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28 has had a long history and can only be condemned. The control of torture and providing advice about what will constitute unaccept- able physical evidence of torture are among the offenses that have been recorded. Falsification of records and devising grmly methods of torture have also been documented. The reasons why health professionals become torturers are, of course, very complicated. A physician's failure to report knowledge of torture or refusal to falsify a death certificate can be based on fear for personal safety and safety of his or her family members. Loss of his or her place of work may be a concern. There Is one older case from Paraguay in which the son of a physician who ran a free health clinic was cruelly tortured and murdered. We can only join Dr. Gonzalez in our appreciation of the many ways in which the medical profession participates in the condem- nation of torture. We must also recognize that physicians are the victims of torture and may lose their civil rights. We are concerned with the refugees who have been tortured and who have now found a home in this country. There are centers here and in Canada and Denmark for the treatment of victims of torture, who have been found to have increased incidence of deafness, nervous problems, psychiatric problems, and psychological problems. The Institute of Medicine recently decided to establish another human rights program in order to facilitate the expansion of human rights activities here on Constitution Avenue. The Institute of Medicine will have a somewhat broader mission, including efforts to bring about basic institutional changes for the protection of individuals from torture and mistreatment. The work of the Cornrnittee on Human Rights is unlike most of our professional activities. It is often difficult to tell when we have been effective or when a particular result has been a consequence of our efforts. If, however, our voices are heard and just one colleague benefits from our expression of concern, then our work has been a success. COMMENTS Albert Soluit I join others in expressing my respect and gratitude to Dr. Juan Luis Gonzalez, president of the Medical Association of Chile, for his stirring condemnation of torture and his efforts to safeguard those who have been or could be victims of torture by or with the assistance

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of physicians and the allied professions. At the same time, we are relieved and encouraged by the recent release and emigration of Dr. Anatoly Koryagin from the Soviet Union to Switzerland. As a psychiatrist, psychoanalyst, and pediatrician and as a U.S. citizen with concern for the rights and needs of children and their parents, ~ am sharply aware of the dangers that follow when our knowledge and our professional authority is misused and abused; that is, subverted to political and ideological processes. In this symposium, the damage caused by such misuse and abuse has been addressed by asking, What are the issues when science and human rights are in conflict? What largely determines the quality of life in any given commu- nity are the prevalent value preferences that become the bases for, or the guiding standards of, acceptable and unacceptable human behav- ior in that community. For example, the Ten Commandments are a set of rules derived from the value preferences of the Judeo-Christian culture from ancient times until now. Of course, the interpretation and modification or rejection of such value preferences represents the process of review and revision and is usually an expression of chang- ing conditions and changing value preferences of a particular culture and especially of the hierarchy of those values that are standards of behavior for a given community in a specific era of our history. Opti- mistically, we hope that change will indicate our capacity to advance civilization. In terms of misuse and abuse of psychiatric knowledge and au- thority, there are a number of crucial value preferences in protecting human rights and assuring psychiatric competency. First, the best interest of the patient is a value preference that requires that the clin- ician do no harm. If there is a conflict between the patient's needs and those of the clinician, the patient's needs shall be paramount. Second, the patient must have the assurance of confidentiality, and if confidentiality cannot be assured, the patient must be warned that confidentiality cannot be provided or guaranteed. Fair warning must be given if confidentiality cannot be assumed. Third, the diagnostic and therapeutic procedures used must be the least intrusive and risky in the context of effective diagnostic and therapeutic procedure alternatives that are available. Fourth, if an experimental treatment or procedure is offered, it should be preceded by providing adequate knowledge and under- standing to enable the patient to make an informed choice and to

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an give informed consent. Further, the risks inherent in such experi- mental treatment or procedures should be overbalanced by what can be gained for the patient by such procedures or treatment. Finally, coercive procedures for diagnosis or treatment are ac- ceptable only if the information and evidence justifying this consid- eration are approved by a peer group of competent clinicians who agree that such coercive procedures will prevent or minimize the threat to life by the patient's deranged behavior. The lives and safety of others and that of the patient must be protected by such coercive procedures. They should not produce a greater risk than those conditions and behaviors that evoked the recommendation of coercive diagnostic, therapeutic, and custodial care and procedures. There should be the guarantee that each child, ordinarily those under the age of 18, will be helped to have the permanent care and guidance of at least one adult who wants that child and can provide him or her with a continuity of affectionate care and safety; that the parent and child will have community support; and that children's needs and rights will be paramount if the family is unable to function adequately, resulting in a conflict between adults' needs and rights and those of the children involved. Although the aforementioned principles should be useful in a wide variety of cultural, political, and ideological settings by those who share these value preferences, they should also be viewed as part of an ongoing process. This process enables us to review and improve our scientific knowledge and its application and to avoid those blind spots associated with smugness. Such clarity is essential, especially when we are witnessing flagrant violations of these principles of clinical practice by governments and groups with whom we are in serious ideological, political, econorrflc, military, and scientific conflict and competition. This is an especially crucial perspective when it becomes state policy to view disagreement with that government as evidence of mental illness. In three recent reports, we can read how unending vigilance is crucial if clinical scientists are to work together in a manner in which we can learn from each other's errors and deficiencies and remain, above all, ethically involved. Elyn R. Saks reviews the use of mechanical restraints in U.S. psychiatric hospitals. Mechanical restraints " . . . in this Note refers

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~1 to the more severe restraining devices such as 'four' and 'six' point re- stra~nts, body sacks and camisoles."8 Saks concludes, after a careful analysis of advantages and disadvantages of restraint and other coer- cive measures, that the abuse of mechanical restraints and seclusion led to 30 deaths between 1979 and 1982 in the State of New York. She further concluded that the law should use a principle of liability that would be designed to deter doctors from using restraints out of the fear that malpractice suits will be brought. According to Saks, this principle of liability, recognizing the limits of a doctor's ability to predict violence, should ease pressure on doctors a. . . besieged by conflicting demands both to protect patients and not to restrain them by making a clear value choice. For example, greater numbers of patients should not be restrained in order to protect against the rare occurrence of self-inflicted injury." The enlightened principle of liability, she continues, should . . . reduce both the use of restraints and the supervention of patients' choices. The fear that, if effective, the rule would cause a dramatic rise in self-injuries is unfounded, as may be seen from the situation in England. English doctors have not significantly resorted to seclusion or medication to compensate for not using mechanical restraints. Such an enlightened rule is needed to reduce the use of mechanical restraints which cause a. . . grave injury to individual liberty and dignity. 9 Time does not permit me to go on, but ~ think when we talk about fighting for the freedom of such a person as Dr. Anatoly Koryagin, for example, who was punitively incarcerated because he criticized what he viewed as egregiously punitive and coercive uses of psychiatric diagnosis and hospitalization, we could temper and better harness our righteous indignation by an awareness of how we are confronted In various countries by the risk of "there, but for the grace of God, go I." For example, in the March 21, 1987 issue of L,ancet there are two significant reports. The first, "Japan's Search for International Evelyn R. Saks, "The Use of Mechanical Restraints in Psychiatric Hospi- tals,n 17`c Yale Law Journal, Vol. 95, No. 8, pp. 1836-1856, July 1986. 9 Ibid.

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Guidelines on Rights of Mental Patients,~ concludes with the fol- lowing: "In view of . . . the absence of a clear set of international standards for the protection of the mentally ill, it would be useful to define a set of basic principles. These were formulated by a pane! of The International Forum on Mental Health Law Reform, organized jointly by the Japanese Society for Psychiatry and Neurology and the International Academy of Psychiatry and the Law and held in Kyoto in January 1987. The Kyoto Principles, unanimously accepted by the panel, state that: 1. Mentally ill persons should receive humane, dignified and professional treatment. 2. Mentally ill persons should not be discriminated against by reason of their mental illness. 3. Voluntary admission should be encouraged whenever hospital treatment is necessary. 4. There should be an impartial and informal hearing before an independent tribunal to decide, within a reasonable admission, whether an involuntary patient needs continued hospital care. 5. Hospital patients should enjoy as free an environment an possible, and should be able to communicate with other persons. Similar concerns and considerations are described in the same issue of Lancetii in the next article with brief reports on the man- agement of mental illness in Japan, United States, India, and Egypt, which concludes that "every government needs to formulate a strat- egy for looking after those usually seen as the least acceptable mem- bers of our society. Because mental illness is still viewed with more superstitious attitudes than physical illness and because ideological convictions may confuse ideological dissent with mental illness (and indeed of- ten have), it is crucial that our efforts to define mental health and mental illness be free of ideological jargon and distortions and free of self-serving ideological and political ambitions. Mental illness and treatment should not, wittingly or unwittingly, be exploited for and corrupted by political and ideological aims. Conversely, by maximizing voluntary mental health services, that is, by minimizing the use of coercion in providing mental health 10T. W. Harding, "Japan Search for International Guidelines on Rights of Mental Patients, Lanect, March 21, 1987, pp. 676-677. ii"The Management of Mental Illness: Forgotten Millions," Lancet, March. 21, 1987, pp. 678-679.