Current legislation on admission of mentally ill patients in China
Introduction
The psychiatric service system of China is institutionally complex. It is uncertain how many administrative systems (Xi Tong) have their own psychiatric facilities, but the great mass of mental health services are provided by four departments. The largest mental health service system is governed by the Ministry of Health and its local bureaus. Nationally, these public psychiatric hospitals are accessible to urban and rural citizens who have health insurance, which covers their medical costs. The second largest system is managed by local departments of the Ministry of Civil Affairs. There facilities mainly serve those who are jobless or homeless and those whose families are otherwise too poor to pay for their care. The third largest system belongs to the military. Hospitals within the military's system operate primarily for military personnel and their families. In recent years a number of these hospitals have begun providing care on a fee-for-service basis to local citizens. Finally, there is a system managed by the provincial or municipal departments of public security, called “Ankang Hospitals.” These hospitals provide care for mentally ill criminal offenders. The level and modality of care throughout these institutions have varied greatly, and overall it is safe to say that the professional standards and level of services have not been high.
To improve mental health services within these different systems and to protect the rights of mentally ill persons, China began passing a series of mental health reform laws in 1985 (Liu, 1998). These laws have seen limited success, and there remains much room for improvement. When in 2005, 78% of countries, and 69% of the population, were covered by mental health laws, China has still no existing mental health legislation at the national level (WHO, 2005a). Three factors help account for why such improvement remains elusive. First, there still lingers a longstanding stigma against mental illness, with the popular assumption being that mentally ill persons pose a threat to the social order (Park, Xiao, & Worth, 2005). As a result, there is a long history of legislation leaning more toward the ensuring of public safety than the guaranteeing of patients' rights. This asymmetry has been exacerbated by the fact that mental health policy has traditionally not been viewed as a high priority issue. Second, mental health services have historically been unequally provisioned throughout the country, with rural areas and poorer urban areas offering fewer opportunities for care (Hu et al., 2006, Yip, 2006). Since it is the local governments who must pay to implement services once those services are mandated at the national level, such mandates can comprise a huge burden for China's less-developed municipalities and regions. The western provinces in particular experience significant financial difficulty in meeting requirements to improve care. Third, the national government is often hesitant to take on problems that are controversial or institute programs that are perceived as being experimental. In such instances, the national government will often pass responsibility for managing the problem or testing the program down to the local level, and will then adopt a wait-and-see attitude before instituting national level legislation. This mode of mixing national level goals with local level projects is common in China, and it has characterized mental health policy for years.
One example of such mixing is Shanghai's 2002 law entitled “Shanghai Municipality Regulations on Mental Health.” During the process of drafting the law, opinions from legal experts, mental health providers, representatives from patient advocacy organizations, and patients themselves were solicited, with the result being a law that was collectively drafted and supported by a number of stakeholders. Since then, several other cities — Ningbo (2006), Beijing (2007), Hangzhou (2007), and Wuxi (2007) — have used a similar methodology to draft their own local mental health laws. These cities are in a position to pave the way regarding mental health reform in large part because of their being located in coastal regions that enjoy levels of high economic development. If these cities' new laws are successful, it is likely that they will serve as models both for other cities and for the national government as well (Hu et al., 2006).
Each of these cities' new laws focuses on protecting patients' rights to receive adequate medical treatment and services and on prohibiting discrimination on the basis of mental illness. However, it is difficult to assess the degree to which these laws are being enforced. As is the case with most of China's mental health care facilities, external review is difficult to achieve.
To promote efforts toward better internal and external review of China's national and local mental health care services, this article will describe and evaluate the legal framework and provisions within Chinese mental health legislation regarding voluntary and involuntary admissions. Given that policies governing involuntary admission constitute one of the most fundamental components of any nation's mental health care system, and given that calls for reforming China's policies regarding involuntary admission continue to be voiced, the authors hope to contribute to the discussion as to what direction policies should be steered and also how to most effectively implement such policies without causing undue financial burdens on cities and regions ill-equipped to invest in additional medical infrastructure.1
This article will also review the progress that is manifested collectively in the recent efforts by the five cities mentioned above to enact their own mental health reforms. By calling attention to these cities' efforts in this article, we aim to point out those areas of the legislation that, to us, are most relevant for improving care and guaranteeing patients' rights. We also aim to point out those areas within the legislation that are still problematic.
Given that China is now in the process of using globally accepted standards in its efforts to improve mental health care, it is incumbent upon researchers and policy-makers to 1) obtain data on the state of mental health care throughout the diverse regions of the country, 2) recognize the local level legislative efforts recently undertaken, and 3) examine the effect that these legislative efforts are having. In so doing, policy-makers at the national level will be in a stronger position to take the best of each city's laws and programs and apply them throughout the country. We aim to contribute to this process by comparing key sections of the five cities' new legislation (focusing particularly on that of Shanghai, given that Shanghai was the first to draft such legislation and that the other four cities followed Shanghai's model closely in the drafting of their own legislations) with international standards. Cognate work had already done by Watchirs in Australia that using a Rights Analysis Instrument to evaluate weather mental health legislation was in compliance with the UN Principles for The Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (Watchirs, 2000, Watchirs, 2005). In this article, we chose the WHO Checklist on Mental Health Legislation (WHO, 2005b). Because the WHO Checklist is respected around the globe as a tool for assessing any country's mental health care laws, we have endeavored to assess the degree to which these five cities' new laws uphold international standards.
Section snippets
Methods
Data on the legislation and practice of mental health admissions in five cities with recently-enacted mental health laws — Shanghai, Ningbo, Beijing, Hangzhou, and Wuxi — were analyzed using the WHO Checklist. This checklist was designed by the World Health Organization to help countries assess whether or not key components of internationally-accepted mental health care standards have been included in local legislation. The analysis was undertaken by a group of psychiatrists who have been
Voluntary admission
According to the World Health Organization, autonomy and informed consent should form the basis of the treatment and rehabilitation of people with mental disorders (WHO, 2005b). According to the WHO Checklist, there are five questions that should be asked in evaluating the degree to which a law governing voluntary admissions guarantees patients' autonomy and right to informed consent:
- 1)
Does the law promote voluntary admission and treatment as a preferred alternative to involuntary admission and
Discussion
Our overall findings are that the legal regulations on detaining mentally ill persons are similar in the five cities of China and in general these laws do adhere to international standards. These regulations emphasize voluntary hospitalization and treatment as the first-line treatment; they require informed consent from the patient or the family member or guardian; and they restrict the use of involuntary treatment. Thus, these regulations basically cover the principals in the WHO Guidelines
Conclusions
Mental health legislation continues to progress in China. However, much remains to be done. National mental health legislation should be more comprehensive and specify procedures for directly, with the overall goal of strengthening the protection of patients' rights, especially as they relate to admissions and treatment procedures. Continued research on the influence of recently-enacted municipal regulations on mental health services in different cities, in particular of how these policies are
Acknowledgments
This work was supported by the Fund on Mental Health Legislation (L12.2, Ministry of Health, P. R. China ), and by an NIH Fogarty International Center grant (5 D43 TW05809) awarded to Byron J. Good, P.I., in the Department of Global Health and Social Medicine, Harvard Medical School. We express our appreciation to Dr. Ken Vickery for his role in editing this paper.
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