Norbert Konrad, Birgit Völlm and David N. Weisstub (eds.)International Library of Ethics, Law, and the New MedicineEthical Issues in Prison Psychiatry201310.1007/978-94-007-0086-4_17
© Springer Science+Business Media Dordrecht 2013
17. Ethical Issues in Prison Psychiatry in România
(1)
Psychiatric Ambulatory Clinic, Oradea, România
Abstract
Forensic psychiatry is required to adhere to the same ethics, rules, and principles found in general medicine. Overall, România’s legislation respects the international mandates of the United Nations and the World Health Organization and European Union concerning the protection of the mentally ill. The protection of Human Rights and the dignity of persons with mental disorders have to be effective everywhere they are even in the prison or jail, warranting the medical care and the adequate treatment and the social, professional and familial rehabilitation. Society is equally interested in maintaining the autonomy and well-being of its citizens as well as protecting them from risks and dangers caused by their mental disorders. All psychiatrists are faced with situations where compulsive interventions are required to safeguard the patients and those surrounding them. Psychiatrists are involved in the care of mentally ill prisoners, those found guilty and those found not guilty by reason of insanity. In addition, the psychiatrist faces challenging professional, ethical and legal issues in regard to caring for the person with mental illness. In România there are a lack of specialized institutions for patients with co-morbid mental disorders and highly dangerous behavior. Patients suffering from a serious mental illness who are considered a high risk to the community are usually treated in a medium-security forensic psychiatric hospital. There are four such forensic hospitals in România. Individuals considered to be a high risk to the community are hospitalised in Jilava Prison, the only high-security forensic psychiatric hospital in România. There have been some improvements in the quality of care delivered in the mental health services (including the forensic psychiatric hospitals) in România since the implementation of the Mental Health Law 2002. Debate about various ethical issues in this specialized field of mental health continues, such as that of limited confidentiality and the patient’s needs versus societal needs and expectations. The psychiatrist can be between what may be legally right and what may be ethically right.
… bad treatment and living conditions – for prisoners with mental health problems – almost invariably lead to human rights violations, and it is the duty of each government to do everything possible to prevent such violations from taking place. Robert van Voren (2009a)
România, like other Eastern Europe countries, lies at the crossroads between the Western world, the Middle East and Asia. As a former communist country, it was behind the Iron Curtain until December 1989. România continues the process of transition from communism to democracy and an open market economy. It has a population of 20.254.866 (Census 2012) covering 237.500 km2 with 42 districts.
17.1 Mental Health Services in România
România has approximately 900 psychiatrists for 20, 25 million people (4.16 per 100.000 population), most of them practicing in large cities. Of those, 260 are child psychiatrists (1.19 per 100.000 population). Most psychiatrists work in the Public Health Services and the remainder work in private practice. There are a relatively small number of clinical psychologists and social workers working in the mental health services. There is a shortage of trained mental health nursing and allied mental health staff working in the public and the private mental health services.
Most psychiatric services are provided by public mental health services (hospitals and out-patient services) run by the Ministry of Health; there are no private psychiatric hospitals. In România there are 16,700 beds for people with mental disorders (76/100.000 inhabitants), of which 4,600 beds are for the chronic mentally ill. There are 37 mental hospitals, 75 psychiatric units in general hospitals, four forensic low/medium security psychiatric hospitals and one high security forensic psychiatric unit in a prison. There are also 66 psychiatric outpatient clinics (community mental health services) (Tătaru 2005; Minister of Health 2006).
The special needs of mentally ill people have not always been recognized and respected. Stigma remains an obstacle in ensuring access to good care for mentally ill patients and affects the patients’ quality of life and their social status. Stigma about mentally ill people leads to the development of negative attitudes (including those of health professionals), poor quality of treatment and services. The national budget for health care is low, and even lower for mental health services.
Despite anti-discrimination legislation, community tolerance for mentally ill people has decreased and unemployment has increased. The mentally ill feel rejected and marginalized in the community. For mentally ill people who have committed a crime, there is a double stigma: ‘he/she is mad and bad’ (van Voren 2009a).
The new Mental Health Law was implemented in România in August 2002. This was the first step towards the reform of the mental health services and the standard of care of mentally ill patients. Chapter 4 of the Mental Health Law lists the types of mental health services in România along with the standards of care for people with mental disorders.
In 2005 the Mental Health Law (2002) was reviewed and amended. The reviewed sections have included the criteria for involuntary admission to psychiatric hospitals, procedures of involuntary treatment for the mentally ill, restriction of patients’ entitlements, rights to complain and confidentiality issues (Minister of Health 2006; Mental Health Law 2002).
17.2 Human Rights and Their Relevance in Forensic Psychiatry
Addressing the issues of the protection of human rights and the dignity of persons with mental disorders has only occurred relatively recently in the history of România. However, even as early as 1520 Neagoe Basarab, the Voivode of Wallachia (1512–1521), wrote in ‘The teachings of Neagoe Basarab to his son Theodosie’ about the absence of punishment for persons with mental disorders, and their living in the monasteries during their illness.
Society is equally interested in maintaining the autonomy and the well-being of its citizens as well as protecting them from risks and dangers caused by mental disorders. The protection of human rights and the dignity of persons with mental disorders should to be upheld throughout the community, including in the prison environment.
Forensic Psychiatry is a subspecialty of psychiatry, “in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment” (American Academy of Psychiatry and the Law 2005).
Forensic psychiatry, which is at the interface between mental health and the law, is focused on assessment and treatment of people with mental disorder who commit crimes and consequently enter the justice system.
Each country has its own laws, but legislation must respect the international mandates and principles concerning human rights and the protection of persons with mental disorders (Eaton et al. 1976). The forensic psychiatrist must understand these laws and principles, and apply that knowledge to the interface between the criminal justice system and mental health.
Forensic psychiatry is required to adhere to the same ethics, rules, and principles found in general medicine (Wettstein 2002). Overall, România’s legislation respects the international mandates of the United Nations and the World Health Organization concerning the protection of the mentally ill. The legislation stipulates the framework for providing adequate treatment and care to the mentally ill persons and the need for respecting the human rights of any person and particularly the human rights of persons with mental disorders. The most important principles derived from these documents are: respecting human dignity, recognizing equal civil rights, access to medical care including medical treatment and social support, professional and family rehabilitation. The legal rights, financial rights and other personal interests of patients with mental disorders must also be protected.
In România, forensic psychiatry is not recognized as a subspecialty. General psychiatrists work as forensic psychiatrists but they do not participate as an expert witness in court; they work in general psychiatric hospitals or in forensic psychiatric hospitals. Issues such as the competency of a person with mental health issues to stand trial and criminal responsibility are assessed by a panel of psychiatrists who provide written psychiatric reports to the courts (Tătaru et al. 2010). Complex assessments may require both psychiatric and psychological evaluation and are provided by psychiatrists and clinical psychologists. Currently, Romanian legislation recognizes that all specialists in psychiatry are competent to prepare psychiatric reports for the courts. Determination of criminal responsibility is ultimately made by the court, after considering the input from the psychiatrist(s).
17.3 Romanian Mental Health Legislation
Involuntary psychiatric treatment is allowed by law if a person suffers from a mental disorder and is a risk to himself or others (Mental Health Law 2002). Involuntary commitment of incompetent patients takes into consideration the best interest of the patient, but also the well-being of the family and the potential risk to others and the community
The standards and practice of involuntary commitment to a psychiatric hospital have changed three times since World War II (1965, 1980, and 2002). The Mental Health Law (2002), which emphasises the protection of a patient’s rights (4), has replaced a number of previous legislations: Decrees 12/1965 and 313/1980. Modalities of involuntary commitment to psychiatric hospitals and to forensic psychiatric hospitals are regulated by the Mental Health Law 2002 (amended in 2005) and also by Art 948 of Romanian Civil Code.
There are legal and ethical issues with respect to involuntary hospitalisation because it restricts a person’s liberty. According to the Madrid Declaration of the World Psychiatric Association in 1996 (Declaration of Madrid 1996), treatment must always be in the best interest of the patient in respect of his dignity and the legal and human rights.
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Psychiatric Treatment in the Detention Systems of Quebec: Trying to Merge Prison and Therapeutic Cultures
Application of the AMA Code of Medical Ethics to Psychiatric Practice in Correctional Facilities and Access to Psychiatric Care in the U.S.A.
Current Ethical Challenges in Prison Psychiatry in England and Wales
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