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English Language Page The law allows a restriction on the freedom of those afflicted with severe mental conditions that may be life-threatening or pose a serious danger to one’s health, as well as when such restrictions are ordered by a court decision. The principle of voluntarism applies to hospitalization, treatment, and the right to refuse to participate in tests and demonstrations. In practice however, this principle applies to a multitude of concrete details of a department’s everyday life. Even if the patient is subjected to forced therapy which is much more stringent, it is advisable to use every opportunity to comply with the principle of voluntarism and discuss with the patient their therapy scheme, the therapy method, etc. Voluntarism of hospitalization A mental disorder or the necessity to conduct a psychiatric examination may serve as grounds for a person’s hospitalization. Voluntarism, i.e. free expression of one’s will, implies a patient’s capability to analyze and assess their situation. Thus, when admitting a patient to a mental institution, the physician in charge of admission must first of all ascertain that the person’s mental condition enables them to consciously express their attitude with respect to their hospitalization, then discuss this issue with them and explain to them that they have the right to refrain from hospitalization, and only after that document the patient’s consent or refusal. The law does not allow exerting pressure against the patient or coercing them into hospitalization. To obtain patient’s consent (not to “wangle” it out) — has to do not only with the art of the physician. It also has to do with the nature and the severity of the patient’s mental condition. Therefore absence or a very low percentage of involuntary hospitalizations indicate that the signature of consent is forged, that it has been obtained by means of pressure or deceit and not by means of enduring participation, or that it has been provided by a person who is not capable of sound thinking. Given that psychiatric institutions provide assistance to patients who first and foremost experience exacerbation of their conditions, as well as those who are helpless, it is legitimate to assume that the percentage of involuntarily institutionalized individuals should constitute a significant portion of those admitted for therapy. Judging by the experience of other countries, it may amount up to 15—20% of all patients. However, our survey has resulted in totally different figures. Having compared the overall number of beds in the clinic, the bed’s yearly turnover and the number of involuntarily institutionalized patients, i.e. those who did not provide their consent in the admission room, we calculated the percentage of involuntary hospitalizations in each of the surveyed clinics. It turned out that in 51 psychiatric institutions (55%) this indicator was below 5% (see Table 3). The Table does not include clinics that treat chronic patients and specialize in treatment of patients with marginal conditions.
Such a low percentage of involuntary hospitalizations is questionable and points to a falsification of voluntarism. Head physicians are aware of that and in some cases they even undertake certain measures. For example, when interviewed, the head physician of the Republican Psychiatric Clinic of Bashkortostan said, “We do everything possible to not document a voluntary hospitalization when the patient is psychotic or retarded.” Another reason behind the low percentage of involuntary hospitalizations is that patients are oftentimes deliberately misguided or pressured. According to a great number of involuntarily hospitalized patients, physicians in charge of admission frequently threaten patients with court proceedings in order to obtain their consent to hospitalization and therapy, and say to patients that if sanctioned by court, their therapy will last at least half a year. This often serves as reason enough for patients to put their signatures on their admission forms or clinical records. This practice is probably resorted to due to ensuing difficulties associated with an obligatory procedure entailing a psychiatric examination by a board of psychiatrists followed by a court hearing (this procedure is described in more detail in the “Legal Protection” section). A head of a psychiatry department of one of the republican clinics confessed, “In our conditions it is impossible to follow the law…” Physicians of the rest of the surveyed clinics probably followed the law more conscientiously. The percentage of involuntary hospitalizations there was significantly higher and fluctuated between 5% and 20% which adequately reflects the real situation. Voluntarism of therapy Voluntarism of therapy is accounted for by the rule of “informed consent,” the significance of which is fundamental for medical law and biomedical ethics. The law requires that the patient be offered information in a manner comprehensible for them about the nature of their mental condition, the particulars of the therapy proposed, as well as about alternative methods, potential risks and side-effects, the length of the course of treatment, and expected results (Part 2, Article 11). According to the law, the patient makes their particular choice only after they have been provided with all the information required by the law. An informed consent is documented with a corresponding record in patients’ medical papers. It is this particular type of consent to therapy that may be considered “informed,” which is an obligatory requirement for subjecting the patient to therapy and hospitalization. Should the therapy scheme change, especially when it comes to the utilization of such methods as insulin-comatose therapy or electroconvulsive therapy, the patient’s consent must again be obtained. Such consent is documented with patient’s signature on a special “Consent to Therapy” form, or in the patient’s clinical papers following a relevant record. In general these requirements were complied with in all of the surveyed psychiatric institutions. All voluntarily admitted patients provide their written consent to therapy within the first several hours of admission putting their signatures on special forms or on their clinical records. All institutions that offer insulin-comatose therapy (a total of 11 clinics) or electroconvulsive therapy (17 clinics) obtain informed consent from their patients for these methods of treatment documenting it in a due fashion (as a rule, on a separate form). Note that compliance with the informed consent requirement is unquestionable when it comes to patients who have been admitted of their own accord. As far as involuntary hospitalizations are concerned, the analysis of the survey data (comparison of the number of patients admitted against their will with the number of cases passed on to the court) indicates that a considerable number of patients who had initially refused to provide their consent to hospitalization did so some very short time later. According to heads of psychiatric institutions in 60 hospitals (64%), almost 100% of their patients are admitted to therapy of their own accord on the basis of their informed consent (see Table 4).
It is a known fact that many of the involuntarily admitted patients may later on give their consent to therapy having discovered acceptable conditions in their departments, friendly attitude of the personnel, etc. But it is rather doubtful and unlikely that 98-100% of patients of regular psychiatric institutions are able to consciously express their will and agree to go into therapy. For comparison, here are some data from other regions: in the Oryol regional psychiatric clinic — 71%; in the Smolensk municipal psychiatric clinic — 88%; in the Tver regional psychiatric clinic #1 — 90%; in the Republican psychiatric clinic of Mordovia — 79% Thus, physicians of the majority of the surveyed psychiatric institutions do not understand or do not want to understand the significance of voluntary treatment based on patients’ informed consent and by doing so, eviscerate the meaning of this fundamental notion that reflects the right of the patient to freedom of choice. None of the surveyed clinics currently tests new pharmaceuticals. Only some of them experiment with drugs that have been recently approved by the Russian Federation’s Ministry of Health Care. Hospitals are supplied with experimental pharmaceuticals for free predominantly by manufacturers and pharmaceutical companies. As a rule, patients are informed in a way comprehensible to them that the drugs that they take are new. Prohibition of exploitation According to the principles of “Protection of Persons With Mental Illnesses and the Improvement of Mental Health Care” adopted by the UN General Assembly on February 18, 1992 (resolution 46/119): In no circumstances shall a patient be subject to forced labor… The labor of a patient in a mental health facility shall not be exploited. Every such patient shall have the right to receive the same remuneration for any work which he or she does as would, according to domestic law or custom, be paid for such work to a non-patient (Parts 3, 4 of Principle #13). Federal Law “On Psychiatric Care” formulates this principle in the following manner: “All patients in outpatient or resident psychiatric therapy shall have the right… to be compensated on par with other citizens for any labor performed in proportion to its quantity and quality.” This principle is not complied with in the majority of Russia’s psychiatric institutions. “Prohibition of exploitation” and “voluntarism of labor” are two independent principles. Oftentimes however, the two notions are replaced with one another when patients’ labor is used based on the voluntarism of labor and positive qualities of labor therapy. Note that exploitation is everything that regardless of voluntarism lies outside the boundaries of occupation (a variety of hobbies) and labor therapy (participation in responsible labor activities), and is not duly and proportionately remunerated. Employment of patients in a variety of labor activities is a longstanding tradition of psychiatry accounted for by the necessity to activate and socially rehabilitate mental patients. During the Soviet period practically all psychiatric institutions disposed of labor-therapeutic workshops in which for a certain amount of remuneration, recovering patients could participate in some kind of socially beneficial labor. Many institutions located in rural areas had their own farms. Today only 34 (37%) of the surveyed clinics have labor-therapeutic workshops (Kirov Regional Psychiatric Clinic named after Bekhterev, Kostroma regional psychiatric clinic, Penza regional psychiatric clinic, St. Petersburg psychiatric clinic #1 named after Kaschenko, and some others) in which 10% to 30% of patients work. Patients are only paid for their work when labor-therapeutic workshops have contracts (for example to sew bed linens, manufacture furniture, or perform various repair works). If the labor performed by patients caters to the hospital’s needs, the work of patients is not paid. Eight clinics (9%) (Lipetsk Regional Neuro-Psychiatric Hospital, Republican Psychiatric Clinic of Bashkortostan, Khabarovsk Territorial Psychiatric Clinic and some others) have their own farms where patients also work. They clean barns and tend to cattle (Bobrovo-Dvorskaya Psychiatric Clinic of the Belgorod region, Tver Regional Psychiatric Clinic #2), work in greenhouses (Chita Regional Psychiatric Clinic #2), and in gardens (Republican Neuro-Psychiatric Dispensary of Udmurtia), etc. It was discovered in the course of the monitoring that some clinics enter into agreements with other organizations to do certain jobs and employ their patients for that purpose. For example the Krasnoyarsk Territorial Psychiatric Clinic #3 signs contracts in the summer to clean the territory of a children’s summer camp, patients of the Moscow Regional Psychiatric Clinic #2 work under a contract at the nearest state farm, and some patients of the Republican Psychiatric Clinic of Tatarstan work at an enterprise in Kazan. Such practice entirely complies with the design and meaning of labor therapy: to involve patients in responsible labor which provides remuneration. Money earned by the patient outside or in labor-therapeutic workshops of the clinic as a rule is deposited in their personal account and the patient receives it upon discharge. In some cases money is paid in cash right away and in such cases it is kept by the head nurse. Note that usually patients receive only a portion of the money they earned, the rest of it is used by the clinic for its own purposes. For example, patients of the Moscow psychiatric clinic #13 that work in its labor-therapeutic workshops receive 30% of the money they earn. The rest of the money is used by the clinic to buy sports accessories. Patients of the Kostroma Regional Psychiatric Clinic and the Moscow Regional Psychiatric Clinic #2 receive 60% of the money they earn, while patients of the Lipetsk Regional Neuro-Psychiatric Hospital receive 20%. Only the Shadrinsk Neuro-Psychiatric Hospital of the Kurgan Region reported that their patients received 100% of the money they earned in their personal accounts. In each particular case clinics must discuss with their patients the terms and conditions of labor and compensation in advance and only in this case such practice may be considered to be in compliance with the law. The amount of compensation that patients receive for their work has a purely nominal nature: it ranges from five to seven rubles a month (Moscow regional psychiatric clinic #2) to 200 rubles (St. Petersburg psychiatric clinic #1 named after Kaschenko where a patient earns approximately eight rubles a day). Such compensation is not adequate for the efforts invested by patients, but their very involvement in labor processes, which is a therapeutic factor, is more important. In addition to working at labor-therapeutic workshops and farms, as well as participating in various external projects under contracts with other organizations, patients are extensively employed in a variety of capacities within the boundaries of the clinic and the department. They assist in the laundry facility and in the kitchen, mend clothes and linens, participate in repair works, deliver food to the canteen, clean and beautify the adjacent territory, or assist in the cleaning of departments, including toilets. Some call it occupation therapy; others, labor therapy. However labor therapy can be called only that which is not elementary, primitive and monotonous work, which is carried out by the patient voluntarily, is filled with individual meaning, and facilitates the recovery process. Everything else can be regarded at best as occupation therapy, and at worst — if the patient does not receive compensation adequate to the invested efforts — as exploitation of people with mental disorders. Claims that patients do it of their own accord are only an attempt to find a proper way to explain employment of patients in the capacity of a free labor force that compensates for the lack of orderly personnel. The wide utilization of such a form of socio-therapy as “occupational therapy” in Russian psychiatry (i.e. filling patients’ time with some business that they are capable of doing and that activates and distracts them from their morbid emotions) has resulted in the fact that physicians do not see the borderline between occupational therapy and the exploitation of patients’ labor. Among the primary criteria that they use are lack of coercion, patient’s willingness to work, game and creative elements in the nature of labor, and beneficial influence of labor upon the process of treatment. However it is rather difficult to assess. For example, in response to an interviewer’s bewilderment caused by the fact that patients clean toilets in their departments, the head of one of the republican neuro-psychiatric dispensaries said without a trace of embarrassment, “They like it; they beg for it. They line up in a queue.” In some cases labor therapy does justify its purposes. The head of the Moscow Psychiatric Clinic #4 said that they never employed their patients to clean the department because patients’ relatives objected to it; instead patients willing to work are allowed to tend to flowers or beautify the clinic’s territory. In the Regional Psychiatric Clinic of the Jewish Autonomous District it is also forbidden to have patients clean floors and toilets; they can only assist in the decoration of the department by hanging up curtains, paintings, etc. In many hospitals patients are employed to deliver food and clean departments and wards, sometimes a special duty for that is established (as is the case, for instance, at the Central Moscow regional psychiatric clinic #1 where Patient Councils are responsible for that). Patients of the Krasnoyarsk territorial psychiatric clinic #3 work in the laundry facility and the kitchen, while patients of the Stavropol territorial psychiatric clinic #1 and the Krasnoyarsk territorial psychiatric clinic #1 assist in the repairs done in their departments. Patients of the Troitsk psychiatric clinic of the Republic of Buryatia are employed in loading-unloading works (up to 40% of all patients), patients of the Chukotka district neuro-psychiatric dispensary are employed in painting fences, patients of the Tver regional psychiatric clinic #2 tend to their farm’s cattle, etc. The head of the Psychiatry Department of the Altai Republican Hospital said that the department is renovated “by patients’ efforts,” while women wash windows and iron, and complained that they had to “have them clean the floors.” Note that the financial and material status of many hospitals prevents them from organizing labor therapy that would be adequate for its real purposes. Many hospitals had to shut down their labor-therapeutic workshops due to a lack of funding, farms of others demised. In this situation administrations of psychiatric institutions decide to embark on the factual utilization of patients’ free labor considering it to be an adequate substitute of labor therapy and frequently abusing the readiness and willingness of patients. |
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