published in: "Forum – The Declaration of Madrid and current psychiatric practice: users' and advocates' views", in: Current Opinion in Psychiatry, Vol. 12 (1999), No. 1, pp. 6-7; and in: Voiceless Movement (Ed.): Deprived of Our Humanity – The Case against Neuroleptic Drugs, Geneva: Association Ecrivains, Počtes & Cie. 1998, pp. 159-162
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Peter Lehmann

Commentary to: WHO Quality Assurance in Mental Health Care: "Draft. Human rights of people with mental disorders" (1997)

We list here some remarks and points that should be added, in our opinion, to the Declaration of Madrid.

Psychiatrists have to reflect that their measures can only suppress ›symptoms‹ with medical methods because treated persons regularly suffer from emotional problems of social nature and not from bodily diseases. To call all subjects ›infirm‹ is libellous.

To base ethical behaviour on the psychiatrist's individual sense of responsibility allows him or her to act arbitrarily. Ethical psychiatric behaviour should be based primarily on the treated person's individual ethic, on the Universal Declaration of Human Rights and other United Nations documents, especially the right of freedom from bodily harm, and on the civil and criminal law.

At any given facility, there should be sufficient space for the number of inmates or patients admitted. There should be phone boxes for inmates or patients in every psychiatric ward. There should be easily visible coin- operated telephones at the entrance hall of each psychiatric institution. In each psychiatric ward there should be an easily visible notice stating that inmates or patients can get writing paper, envelopes and stamps if wanted. There should be notice boards in every ward on which local, regional and national organisations of (ex-) users and survivors of psychiatry can put uncensored information. For each inmate or patient there should be the offer to have a daily walk in the open air for at least 1 h. On each ward there should be a kitchen where inmates or patients can prepare food and drinks around the clock. The nonsmokers' right to have good air to breathe should be guaranteed. The smokers' right to smoke as long as they want should also be guaranteed. Meals served to inmates or patients should meet recommended minimum nutritional requirements. The needs of people who want special diets should be met.

Psychiatrists should provide not only relevant information to empower individuals to make a rational decision; they should give all information about the risks of treatment which are possible and not to be excluded.

It should be acknowledged by psychiatric associations and/or by reforms of the law that advance directives (made during non-doubted states of normality) about wanted and unwanted treatments have to be respected.

Psychiatrists who treat without informed consent should lose their medical approbation. The national psychiatric associations should have a section particularly dedicated to human rights. No decision should be made without the consent of national organisations of (ex-) users and survivors of psychiatry.

(Ex-) users and survivors of psychiatry should be involved in the education (including the boards of examiners) of psychiatrists meaningfully and on a well paid level. Organisations of (ex-) users and survivors of psychiatry should be acknowledged as organisations of individuals with a high level of expertise. There should be ombudsmen and ombudswomen who are (ex-) users and survivors of psychiatry at national levels.

There should be bodies including (ex-) users and survivors of psychiatry specifically charged, at national levels, with monitoring the respect of human rights of people with mental disorders or who are said to have mental disorders. The task of these bodies should include the registration of new treatment measures and decisions of ethics' commissions in research fields. Help and support should be made available by staff to family members, friends and persons of trust.

Treatment, if ethical, should be primarily based on nonpharmacological measures such as psychotherapy. Psychosurgery and other intrusive treatments which may possibly cause irreversible damage, such as psychiatric drugs, electro- and insulin shock treatments, should never be carried out on an involuntary inmate or patient without informed consent. Sterilisation, abortion or any treatment that can be harmful for the inmate's or patient's (future) children should never be carried out on people with mental disorders or who are said to have mental disorders.

Clinical trials and experimental treatments should never be carried out on an involuntary inmate or patient without informed consent. The institutions and persons carrying out these trials should be obliged to prove that resultant damage is not a result of these measures.

Information obtained in the treatment relationship should principally be kept in confidence. Written records should be appropriately maintained for all inmates and patients, who should be entitled to access their own records at any time and without justification. Copies of records should be available. Inmates and patients should have the right to revise records or to add commentaries.

Peter Lehmann, Chair, European Network of (ex-) Users and Survivors of Psychiatry