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English Language Page Among the legislative acts of the past determining basic principles of legal relationships in the sphere under review are the 1977 USSR Constitution, the “Fundamental Principles of the USSR Legislation on Public Health” adopted in 1969, the 1971 RSFSR Law “On Public Health,” Decrees of the Presidium of the RSFSR Supreme Soviet “On the Compulsory Medical Treatment and Reforming by Means of Labor Patients Afflicted With Drug Addiction” (1972) and “On the Compulsory Medical Treatment and Reforming by Means of Labor of Chronic Alcoholics” (1974). The “Fundamental Principles of the USSR Legislation on Public Health” proclaimed the right of citizens to health care and placed all state agencies and public organizations under an obligation to exercise public health care activities (Article 3). Under that law chronic alcoholism and drug-addiction were described as diseases posing a threat to surrounding people (along with quarantine infections, lepra, venereal and some other diseases). At the same time, it was stated that the USSR and union republics’ legislation may establish specific instances of and procedure for compulsory medical treatment and compulsory hospitalization of persons suffering from those diseases. Further to those provisions, Article 58 of the RSFSR Law “On Public Health” provided for obligatory outpatient observation and treatment of persons afflicted with chronic alcoholism or drug-addiction and in case of refusing voluntary treatment — for their involuntary treatment at the so-called medical-labor inebriate reformatories (hereinafter referred to as LTPs) incorporated as part of the Ministry of Internal Affairs. Thus, the legislation of those years pointed out to a distinctive specificity of the civil and medical status of drug addicted patients. Article 42 of the 1977 USSR Constitution reaffirmed the right of citizens to protection of their health and the obligation of the state, along with public organizations, to protect it. The said legislative acts served as a basis for relevant regulatory documents that followed. The peculiarity of regulation of legal relationships in the said problem sphere was that those were resolved, predominantly, by executive power bodies — by decisions, instructions of the USSR and RSFSR Council of Ministers, orders of the ministries of health and internal affairs and other departments which, at that time carried out the greater part of work in the sphere of alcohol-related and anti-drug policies. In particular, the legal status of persons in compulsory resident therapy at LTP, was similar to the legal status of persons serving prison terms for committing a crime and the regime of confinement at LTP resembled that of correctional labor institutions. Thus, for instance, an illegal hand-over of forbidden objects to persons held at LTP, pretrial detention facilities and correctional labor institutions entailed criminal liability of the same degree of gravity. A breakout from LTP and while en route thereto, was equated, in terms of seriousness of its social danger, to an escape of a criminal from the place of exile and was punishable with one year of imprisonment. LTP inmates just as offenders against the law convicted to imprisonment were subject to a summary divorce procedure. Initially, LTPs were set aside for patients afflicted with alcoholism and drug-addiction “evading medical treatment or keeping on drinking after treatment, violating labor discipline or rules of socialist communal life,” despite measures of disciplinary, public or administrative influence that were applied to them. Later on, the majority of qualifying features listed above, were gone from the regulatory documents and any person with a diagnosis of “chronic alcoholism” or “drug-addiction” formally dodging voluntary medical treatment, was faced with a threat of being committed to LTP. In fact, LTPs were labor penal camps — with their paramilitary security guards, regime of a correctional institution and forced labor. LTPs were used as a means to isolate patients with drug habits and, not infrequently, also persons in abuse of psychoactive substances without phenomena of addiction thereto, from the rest of society and also as a source of cheap labor. In accordance with the 1987 Instructions of the Ministry of Internal Affairs On the Functioning of LTPs, the work-record cards of persons released from LTP were to bear an indication of a period of their stay there. Although the Instructions stipulated that the working conditions at LTP should be regulated by the labor legislation, the persons in therapy there were subject to serious exceptions from the labor legislation. For instance, LTP inmates were excepted from the legislation on the labor contract, leaves of absence, disciplinary penalties, procedure for settlement of labor disputes, payment of social insurance fees. Just as in case of enduring a criminal punishment, the law provided for a possibility to reduce a term of confinement at LTP, although that did not apply to persons repeatedly committed to LTP. A major limitation of rights of drug addicted patients was that they were denied a possibility to appeal a judgment on commitment to LTP, extension or reduction of the term of confinement there in due process of law. The involvement of a lawyer in cases connected with commitment to LTP was not provided. Similarly, no provision was made that those judgments may be protested against in the exercise of supervisory functions. The effectiveness of such medical treatment was extremely low. The overwhelming majority of persons who had been to LTP, started to take up alcohol or narcotics again within the first three months after their release. Many of them found themselves at LTP again and again. The investigations that had been undertaken suggested that confinement at LTP substantially accelerated and aggravated the process of desocialization of drug addicted patients (break-down of family, loss of dwelling, job, criminalization of behavior, criminal records, etc.) as compared with those of them who avoided that institution. Beginning from the second half of the 70s of the last century, those institutions have acquired a mass character. By the year 1987, 1,5 million persons abusing psychoactive substances have gone through “reforming by means of labor” at LTP. In 1989, the USSR had 314 LTPs with a total limit of population (number of seats) of about 300 thousand persons. In the late 80s, against the background of democratic processes going on in society, there started to occur mass refusals of LTP patients to turn out for work, smashing out of workshops, arsons of barracks. During 1989 alone, LTP had as many as 200 riots, including twenty of them in which hostages were taken and patients attempted to break through the fencing. In 1979, the USSR Ministry of Health approved the Instructions “On the Procedure for Provision of Data on the Mental Condition of Citizens.” Under the Instructions, such data on mental patients and their diagnoses should not be disclosed to anyone, except for investigatory judicial agencies and psychiatric institutions. That state of things was consistent with the obligation of medical officers to keep confidentiality. However, the Instructions pointed out that it was applicable to patients afflicted with chronic alcoholism, toxicomania and narcomania only in instances when the patients were taking a critical attitude to their condition, were firmly committed to medical treatment and diligently carrying out all medical prescriptions. It followed that, in case the patient failed to comply with those conditions, the physicians may be absolved from the obligation to keep confidentiality. Thus, the physician’s moral and official duty was made conditional upon behavior of the patient. Considering that a lack of criticism of one’s condition is a specific symptom of disease of drug addiction (anosognosia), in practice, no one of the patients applying for assistance to a narcological service, could rely on confidentiality. That provision alone put the patients afflicted with alcoholism and drug-addiction in a position of “second-rate” patients. The Instructions “On the Procedure For Identification and Registration of Persons Practicing Non-Medical Consumption of Narcotic Drugs or Other Substances Leading to Intoxication, Formalization and Commitment for Compulsory Treatment of Patients Afflicted with Narcomania” approved jointly by the USSR Ministry of Health and the USSR Ministry of Internal Affairs in 1988, allowed for a possibility to appeal the validity of established diagnoses of “narcomania” or “toxicomania” with a superior health care agency. As to the possibility of appealing a diagnosis before a court, that was completely out of the question at that time. Widely popular in those years was a conception of cheap, self-repaying, so-called “industrial narcology” that was actively imposing the practice of “reforming” drug addicted patients who committed no offence “by means of labor” in the course of their confinement (up to three — six months) at inpatient institutions under industrial enterprises, to the detriment of real medical psychological and social assistance to patients and their families. The availability of a narcological disease could, to a certain extent, affect the possibility of citizens to exercise their political rights, in particular, the right to elect. Thus, under Clause 3 of Article 32 of the USSR Constitution, active and passive electoral right was denied to citizens held at institutions of confinement. In case of an offence committed by a person registered with a narcological dispensary, it was common practice to order compulsory treatment for alcoholism or narcomania which, was, predominantly, conducted at institutions of confinement. Therefore, such persons were bound to receive criminal punishment in the form of imprisonment. On the other hand, a person without a diagnosis of drug addiction, with other things being equal, may be given a more lenient and even conditional sentence, remain at liberty and thus retain his or her electoral rights. So, a narcological disease, was actually associated with the deprivation of electoral rights in case of committing a crime. It should also be mentioned that patients with drug habits were devoid of the right to receive a temporary disability certificate for a predominant disease, let alone, a permanent disability status the receipt of which, in view of a diagnosis of drug-addiction, remains inaccessible to them today. By and large, an analysis of the regulatory base of the Soviet period concerning patients with drug habits testifies not so much to the intention to realize their legitimate right to health care, but to the desire to protect society from such patients. The patient was equated to an offender against the law, isolated and subjected to correction and reforming with the help of “work therapy.” The anti-alcoholism and anti-drug-addiction efforts, most often, took the form of a crusade against the patients who were declared socially dangerous “elements” and the methods of treatment were a means of suppression of their eventual antisocial behavior. In the post-Soviet times, attempts were made to democratize approaches to the sphere of public relations under review. An opinion prevailed that degradation of human dignity, curtailment of the legal status of the citizen merely by reason of a disease, deprivation of legal remedies might not be justified by the goals of drug disease control. It was stated that it was essential to be guided by the well-balanced principles of regulation of mutual relationships between society and drug addicted patients, in particular — to give up perceptions that it is possible to “punish” for a disease and impose medical treatment by force, as being contradictory to both legal and ethical values. The 1993 RF Constitution proclaimed (under Article 41) the unconditional right of everyone to health care and medical assistance. Moreover, it provided for free medical assistance at state-run and municipal institutions. Those provisions also apply to drug addicted patients. The follow-up regulatory acts outlined the ways of implementing the constitutionally guaranteed rights of the citizens. Thus, in 1993 the RF Supreme Soviet approved the Conception of the State Policy of Control Over Narcotic Drugs in the Russian Federation. That document, not being a law, did not change, in substance, the legal status of drug addicted patients but declared intentions and desires of the supreme power bodies for certain changes. Notably, the Conception contained quite obvious humanistic aspirations. Specifically, it pointed out to a necessity to observe a well-balanced application of both coercive and educational measures, emphasizing a preference for indirect and mediate influence upon potential drug users, a striving for gradual changing of social and cultural stereotypes. As a measure to restore the health of drug addicted patients it was suggested to set up a state-run foundation of social support and rehabilitation of drug addicts. It was recommended that the persons who had committed minor drug-related offences be subjected to medical treatment, rather than to punishment. Nothing of the above was realized in practice. A step forward in the same direction was the Federal Law “On the Psychiatric Care and Guarantees of Rights of Citizens in Therapy” that took effect in January 1, 1993. The Law offers an extensive list of rights of mental patients. Specifically, voluntarism in applying for psychiatric care; receipt of information on one’s rights; observance of medical confidentiality; necessity to have one’s consent in writing to medical treatment; right to refuse or terminate medical treatment and some others. The observance of those rights was guaranteed by availability of the right of the person to appeal actions associated with psychiatric care offered to him either in court, before a superior agency or prosecutor’s office. Formally, that law has nothing to do with narcology; it makes no mention of drug addicted patients, narcological inpatient institutions or a physician — an expert in narcology and psychiatry; nor does it grant any rights to drug addicted patients or regulate the provision of narcological care. Therefore, formally, from the legal standpoint, it may not be applicable to regulate legal relationships in the sphere of provision of narcological care. However, the judicial precedents and available therapeutical practice, both in narcology and psychiatry, suggests that the law has been applied de facto ever since its adoption, notably, as a law with a direct effect. That is largely explained by the fact that, in many cases it is virtually impossible to differentiate between narcological and psychiatric care. It is only natural that in instances when the provision of narcological care involves the provision of or turns into psychiatric care (specifically, in case of psychotic conditions), the patients indisputably become subject to all and any provisions of the law dealing with their rights, instances and limits of offering involuntary narcological care (hospitalization, involuntary certification, confinement at inpatient institution, etc.). The rights of the patients envisaged under Federal Law “On the Psychiatric Care and Guarantees of Rights of Citizens in Therapy” fully accounted for the “RF Fundamental Principles of Legislation “On the Health Care of Citizens” (hereinafter referred to as the Fundamental Principles) containing a complete list of rights of citizens in the given sphere. Of primary importance in the Fundamental Principles is Article 17 which guarantees protection of citizens against any form of discrimination on the ground of availability of a disease. That provision virtually reduced to zero many earlier established norms with respect to drug addicted patients. Under the Fundamental Principles, the legal status of the person in therapy shall be determined, specifically, by the rights: to the confidentiality of information on one’s health and diagnosis; to a voluntary informed consent to medical intervention and refusal thereof; to receive information about the condition of one’s health; to employ the services of a lawyer and also to apply to superior officials or to the court in case of violation of any of his rights, etc. It is fundamentally important that the Fundamental Principles regulate all eventual exceptions from the rule of confidentiality and instances of resorting to involuntary medical interference (such as a threat to surrounding people, grave mental pathology and socially dangerous acts). The Fundamental Principles provide for no special legal status for patients afflicted with alcoholism or narcomania, consequently, all the provisions of that law, shall apply to them in the same degree as to other categories of patients. At the same time, up to date, no decision has been made as to whether alcoholism, narcomania and toxicomania should be put on the lists of socially important diseases and diseases posing a threat to surrounding people to be approved by the government. The Fundamental Principles (Articles 41, 42) envisage specific types and scope of the medical-social care for those categories of patients. However, the lists have not yet been compiled. Apparently, that is connected with the fact that under the said articles of the Fundamental Principles persons afflicted with socially important diseases and diseases posing a threat to surrounding people are entitled to privileges in offering medical-social care, including privileges in the provision of housing for persons suffering from diseases posing a threat to surrounding people. There are grounds to believe that no provision of privileges to drug addicted patients will be realized in the foreseeable future. The putting into effect of the Fundamental Principles invalidated all earlier regulatory acts in the given sphere contradictory thereto. Furthermore, in July of 1993 the RF Supreme Soviet adopted the Decision “On the Procedure for Putting Into Force of Federal Law “On the Departments and Agencies In Execution of Criminal Penalties in the Form of Imprisonment” which provided for liquidation of the LTP system as from July 1, 1994. Thus, by the mid 90s, the Russia’s legislation had no legal grounds for imposition and application to patients afflicted with alcoholism, narcomania and toxicomania of former repressive measures in the form of commitment to medical-labor inebriate reformatories and obligatory registration with dispensaries, which implied a whole range of legal limitations and unceremonious intervention in the patients’ private life. However, notwithstanding the advantages and progressive nature of the 1993-1994 legal acts discussed above as compared with the previous Russia’s legislation, they failed to facilitate a detailed revision of the entire legislative base regarding patients with drug habits. No legal guarantees that would protect the rights of drug addicted patients and assimilate them in terms of their rights to other patients — of psychiatric or at least somatic-neurological type — were created. The situation of uncertainty in that respect was mothballed and as such has remained up to this day. The point of non-reversion to the repressive policies has not yet been passed. In that connection we cannot but dwell upon a protracted discussion as to whether Federal Law “On the Psychiatric Care and Guarantees of Rights of Citizens in Therapy” should be supplemented with the provisions making that law applicable to the provision of narcological care or whether a special law dealing with narcological care should be passed. In our view, the advocates of the former approach are right when insisting on the unity and inseparable link between psychiatry and narcology. A group of drug-related diseases is classified as exogenous mental conditions and as such constitutes an inalienable part of psychiatry. Narcology makes use of the same methods and means of diagnostics and treatment as psychiatry. The training of experts in narcology is carried out on the basis of the basic knowledge in psychiatry. No clear-cut clinical criteria are available that would allow to differentiate between drug-induced and mental diseases as the syndrome of addiction by itself is a mental disorder and addicted patients always suffer, with a varying degree of intensity, from psychopathological disorders (affective-will, cognitive, neurotic, character, behavior and other disorders). Diseases of drug addiction just as many mental diseases are of the systematic, procedural and progredient character. Unfavorably progressing diseases of drug addiction include a whole range of psychotic conditions, both acute and chronic, and result in a serious mental pathology (degradation of personality, encephalopathy, dementia) disabling the patient. The indissoluble connection between psychiatry and narcology, mental diseases and diseases of drug addiction is reflected in the structure of text books and manuals on psychiatry of all known national schools and in all known classifications of mental disorders, including the “WHO (World Health Organization) International Classification of Diseases” adopted by the RF Ministry of Health which deals with alcoholism, narcomania and psychoactive substances abuse with harmful aftereffects under the class of mental diseases and behavior-related disorders. As to the separation of psychiatric and narcological services ( reorganization of the narcological service as a separate unit out of the psychiatric service) that has been observed in the Russian Federation since 1976, it took place, not out of considerations of principle but for reasons of organizational-methodological character, pursuing the aim to improve the management of psychiatric care offered to the population and to stimulate the development of narcology in the conditions of growing incidence of alcoholism. All that suggests that it would be appropriate to regulate the narcological care within the framework of Federal Law “On the Psychiatric Care and Guarantees of Rights of Citizens In Therapy.” A drug-addicted patient exists as if in three identities: generally psychiatric, specifically narcological and generally somatic, but that does not imply that the legal relationships arising in the provision him with medical assistance should be described by three different laws; for instance, in the morning, (hang-over) — with the law on narcology, in the afternoon (somatic complaints) — with the law on health care and in the evening — (pre-delirious condition) — with the law on psychiatry. The opponents of “the psychiatric approach” to narcological care are usually referring to two different, mutually contradictory arguments. According to one of them, the narcological pathology, except for psychotic conditions, is devoid, en masse, of the psychiatric specificity and, therefore, narcological care may well be regulated under the general health care legislation, i.e. the Fundamental Principles and, conceivably, under other follow-up federal laws. Such position, denying narcology its specificity, is completely inconsistent with the medical-biological principles of formation of addiction, is ignoring the clinical picture of diseases of drug addiction and, therefore, does not stand up under scrutiny. According to another argument, the narcological pathology and specific features of providing narcological care, precisely by virtue of its specificity, do not fully coincide with the area of operation of Federal Law “On the Psychiatric Care and Guarantees of Rights of Citizens in Therapy.” Thus, it is essential to prepare a separate law on the narcological care. Notably, when speaking of a distinctive specificity of the narcological contingent of patients, they usually imply a social component of narcopathology — behavior-related disorders and enhanced delinquency. That argument is likewise unfounded. The specificity of narcology is of a psychiatric type (which makes it similar to psychiatry): anosognosia in patients, inevitability of paternalism in relation to a major part of patients, necessity to resort in specific cases to compulsion and coercion to treatment, a high risk of delinquent behavior (which, however, is not higher than in some other groups of mental pathology). The search for some other specificity of the narcological contingent or for its novel identity — represents a latent nostalgia for the senseless and unreasonable repressive legislation in respect of drug addicted patients, search for its theoretical substantiation, desire to ignore the civil rights of patients and, ultimately, abandonment of the conception of alcoholism and narcomania (toxicomania) as a disease. The need to extend the jurisdiction of Federal Law “On the Psychiatric Care” to drug addicted patients is connected with the fact that the Law not only offers the scientifically substantiated clinical-social criteria for provision of involuntary psychiatric care but also regulates in detail a procedure for involuntary hospitalization from the viewpoint of protection of the rights of the patients. The point is not to abandon involuntarism as such in case of the narcological contingent of patients but strict legislative regulation of all involuntary measures and control over their application which, in our view, constitutes an issue of paramount importance for protection of the rights of drug addicted patients. In that respect, today, mental patients are much better protected than the patients of the narcological type whose rights are not specially dealt with in any legislative act. Meanwhile, the prospect of making relevant amendments and changes in Federal Law “On Psychiatric Care,” seems to be scarcely probable today. The law-maker has made a certain evolution as regards the issue. If, in the beginning of the 90s, for instance, at the time of adoption of the RF Criminal Code, it made no distinction between psychiatry and narcology, today, on the reverse, it is inclined to set those two notions too wide apart. At least, an attempt made in the year 2002 to include in the text of the revised version of the Law an indication that its jurisdiction also extends to persons with mental disorders induced by the abusive use of psychoactive substances, found no understanding with the staff of the government and law-makers. The next milestone in the history of shaping the modern legal status of drug addicted patients was Federal Law “On Narcotic Drugs and Psychoactive Substances” which took effect in April, 1998. It is hard to overestimate the role of that law in establishing the legal framework for the state policy in the sphere of regulation of legal turnover of narcotic drugs and psychoactive substances and countering their illegal turnover. However, in the sphere of protection of the rights of patients afflicted with narcomania that law had a negative, rather than positive role. As compared with the Fundamental Principles, it was objectively a step backward. Federal Law “On Narcotic Drugs and Psychoactive Substances” included as its part Chapter 7 entitled Narcological Care to Patients Afflicted With Narcomania containing merely four articles which certainly may not be viewed as sufficient the more so that some norms are just references. Some specific legal norms of the law are also wide open to criticism. To begin with, let us revert to the legal aspects of the norm on compulsory treatment. Part 3 of Article 54 provides for imposition by court decision of compulsory measures of medical character vis-a-vis patients afflicted with narcomania, being under medical observation and taking narcotic drugs or psychoactive substances without medical prescription or evading medical treatment. The norm indicates that those measures are envisaged under the Russia’s legislation but, as is known, such approach has not yet been reflected in the legislation. Considering that the said provision has remained unsecured for quite a long time, one may conclude that the law-maker hastened to reinforce its position which comes into conflict with the rights of the patients to a voluntary consent to medical interference or refusal of such interference, guaranteed under the Fundamental Principles, thereby having expressed its attitude to the rights of drug addicted patients. Part 1 of Article 54 of the Law deals with the guarantees in providing patients afflicted with narcomania with narcological care which includes examination, consulting, diagnostics, treatment and medical-social rehabilitation. However, up to now, that norm has not been backed up with the respective funding and a considerable part of patients with narcomania, even at state-run and municipal institutions, are receiving care on a paid basis, especially in the sphere of rehabilitation services. Part 2 of Article 55 of the same Law indicates that the treatment of patients with narcomania shall be conducted only at institutions of the state and municipal health care systems. The expediency of such limitation is doubtful as under Clause 1 of the said Article institutions of the private health care system are allowed to offer the diagnostics of narcomania, examination, consulting and medical-social rehabilitation of patients afflicted with narcomania which is inseparably connected with treatment. The advocates of banning treatment of narcomania by private structures are referring to the regulations on the free medical assistance to citizens suffering from socially important diseases or diseases posing a threat to surrounding people specified under Articles 41, 42 of the above-mentioned Fundamental Principles. However, such references are not fully true to reality since, as it was already pointed out, a list of such diseases has not been approved. Only following its approval and inclusion therein of diseases of drug addiction, one may refer to certain privileges in providing medical care. Furthermore, ban on private medical practitioners to treat patients afflicted with narcomania represents a certain derogation from the right of such patients to medical assistance. It is possible to speak of that right being secured in the full scope only when the state and municipal health care systems provide patients afflicted with narcomania with timely, effective and comprehensive medical care. In the conditions when no such care is available, the patient is forced to apply to private practitioners who may charge, considering the ban, higher rates for their services (the so-called pay for the risk). Besides, the ban infringes upon the right of the patient to choose a physician and health care institution, by binding him to a particular state-run or municipal institution and methods of treatment used there. Under Part 6 of Article 31 of Federal Law “On the Narcotic Drugs and Psychoactive Substances,” it is forbidden to treat narcomania with narcotic drugs and psychoactive substances. That creates considerable difficulties in the treatment of some patients afflicted with narcomania, for instance, in instances of narcomania in new-born babies or serious long-term forms of narcomania and condemns some patients to unnecessary suffering in the course of the treatment which runs counter to the psychiatric deonthology (medical ethics). Here we are dealing with the limitation of the rights of patients to medical assistance. Moreover, the legislative ban on application of narcotic drugs in the treatment of patients afflicted with narcomania prevents a large group of patients from having a substitution therapy widely practiced throughout the world and favored by the World Health Organization and other authoritative international organizations as an effective remedy of prevention of HIV-infection. One may have different views regarding application of narcotic drugs in the treatment of drug-addicted patients, criticize and refrain from respective methods but will have to agree that the legislative ban is not the best way to solve scientific medical disputes. We should also mention Article 50 of the said Law which provides for “monitoring of the progress of social rehabilitation” of persons who committed crimes involving an illegal turnover of narcotic drugs, psychoactive substances and their precursors — substances used to prepare narcotics. The case in point is banning such persons to attend certain places, restraining their stay outdoors after a certain hour of the day, departure to other localities without a permission of the police organs. In fact, that is an administrative supervision which applies to patients afflicted with narcomania and released from prison. It seems that in respect of such persons, it should be worth providing for some exceptions from the general rules so that the regime of administrative supervision would not contradict their medical-social rehabilitation. The criminal legislation currently in force stipulates no liability for an illegal consumption of narcotic drugs but the discussion as to the relevance of that measure still continues. That was reflected in Article 40 of Federal Law “On the Narcotic Drugs and Psychoactive Substances” which expressly says that in the Russian Federation it is prohibited to take narcotic drugs and psychoactive substances without medical prescription. The article provides for no specific penalties for violation of the ban but it may be seen as a confirmation of a tendency towards the criminalization of non-medical consumption of narcotic drugs and psychoactive substances. The tendency has recently been partly materialized which will be dealt with further below. Regrettably, perceptions continue to prevail that in the sphere of prevention of diseases of drug addiction, maximum effectiveness may be achieved by using measures of force. Meanwhile, it is quite obvious that the policy of force gives rise to equal counter action which makes it impossible to create favorable conditions to ensure the rights of citizens, including of patients with drug habits, to health care. Among such measures of force ensuring the right to health care, one may refer to a ban envisaged under the latest RF Administrative Code (2002) on the consumption of narcotic drugs or psychoactive substances without medical prescription (Part1, Article 6).In fact, that norm represents a compulsion to treatment inasmuch as it provides for exemption from administrative penalty in case of voluntary application for treatment at a health care-preventive institution. Should a patient fail to take such a decision, he shall face a punishment that may be regarded a punishment for a disease, in the form of a considerable fine or arrest for a term of up to fifteen days. It turns out that consumption of drugs entails an administrative penalty. The RF Administrative Code also envisages administrative liability for drinking alcoholic and alcohol-containing products or consumption of narcotic drugs or psychoactive substances in public places (Part 20, Article 20). Here it is appropriate to recall a ruling of the USSR Committee of Constitutional Supervision made as far back as in 1990. According to the Committee, bringing to liability for consumption of psychoactive substances is inconsistent with the constitutional principles as neither the Constitution nor international acts provide for an obligation of the person to take care of his or her own health and it may not be enforced with measures of coercive character. In conclusion, it was expressly stated that “the consumption of drugs by itself shall not be considered as an administrative offence or crime.” The domestic legislation also comprises other regulatory legal acts whose individual provisions limit the rights of drug addicted patients, basically, civil, economic and social rights of citizens. The Fundamental Principles disclose the substance of the right of citizens to medical assistance, specifically, through the rights of the patient envisaged under Article 30 and contain no exceptions from those rights in respect of patients with drug habits. Under Article 30 of the Fundamental Principles the patient has the right to confidentiality of information about the state of his health and diagnosis which is consistent with the provisions of Article 61 of the “Fundamental Principles On Confidentiality.” Under Article 9 of Federal Law “On the Psychiatric Care and Guarantees of Rights of Citizens In Therapy,” confidentiality shall also be observed in the provision of psychiatric care. The requirement of confidentiality is not always adhered to. In accordance with the lists of medical psychiatric counter-indications for carrying on individual types of professional activity, persons having a diagnosis of alcoholism, narcomania, toxicomania are prohibited to pursue certain professions. But there is no way to realize that without violating medical confidentiality and disclosing a relevant diagnosis when taking on a job. A list of medical psychiatric counter-indications was approved for the last time by April 28, 1993 Decision of the RF Council of Ministers #377. The judicial practice on that issue is available. Thus, the February 22, 2000, Decision of the RF Supreme Court recognized the validity of Part 8 of the Regulations “On the Procedure For Performance of Obligatory, Preliminary Medical Checkups When Applying for Work and Regular Medical Checkups at the Federal Railway Transport” approved by March 29, 1999 Order of the Ministry of Railway Transport. In applying to the court the applicant was challenging the validity of the content of the said Clause under which persons applying for work or training at railway transport enterprises shall produce certificates on the absence of registered diseases issued by psycho-neurological dispensaries. The court ruled that the said provision is designed for safety of operation of the railway transport and dismissed the complaints. We believe that the availability of a diagnosis on corresponding lists prohibiting patients from pursuing certain professions should not be a sufficient ground to deny them employment. The capabilities of a patient to do specific types of work should be established by a competent composite, rather than just a medical board. The prohibition of work should be due to the inability to perform it, rather than by a diagnosis that has been made. The confidentiality is closely linked with the issuing of temporary disability certificates. At present, that is allowed but a procedure for issuing such certificates is at variance with Part 4 of Article 49 of the Fundamental Principles which says that when issuing a disability certificate, data regarding a diagnosis, for purposes of confidentiality, shall be indicated only with the consent thereto of the patient and in the absence of such a consent, only a reason for disability shall be indicated. However, Clause 2.10 of the Instructions “On the Procedure For Issuing Documents Certifying Temporary Disability of Citizens” approved by October 19, 1994 Order #206 of the RF Health Ministry Medical Industry Department and by October 19, 1994 Decision #21 of the RF Social Insurance Fund, envisages that “in instances when an illness or injury that has caused a temporary disability, was resultant from alcoholic, narcotic or non-narcotic intoxication, a temporary disability certificate shall be issued by making a relevant note of intoxication in both the case history (outpatient medical card) and in the disability certificate.” That provision was challenged as illegal at the Supreme Court of the Russian Federation. In its Decision of March 27, 2002, the court pointed out that the said clause of the Instructions in so far as it prescribes to establish, when issuing a disability certificate, whether an illness (injury) has or has not been resultant from an alcoholic, narcotic or non-narcotic intoxication, is at variance with Article 49 of the Fundamental Principles since it obligates, in the examination of temporary disability, to determine circumstances not connected with such examination or provision of medical assistance. At the same time, according to the court, the issuing of a disability certificate bearing a relevant note of intoxication which affects payment of temporary disability allowance, does not contradict the applicable legislation. As far as the said part was concerned, the court sustained Clause 2.10 of the Instructions, having declared it to be illegal and invalid only concerning the words “when an illness or injury that has caused temporary disability were resultant from an alcoholic, narcotic or non-narcotic intoxication.” Thus, the court neglected the above mentioned provisions of the Fundamental Principles under which a diagnosis may be indicated in the disability certificate only with the consent thereto of the patient. That is a direct evidence of discrimination de facto on the ground of availability of an illness. The confidentiality is also violated by the rule applicable since Soviet times, under which the police organs shall be kept informed of patients applying for assistance to a narcological dispensary. Today, it is further elaborated in several regional regulatory acts. In particular, under the 1998 Decision of the Moscow government “On Measures to Prevent the Spread of Narcomania Among Minors” it is ordered that police organs and the Health Committee approve the Instructions “On the Procedure For Mutual Exchange of Information Between Health Care Institutions and Police Organs of the City of Moscow Regarding Minors Taking Narcotic Drugs, Psychoactive and Other Intoxicating Substances and Also Adult Drug Addicts Who Have Under-Age Children.” Under Article 69 of the RF Family Code, chronic alcoholism or narcomania constitutes a basis for depriving the patient of his or her parental rights. Such cases shall be resolved by the court, with the availability of a medical testimony. Persons deprived of parental rights shall, in accordance with Article 71 of the RF Family Code, lose all the rights based on their relationship to children and also may, under Article 98 of the RF Housing Code, be evicted from their homes without being provided with an alternative dwelling, should it be recognized that they may not live together with their children. Instead of eviction, such persons may be obligated by court to exchange the premises they occupy for other ones. It is clear from the above provisions that the deprivation of parental rights is accounted for by the availability of a relevant diagnosis. The Law does not disclose other circumstances associated with a narcological disease that should necessitate the application of such measure. We believe that the depravation of parental rights should be justified, primarily, by failure of parents to comply with their duties vis-a-vis the child which should be recorded in the law. To confirm that drug addicted patients are neglecting their parental duties, a comprehensive examination should be undertaken to establish an objective state of affairs. In case a drug addicted patient enjoys a prolonged period of remission and his or her diagnosis has not been cancelled for some formal grounds, the patient should not face a risk of deprivation of parental rights merely due to the availability of diagnosis of drug addiction. The state of alcoholic, narcotic or other toxic intoxication affects the realization by the patient afflicted with a narcological disease of his labor rights. Thus, under Part 1 of Article 76 of the RF Labor Code, the employer is obligated to take off or not admit to work an employee who has reported for work in the state of alcoholic, narcotic or other toxic intoxication. Moreover, even one-time reporting for work in the said state constitutes a gross violation of labor duties and may serve as is stipulated under Clause 6 (b)of Part 1 of Article 81 of the RF Labor Code as a ground to dissolve a labor contract on the initiative of the employer. In the former case, there should be a qualifying feature — a degree of intoxication determining one’s inability to do the work. In the latter case, — it should be repeated, regular and not one-time occurrence. Under Article 1078 of the Civil Code, the legally capable citizen shall not be held responsible for the harm inflicted by him if he has done it in a state in which he was unable to realize the meaning of his actions or control them. Part 2 of the said Article, however, provides that the inflictor of harm shall not be absolved from responsibility if the state in which he could not realize the meaning of his actions or control them was self-induced by him by taking alcoholic drinks or narcotic drugs. Such state, actually, a state of insanity, induced by consumption of psychoactive substances is most likely to develop in patients with drug habits. The exception of the said category of persons from a general principle of innocence may be regarded as discriminatory. Thus, beginning from the 90s the Russia’s legislation concerned with the provision of narcological care and approaches to the legal status of the said category of patients have undergone considerable changes in favor of humanization and democratization. However, after some obvious progress, the process has come to a standstill. There still exists a whole range of limitations of the rights of drug addicted patients. Some of them and even their wordings have been borrowed from the laws dating back to Soviet times. Similarly, many departmental regulatory acts have remained in force since those times. In fact, the provision of narcological care to patients with drug habits has not been legislatively backed up. Still missing is a body of commonly accepted conceptual terms. Individual legal norms regarding the legal status of drug addicted patients “are scattered about” within a very wide range of legislative documents. Moreover, individual legislative acts granting specific rights to drug addicted patients are obvious contradictory among themselves which continues to be neglected. Several guaranteed rights are not implemented, some of them being declarative in nature as they are not secured in any way. Regardless of most obvious psychiatric specificity of the narcological contingent of patients, they are rejected by the psychiatry legislation. As a result, legal vacuum and nihilism is observed in the sphere of regulation of legal relationships arising in the provision of narcological care, which is fraught with the restoration of the repressive legislation of previous years. Today, drug addicted patients represent one of the least legally protected groups of the population not only because their rights have not been specifically recorded in any document, but also because their legal status continues to stay in the background in terms of public awareness and outside the interest of human rights activities. |
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