Dignity- a fundamental principle of mental health care

The term ‘Dignity’ can be traced to more than 2,500 years back. ‘Dignitas hominis’ in classical Roman thought usually meant ‘status of honor and respect’ which was provided to someone only who was worthy of that honor and respect because of a particular status that he or she had (e.g. because of a specific public position)1. Afterwards, the concept has been influenced by religions, philosophies across hundreds of years until, it was introduced into legal frameworks in twentieth century through the Universal Declaration of Human Rights (UDHR) in its first article which enshrined the notion of universality of human dignity in international law, by stating that, “All human beings are born free and equal in dignity and rights”. Article 25 of UDHR has stated that, “Everyone has the right to a standard of living adequate for the health and well-being.., including…. medical care and necessary social services”2. The UDHR has contributed in establishing a moral grounding for improved standards of care on the basis of our basic responsibilities towards each other as equal members of “humanity”3. The concept of ‘universality of dignity’ has also been reflected in several other international treaties and conventions including, most recently, the Convention on Rights of People with Disabilities4.

The UK's Royal College of Nursing provides a useful definition of dignity in relation to nursing care, which can be applied to the health care field more generally as “Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals”. The definition identifies two dimensions of dignity:first is the self-worth as perceived by the individual and the second is the worth of the individual which is reflected in the respectful attitudes and practices of others5.

All around the world, many people with mental disorders are deprived of their right to be treated as valued individuals. In fact, they are not only marginalized in their communities but they are also subject to wide ranging forms of human rights violations in treatment facilities.

Dignity, social justice and WHO Mental Health Action Plan 2013-2020

The concept of dignity is interlinked with social justice. And social justice is generally equated with the notion of equal opportunities and privileges in society including for the most marginalized. Dignity of each individual member of society is reached only when all its individuals including the most marginalized, are treated as equals.

In May 2013, for the first time, 194 WHO Member States endorsed the Mental Health Action Plan 2013-2020 (MHAP) at the 66^th World Health Assembly6. The MHAP highlights the importance of promoting social justice, equality and dignity for people affected by mental disorders on an equal basis with others so as to end their marginalization and disenfranchisement in society. The MHAP mentioned explicitly in its vision the importance of equal distribution of opportunities and privileges for people affected by mental disabilities, “The vision of the action plan is a world in which persons affected by these disorders are able to exercise the full range of human rights and to access high quality, culturally-appropriate health and social care in a timely way to promote recovery, in order to attain the highest possible level of health and participate fully in society and at work, free from stigmatization and discrimination”6.

Many of the proposed actions for Member States, WHO Secretariat and other partners which are outlined in the action plan are relevant to dignity and social justice. These include the following actions: (i) Include people with mental disorders as a vulnerable and marginalized group requiring prioritized attention and engagement within development and poverty-reduction strategies, for example, in education, employment and livelihood programmes, and the human rights agenda. (ii) Introduce actions to combat stigmatization, discrimination and other human rights violations towards people with mental disorders.

The MHAP also highlights the importance of respect for the inherent human dignity when developing policies and plans and services in the area of mental health6.

Dignity and mental health governance

Creating policies, plans, and laws for mental health is the bedrock for good governance and service development. One of the indicators for policies, plans and laws is their alignment with international human rights instruments.

According to WHO Mental Health Atlas 20147, two-thirds of countries have reported having a stand-alone mental health policy or plan and half have a stand-alone mental health law. However, most of the policies and laws, as self-reported by Member States of WHO, are not fully in line with international human rights instruments, implementation is often weak, and persons with mental disorders and family members are frequently only marginally involved in their development. Additionally, only two-thirds of responding countries consider that their national policy/plan promotes a full range of services and supports to enable people to live independently and be included in the community or a recovery approach. Between 60-75 per cent only of countries consider their laws to promote the rights of persons with mental disorders to exercise their legal capacity; promote alternatives to coercive practice; provide for procedures to enable people with mental disorders to protect their rights7.

Dignity and liberty

Processes of involuntary placement, involuntary treatment and long durations of inpatient stay for people with mental disorders impact on some of their most fundamental rights, including the right to liberty and the right to exercise legal capacity. For this reason, human rights standards have set out strict safeguards to prevent interference in these rights.

Globally, based on Mental Health Atlas 2014 data, more than one in ten (11.6%) of admissions were on an involuntary basis. The range of involuntary admission percentage varies widely, for example, more than 30 per cent of countries which responded to this question in mental health atlas questionnaire (n=74) have reported involuntary admissions at mental health facilities ranging from 50 to 100 per cent. Worldwide, The great majority of inpatients to mental hospitals are discharged within one year (global median, 80%). However, in certain Regions including the South East Asia Region more than 20 per cent of inpatients stay longer than five years7.

Institutionalization of people in mental hospitals negatively impacts on people's sense of self-worth and usually leads to negative perception of the society for the long term residents of these institutions8.

Dignity, recovery and community integration

Physical and mental health services that are available, acceptable, accessible and of good quality is a fundamental human right9. The lack of, or poor quality of services can lead to socio-economic marginalization, poor health outcomes and negative effects on equality of opportunity and dignity. As mentioned, The Mental Health Action Plan6 highlights the importance of considering social justice and dignity in all actions towards people affected with mental disorders. Although equality is an integral part of social justice, yet the meaning of social justice is broader. John Rawls postulates a theory of social justice referred to as “justice as fairness”. According to Rawls, social justice is about assuring the protection of equal access to liberties, rights, and opportunities, as well as taking care of the least advantaged members of society10.

Worldwide, huge inequalities in access to mental health services, and social benefits for people affected by mental illness exist. On average globally, there is less than one mental health worker per 10,000 people. In low income countries rates fall below one per 100,000 people, whereas in high-income countries the rate is one per 2000 people. The care available in mental health facilities around the world is not only of limited quantity but in many situations is of poor quality and in many instances actually hinders recovery7. It can still be common in some countries for people to be locked away in small, prison-like cells or to be chained to their beds, unable to move. In 2012, WHO launched Quality Rights project which has for one of its aims to support countries to put in place good quality services that respects their dignity, autonomy and recovery11.

The rate of persons with severe mental disorder who receive income support or other forms of non-monetary support (e.g. access to employment, educational assistance) is influenced by countries’ income level, with a far higher rate of support seen in high-income countries (520 persons per 100,000 population) compared to lower-income countries (12-14 in low and lower-middle income countries)7. The failure to provide a full range of services and support to people with mental health conditions leads to increased isolation and exclusion from society. It results in people being discriminated against and denied opportunities in employment and education, despite the fact that these are central to people's sense of self-worth and mental health and well-being. Lasalvia et al12, in a cross-sectional survey of 1082 persons with depression across 35 countries concluded that higher levels of experienced discrimination were associated with several lifetime depressive episodes, at least one lifetime psychiatric hospital admission and poor levels of social functioning. Discrimination related to depression acts as a barrier to social participation and successful vocational integration. Of the 1082 people with depression, 79 per cent reported experiencing discrimination in at least one life domain; 405 (37%) participants had stopped themselves from initiating a close personal relationship, 271 (25%) from applying for work, and 218 (20%) from applying for education or training12.

Dignity as a human right

As of July 2015, the Convention on the Rights of Persons (CRPD) with Disabilities, has 159 States signatories13. The CRPD, the first human rights treaty of the third millennium, is an international human rights treaty of the United Nations. According to its very first article, the stated purpose of the CRPD is to protect the rights and dignity of persons with disabilities (Article 1, CRPD). The CRPD is a unique treaty among other international human rights instruments in that it has an objective that clearly focuses on ‘dignity’ of a vulnerable population group of the humanity4. The Convention promotes a shifting of views of persons with disabilities from objects of medical treatment, towards viewing them as full members of society, with equal dignity and equal rights.

Dignity of people with disabilities including those with mental disabilities, is highlighted in CRPD across several articles. Article 3 underscores the fact that dignity is one of the key principles underpinning the entire Convention. Article 19 underscores the right of people with disabilities to live in the community, with choices equal to others, and to their full inclusion and participation in the community. Aiming to ensure the development of generations of people with disabilities who have a full sense of self-worth and dignity, in Article 24, CRPD stipulates that education of children with disabilities has to ensure the full development of human potential and sense of dignity and self-worth. Additionally, Article 27 highlights right to work, on an equal basis with others and to gain a living by work freely chosen4. Health care of people with disabilities including those with mental disabilities is highlighted in Article 25 which requires “health professionals to provide care of the same quality to persons with disabilities as to others, …, raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities through training and the promulgation of ethical standards”3.

Conclusion

Many people with mental disorders are deprived of their right to be treated with dignity as valued members of society. They are not only discriminated against, and marginalized in their communities but also in the mental health service context where they should be receiving care and support. Governments, national and international partners of health care provision must ensure that all laws, policies, and practices in mental health care promote dignity and respect for people with mental health conditions on an equal basis with others.