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Overarching Conceptual Issues 

Overarching Conceptual Issues
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This first section introduces wide-ranging issues that are raised by the consideration of the relationship of mental health and human rights. Winton Higgins traces the historical emergence of the idea, culture, and institutional framework of human rights; the gradual spreading of the human rights net under the 'universal' rubric from white males to many other human categories (black people, women, sexual minorities, etc), and eventually to people with mental disorders; and the process whereby abusers lost impunity and rights therefore became meaningful by becoming enforceable. Charles Watters complements this by exploring linkages over time between mental health and illness and ideas of human rights. He highlights the conditions of those both within and outside mental health systems. He notes how the parameters of mental health have expanded, particularly in terms of familial relations and societal contribution, beyond what would formerly have been expected for people with mental disorders. He distinguishes ‘bare’ survival or ‘negative liberty’ as freedom from constraint, and the positive liberty of citizens, in which the state facilitates people realizing their goals. Watters illustrates how disorders are historically conditioned, as seen in the history of post-traumatic stress disorder, how entitlement is not true access (highlighted by the case of asylum-seekers), and the limits of social contracts as applied to those with mental illnesses.

Michael Perlin and Eva Szeli consider the relationship between human rights and the law, and specifically, the relatively recent meeting of mental health law and human rights law. They note the neglect of human rights of people with disabilities for decades by international human rights protection agencies. Although recent political, legal, social, and cultural developments have helped shift the environment so as to support a movement that ‘extends’ rights to this population, these rights are often ignored or granted only on paper. They argue the cause is sanism: an irrational prejudice akin to other prejudices of racism, sexism, homophobia, and ethnic bigotry, that infects jurisprudence and lawyering practices, that is largely invisible and socially acceptable, based predominantly upon stereotype, myth, superstition, and deindividualization, is sustained and perpetuated by ‘ordinary common sense’ (OCS) and heuristic reasoning in an unconscious response to events in everyday life and in the legal process. They issue the challenge to give life to international human rights for this population.

The connection between culture, context, mental health and human rights is addressed in Laurence Kirmayer’s chapter. He addresses three broad questions concerning the cross-cultural applicability of human rights in the domain of psychiatry: (1) Do the theory and practice of psychiatry and other mental health disciplines apply across disparate cultures? (2) Are human rights principles universally applicable? and (3) Are human rights principles applicable to mental health issues across cultures? Kirmayer notes that ‘culture’ names a process, not a thing, that cultural knowledge and institutions as part of open, fluid, dynamic systems are contested, and that a multiplicity of types of cultures are available in the contemporary world. He notes the twin dangers of endorsing cultural stereotypes and dismissing ‘culture’ altogether, rather than acknowledging its place in all our lives. Cultural context (whether local, or imported, Western and medical) potentially shapes all aspects of mental disorders and the meaning of and response to symptoms and illnesses. Psychiatry may have a liberating or debilitating role depending on how it is culturally experienced or received, and when used for involuntary treatment, may be empowering or oppressive. Kirmayer examines the meanings of relativism and universality in human rights discourse, and the contrast between Western autonomy and non-Western interdependence. Despite their anchorage in different cultural forms of life, Kirmayer advances arguments for the universality of human rights across and embedded within cultures. He discusses cultural notions of human, humanness, the humane, and dehumanization understood through cultures; comments on the right to culture and community; the potential for engaged dialogue between diverse cultures in a global society; the cultural responsiveness of mental health services; and the globalization of psychiatry as a human rights opportunity and challenge.

Jennifer Randall, Graham Thornicroft, Elaine Brohan, Aliya Kassam, Elanor Lewis-Holmes, and Nisha Mehta consider forms of social exclusion and systematic disadvantage affecting people with mental disorders in all domains of life. They examine stigma as comprising ignorance, prejudice, and discrimination; relevant international human rights conventions; three Articles of a recent human rights convention to illustrate stigma as a critical human rights issue; and give examples of the work of relevant international non-governmental organizations active in this field. They examine the right to health (Article 25 of Convention on the Rights of Persons with Disabilities (CRPD)), the Right to Work and Employment (Article 27 of CRPD), the work of NGOs in the area, the significance of stigma, and particularly how it can be effectively reduced.

Sandy McFarlane and Richard Bryant discuss the relationship of advances in genetics and neurobiology and human rights with particular reference to the case example of traumatic stress. They appraise positive and negative possibilities associated with providing biological information—the latter associated for example with employment and insurance. They place this in the context of the later 19th century preoccupation of the role of heredity in mental illness, and the prejudices, abuses, and atrocities that flowed from this. They review the implications of the impact of traumatic stress on genes and chromosomes, with implications for mental health, and the ethical dilemmas associated with genetic testing for participants (including denial of life opportunities) and families. They examine a range of risk factors for post-traumatic stress disorder (PTSD) which could constitute potential markers, problems with their reliability and predictive capacity, and the ethical problems arising. They also consider genetic screening, the rights of the unborn child, parental rights, and the potential psychosocial consequences and injustices for those children at high genetic risk, who may never express the genetic disorder. Such scenarios have profound, even alarming implications, and need to proceed with due regard to people’s rights.

Tristan McGeorge and Dinesh Bhugra tackle the topic of race, class, mental health, and human rights. They ponder differential rates of mental disorders (especially depression and psychosis) among racial and ethnic minorities in the UK, and note negative and adversarial pathways to care for black and minority ethnic patients. They document self-reported racism as a confirmed contributor to common mental disorders and psychosis, and institutional racism in mental health services. They note strategies for improving race equality in mental health, including the role of education in medical schools and psychiatrist training, government organizations, and advocacy groups, and note the role of human rights frameworks in the reform process, including international, regional, and national measures.

Roshni Mangalore, Martin Knapp, and David McDaid contemplate mental health economics, mental health policies, and human rights. How do states and the international community achieve positive mental health outcomes, given their human rights duties and the limits of available resources? Noting that mental health problems and mental health policies and programmes (or lack thereof) can violate human rights and diminish capabilities, they propose introducing fundamental freedoms and human rights into the analysis of economic processes. They adopt the notion of core capabilities, the empirical application of which they discuss in examining individual entitlements, modelling achievement for different groups regarding prevention and interventions, and freedom of choice and opportunity freedom. They introduce the notion of needs, as the basic entity linking human rights, capabilities, resource allocation, and equity in mental health. Further analysing need, especially of the least favoured or worst off, they ask whether applying utilitarian principles of cost-effectiveness in allocating mental health care resources results in denial of human rights (e.g. rationing access to interventions). Resource efficiency, where only economic needs that produce net benefits are met, or where health is regarded as a market commodity, is contrasted with equity approaches. These may sacrifice efficiency gains to focus resources on those socially marginalized and/or suffering severe mental illness, and may include normative need for services, providing good health and equal opportunity for quality living. The authors also consider resource insufficiency (e.g. budgetary allocations, pharmaceuticals), barriers to resource sufficiency (resource inappropriateness, attitudes, financing mechanisms), recognizing value judgments (e.g. re cost-effectiveness) and the importance of economic evaluation in rationing.

Catherine Esposito and Daniel Tarantola trace the important history of how the confrontation with HIV was critical to making the link between health and human rights. They expound on the reciprocal relationships between HIV, health, and human rights, and make suggestions about how this relationship could be improved, through overcoming structural, systemic, and financial obstacles that pre-empt comprehensive, effective responses to co-morbidity. They cite unnecessary hospitalizations of people with serious mental disorders, and in various parts of Asia, compulsory treatment of drug addicts at high risk of HIV in mandatory drug treatment facilities without access to due process. The power to reduce vulnerability is rooted in governments’ ability to deliver on their human rights obligations. They argue for supportive policy, legal, and research environments that acknowledge rather than ignore the relationships between HIV, mental health, and human rights, that increase awareness of the advantages of bridging these domains, and adopt strategies in mental health, HIV, primary care, and social services to do so, including making these services economically affordable, high-quality, and non-discriminatory. Mental health literacy campaigns may assist participation for those living with HIV. Accountability processes and reports (e.g. declarations, international treaty monitoring, Millenium Development Goals, national monitoring) need to attend to the issue and impact of HIV/mental health co-morbidity.

Amita Dhanda discusses universal legal capacity as a universal human right. She accepts the enriching value of universalism for human rights discourse, provided (with some postmodern and feminist critiques) it is inclusive and does not privilege the preferences of dominant groups, nor allow hierarchies within groups such as people with disabilities. She contends the CRPD in Article 12 recognises universal legal capacity for people with disabilities, whilst acknowledging differences between them in exercising this, through strategies such as reasonable accommodation and support through co-facilitation or joint decision-making. Universal legal capacity promotes social interaction between all members of society, disabled and non disabled. This inclusive mode of social relationship creates opportunity for developing the capabilities of empathy and social solidarity, and supports self-determination. It challenges the privileging of cognitive faculties, recognizes multiple intelligences potentially affecting decision-making, and confronts the discriminatory denial of legal capacity to those suffering mental disorders compared with physical disorders. It extends general defences for criminal responsibility already available to non-disabled persons, as well as individuated procedures in these cases. The author details the battle, often with states parties, for universal capacity with support against the paradigm of selective capacity with provision for substitution. These arguments are of central significance to mental health law.

In their commentary, Ezra Susser and Michaeline Bresnahan observe the history of public health and its connections to social justice, as illustrated through its outstanding practitioners. Thus Philippe Pinel and colleagues proposed that people with mental illnesses should be treated with respect and dignity, William Farr reported appalling mortality rates in English asylums; Edward Jarvis exposed misleading US Census statistics about freed black people’s rates of mental illness; Joseph Goldberger discovered the nutritional origins of pellagra through working in asylums; Edgar Sydenstricker envisioned public health as social justice. Recently, reducing cigarette smoking was a capstone achievement, but the link with mental health (through addictive behaviour, and common mental disorders) has been almost completely missed. The low priority given to mental health by public health, tobacco companies’ denials, and public mental health leaders not realizing their central role, have all contributed. Though non-communicable diseases have the largest global mortality, the authors emphasize that, as longevity increases, life quality as well as duration increasingly matters. Mental disorders are leading causes of disability and their neglect constrains the advance of health (including mortality) and wealth globally. The public health community needs to stop neglecting mental health and make it central to its agenda.

We are very fortunate to have Eugene Brody’s commentary which offers a personal perspective on technology and human rights. Gene Brody died during the preparation of this book. As someone who worked tirelessly and fruitfully in this field for decades, he reflects on his understanding of human rights in relation to mental health, the challenge of moving to practical application, and the impacts of bio- and communications technologies and globalization. In particular he crystallizes this through his early experience as an eyewitness of Nazi prisoners of the International Military Tribunal, and his personal encounter with and response to one in particular, a military gauleiter. The episode goes to the heart of some of the dilemmas raised by this book.