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English Language Page At present Russia has seven specialized psychiatric clinics with intensive surveillance. We are going to discuss the problem of observing the rights of persons undergoing compulsory treatment in these institutions using the example of the Kaliningrad special type psychiatric clinic with intensive surveillance (Chernyakhovsk). The Kaliningrad clinic is the most open for public control specialized hospital with intensive surveillance. The management of the hospital regards provisions for fundamental constitutional rights of patients as a priority. During the recent decade the clinic was visited by delegations of international inspections many times, and the representatives of Independent Psychiatric Association of Russia came there three times. The administration of the clinic always displayed absolute openness and was ready to cooperate with human rights organizations which is not often characteristic of the heads of psychiatric clinics in general, and of those which provide compulsory treatment in particular. Thus the management of the Kazan specialized clinic with intensive surveillance did not allow the representatives of the Independent Psychiatric Association of Russia to examine the clinic and to work with its archives in 1995 demanding a special permission of the RF Ministry of Health Care (which banned this work as “inexpedient” at last), and at the St. Petersburg, Oryol, and Sychev clinics the examination of the Independent Psychiatric Association of Russia was strictly controlled by the head doctors. The Russian legislation provides for four kinds of compulsory treatment of the persons who committed various acts which are dangerous for the public under the condition of mental disorder: • compulsory surveillance and psychiatric treatment at an outpatients clinic; • compulsory treatment at a psychiatric clinic of ordinary type; • compulsory treatment at a specialized type psychiatric clinic; • compulsory treatment at a specialized type psychiatric clinic with intensive surveillance. The biggest restrictions of patients’ rights are characteristic for compulsory treatment at a specialized type clinic with intensive surveillance. Compulsory treatment with intensive surveillance (it was called strict surveillance earlier) has been used in Russia since 1939 when the Kazan special type psychiatric clinic was organized in the system of the Ministry of Internal Affairs of the USSR. Later the Leningrad, Dnepropetrovsk, Blagoveschensk, Tashkent, Alma-Ata, Oryol, Mogilev, Smolensk, Kostroma, Volgograd, and Kaliningrad (in the town of Chernyakhovsk, 1965) were created within the system of the Ministry of Internal Affairs. Special psychiatric clinics of the Ministry of Internal Affairs were closed institutions without any access to outside control, to say nothing of public control. The legal situation of the patients of these institutions was mainly determined by the instructions of the Ministry of Internal Affairs which established numerous restrictions and bans. Patients were not informed of their rights and they were not provided with sufficient data on their mental disorders and methods of treatment used. The private correspondence of patients was strictly monitored, and they had no opportunity to lodge complaints or appeal to the court, prosecutor’s office, or to authorities without censorship. They were not allowed to satisfy their religious needs, to invite a lawyer, to take part in the elections of government bodies. Patients working at the labor treatment workshops did not have adequate remuneration for the goods produced during labor therapy. Inside departments patients were accommodated in extremely overcrowded wards which had no more than 1.5—2 m2 per person often sleeping on double deck beds. They could not move freely over the department and communicate with other patients without the permission of the personnel, they had no right to wear their own clothes and keep basic necessities. All the bans and restrictions were justified by the particular dangerousness of these patients undergoing compulsory treatment. Yet in the overwhelming majority of cases these restrictions exceeded necessary measures. They were not determined by the psychopathological peculiarity of patients, they were enforced by extremely low sanitary conditions in which patients were kept and were established to make the work of the personnel and surveillance convenient. Unmotivated restrictions of patients’ rights were also grounded by the peculiarity and faults of the legislation which was in force in the country at that period. International human rights acts and ethical norms to promote the protection and the enjoyment of civil rights of persons with mental illness were not enforced in the territory of the Soviet Union. In 1989, all the special psychiatric clinics were transferred from the Ministry of Internal Affairs to the Ministry of Health Care. During the several years that followed this transfer considerable changes were seen in legislation, economic and public life. Besides the Constitution, the new civil and criminal legislation was adopted which took into consideration basic international norms in the sphere of human rights. To settle legal issues emerging in the delivery of psychiatric care, fundamental legislative acts were adopted by the Russian Federation, such as Federal Law “On Psychiatric Care and Rights of Citizens” of July 2, 1992, and “Foundations of the Legislation of the Russian Federation on the Protection of Health of Citizens” of July 22, 1993. The above mentioned laws regulated specific legal relations in the sphere of psychiatric care to a considerable extent, they fixed basic rights of persons with mental illness and established legal restrictions of some rights in the cases when it is necessary. They gave a more clear definition of the rights, obligations and responsibilities of government bodies, organizations and citizens participating in the delivery of psychiatric care. Separate issues of the legal situation of mentally ill patients are regulated by the RF Civil, Labor, Housing, Administrative and Family Codes, and by a number of legal norms adopted by the government, the RF Ministry of Health Care and other agencies. At present the management of the clinics and experts feel no deficit in legal, normative documents, instructions and recommendations regulating social and legal aspects of psychiatric care. But the realization of rights of persons with mental illness when they stay at psychiatric clinics in general, and at specialized clinics for compulsory treatment in particular is a grave problem. The government and non-government organizations of most countries admit that persons with mental illness belong to the most vulnerable and unprotected category of population. The human community has sufficient awareness of their right to be protected from various kinds of abuse and infringements. “But the joy born by the awareness that we live in such a period of history when this happened is not complete: now we face a huge problem of providing for the observance of these rights.” Discussing the issues concerning the observance of patients’ rights at the Kaliningrad special type psychiatric clinic with intensive surveillance, we are going to rely on Federal Law “On Psychiatric Care and Rights of Citizens in It” (Federal Law “On Psychiatric Care” further on) in combination with “The Foundations of the Legislation of the Russian Federation on the Protection of the Health of Citizens” (Foundations further on), compared to “The Principles for Protection of Persons with Mental Illness and Improvement of Mental Health Care,” adopted by UN Resolution # 46/119 of February 18, 1992 (UN Principles further on). The documents which we rely on give the priority and the principle importance to the right of the patient for respectful and humane attitude which excludes the humiliation of his or her human dignity (Part 2, Article 5 of Federal Law “On Psychiatric Care,” Part 1, Article 30 of the Foundations, UN Principles #1 (Clauses 2 and 3), 8 (Clause 2). To realize this right it is not enough to provide acceptable sanitary conditions of life for patients who undergo long compulsory treatment. One should form and maintain in doctors and other medical personnel the attitude to every patient as a personality who has problems with mental health with which he or she cannot deal with on his own. From 1965 till 1989, when the Kaliningrad special type psychiatric clinic with intensive surveillance worked in the system of the Ministry of Internal Affairs, in maintained extremely severe restrictions on the life of patients. Inmates of prisons were used as ward assistants to maintain permanent surveillance of patients, and they often resorted to rudeness and even secret beatings in their work with patients. The staff of nurses was extremely little at this clinic, it had one post of a nurse per 60-80 and more patients. With such a work load the nurse could not maintain proper surveillance over patients and the work of assistants. The rudeness of junior medical personnel often generated dangerous conflicts in the departments. When the clinic was transferred to the system of the RF Ministry of Health Care, the situation was gradually improving, but many problems persisted. Thus since 1994, the job of an assistant went to hired workers. Yet many of them proved to be incapable to perform this work due to their low moral characteristics. The problem of junior medical personnel is a long standing one, and it has not been solved. Although the number of junior medical personnel of the Kaliningrad special type psychiatric clinic with intensive surveillance considerably went up with the introduction of staff norms of the Ministry of Health Care, due to extremely low salaries, hard work conditions and low prestige of this activity, the clinic has had only about 50-60% of its junior medical staff in recent years. The deficit of the junior personnel makes the administration retain undesirable restrictions in the movement of patients, in their useful initiatives in departments and other premises of the clinic. Besides that, some medical assistants are inclined to rude behavior with patients and require permanent control, and sometimes disciplinary punishments. The representatives of the European Committee for the Prevention of Torture who examined the Kaliningrad special type psychiatric clinic with intensive surveillance in 2003 also noted separate facts of rude behavior on the part of medical assistants about which patients told them. The problem of respectful and humane attitude to patients also concerns the work of doctors and nurses. Some of them, especially those who came to the clinic before its Ministry of Health Care period, retain open or concealed neglect and hostility in their attitude to patients. They prefer overwhelmingly medication therapy and maximum restrictions and bans as far the demands and needs of patients are concerned. This often interferes with the creation of positive climate in the department to promote successful rehabilitation measures. The Administration of the Kaliningrad special type psychiatric clinic with intensive surveillance constantly explains and implements ethical norms when organizing the work of medical personnel and its professional training at all levels. In 2000-2002, all the psychiatrists and nurses of the clinic were certified after studying at certification training centers which had positive influence on the psychological climate of the clinic but could not solve the problem of respectful attitude to patients. The health care legislation obliges psychiatric institutions to give patients information on their rights, and on the nature of their mental disorders and methods of treatment used (Part 2, Article 5 and Part 3, Article 37 of Federal Law “On Psychiatric Care,” Part 9, Article 30 of the Foundations, UN Principles #11, 12, and 21). The Kaliningrad special type psychiatric clinic with intensive surveillance provides every patient with this information during the first interview and doctor’s examination when he or she enters the clinic. The doctor in charge of the patient registers this fact in the patient’s case history signed by the doctor and the patient. Yet this registration is often follow because many patients are not able to understand explanations given to them due to their mental conditions. Every department places the text of Federal Law “On Psychiatric Care and Rights of Citizens in It” where it is available and every patient can easily read it if he or she feels like it. The doctor in charge of a patient, the head of the department, legal adviser or the heads of the clinic can also explain the patient his or her rights. But most patients have no interest in their rights and do not ask for explanations. The rights and obligations of patients of a clinic are explained in understandable form in the Rules of Internal Order for Patients which are placed where patients have easy access to them in the departments of the clinic. Besides that, every patient can address directly the head of the department or the head doctor any questions concerning his or her stay or treatment at the clinic. He or she can do it both orally during doctors’ rounds and interviews, and in the written form. The clinic registers the appeals of patients. Answers to their questions and demands are registered in their case history. Despite the fact that the patients of the Kaliningrad special type psychiatric clinic with intensive surveillance are undergoing the compulsory treatment, doctors try to implement the principle of the informed consent of a patient to psychiatric examination and treatment, the basis of psychiatric care. When implementing compulsory measures of medical nature, the treatment may be conducted without the patient’s or his legal representative’s consent (Part 4, Article 11 of Federal Law “On Psychiatric Care,” Foundations Article 34; UN Principles #5, 11, Clause 6, 16). Nevertheless both during the primary examination and interview of the patient sent for compulsory treatment, and later the doctor in charge of the patient takes necessary efforts to explain him or her the peculiarities of his or her disease and the treatment of it. It is only in extremely rare cases when from the very beginning the doctor manages to achieve truly informed consent to the treatment in the communication with the patient which is based on the critical assessment of disorders by the patient himself. In the overwhelming majority of cases patients display anosognosia (unawareness of the illness) and negative attitude to the treatment indicated. Due to this it is common practice to take medicine under the insistence of the personnel when the patient is forced to comply with its demands. At first it is often necessary to use measures of physical restraint when conducting injections or infusions of the medicine. As a rule this takes place when there is immediate threat of injuring the patient himself or people around him. Cases when the taking of medicine is involuntary or forced injections are registered at the Kaliningrad special type psychiatric clinic with intensive surveillance in cases history by the commission comprising the doctor in charge of the patient, the head of the department and deputy head doctor on medicine. A considerable part of patients having positive dynamic of the clinical picture gradually display the awareness of their disorders and of the need for medical therapy. This provides the basis for the creation of partnership relations between the doctor and the patient which make it possible to conduct productive discussions of clinical and psychological issues with the patient and to adopt a more adequate treatment on his or her consent. In some part of the patients negative attitude to the personnel, to the mode of treatment and therapeutic measures is retained during their stay at the clinic. At the Kaliningrad special type psychiatric clinic with intensive surveillance patients are able to freely, without any censorship, send complaints or statements to the bodies of representative and executive power, to the prosecutor’s office, the court or a lawyer. 3—4 complaints and statements are sent to the corresponding bodies annually. When there is a desire to send a letter to some human rights organizations, patients are provided with necessary addresses. The right to the psychiatric care in the least restrictive conditions and at the place of residence when it is possible (Part 2, Article 5, Article 37 of Federal Law “On Psychiatric Care,” UN Principles #7-1, 9, 13) obliges the psychiatric service to conduct the examination and the treatment of the patient with the maximum protection for his or her social and family ties. Breaking these ties for a long time has unfavorable effect on the process of treatment and rehabilitation and creates considerable difficulties in the future reconstruction of the social functions of a patient. Yet the principle of delivering psychiatric care at the place of residence cannot be observed for patients undergoing long periods of treatment at specialized hospitals with intensive surveillance at present since every psychiatric hospital for compulsory treatment with intensive surveillance of the Russian Federation serves several regions located at considerable distance from it. Patients sent for compulsory treatment are among those who suffer in the gravest possible way from isolation from their habitual environment. From the moment when crime is committed, long incarceration periods during investigations and psychiatric examinations with the further compulsory treatment bring about a radical change in the situation in which the patient found himself before compulsory hospitalization. Everyday environment, personal belongings, social contacts, everyday agenda, all the habitual way of life disappears on a sudden for a long time. The patient finds himself in the situation where nothing depends on him, he or she is deprived of the ability to dispose of his or her time and belongings, does not know the term of his or her treatment. In this situation it is especially important to create the conditions of maximum possible freedom for the life of patients at a psychiatric hospital with intensive surveillance. This requires a bigger medical personnel and a whole set of additional rooms besides department wards. It is necessary to take into consideration the fact that the Kaliningrad special type psychiatric clinic with intensive surveillance conducts compulsory treatment of patients who are particularly dangerous for themselves and for the people around them due to the nature of their mental disorders and dangerous acts they have perpetrated. The deficit of the junior medical personnel at the clinic considerably restricts the potential for effective surveillance of patients and forces restrictions on their freedom of movement. The rule of intensive surveillance established by the law to provide for patients’ safety (Parts 1,2, Article 30 of Federal Law “On Psychiatric Care”) requires that the administration of a hospital observes a number of restrictions for patients (Parts 1,2, Article 30 and Part 7, Article 39 of Federal Law “On Psychiatric Care,” UN Principles: General Restrictions and Principle #11 (Clause 11)). In order to have the optimal combination of the principle of intensive surveillance with the principle of the least restrictive conditions, the Kaliningrad special type psychiatric clinic with intensive surveillance developed the above mentioned Rules of Internal Order for Patients and the Safety Rules in the Work with Mental Patients for the Personnel. In correspondence with the above mentioned rules the clinic uses only such measures of restraint which are to provide for the safety of the patients and the personnel in the measures of treatment and rehabilitation. The patients, in particular, are banned from independent free movement over the premises of the clinic and beyond them without being accompanied by the personnel. The patients are also never left alone in the rooms of the clinic. When patients suffer from acute attacks of the disease with psychomotor agitation or facts of aggression or autoaggression, they are placed in surveillance wards with a separate post of a medical assistant. The method of physical restraint (fastening to the bed with wide strong cloth belts) is used in exceptional cases only when they are prescribed and surveyed by the doctor in charge of the patient. This measure is prescribed for the period of time which lasts before sedative medicine comes into effect which usually makes up less than 2 hours. The doctor who prescribed this measure makes a corresponding record in the case history, and, when it is necessary, he prolongs the fastening of the patient stating the grounds for it. During recent years improved medical supplies to the clinic caused a dramatic decrease in the use of physical restraint, and now it is used only several times a month with the total number of patients being 500 people. The personnel of department is required to conduct permanent 24 hours surveillance of every patient in an unostentatious way without producing psychological pressure, annoying, or arousing protest in the patient. The clauses of legislation concerning the delivery of psychiatric care in the conditions which meet the demands of sanitation and hygiene (Article 5 of Federal Law “On Psychiatric Care,” Part 3, Article 30 of the Foundations) with adequate room for the private sphere of every patient (the UN Principle #14a) are of ultimate importance. The overwhelming majority of Russian psychiatric hospitals are not able to accommodate patients with sufficient freedom of movement due to deficit of ward room. Many hospitals are working in decrepit buildings which have no central heating and hot water. In these conditions the personnel of all the clinics cannot provide patients with normal hygienic living standards. Here one should admit that in some cases the very conditions of providing care at hospitals are a form of unacceptable brutal treatment. The basic sanitation and maintenance norms for psychiatric hospitals were established by Order #92 of the RF Ministry of Health Care and Medical Industry of April 11, 1995. But at the present stage the Kaliningrad special type psychiatric clinic with intensive surveillance cannot fully observe these norms due to the fact that its technical equipment does not correspond to the requirements of this order. The departments for medical treatment and maintenance departments of the clinic are housed in non-standard buildings which were rebuilt to meet the needs of the clinic, and which were a prison (from late 19th century till 1945 in Germany, and from 1945 till 1965 in the USSR). A partial reconstruction of its rooms conducted later could not greatly improve the standards of patients’ accommodation. The reconstruction of the clinic planned for 1995—1997 (within the framework of the Federal program of Urgent Measures for the Improvement of Psychiatric Care) did not take place due to the lack of financing. The norms of ward area allocated to mental patients (7 m2 per one patient) adopted by sanitary legislation are not observed at the Kaliningrad special type psychiatric clinic with intensive surveillance which has 3.5 m2 per one patient. The hospital does not have sufficient area for psychological and psychotherapeutic work, for physical exercises, cultural therapy and occupation therapy, and rooms for organized day time accommodation of patients which puts substantial restrictions on the movements of patients at day time. Thus, the sanitary and hygienic conditions of patients at the Kaliningrad special type psychiatric clinic with intensive surveillance do not meet established requirements. At the same time the departments of the clinic are kept clean and neat by regular cleanings. The clinic conducts the necessary set of counter-epidemic measures which resulted in the fact that there have been no flare-ups of infection diseases for the last 10—12 years. One of the most important standards of accommodating patients at a hospital is the supply of adequate food. During recent years the clinic organized the feeding of patients according to the norms adopted by the Russian Ministry of Health Care concerning the list of products, their energy and nutritive value. The clinic has finances to acquire the products of good quality and variety. The Rules of Internal Order provide patients with sufficient time to spend in the open air, they can take three hour walks on a daily basis according to the schedule during which the wards are hygienically cleaned and aired. In order to improve the accommodation standards of patients and their psychosocial rehabilitation at the Kaliningrad special type psychiatric clinic with intensive surveillance the Russian Ministry of Health Care issued Order #309 of July 14, 2003, which provides for a decrease in the number of patients and the reconstruction of the clinic before 2006. The right of the patient for staying at a psychiatric hospital during the time which is necessary for examination and treatment has important social and psychological importance for the patient (Part 2, Clause 5 of Article 5 of Federal Law “On Psychiatric Care,” Parts 2 and 3, Article 102 of the RF Criminal Code , UN Principles #16,17). This right is infringed on at specialized hospitals often enough. The length of compulsory treatment at a psychiatric hospital with intensive surveillance is not determined by the court beforehand. It depends on the peculiarity and graveness of mental disorders which determine the particular threat a patient poses to himself and people around him, and on the efficiency of treatment and rehabilitation measures. Russian legislation provides for a regular, at least once in six months, re-examination of mental patients by a commission of psychiatrists at a hospital with intensive surveillance. The conclusions of the commissions concerning the necessity of further compulsory treatment or its cancellation (change) are sent to the court which passes the final decision. Unfortunately, the law makes it possible for the court to decide the issue of prolongation or cancellation of compulsory treatment in the absence of the patient (Parts 4 and 5, Article 445 of the RF Criminal Procedure Code). In practice all petitions of the Kaliningrad special type psychiatric clinic with intensive surveillance are examined by the court in the absence of the patient which infringes on the right of patient for protection in court. The participation of a patient in a court session could promote a more objective review of the issue of the length of compulsory treatment and the fullest observance of his or her rights (the UN Principle #18 (Clause 5)). Besides that some Russian judges share a silent belief that the length of treatment at a psychiatric hospital should not be considerably less than the term of incarceration for the corresponding crime. Sometimes doctors recommend to change the type of treatment since the condition of the patient does not require such serious restrictions, and the court refutes it referring to social danger. As a result some patients remain under compulsory treatment for 10—15 years, and then they simply cannot return to normal life. At present three persons have been staying at the clinic for more than ten years since in the course of five years the court would consistently turn down the petition of the clinic to change the type of compulsory treatment. It is probable that judges feel the pressure of the perpetrated crimes, and they do not take into account the arguments of the clinic concerning improved mental conditions of these patients. The right to all types of treatment on medical indications (Part 2, Article 5, Article 10, Article 39 of Federal Law “On Psychiatric Care,” UN Principles #8, 9, 10, 14) is sufficiently provided for at the Kaliningrad special type psychiatric clinic with intensive surveillance. All medicine prescribed both by psychiatrists, and by doctors of other specialization is provided for patients for free according to medical indications. The medical therapy is conducted according to the standards developed by the Moscow Science and Research Institute of the Russian Ministry of Health Care. The supply of medication to the hospital has substantially improved in recent years, and it allows for scheduled therapy of patients using most efficient drugs. Besides psychiatric care, the patients of the clinic are provided with consultations and treatment by other experts who are either on the staff of the clinic (neuropathologist, common therapy doctor, dentist), or invited from other medical institutions. Patients suffering from chronic diseases of internal organs and systems stay under dynamic surveillance of corresponding experts and receive inhibition and prophylactic treatment according to the standards of curing patients adopted by the RF Ministry of Health Care. The clinic has a physiotherapy room and a dentist’s room equipped with everything that is necessary. Yet due to absence of necessary experts and equipped room the hospital does not use physical exercises and massage which are indicated for most patients. All the necessary units have been created at the Kaliningrad special type psychiatric clinic with intensive surveillance to provide for the examination of patients: a clinical laboratory, an X-ray room, a functional diagnostics room, and an otorhinolyaryngologist and an ophtalmologist receive patients on a regular basis. When it is necessary, materials for laboratory examination are sent to other laboratory institutions of the town and of the region. Unfortunately, psychological study of patients including psychocorrection and psychosocial rehabilitation cannot be conducted according to the necessary standards due to the deficit of psychologists and experts in psychotherapy, and low training standards of social workers. Tests of medical means and methods on persons with mental illness without their consent are banned in the Russian Federation (Part 2 (Clause 8), Article 5 of Federal Law “On Psychiatric Care,” Article 43 of the Foundations, UN Principle #11 (Clause 15)). No such tests are conducted at the Kaliningrad special type psychiatric clinic with intensive surveillance. Its patients are not used for scientific research and in the process of training. Photographing, video recordings and filming of patients are made only with their consent, and it was noted many times by the correspondents of Russian and foreign media, and during examinations of the clinic by the commissions of international psychiatric and human rights organizations in the course of recent 15 years. At the Kaliningrad special type psychiatric clinic with intensive surveillance all patients are informed of their right to invite experts involved in psychiatric care from other organizations on their will to work at the commission of the clinic (Part 2 (Clause 9), Article 5 of Federal Law “On Psychiatric Care,” Part 4, Article 30 of the Foundations). Nevertheless patients have never asked the administration of the clinic for it. Mental patients have the right to the aid of a lawyer, a legal representative or other person in accordance with the procedure established by law (Part 2 (Clause 10), Article 5, Article 7 of Federal Law “On Psychiatric Care,” Part 12, Article 30 of the Foundations, UN Principles #1, 11, 12, 18). This right is of extreme importance due to the limited potential for the patient himself to independently protect his rights, and the administration of the Kaliningrad special type psychiatric clinic with intensive surveillance does not interfere with the patients’ ability to realize this right. Yet only few patients could afford to pay for a lawyer, so this right remains unrealized for the overwhelming majority of patients. It is necessary to make changes in legislation to provide for the help of a lawyer even when mental patients cannot afford to pay for it. At present patrons of patients represent them (when certified patients have any) and, to a greater extent, by the administration of the clinic. The clinic has staff positions of a legal advisor and social workers to promote the solution of everyday issues concerning civil rights of patients in various areas. The above mentioned experts serve all the patients no matter whether they have been considered as certified by the court, or not. When the administration needs help in protecting patients’ interests in particularly complicated cases, it is provided by the Chernyakhovsk legal consultation office on the basis of a long term contract. The Russian legislation provides for the right of patients to receive psychiatric care under confidential conditions. To provide for the implementation of this right the administration of a psychiatric institution, or experts and medical personnel involved in psychiatric care must observe medical secrecy (Articles 8 and 9 of Federal Law “On Psychiatric Care,” Part 6, Article 30, Article 61 of the Foundations, UN Principle #6). The Professional Ethics Code of a Psychiatrist adopted by the Russian Society of Psychiatrists in 1994 also obliges the doctor involved in psychiatric care to keep medical secrecy (Article 8 of the Code). Taking into consideration these requirements, the information on the presence of mental disorders in a patient and the facts when he applied for psychiatric care is provided by the administration of a clinic without his consent on official appeals: • by the bodies of investigation and the court in association with the conduct of investigation or court review; • by medical workers and medical institutions involved in providing the patient with medical care; • by health care management bodies of a higher level reviewing complaints and statements of patients or their legal representatives. To conduct correspondence with other bodies and institutions in the interests of the patient (municipal, utility services and housing, social security bodies and educational institutions and organizations where the patient studied or worked earlier, and so on) the Kaliningrad special type psychiatric clinic with intensive surveillance uses forms and stamps featuring the words “Federal Clinic with Intensive Surveillance” which do not mention the psychiatric nature of the institution. This procedure was introduced by Order #128 of the RF Ministry of Health Care and Medical Industry of the of May 17, 1995, and Decision #25 “On Stamps Used in Medical Documents” of the Fund of Social Insurance of the Russian Federation of May 17, 1995. It is particularly important for patients undergoing compulsory treatment that social care and protection are guaranteed to them by the state (Article 39 of the RF Constitution, Article 35 of the RF Civil Code, Article 16 of Federal Law “On Psychiatric Care,” Article 20 of the Foundations, UN Principles #1, 13 (Clause 2)). In their overwhelming majority the patients of the Kaliningrad special type psychiatric clinic with intensive surveillance have a persistent and long standing disability to work, being provided with a disability pension resulting from it. A service of social workers is functioning at the clinic which supplies patients with basic necessities through trading organizations. Social workers compose appeals on behalf of the patients and the hospital to various bodies concerning the resumption of working period, collecting necessary documents to receive a pension and establish patronage, to receive a passport. As the Kaliningrad special type psychiatric clinic with intensive surveillance has patients certified as insane by the court (6.5 % of their total number), all the functions of patronage over them are fully performed by the administration of the clinic. In the workshops for labor treatment patients undergo labor therapy and are trained in various labor skills and professions (carpentry, sewing, bookbinding, shoe making). Patients are paid for their work according to the quality and quantity of their produce. The process of labor therapy at psychiatric hospital for compulsory treatment has remarkable positive influence on the level of social functioning of patients. Work in workshops for labor treatment is quite attractive for patients. It has positive effect on their psychophysical conditions, arouses the feeling of emotional satisfaction with the results of labor in the form of products or pieces of craftsmanship. Labor therapy relieves the hardships of long treatment at the hospital for a patient. Yet the produce of workshops for labor therapy has no wide demand, so only about 15—20% of patients are involved in productive labor at present. The isolation of patients from habitual environment requires that the hospital should organize constant contacts with outside world, make information available to patients, and create the conditions for patients to realize their religious preferences. The right for freedom of conscience and religious belief is to be provided for by the administration of a psychiatric hospital to the maximum possible extent (Article 28 of the RF Constitution; Federal Law “On the Freedom of Conscience and Religious Associations” (# 125-FZ) of September 25, 1997; Part 2, Article 37 of Federal Law “On Psychiatric Care”; Part 13, Article 30 of the Foundations; the UN Principle #13 (Clause 1d)). The opportunity to freely satisfy his or her religious needs is of particular importance for a patient, and it absolutely has positive effect on his or her psychological condition and mood. The majority of the religious patients of the Kaliningrad special type psychiatric clinic with intensive surveillance are Orthodox Christians, but some of them are Catholics, Muslims. The hospital is regularly visited by the priests of the Chernyakhovsk Orthodox parish. On their asking patients are allowed to stay alone with the priest. The doctor in charge of the patient allows it depending on the condition of the patient. Up to 80-100 patients can participate in a service conducted in the church which was furnished and equipped by the patients themselves. Catholic and Muslim patients also have an opportunity to pray in wards. Patients can also keep in the wards and use religious literature and cult objects, perform canons and rites if it does not interfere with the comfort of other patients. A patient can be forbidden to pray aloud in the ward especially when other patients are resting. The decision to permit it or not is taken by the doctor in charge of the patient in every case. On their own wish patients can subscribe for books, newspapers and magazines (except openly erotic publications and specialized psychiatric literature). They can also use a library having a lot of fiction (more than 12 thousand volumes). In every department patients can watch television (except those who are kept at a surveillance ward due to an acute attack of their disease), radio speakers of the central radio station function in wards. Thus the patients of the Kaliningrad special type psychiatric clinic with intensive surveillance have the opportunity to get information about developments in the outside world. The doctor in charge of a patient exercises selective control of the patient’s correspondence. If he or she discovers letters containing threats or insults directed against concrete persons, they are discussed with the patient to take a reasonable decision in every separate case. Patients receive and send parcels and remittances under the agreement with the doctor in charge of the patient and the head of the department. The hospital is equipped with a telephone booth so that patients could use long distance telephone communications which is provided to them under the supervision of the medical personnel. Since the departments have no rooms for appointments, patients meet their relatives and friends at the common meeting room of the clinic on every day of the week during working hours. The meetings are to be agreed upon with the head of the department, and they take place under the surveillance of medical personnel. The latter is necessary for safety reasons. Inside a department a patient has the right to wear his or her own clothes, to keep basic necessities the list of which is also known to patients. The rights of the patient of a psychiatric hospital for housing are provided for by the RF Housing Code of March 28, 1998 (Articles 29, 36, 39, 41, 46, 60, 77), by Federal Law #181 “On Social Protection of Disabled Persons in the Russian Federation” of November 24, 1995, by Decree #214 of the RF Government of February 28, 1996, by Decree “On the Right to Use Additional Room in Housing of the All-Union Central Executive Committee and the Council of People’s Commissars” of February 28, 1930. A patient with mental illness retains the right for the housing he owns during his stay at a psychiatric hospital. Besides that, the law provides for his right to have larger room than that which is allocated to a citizen according to social norms. In practice the rights of mental patients concerning housing are often infringed on. This makes the administration of the Kaliningrad special type psychiatric clinic with intensive surveillance conduct permanent correspondence with courts, prosecutor’s offices, municipal bodies and relatives of many patients concerning retaining, returning or providing them with the housing they must have according to the law. With every year the solution of these problems becomes more difficult and often takes several years. Last year, for instance, there were no positive moves in this respect. The electoral rights of persons with mental illness need permanent protection. There is an opinion that any mental patient is automatically deprived of the ability to take part in elections. The legislation of the Russian Federation envisages that only those citizens who have been certified as insane by the court are regarded as incapacitated. (Article 32 of the RF Constitution; Article 29 of the RF Civil Code; laws on the referendum and elections of representative and executive bodies of power). Taking into consideration the above mentioned laws, the administration of the Kaliningrad special type psychiatric clinic with intensive surveillance provided all non-certified patients with the opportunity to take part in the elections of the President of the Russian Federation, of the deputies of the State Duma of the Russian Federation, and in elections of the bodies of power in the Kaliningrad region and the Chernyakhovsk municipality. Yet this made some citizens, including some deputies, complain of lawless actions of the management of the clinic. The authors of the complaint claimed that the patients of the clinic which were certified as insane by the court in criminal cases automatically become non-voters. These complaints were examined by the prosecutor’s office which did not find any violations of law in the activity of the administration of the clinic. This article makes an attempt to outline the eventual situation with the civil rights of patients in one of the seven psychiatric hospitals with intensive surveillance. One should note that the conditions in which these hospitals function are not the same. Their ability to create proper sanitary conditions of life in many ways depend on the location of the clinic, whether it is in the regional center with an extensive technical and utility services structure, or in countryside. These hospitals are also not equal in their ability to fill the positions of their staff with qualified professional experts who are necessary to implement the programs of social rehabilitation of patients according to up-to-date standards. Yet, no matter what is the material potential of a hospital, its administration and personnel must, first and foremost, provide for considerate and respectful attitude to every patient. Besides providing for a patient’s right for adequate treatment, it is also important to take into account the personal interests of the patient, to go deep into the problems which he or she is not capable of solving due to his or her mental condition and isolation from habitual environment. At the same time the administration and the personnel are to provide for the comfort and admissible freedom of patients in reasonable balance with necessary safety measures. It is not only the administration and the personnel of the psychiatric institution whose goal and obligation is to provide for the observance of patient’s rights. Civil rights of persons with mental illness which are envisaged by legislation are to be provided for by the executive power of all levels. The observance of the rights of patients with mental illness ought to be monitored by the prosecutor’s office and the public on a permanent basis. |
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