The Egyptian initiative for personal rights publishes the text of a letter sent by international mental health professionals to the Health Committee of the Egyptian Parliament, the Secretariat for Mental Health and the Ministry of Health, prior to the discussion of new amendments to the Mental Health Law in Parliament on December 12. The letter clarifies the violations involved in some of these amendments to the patient's rights and to the established rules and practices recognized worldwide, especially in regards to the regulation of ECT. The EIPR had mentioned these violations in a previous statement issued on December 15th ( PR in Arabic) 

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Professor Menen Abdel Maksoud, Secretary General for Mental Health, Ministry of Health and Population. 

Dr Mohamed al Amery, Chair of Health Committee, the House of Representatives.

Professor Ahmed  Okasha

Dear Professor Menen Abdel Maksoud, Dr Mohamed al Amery and Professor Ahmed  Okasha

We understand that on 12th Dec, the House of Representatives will be considering a proposed change in the Egyptian mental health legislation. We appreciate that you will wish to achieve the best possible outcomes for people with mental disorders and disabilities in Egypt, and so we are writing to bring to your attention that these new proposals are in direct contravention of both longstanding and more recent key international principles of mental health law. 

Specifically, it is of grave concern that the proposed changes to legislation due to be considered by Parliament on Dec 9th-12th includes the propositions that:

Involuntary ECT can be given without the need for a second opinion

ECT is to be given without written consent

Patients need not be informed that they are to receive ECT. Instead the term “Brain synchronizing treatment” is to be used without reference to the use of electric current, or indeed to potential side effects.

Excluding service user from the Mental Health Act Commission

The licensing of psychotherapists is entirely within the realm of psychiatrists.

The international principles relevant to for mental health legislation have been successively affirmed  in many internationally accepted UN conventions for many decades, indeed since the Universal Declaration of Human Rights 1948; followed by the International Covenant on Economic , Social and Cultural Rights 1976 which includes the  right to the enjoyment of the highest attainable standard of mental and physical health; the International CovenantofCivil and Political Rights 1976 which includes the right to liberty and freedom from inhuman or degrading treatment; the convention against Torture and Other Inhuman or Degrading Treatment or Punishment (1984); and the Convention on the Rights of the Child (1989). 

There are also agreed international standards of good practice which include the Principles for the Protection of Persons withMental Illness and for the Improvement of Mental Health Care (MI Principles), theStandard Rules for Equalization of Opportunities for Persons with Disabilities, the Declaration of Caracas, the Declaration of Madrid and other standards such as WHO’s Mental health care law: ten basic principles, and latest WHO guidance.

Furthermore, there have been a number of relevant  United Nations General Assembly Resolutions, namely resolution 46/119, in 1991, comprising principles for protecting the human rights of persons with mental disorders, which  bring together a set of basic rights that the international community regards as inviolable in community and treatment settings. 

These principles have been further developed in The Convention on the Rights of Persons with Disabilities,  2007, which stated that people with disabilities they have a right to equal recognition before the law. The subsequent General Comment No.1 on Article 12 (adopted in 2014) states that all persons possess decision-making capacity, which substitute decision-making is inconsistent with the right to equal recognition before the law. Instead,the Convention and General Comment 1 mandate supported decision-making, whereby the necessary accommodations are made (and support provided) to ensure that individuals can express their own will and preferences. In rare instances in which individuals may be unable to do so, practitioners and other officials should make every effort to arrive at the most accurate interpretation of the individual’s will and preferences.

 In 2013,the United Nations’ Special Rapporteur on torture and other cruel, inhuman and degrading treatment or punishment called on states to “impose an absolute ban on all forced and non-consensual medical interventions…including the non-consensual administration of psychosurgery, electroshock and mind-altering drugs [and] the use of restraint.

” These principles have been further emphasised in United Nations High Commissioner for Human Rights, Mental health and human rights, Report of the United Nations High Commissioner for Human Rights,A/HRC/34/32.2017 and UN Human Rights Council,Resolution on Mental Health and Human Rights, A/HRC/36/L.25. 2017.

International associations of mental health professionals have also endeavoured to ensure the human rights of persons with mental disorders by issuing guidelines for standards of professional behaviour and practice. Such guidelines are contained, for example, in the Declaration of Madrid, adopted in 1996 by the General Assembly of the World Psychiatric Association. Among other standards the Declaration insists on treatment based on partnership with persons who have mental disorders and on the enforcement of involuntary treatment only under exceptional circumstances.

Thus, taking all the above into account, it is of grave concern that the proposed changes to legislation due to be considered by Parliament on Dec 12th includes the propositions set out in the second paragraph of this letter.

Where planned on a voluntary basis, ECT should always be fully explained and discussed, including its potential side effects, and informed written consent should always be obtained beforehand.  The use of the term “Brain synchronizing treatment” is misleading, indeed false, and hence of itself unethical. 

In 2013 ,the United Nations’ Special Rapporteur on torture and other cruel, inhuman and degrading treatment or punishment called on states to “impose an absolute ban on all forced and non-consensual medical interventions…including the non-consensual administration of ….electroshock… “. This therefore makes it all the more crucial that if, despite the view of the UN Rapporteur that non-consensual electric shock should never be given, the clinician should still consider ECT advisable, it should be mandatory that a second opinion should be obtained before giving such a treatment on an involuntary basis, and indeed such has been the standard for the last half century. 

Similarly, it has long been an accepted principle that service users and other independent stakeholders should be included in the statutory bodies established to give oversight to the implementation of mental health legislation.

Trained psychotherapists may be drawn from a variety of professions, and as such, their licensing bodies need to be multidisciplinary rather than confined to psychiatry. 

We are grateful to you for your consideration of this letter and attach a list of the relevant international conventions and treaties.

Yours sincerely

• Rachel Jenkins, Professor Emeritus, Kings College London and Director of WHO Collaborating Centre for Mental Health, Institute of Psychiatry, 1997-2012 and Consultant to Egymen programme 2001-10.
• Nasser Loza, President Elect, World Federation of Mental Health.
• Benedetto Saraceno, Secretary General of the Lisbon Institute of Global Mental Health.
• Shekhar Saxena, Professor of the Practice of Global Mental Health, Harvard T H Chan School of Public Health.

References:

United Nations High Commissioner for Human Rights.Mental health and human rights.Report of the United Nations High Commissioner for Human Rights.A/HRC/34/32. 2017. 

UN Human Rights Council.Resolution on Mental Health and Human Rights. A/HRC/36/L.25. 2017

Committee on the Rights of Persons with Disabilities. Guidelines on Article 14 of the Convention on the Rights of Persons with Disabilities: the right to liberty and security of persons with disabilities. Adopted during the Committee’s 14th session, September 2015

Committee on the Rights of Persons with Disabilities. General Comment No. 1 on Article 12: Equal recognition before the law. CRPD/C/GC/1. 2014. 

Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatmentor punishment, Juan E. Méndez.A/HRC/22/53. New York: United Nations GeneralAssembly; 2013. 

Principles for the Protection of Persons with Mental Illnesses and the Improvement of Health Care - General Assembly Resolution 46/119 of 17th December 1991 (‘ the UN Principles’)

Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment – General Assembly resolution 43/173 of 9th December 1988 

Convention on the Rights of the Child (1989)

Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment – General Assembly resolution 43/173 of 9th December 1988

Convention Against Torture and Other Inhuman or Degrading Treatment or Punishment (1984)

Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment – General Assembly Resolution 37/194 of 18th December 1982

Declaration on the Rights of Mentally Retarded Persons – Proclaimed by General resolution 2856(XXVI) of 20th December 1971

Universal Declaration of Human Rights (1948)

Relevant WHO documents on Human Rights and Mental Health Legislation.

WHO, Guidelines for the Promotion of Human Rights of Persons with Mental Disorders, World Health Organisation

WHO, Mental Health Care Law: Ten Basic Principles, World Health Organization, Geneva, 1996 

WHO Mental health legislation and human rights 2003