United
Nations Principles for the protection of persons with mental illness and the
improvement of mental health care
Adopted by General Assembly
resolution 46/119 of 17 December 1991
Application
These Principles shall be applied without discrimination of
any kind such as on grounds of disability, race, colour, sex, language,
religion, political or other opinion, national, ethnic or social origin, legal
or social status, age, property or birth.
Definitions
In these Principles:
"Counsel" means a legal or other qualified
representative;
"Independent authority" means a competent and
independent authority prescribed by domestic law;
"Mental health care" includes analysis and
diagnosis of a person's mental condition, and treatment, care and
rehabilitation for a mental illness or suspected mental illness;
"Mental health facility" means any establishment,
or any unit of an establishment, which as its primary function provides mental
health care;
"Mental health practitioner" means a medical
doctor, clinical psychologist, nurse, social worker or other appropriately
trained and qualified person with specific skills relevant to mental health
care;
"Patient" means a person receiving mental health
care and includes all persons who are admitted to a mental health facility;
"Personal representative" means a person charged
by law with the duty of representing a patient's interests in any specified
respect or of exercising specified rights on the patient's behalf, and includes
the parent or legal guardian of a minor unless otherwise provided by domestic
law;
"The review body" means the body established in
accordance with Principle 17 to review the involuntary admission or
retention of a patient in a mental health facility.
General limitation clause
The exercise of the rights set forth in these Principles may
be subject only to such limitations as are prescribed by law and are necessary
to protect the health or safety of the person concerned or of others, or otherwise
to protect public safety, order, health or morals or the fundamental rights and
freedoms of others.
Principle 1
Fundamental freedoms and basic rights
1. All persons have the right to the best available
mental health care, which shall be part of the health and social care system.
2. All persons with a mental illness, or who are being
treated as such persons, shall be treated with humanity and respect for the
inherent dignity of the human person.
3. All persons with a mental illness, or who are being
treated as such persons, have the right to protection from economic, sexual and
other forms of exploitation, physical or other abuse and degrading treatment.
4. There shall be no discrimination on the grounds of
mental illness. "Discrimination" means any distinction, exclusion or
preference that has the effect of nullifying or impairing equal enjoyment of
rights. Special measures solely to protect the rights, or secure the
advancement, of persons with mental illness shall not be deemed to be discriminatory.
Discrimination does not include any distinction, exclusion or preference
undertaken in accordance with the provisions of these Principles and necessary
to protect the human rights of a person with a mental illness or of other
individuals.
5. Every person with a mental illness shall have the
right to exercise all civil, political, economic, social and cultural rights as
recognized in the Universal Declaration of Human Rights, the International
Covenant on Economic, Social and Cultural Rights, the International Covenant on
Civil and Political Rights, and in other relevant instruments, such as the
Declaration on the Rights of Disabled Persons and the Body of Principles for
the Protection of All Persons under Any Form of Detention or Imprisonment.
6. Any decision that, by reason of his or her mental
illness, a person lacks legal capacity, and any decision that, in consequence
of such incapacity, a personal representative shall be appointed, shall be made
only after a fair hearing by an independent and impartial tribunal established
by domestic law. The person whose capacity is at issue shall be entitled to be
represented by a counsel. If the person whose capacity is at issue does not
himself or herself secure such representation, it shall be made available
without payment by that person to the extent that he or she does not have
sufficient means to pay for it. The counsel shall not in the same proceedings
represent a mental health facility or its personnel and shall not also
represent a member of the family of the person whose capacity is at issue
unless the tribunal is satisfied that there is no conflict of interest.
Decisions regarding capacity and the need for a personal representative shall
be reviewed at reasonable intervals prescribed by domestic law. The person
whose capacity is at issue, his or her personal representative, if any, and any
other interested person shall have the right to appeal to a higher court
against any such decision.
7. Where a court or other competent tribunal finds that
a person with mental illness is unable to manage his or her own affairs,
measures shall be taken, so far as is necessary and appropriate to that
person's condition, to ensure the protection of his or her interest.
Principle 2
Protection of minors
Special care should be given within the purposes of these
Principles and within the context of domestic law relating to the protection of
minors to protect the rights of minors, including, if necessary, the
appointment of a personal representative other than a family member.
Principle 3
Life in the community
Every person with a mental illness shall have the right to
live and work, as far as possible, in the community.
Principle 4
Determination of mental illness
1. A determination that a person has a mental illness
shall be made in accordance with internationally accepted medical standards.
2. A determination of mental illness shall never be
made on the basis of political, economic or social status, or membership of a
cultural, racial or religious group, or any other reason not directly relevant
to mental health status.
3. Family or professional conflict, or non-conformity
with moral, social, cultural or political values or religious beliefs prevailing
in a person's community, shall never be a determining factor in diagnosing
mental illness.
4. A background of past treatment or hospitalization as
a patient shall not of itself justify any present or future determination of
mental illness.
5. No person or authority shall classify a person as
having, or otherwise indicate that a person has, a mental illness except for
purposes directly relating to mental illness or the consequences of mental
illness.
Principle 5
Medical examination
No person shall be compelled to undergo medical examination
with a view to determining whether or not he or she has a mental illness except
in accordance with a procedure authorized by domestic law.
Principle 6
Confidentiality
The right of confidentiality of information concerning all
persons to whom these Principles apply shall be respected.
Principle 7
Role of commun
ure
1. Every patient shall have the right to be treated and
cared for, as far as possible, in the community in which he or she lives.
2. Where treatment takes place in a mental health
facility, a patient shall have the right, whenever possible, to be treated near
his or her or the of his or her relatives or friends and shall have the right
to return to the community as soon as possible.
3. Every patient shall have the right to treatment
suited to his or her cultural background.
Principle 8
Standards of care
1. Every patient shall have the right to receive such
health and social care as is appropriate to his or her health needs, and is
entitled to care and treatment in accordance with the same standards as other
ill persons.
2. Every patient shall be protected from harm,
including unjustified medication, abuse by other patients, staff or others or
other acts causing mental distress or physical discomfort.
Principle 9
Treatment
1. Every patient shall have the right to be treated in
the least restrictive environment and with the least restrictive or intrusive
treatment appropriate to the patient's health needs and the need to protect the
physical safety of others.
2. The treatment and care of every patient shall be
based on an individually prescribed plan, discussed with the patient, reviewed
regularly, revised as necessary and provided by qualified professional staff.
3. Mental health care shall always be provided in
accordance with applicable standards of ethics for mental health practitioners,
including internationally accepted standards such as the Principles of Medical
Ethics adopted by the United Nations General Assembly. Mental health knowledge
and skills shall never be abused.
4. The treatment of every patient shall be directed
towards preserving and enhancing personal autonomy.
Principle 10
Medication
1. Medication shall meet the best health needs of the
patient, shall be given to a patient only for therapeutic or diagnostic
purposes and shall never be administered as a punishment or for the convenience
of others. Subject to the provisions of paragraph 15 of Principle 11, mental
health practitioners shall only administer medication of known or demonstrated
efficacy.
2. All medication shall be prescribed by a mental
health practitioner authorized by law and shall be recorded in the patient's
records.
Principle 11
Consent to treatment
1. No treatment shall be given to a patient without his
or her informed consent, except as provided for in paragraphs 6, 7, 8, 13 and
15 below.
2. Informed consent is consent obtained freely, without
threats or improper inducements, after appropriate disclosure to the patient of
adequate and understandable information in a form and language understood by
the patient on:
( a ) The diagnostic assessment;
( b ) The purpose, method, likely duration and expected
benefit of the proposed treatment;
( c ) Alternative modes of treatment, including those
less intrusive; and
( d ) Possible pain or discomfort, risks and
side-effects of the proposed treatment.
3. A patient may request the presence of a person or
persons of the patient's choosing during the procedure for granting consent.
4. A patient has the right to refuse or stop treatment,
except as provided for in paragraphs 6, 7, 8, 13 and 15 below. The consequences
of refusing or stopping treatment must be explained to the patient.
5. A patient shall never be invited or induced to waive
the right to informed consent. If the patient should seek to do so, it shall be
explained to the patient that the treatment cannot be given without informed
consent.
6. Except as provided in paragraphs 7, 8, 12, 13, 14
and 15 below, a proposed plan of treatment may be given to a patient without a
patient's informed consent if the following conditions are satisfied:
( a ) The patient is, at the relevant time, held as an
involuntary patient;
( b ) An independent authority, having in its
possession all relevant information, including the information specified in
paragraph 2 above, is satisfied that, at the relevant time, the patient lacks
the capacity to give or withhold informed consent to the proposed plan of
treatment or, if domestic legislation so provides, that, having regard to the
patient's own safety or the safety of others, the patient unreasonably
withholds such consent; and
( c ) The independent authority is satisfied that the
proposed plan of treatment is in the best interest of the patient's health
needs.
7. Paragraph 6 above does not apply to a patient with a
personal representative empowered by law to consent to treatment for the
patient; but, except as provided in paragraphs 12, 13, 14 and 15 below,
treatment may be given to such a patient without his or her informed consent if
the personal representative, having been given the information described in
paragraph 2 above, consents on the patient's behalf.
8. Except as provided in paragraphs 12, 13, 14 and 15
below, treatment may also be given to any patient without the patient's
informed consent if a qualified mental health practitioner authorized by law
determines that it is urgently necessary in order to prevent immediate or
imminent harm to the patient or to other persons. Such treatment shall not be prolonged
beyond the period that is strictly necessary for this purpose.
9. Where any treatment is authorized without the
patient's informed consent, every effort shall nevertheless be made to inform
the patient about the nature of the treatment and any possible alternatives and
to involve the patient as far as practicable in the development of the
treatment plan.
10. All treatment shall be immediately recorded in the
patient's medical records, with an indication of whether involuntary or
voluntary.
11. Physical restraint or involuntary seclusion of a
patient shall not be employed except in accordance with the officially approved
procedures of the mental health facility and only when it is the only means
available to prevent immediate or imminent harm to the patient or others. It
shall not be prolonged beyond the period which is strictly necessary for this
purpose. All instances of physical restraint or involuntary seclusion, the
reasons for them and their nature and extent shall be recorded in the patient's
medical record. A patient who is restrained or secluded shall be kept under
humane conditions and be under the care and close and regular supervision of
qualified members of the staff. A personal representative, if any and if
relevant, shall be given prompt notice of any physical restraint or involuntary
seclusion of the patient.
12. Sterilization shall never be carried out as a
treatment for mental illness.
13. A major medical or surgical procedure may be
carried out on a person with mental illness only where it is permitted by
domestic law, where it is considered that it would best serve the health needs
of the patient and where the patient gives informed consent, except that, where
the patient is unable to give informed consent, the procedure shall be
authorized only after independent review.
14. Psychosurgery and other intrusive and irreversible
treatments for mental illness shall never be carried out on a patient who is an
involuntary patient in a mental health facility and, to the extent that domestic
law permits them to be carried out, they may be carried out on any other
patient only where the patient has given informed consent and an independent
external body has satisfied itself that there is genuine informed consent and
that the treatment best serves the health needs of the patient.
15. Clinical trials and experimental treatment shall
never be carried out on any patient without informed consent, except that a
patient who is unable to give informed consent may be admitted to a clinical
trial or given experimental treatment, but only with the approval of a
competent, independent review body specifically constituted for this purpose.
16. In the cases specified in paragraphs 6, 7, 8, 13,
14 and 15 above, the patient or his or her personal representative, or any
interested person, shall have the right to appeal to a judicial or other
independent authority concerning any treatment given to him or her.
Principle 12
Notice of rights
1. A patient in a mental health facility shall be
informed as soon as possible after admission, in a form and a language which
the patient understands, of all his or her rights in accordance with these
Principles and under domestic law, which information shall include an
explanation of those rights and how to exercise them.
2. If and for so long as a patient is unable to
understand such information, the rights of the patient shall be communicated to
the personal representative, if any and if appropriate, and to the person or
persons best able to represent the patient's interests and willing to do so.
3. A patient who has the necessary capacity has the
right to nominate a person who should be informed on his or her behalf, as well
as a person to represent his or her interests to the authorities of the
facility.
Principle 13
Rights and conditions in mental health facilities
1. Every patient in a mental health facility shall, in
particular, have the right to full respect for his or her:
( a ) Recognition everywhere as a person before the
law;
( b ) Privacy;
( c ) Freedom of communication, which includes freedom
to communicate with other persons in the facility; freedom to send and receive
uncensored private communications; freedom to receive, in private, visits from
a counsel or personal representative and, at all reasonable times, from other
visitors; and freedom of access to postal and telephone services and to
newspapers, radio and television;
( d ) Freedom of religion or belief.
2. The environment and living conditions in mental
health facilities shall be as close as possible to those of the normal life of
persons of similar age and in particular shall include:
( a ) Facilities for recreational and leisure
activities;
( b ) Facilities for education;
( c ) Facilities to purchase or receive items for daily
living, recreation and communication;
( d ) Facilities, and encouragement to use such
facilities, for a patient's engagement in active occupation suited to his or
her social and cultural background, and for appropriate vocational
rehabilitation measures to promote reintegration in the community. These
measures should include vocational guidance, vocational training and placement
services to enable patients to secure or retain employment in the community.
3. In no circumstances shall a patient be subject to
forced labour. Within the limits compatible with the needs of the patient and
with the requirements of institutional administration, a patient shall be able
to choose the type of work he or she wishes to perform.
4. The labour of a patient in a mental health facility
shall not be exploited. Every such patient shall have the right to receive the
same remuneration for any work which he or she does as would, according to
domestic law or custom, be paid for such work to a non-patient. Every such
patient shall, in any event, have the right to receive a fair share of any
remuneration which is paid to the mental health facility for his or her work.
Principle 14
Resources for mental health facilities
1. A mental health facility shall have access to the
same level of resources as any other health establishment, and in particular:
( a ) Qualified medical and other appropriate
professional staff in sufficient numbers and with adequate space to provide
each patient with privacy and a programme of appropriate and active therapy;
( b ) Diagnostic and therapeutic equipment for the
patient;
( c ) Appropriate professional care; and
( d ) Adequate, regular and comprehensive treatment,
including supplies of medication.
2. Every mental health facility shall be inspected by
the competent authorities with sufficient frequency to ensure that the
conditions, treatment and care of patients comply with these Principles.
Principle 15
Admission principles
1. Where a person needs treatment in a mental health
facility, every effort shall be made to avoid involuntary admission.
2. Access to a mental health facility shall be
administered in the same way as access to any other facility for any other
illness.
3. Every patient not admitted involuntarily shall have
the right to leave the mental health facility at any time unless the criteria
for his or her retention as an involuntary patient, as set forth in Principle
16, apply, and he or she shall be informed of that right.
Principle 16
Involuntary admission
1. A person may ( a ) be admitted involuntarily to a
mental health facility as a patient; or ( b ) having already been admitted
voluntarily as a patient, be retained as an involuntary patient in the mental
health facility if, and only if, a qualified mental health practitioner
authorized by law for that purpose determines, in accordance with Principle 4,
that that person has a mental illness and considers:
( a ) That, because of that mental illness, there is a
serious likelihood of immediate or imminent harm to that person or to other
persons; or
( b ) That, in the case of a person whose mental
illness is severe and whose judgement is impaired, failure to admit or retain
that person is likely to lead to a serious deterioration in his or her
condition or will prevent the giving of appropriate treatment that can only be
given by admission to a mental health facility in accordance with the principle
of the least restrictive alternative.
In the case referred to in subparagraph ( b ), a second such
mental health practitioner, independent of the first, should be consulted where
possible. If such consultation takes place, the involuntary admission or
retention may not take place unless the second mental health practitioner
concurs.
2. Involuntary admission or retention shall initially
be for a short period as specified by domestic law for observation and
preliminary treatment pending review of the admission or retention by the
review body. The grounds of the admission shall be communicated to the patient
without delay and the fact of the admission and the grounds for it shall also
be communicated promptly and in detail to the review body, to the patient's
personal representative, if any, and, unless the patient objects, to the
patient's family.
3. A mental health facility may receive involuntarily
admitted patients only if the facility has been designated to do so by a
competent authority prescribed by domestic law.
Principle 17
Review body
1. The review body shall be a judicial or other
independent and impartial body established by domestic law and functioning in
accordance with procedures laid down by domestic law. It shall, in formulating
its decisions, have the assistance of one or more qualified and independent
mental health practitioners and take their advice into account.
2. The review body's initial review, as required by
paragraph 2 of Principle 16, of a decision to admit or retain a person as
an involuntary patient shall take place as soon as possible after that decision
and shall be conducted in accordance with simple and expeditious procedures as
specified by domestic law.
3. The review body shall periodically review the cases
of involuntary patients at reasonable intervals as specified by domestic law.
4. An involuntary patient may apply to the review body
for release or voluntary status, at reasonable intervals as specified by
domestic law.
5. At each review, the review body shall consider
whether the criteria for involuntary admission set out in paragraph 1 of
Principle 16 are still satisfied, and, if not, the patient shall be discharged
as an involuntary patient.
6. If at any time the mental health practitioner
responsible for the case is satisfied that the conditions for the retention of
a person as an involuntary patient are no longer satisfied, he or she shall
order the discharge of that person as such a patient.
7. A patient or his personal representative or any
interested person shall have the right to appeal to a higher court against a
decision that the patient be admitted to, or be retained in, a mental health
facility.
Principle 18
Procedural safeguards
1. The patient shall be entitled to choose and appoint
a counsel to represent the patient as such, including representation in any
complaint procedure or appeal. If the patient does not secure such services, a
counsel shall be made available without payment by the patient to the extent
that the patient lacks sufficient means to pay.
2. The patient shall also be entitled to the
assistance, if necessary, of the services of an interpreter. Where such
services are necessary and the patient does not secure them, they shall be made
available without payment by the patient to the extent that the patient lacks
sufficient means to pay.
3. The patient and the patient's counsel may request
and produce at any hearing an independent mental health report and any other reports
and oral, written and other evidence that are relevant and admissible.
4. Copies of the patient's records and any reports and
documents to be submitted shall be given to the patient and to the patient's
counsel, except in special cases where it is determined that a specific
disclosure to the patient would cause serious harm to the patient's health or
put at risk the safety of others. As domestic law may provide, any document not
given to the patient should, when this can be done in confidence, be given to
the patient's personal representative and counsel. When any part of a document
is withheld from a patient, the patient or the patient's counsel, if any, shall
receive notice of the withholding and the reasons for it and shall be subject
to judicial review.
5. The patient and the patient's personal
representative and counsel shall be entitled to attend, participate and be
heard personally in any hearing.
6. If the patient or the patient's personal
representative or counsel requests that a particular person be present at a
hearing, that person shall be admitted unless it is determined that the
person's presence could cause serious harm to the patient's health or put at
risk the safety of others.
7. Any decision whether the hearing or any part of it shall
be in public or in private and may be publicly reported shall give full
consideration to the patient's own wishes, to the need to respect the privacy
of the patient and of other persons and to the need to prevent serious harm to
the patient's health or to avoid putting at risk the safety of others.
8. The decision arising out of the hearing and the
reasons for it shall be expressed in writing. Copies shall be given to the
patient and his or her personal representative and counsel. In deciding whether
the decision shall be published in whole or in part, full consideration shall
be given to the patient's own wishes, to the need to respect his or her privacy
and that of other persons, to the public interest in the open administration of
justice and to the need to prevent serious harm to the patient's health or to
avoid putting at risk the safety of others.
Principle 19
Access to information
1. A patient (which term in this Principle includes a
former patient) shall be entitled to have access to the information concerning
the patient in his or her health and personal records maintained by a mental
health facility. This right may be subject to restrictions in order to prevent
serious harm to the patient's health and avoid putting at risk the safety of others.
As domestic law may provide, any such information not given to the patient
should, when this can be done in confidence, be given to the patient's personal
representative and counsel. When any of the information is withheld from a
patient, the patient or the patient's counsel, if any, shall receive notice of
the withholding and the reasons for it and it shall be subject to judicial
review.
2. Any written comments by the patient or the patient's
personal representative or counsel shall, on request, be inserted in the
patient's file.
Principle 20
Criminal offenders
1. This Principle applies to persons serving sentences
of imprisonment for criminal offences, or who are otherwise detained in the
course of criminal proceedings or investigations against them, and who are
determined to have a mental illness or who it is believed may have such an
illness.
2. All such persons should receive the best available
mental health care as provided in Principle 1. These Principles shall apply to
them to the fullest extent possible, with only such limited modifications and
exceptions as are necessary in the circumstances. No such modifications and
exceptions shall prejudice the persons' rights under the instruments noted in
paragraph 5 of Principle 1.
3. Domestic law may authorize a court or other
competent authority, acting on the basis of competent and independent medical
advice, to order that such persons be admitted to a mental health facility.
4. Treatment of persons determined to have a mental
illness shall in all circumstances be consistent with Principle 11.
Principle 21
Complaints
Every patient and former patient shall have the right to
make a complaint through procedures as specified by domestic law.
Principle 22
Monitoring and remedies
States shall ensure that appropriate mechanisms are in force
to promote compliance with these Principles, for the inspection of mental
health facilities, for the submission, investigation and resolution of
complaints and for the institution of appropriate disciplinary or judicial
proceedings for professional misconduct or violation of the rights of a
patient.
Principle 23
Implementation
1. States should implement these Principles through
appropriate legislative, judicial, administrative, educational and other
measures, which they shall review periodically.
2. States shall make these Principles widely known by
appropriate and active means.
Principle 24
Scope of principles relating to mental health facilities
These Principles apply to all persons who are admitted to a
mental health facility.
Principle 25
Saving of existing rights
There shall be no restriction upon or derogation from any
existing rights of patients, including rights recognized in applicable
international or domestic law, on the pretext that these Principles do not
recognize such rights or that they recognize them to a lesser extent.
