Amendments to the mental health patient’s care law violate patients’ rights to health and safety
The Egyptian Initiative for Personal Rights warned today that some of the amendments to the mental health law proposed by the government—in particular, those related to electroconvulsive therapy (ECT)—violate the rights of patients to treatment and physical safety. They also contravene several international conventions, principles, resolutions, and recommendations as well as Egypt’s international obligations under these conventions, and do not adhere to recommendations of the World Health Organization and the well-established medical practice. The EIPR therefore demands that the amendments be shelved.
The EIPR confirmed that a number of prominent psychiatry professors and practitioners, in Egypt and abroad, including the former director of the mental health program at WHO and the president of the World Psychiatric Association, are deeply concerned by the amendments. They explained the cause of their concern in a letter to the secretary-general of mental health department and the chair of the Parliamentary Health Committee, asking them to consider these reasons when debating the amendments.
On 7 November 2019, the government proposed amendments to Law 71/2009 on mental health patient’s care to the parliament. The parliament gave preliminary approval and its Health Committee is currently discussing the amendments.
The most serious of the amendments is that related to Article 28 of the law, which regulates compulsory treatment, including ECT. In its present form, the article states that psychiatric patients admitted against their will may not be given any treatment, including ECT, before an independent assessment is conducted to review the opinion of the treating physician; the assessment is to be carried out by a psychiatrist, registered with the Mental Health Council, within 24 hours, although the patient may be given emergency treatment pending the completion of the assessment. The goal of the evaluation, which comports with established medical practice, is to protect the patient and affirm that his isolation and treatment are medically necessary. This reduces the space for errors or malpractice, and it protects the physician from any questions about the abuse of his authority.
The proposed amendment disrupts this independent evaluation, allowing the patient “when necessary” to be given “two courses to synchronize brain rhythm pending the conclusion of the stipulated assessment…in line with the rules set forth in the implementing regulations of this law.”
The EIPR sees several serious flaws and errors in this amendment, starting with the use of the phrase treatment to “synchronize brain rhythm” rather than the term ECT. The phrasing in the amendment is not based on any scientific literature and is therefore “false and misleading and unethical,” according to the letter sent to the parliament and government by mental health professionals.
This amendment would open the door to the abuse of ECT by codifying an exception to the independent assessment, using the vague phrase “when necessary” to establish the exception without defining necessity or clarifying the medical need for the exception, the cause for haste, who defines this necessity, and who can administer the treatment. This is particularly important since the law permits non-specialists to commit psychiatric patients against their will; and hence they would be authorized to administer ECT without waiting for the opinion of an independent specialist.
It is important to note that before ECT is administered, an internal physician must examine the patient to determine his medical fitness; the examination may include an ECG or other tests. The patient must also see an anesthesiologist, who should be present during ECT. Finally, the patient must fast for at least six hours prior to the administration of anesthesia. Is this not sufficient time to conduct an independent evaluation? What is the logic whereby it is “necessary” to forgo an independent evaluation, but permissible to give the patient two courses of ECT prior to it, when typically ECT is administered at three-day intervals?
All cases of involuntary commitment are by their very nature emergencies, insofar as the patient’s state or the threat he constitutes to himself or others can only be mitigated by urgent medical intervention, likely compulsory. The exception that the proposed amendments admits in practice means that any patient committed involuntarily may receive ECT without a second, independent evaluation of his condition by a specialist.
Moreover, the WHO’s Resource Book on Mental Health, Human Rights, and Legislation states that emergency treatment should not include ECT or other irreversible treatments such as psychosurgery. For decades, it has been established medical practice to limit involuntary ECT to the narrowest bounds and then only after the approval of an independent physician.
Hospital records include numerous cases of patients who suffered complications or even death following ECT. On the other hand, we doubt there are patients whose health or lives were endangered because they were unable to immediately undergo ECT without an initial independent evaluation, as the amendments to this law seem to suggest.
ECT is an invasive treatment administered under general anesthesia and muscle relaxants, just like surgery. Rules ensuring that the therapy is used with the least risks possible should be strengthened instead of opening up loopholes that weaken these guarantees.
Arguing that the implementing regulations will correct any oversights in the legislation is unacceptable; it is the law, which comes under the oversight of the parliament, that must protect rights. The law is what defines the scope of the implementing regulations, and not vice-versa.
Although the explanatory memorandum of the proposed amendments states that they provide “additional guarantees for mental health patients’ rights by providing adequate protection to the patient against ill treatment and exploitation,” in fact, the amendments erode such protection. This is seen not only in the way they weaken guarantees for involuntary treatment in the case of ECT, but also in how they exclude representatives of patients and their families from the mental health councils, restrict the role of social workers in mental health care, and increase fees for treatment, including at public hospitals, which do indeed suffer from a severe funding shortfall and are the principal provider of mental health services for the poor in Egypt.