Universal rights and mental illness in Ireland

The human rights group Amnesty International has recently expanded the range of rights it promotes to include the right of persons with mental illness to enjoy the best available mental health care. The Irish section of Amnesty has launched a report and promotional campaign on the rights of persons with mental illness, using internationally recognised norms of best practice reflected in international conventions that generate binding legal obligations of the Irish state. The report is critical of piecemeal reforms and inadequate resourcing of mental health services, and calls for a more comprehensive implementation of the recommendations of domestic and international reports.

The role of Amnesty International

Formulation of policy in the area of mental health is increasingly influenced, directly or indirectly, by prevailing normative trends within the international community. Norms of best practice in terms of quality of care and service delivery have been articulated by bodies as diverse as the United Nations (UN), the Council of Europe and the World Health Organization. Whereas general human rights instruments, such as the UN’s Universal Declaration of Human Rights, protect the rights of persons with mental illness through the principles of equality and non-discrimination, more specific standards of care are also being crafted from a ‘civil rights’ perspective. The human rights group Amnesty International has recently expressed concern that the Irish government has failed to give full effect to its international obligations towards people with mental illness.

Amnesty is an independent, worldwide voluntary movement working for the protection of internationally recognised human rights. In the past, it has paid particular scrutiny to the plight of prisoners, especially prisoners of conscience, but through its research, actions and campaigns has always endeavoured to make governments accountable for human rights violations in general. Recent internal debate within the organisation, however, has resulted in a broadening of the mandate of Amnesty to allow for greater analysis of and comment upon the causes, as opposed to merely examples of, human rights violations. There has also been a heightened recognition and impetus at international level to address inequalities experienced by people with mental illness, as well as a drive for recognition of this issue as a human rights one. Although launching a promotional campaign on the rights of people with mental illness might be seen as a departure from the traditional work of Amnesty, the organisation sees mental health care as central to the human dignity of the person as other civil and political rights. Amnesty aims to highlight the Irish state’s care and protection of all people with mental illness in relation to international conventions ratified by Ireland. Adherence to such standards is consistent with article 12 of the UN International Covenant on Economic, Social and Cultural Rights (ICESCR) and the principles for the protection of persons with mental illness, which provide the right for everyone to the enjoyment of the ‘highest attainable standard of mental health care’ (United Nations, 1992).

The campaign

Throughout 2002, a consultation exercise was undertaken by the Irish section of Amnesty with many groups, agencies and individuals involved in the mental health arena in Ireland. This enabled familiarisation with the language, concerns and sensitivities of key mental health issues and debates. A wide-ranging review of the legal provisions and procedures for protecting the rights of people with mental illness was conducted and the standard of therapies and treatments generally available was also examined. A special advisory group assisted in the drafting of a report to coincide with the launch of the campaign and assisted with devising its key themes, tone and style. Experts who participated in the advisory group included service users, mental health professionals, organisations such as Schizophrenia Ireland and the Irish Council for Civil Liberties. The only precedent for Amnesty before the initiative of the Irish section was a report published in October 2002 on the treatment of people with mental disabilities in Bulgaria; however, this report focused on civil and political rights only. The Irish section’s report was expected to go further and address some of the economic, social and cultural rights affected when a state fails in its responsibilities towards people with mental illness. A broad review of existing indigenous and international mental health literature and reports was also conducted to examine the Irish state’s compliance with and implementation of their recommendations.

The promotional campaign along with the report Mental Illness: The Neglected Quarter (Crowley, 2003) was launched by Amnesty in February 2003, the organisation having received a favourable response and advance endorsement from many organisations including the Irish College of Psychiatrists. The time frame for the campaign was expected to be 1 year and the initial phase focused on a general debate about government policy towards mental health care. Other phases were to focus on individual areas of concern such as homelessness and mental illness and services for juvenile offenders. Local Amnesty groups were asked to participate by writing to and lobbying public representatives and health board officials, calling on them to act on the report’s recommendations.

Awareness-raising through the use of local media was encouraged and groups were asked to work in tandem with existing patient advocacy and interest groups where possible, whereas monitoring of the media reporting generally for sensationalism or inaccuracies was felt to be a critical role for the local membership.

The report’s key recommendations

Amnesty in this report gave consideration to the efforts and shortcomings of the Irish state in the execution of its duty to afford persons with mental illness the fundamental rights that those without illness often take for granted. Standards derived from developments primarily in the UN (and its specialised agencies such as the World Health Organization) as representing the main organisation with global competence in the field of human rights protection. Amnesty called on the Irish government to take cognisance of the UN’s Committee on Economic, Social and Cultural Rights second report (2002), which recommended the adoption of new disability rights-based legislation, without denying persons with disabilities the right to judicial redress in cases of abrogation of those rights. The term ‘disability’ was used in accordance with contemporary UN usage, to include those enduring any restriction of opportunity because of mental illness. Amnesty’s report urged a wide-ranging review of mental health services addressing inadequacy of funding and service provision particularly at the level of community care. The report highlighted a lack of acute admission beds and raised concerns about the standards of inpatient care including polypharmacy and the undue emphasis placed on medication as the mainstay of treatment as opposed to a broader range of therapies embracing psychosocial interventions. Adequate resourcing of the Government’s newly established Mental Health Commission and prompt, and effective action in implementing the criticisms and recommendations of previous government reviews, was also urged. Specialised mental health care for groups such as travellers, refugees, juveniles and homeless people was felt to be central in aiming to provide care in the least restrictive environment for disadvantaged and minority groups. The Irish Government was also urged to take the lead in stigma reduction and to review the need for a comprehensive system of personal advocacy to ensure that all people with mental illness are assisted in exercising the full range of their rights.

Amnesty’s report - implications and discussion

Amnesty’s report takes the principle of human rights in abstract form and places it in the context of a health care system constrained by finite resources, yet rising costs, competing demands and increasing expectations. The report usefully compares the extent of the right to a certain standard of mental health care (using international norms) as it should be afforded, with the way in which that right actually translates into a positive benefit to the service user. The not unsurprising conclusion is that in Ireland, as in many other countries, mental health has not received the same level of visibility, commitment and resources as is warranted by the magnitude of the mental health burden (World Health Organization, 2001).

Amnesty recognises that resources are critical in delivering quality health services that allow persons with mental illness to achieve their economic, social and cultural rights. This report acknowledges areas of progress and draws attention to some increased investment in community care and models of best practice, but accuses the Irish Government of making piecemeal and inconsistent progress in its efforts to reduce the stigma of mental illness through the establishment of high-quality community-based services. It is especially critical of the reduction in the proportion of general health expenditure on mental health from 9.4% of the total health budget to 7.2% in 2001.

The challenge for Amnesty in focusing its energies on this subject is to avoid inadvertently reinforcing negative stereotypes about mental illness. This is all too important given Amnesty’s association with subjects such as torture and arbitrary detention. Drawing excessively on the disability aspects of mental illness and portraying all sufferers of mental illness as voiceless could have the effect of exaggerating incapacity and alienating patient advocacy groups, who have long campaigned for the greater exercise of personal responsibility by service users. The potential to demoralise professionals on the ground, by failing to recognise their difficulties and efforts to make the optimal use of scarce resources, must be avoided and any misrepresentations of Amnesty’s campaign to suit other agendas must be challenged vigorously.

The Irish government could perhaps justifiably point to its efforts in overhauling mental health legislation and endowing a new Mental Health Commission as illustrating its commitment to improving the accountability and quality of mental health services. The reality of achieving parity of priority for mental health alongside specialties such as oncology and cardiology is, however, more than a purely rights-based rhetoric. Amnesty, by entering this debate, acknowledges the broader role of issues such as stigma, resourcing and basic human equality, thereby challenging the state to live up to the best available international standards of mental health care as opposed to the setting of domestic policy in accordance with lower common denominators.