in Institut Philippe-Pinel c. A. G., [1994] R.J.Q. 2523 (C.A.) and the Appeal Court of Ontario in Fleming v. Reid. (1991) 4 O.R. (3d) 74 (A.C. Ont).
73. See text relating to notes 22-26.
74. See U.N., Communication écrite soumise par l'Organisation mondiale de la santé à la Commission des droits de l'homme au sujet de la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux. U.N. Doc. E/CN.4/1988/66 (1988); U.N., Renseignements fournis par l'O.M.S. sur la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux, U.N. Doc. E/ CN.4/Sub.2/1987/WG.3/WP.2 (1987); U.N., Communication soumise par l'Organisation mondiale de la santé, U.N. Doc. E/CN.4/Sub.2/1988/WG.3/WP.3 (1988) and U.N., Principles and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder - Report from the Secretary-General, U.N. Doc. E/CN.4/1990/53/Add.3 (1990).
75. See U.N., Communication écrite soumise par l'Organisation mondiale de la santé à la Commission des droits de l'homme au sujet de la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux. U.N. Doc. E/CN.4/1988/66 (1988); U.N., Renseignements fournis par l'O.M.S. sur la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux, U.N. Doc. E/ CN.4/Sub.2/1987/WG.3/WP.2 (1987); U.N., Communication soumise par l'Organisation mondiale de la santé, U.N. Doc. E/CN.4/Sub.2/1988/WG.3/WP.3 (1988) and U.N., Principles and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder - Report from the Secretary-General, U.N. Doc. E/CN.4/1990/53/Add.3 (1990).
76. See U.N., Communication écrite soumise par l'Organisation mondiale de la santé à la Commission des droits de l'homme au sujet de la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux. U.N. Doc. E/CN.4/1988/66 (1988); U.N., Renseignements fournis par l'O.M.S. sur la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux, U.N. Doc. E/ CN.4/Sub.2/1987/WG.3/WP.2 (1987); U.N., Communication soumise par l'Organisation mondiale de la santé, U.N. Doc. E/CN.4/Sub.2/1988/WG.3/WP.3 (1988) and U.N., Principles and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder - Report from the Secretary-General, U.N. Doc. E/CN.4/1990/53/Add.3 (1990).
77. See U.N., Communication écrite soumise par l'Organisation mondiale de la santé à la Commission des droits de l'homme au sujet de la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux. U.N. Doc. E/CN.4/1988/66 (1988); U.N., Renseignements fournis par l'O.M.S. sur la question des personnes détenues pour maladie mentale ou souffrant de troubles mentaux, U.N. Doc. E/ CN.4/Sub.2/1987/WG.3/WP.2 (1987); U.N., Communication soumise par l'Organisation mondiale de la santé, U.N. Doc. E/CN.4/Sub.2/1988/WG.3/WP.3 (1988) and U.N., Principles and guarantees for the protection of persons detained on grounds of mental ill-health or suffering from mental disorder - Report from the Secretary-General, U.N. Doc. E/CN.4/1990/53/Add.3 (1990).
78. U.N., Principes et garanties pour la protection des personnes détenues pour maladie mentale ou atteintes de troubles mentaux, Rapport du Secrétaire général. U.N. Doc. E/CN.4/1990/53/Add.1 (1989).
79. Id., at 12. Nearly 50 governments participated in the consultations in 1982 and in 1989-1991, but fewer participated in the Working Group sessions. Only five submitted written statements, and only the Government of Japan made explicit its opinion on the consent-to-treatment issue.
80. Larry Gostin was the Rapporteur of the Committee of the Experts relating to the issues of civil admission and consent to treatment during the two meetings of international experts held in 1980 for the elaboration of the two first international Drafts of principles and guidelines related to mental health. See Consent to unusually hazardous, unestablished or irreversible treatments in psychiatry: A review of the Draft United Nations Guidelines for the protection of persons suffering from mental health, in Association Internationale de droit Pénal, supra note 16.
81. U.N., Written statement submitted by Disabled Peoples' International, a non-governmental organization in consultative status (Category II), U.N. Doc. E/CN.4/Sub.2/1988/NGO/27 (1988) at 3, and U.N., Written statement submitted by the Disabled Peoples' International, a non-governmental organization, in consultative status, (Category II). U.N. Doc. E/CN.4/1989/NGO/75 (1989).
82. U.N., Written statement submitted by Disabled Peoples' International, a non-governmental organization in consultative status (Category II), U.N. Doc. E/CN.4/Sub.2/1988/NGO/27 (1988) at 3, and U.N., Written statement submitted by the Disabled Peoples' International, a non-governmental organization, in consultative status, (Category II). U.N. Doc. E/CN.4/1989/NGO/75 (1989).
83. Supra note 48, at 74.
84. Id. at 82.
85. All the different Drafts of the U.N. Principles show variations in the wording of provisions concerning the recognition of the patient's rights. These variations correspond to the preoccupations of the participants who were involved at each period of time. This observation is not only made at the end of the drafting process, but throughout the drafting process: it was continually present since the very beginning, in 1980. See the two first Drafts of the international expert committee, supra note 16.
86. Id., Principle 11(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, the method, likely duration, and expected benefit of the proposed treatment; (c) Alternative modes of treatment, including those less intrusive; (d) Possible pain or discomfort, risks and side-effects of the proposed treatment.
87. This is, in fact, a crucial claim in the context of handicapped people's fight for equality: "this imminently sensible concept of informed consent could substantially advance the promise that handicapped persons are equal citizens under the law." Steven J. Schwartz, Equal Protection in Medication Decision: Informed Consent, Not Just the Right to Refuse, in American Bar Association. THE RIGHT TO REFUSE ANTIPSYCHOTIC MEDICATION 74, at 78 (1986).
88. The fact that the right to refuse a treatment is formulated after the definition of informed consent, provided in paragraph (2), tends to confirm this interpretation.
89. For a more detailed comment on the discrimination clause, see the conclusion of this article.
90. The French version of this paragraph is somehow different. It targets the patient who "manifeste l'intention de renoncer au droit de donner son consentement en connaissance de cause." The patient's intention in connection with the decision about treatment is precisely the object of concern when it is a refusal of treatment.
91. U.N. Principles, Supra note 4. Principle 11 (3) provides that "A patient may request the presence of a person or persons of the patient's choosing during the procedure for granting consent." This Principle is not the recognition of a right. It rather transforms into a privilege the right to communication recognized in Principle 13(c). It does not tell who has, or should have, the authority to accept or refuse the patient's request nor does it say on what basis the decision should be taken. Moreover, it is explicitly linked to the informed consent, referred to by paragraph (2), and makes the application of the privilege uncertain for the patient who seeks to refuse or to stop a treatment. Would a patient in this situation see the privilege refused because he is not in the process of giving his consent?
92. Id., Principle 12(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 and explanation of those rights and how to exercise them.
93. Id., Principle 11(6).
94. Id., Principle 11(7).
95. Id., Principle 11(8).
96. Id., Principle 11(13).
97. Id., Principle 11(15).
98. The French version does not refer to a "plan of treatment" but only to the term "treatment."
99. For a detailed discussion of mental competency see David N. Weisstub (chairman), ENQUIRY ON MENTAL COMPETENCY, FINAL REPORT (1990).
100. This favors the traditional psychiatric perspective in presuming, first, that only the involuntarily admitted patient suffers from a lack of capacity and, second, that the patient admitted on a voluntary basis is able to consent when he or she is not resisting or until he or she refuses. It is important to note that resisting or refusing a treatment may be considered, by a mental health professional, as a sign of impaired judgment. Impaired judgment is. in fact, a criterion, among others, meant to justify the involuntary admission, as it is explicitly specified in U.N. Principles: supra note 4. Principle (16(1)b).
101. Id. Principle 11(8) provides special conditions applicable to the situation where the treatment "is urgently necessary in order to prevent immediate or imminent harm to the patient or to other persons." In that case it is mentioned that informed consent is not necessary, but that the "treatment shall not be prolonged beyond the period that is strictly necessary for this purpose." It is striking that, under Principle 11(6), there is no such time limitation when a refusal is considered unreasonable!
102. Rosenthal & Rubenstein, supra note 4, at 265.
103. It is appropriate to recall Larry Gostin's comment as he was the Rapporteur of the Committee of the Experts relating to the issues of civil admission and consent to treatment during the two meetings of international experts, held in 1980. See Association de droit pénal, supra note 48, at 79: There is increasing recognition that if a psychiatric patient is competent . . . and expressly refuses to consent to treatment, his views should be respected. This is not necessarily to suggest that it is always in his best interests to refuse treatment, but only that it would be an affront to his human dignity and self-esteem if treatment were to be imposed directly against his express wishes. There can be no greater intrusion on a competent human being than to compel him to receive physical treatment which he does not want.
104. Leading to the same conclusion, but from a different analysis perspective, see Thomas Szasz, The Myth of the Rights of Mental Patients, LIBERTY 19 (1989).
105. As explained by Paul Sieghart, supra note 29, at 17s: "Indeed, the concept of 'non-discrimination' is so central to international human rights law that all but one of the major instrument prescribe it in an Article of general application, expressed to extend to all the specific rights which they declare."
106. In the French version the expression is "améliorer leur état de santé." This clause confirms the dichotomous conception promoted by the U.N. Principles: they again set the protection of the patient's rights in opposition to the improvement of the patient's mental health.
107. U.N. Principles, supra note 4. Principle 1(4).
108. Moreover, confirming this interpretation, the U.N. Principles, id., provide a general limitation clause: The exercise of the rights set forth in these Principles may be subjected only to such limitations as are prescribed by law and are necessary to protect the health or safety of the person concerned or others, or otherwise to protect public safety, order, health or morals or the fundamental rights and freedoms of others. This clause seems to be an answer to some concerns voiced by the Government of Japan, in 1990, while participating to the drafting process. In a general comment on the U.N. Principles, the Government of Japan stated, U.N. Principles and guarantees for the protection of persons, supra note 18, at 2: The protection of human rights of mentally ill persons is, naturally, the primary objective of the principles. However, protection of the rights of other citizens is no less important and should be equally guaranteed. It is proposed, therefore, that a clause should be inserted somewhere in the introductory part to the following effect: "With due consideration for the protection of the rights of other citizens."
109. In addition, it should be noted that this interpretation is contrary to the "saving of existing rights" clause provided under Principle 25. U.N. Principles, supra note 4: There shall be no restriction upon or derogation from any existing rights of patients, including rights recognized in applicable international or domestic law, on the pretext that the present Principles do not recognize such a right or that they recognize them to a lesser extent.
110. Rosenthal & Rubenstein, supra note 4, at 267: The compromise is hardly uncommon in mental health law. The human rights imprimatur is troubling, however, because coercion in the name of treatment, once unleashed, is very difficult to control. Having said this, the Principles nevertheless represent a remarkable achievement and contain human rights guidelines worthy of attention and enforcement. Their recognition that mental health interventions raise human rights concerns whether motivated by malignant or therapeutic ends, and that mental illness is no basis to deprive people of their civil rights, provides a basis to address many, if not all, human rights issues in mental health treatment.