The concept of human dignity carries with it the idea that each person, from the birth, by the nature of his being, must be treated with respect and care regardless of age, gender, socio- economic status, health, ethnic origin, political ideas or religion. People with mental illness risk being stigmatized and their dignity no longer respected.
Material and method
The authors propose an insight into the psychiatric pathology literature, analyzing the way people with such diseases are perceived and treated-both in the community and in the hospital environment, the consequences that affect them as well as the possible solutions for the removal of the stigma and improving the quality of life and health.
In many places the dignity of people with mental illness is violated: by involuntary placement in psychiatric institutions they risk being isolated from society and subjected to inhuman and degrading treatment, being victims of neglect and abuse (physical, emotional,
sexual); by denying access to health care risk premature death; by restricting access to education risk being marginalized and excluded from employment opportunities, and the diagnosis of mental illness in adulthood is likely to lead to loss of job and of social prestige.
The solutions lie on the one hand in improving the policies of the medical system and the legislative framework, and on the other hand in the collaboration of the institutions, focusing on protecting the health and rights of people with mental illness and their involvement in the life of the community.
Psychiatric pathology predisposes to violation of human dignity, and measures are needed to reduce stigma, discrimination and marginalization by promoting policies that protect the health and rights of mentally ill patients.
Tablet of Contents:
2. Perception in the hospital environment and its consequences
3. Perception in the community and its consequences
4. Protecting the dignity of people with mental illness
The concept of human dignity carries with it the idea that each person, from the birth, by the nature of his being, must be treated with respect and care regardless of age, gender, socio- economic status, health, ethnic origin, political ideas or religion. Broadly, a person’s dignity is respected when he/she can live his/her life without being the victim of violence or abuse of any kind and without being discriminated, when can exert his/her right to autonomy and self- determination, when is included in the life of the community and when he takes part in the process of implementing the policies that concern him .
In the medical area there are categories of patients who are at risk of being stigmatized due to the particular nature of their condition. These include those with mental illness, followed by AIDS/HIV infected patients, those with venereal diseases, leprosy or various skin disorders . By stigma associated to these conditions, patients risk being approached in a manner that can affect their dignity .
The present paper analyzes psychiatric disorders in the view of their risk of harm to dignity, following the way people with such diseases are perceived and treated- both in the community and in the hospital environment, the consequences that affect them, as well as the identification of possible solutions for the removal of stigma and to improve the quality of their lives and health.
Promoting and protection of human rights and health care are fundamentally linked.
The protection of the dignity of the human being is supported by numerous international bodies, the Universal Declaration of Human Rights – adopted in 1948 in Paris by the United Nations (UN) General Assembly – stating from the first article that “all human beings are born free and equal in dignity and rights” .
At the same time, protecting the dignity of patients is underlined by one of the principles of the Constitution of World Health Organization (WHO) of 1946, which states that: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” [5, 6].
Likewise, human rights and human dignity are also interlinked. Similar to human rights, human dignity is considered inherent, inalienable and universal [5, 7], and respect for human rights is ensured by respecting its dignity . And when we speak of different types of dignity, “intrinsic dignity” is that which is attributed to every human being simply by virtue of being a human being and which is invoked as a basis for human rights .
The United Nations Convention on the Rights of Persons with Disabilities (persons with physical, mental, sensory, or intellectual disabilities) aims to “protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their intrinsic dignity” . This internationally referenced document states that: “health professionals must provide care of the same quality to persons with disabilities as to others, including on the basis of free and informed consent” .
In the same sense, the Convention foresees the dissolution of constrained institutionalization, the dissolution of forced treatment, by the fulfillment of their aim, which refers to the protection and enforcement of all human rights, the assurance of the fundamental freedom of all persons with disabilities, the promotion of respect for their inherent dignity .
There is also a close link between human dignity and social justice, the latter involving equality in access to opportunities and privileges within society for all individuals .
People with mental illness risk being stigmatized, and dignity not respected . The stigma associated with psychiatric disorders arises from both the “culture of the environment” and the particular mode of manifestation of mental illness, giving patients bizarre or violent behaviors [12-15]. Sometimes, particular circumstances occurred during life can trigger a psychiatric illness in an otherwise healthy person, or the prolonged psychological pain can lead to the development of a psychiatric illness, an example being the pathological grief after death of a loved person, which can lead to depression, melancholic psychosis or grief mania . These people need as well to be protected from violation of their dignity.
Psychiatric illnesses can be found among all categories of people, and their impact can be accentuated by association with other factors such as the profession of the affected person.
When mental illnesses are present among healthcare professionals, stigma associated with mental illness is especially an important impediment to their request for aid for treatment and recovery .
In general, the presence of a disruption of the state of health will result in smaller or larger changes in body control capacity, having consequences both in the field of emotional life and psychiatric state. This impairment of control is felt more strongly by patients suffering from mental illness or dementia and may be challenging in the process of recognizing patient’s dignity .
Although there are many national and international institutions and documents that promote respect for patients’ rights, including the transition from medical paternalism to individual autonomy, obtaining informed consent, dignity of patients with psychiatric illnesses is infringed both in the medical sphere and in their communities .
2. Perception in the hospital environment and its consequences
The UN Convention on the Rights of Persons with Disabilities, legally in force in 2008, aims to “promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity”. This Convention has come to support its recipients (“those who have long- term physical, mental, intellectual or sensory impairments”) by encouraging the abolition of forced institutionalization and forced disability treatment . However, the hospital climate is still sometimes the site of serious deviations from respect for human rights and patients with psychiatric disorders: some patients with psychiatric disorders are admitted against their will in specialized medical institutions, thus being isolated from society [1, 11]; these institutions are sometimes the site of abuses and negligence, as well as inhumane and degrading treatment  such as bed chaining, making impossible for patients to move .
Health care is an essential point in patients’ recovering and surviving and the Convention on the Rights of Persons with Disabilities states that health care should be of the same quality for people with disabilities as for everyone else . However, access to health care is sometimes restricted to patients with psychiatric disorders, so that due to lack of appropriate medical care there is a risk for them to die prematurely . Also, the stigma associated with psychiatric illness strongly influences the language and attitude of medical staff [17, 18], leading to a serious violation of patients’ dignity. Thus, as identified by Knaak et al., (2007), psychiatric patients experienced attitudes that made them feel “devalued, dismissed and dehumanized” by the medical staff they came into contact with , be left to wait a long time before being examined and sometimes receiving subtle or outspoken threats of forced treatment . As a result of such behaviors and approaches for patients with mental illness, numerous complaints have been made to the European Court of Human Rights regarding the devaluation of patients’ needs, poor treatment or even over-medication [10, 19]. The latter situation is all the more serious when it materializes, forced treatment leading to significant and lasting psychological trauma .
Doctor-patient relationship is deeply affected in these patients, representing a barrier on the way to recovery : a disturbed paternalist relationship in which they are not asked for opinion on treatment options, are not included in the decision-making process, they are not asked to sign the informed consent, they do not receive the necessary information in order for them to know their state of health , they are approached in a pessimistic manner , sometimes even being told they will never become healthy again .
Mental illness stigma resulting from the pessimistic approach of the discussion regarding the patients’ health state , along with inadequate skills and training of medical staff-leading to anxiety and fear in addressing patients, which will make them to avoid and keep distance , are serious barriers in accessing the health care programs and in the quality of care, both in terms of treatment and recovery . As a result, they will affect doctor-patient interaction and quality of care, resulting in less effective treatment and weaker outcomes, which raises concerns about patient safety [3, 17]. By delaying to meet the doctor, non- adherence to treatment, and implicitly lack of appropriate treatment for the illness, the latter may become complicated, with the person risking even profound disability .
Kogstad (2009) conducted a study on a series of patients with psychiatric disorders, collecting information about their treatment when they came into contact with medical staff and reflected in varying degrees of dignity: miscommunication, rejection and humiliation/punishment .
Thus, with regard to communication, patients reported that they were treated superficially, not being taken seriously when sharing to physicians their physical suffering  – a phenomenon that is otherwise common, that somatic pains to be attributed to psychic disorders when the doctor knows that the patient suffers from psychiatric illness . This approach could also have negative consequences on health, as this will delay diagnosis and implicitly treatment [17, 21].
Rejection materialized in lack of empathy for patients’ suffering, particularly in cases of suicide attempts, when patients were only receiving medication, then sent home without talking to them and not being followed after discharge .
Regarding humiliation and punishment, the patients received an arrogant attitude from the part of the medical staff, the medication was either forcibly administered or, on the contrary, they were forcibly removed or were the subject of threatening to calm down . They were also laughed, forcibly admitted or isolated from other patients for different time intervals .
3. Perception in the community and its consequences
The stigma associated with psychiatric disorders causes the patients to be deprived of education by restricting access to educational institutions, thereby risking marginalization and subsequently being denied their access to the workplace [1, 11]. The severity of this type of “treatment” is inversely proportional to the country’s income, being more evident in low- income countries .
When psychiatric disease is diagnosed in adulthood, the associated stigma may lead to loss of workplace and consequently loss of social prestige or even isolation from the family and society . Likewise, some work colleagues might question the professional competence of those with mental illness [3, 17, 22], associate them some degree of danger in the conduct of their activities , considering them unpredictable [3, 17], or even unfit for work in general , sometimes endangering also public safety . A study in India shows that urban workers do not want colleagues with psychiatric disorders around them at workplaces .
The way of perception and the consequences are different from one culture to another, from one region to another. Thus, rules of coexistence specific to certain cultures can make the stigma to extend to other family members, posing problems when they want to occupy certain functions or even to build a family .
Human dignity in psychiatric disorders is also violated by the impossibility of full admission to society [3, 24], such as participation in public affairs, voting or even the holding of public functions, participation in cultural and recreational activities .
Despite the fact that it would be a beneficial action, patients with psychiatric disorders are not consulted when deciding on mental health policies or legislative reforms in this area that concern and affect them .
4. Protecting the dignity of people with mental illness
A series of solutions can help remove stigma , with results both in the social level-better integration into society  and in the medical level-encouraging to ask for help, adherence to treatment , all of which ultimately contribute to a better quality of life and health among patients with mental illness . These efforts are all the more important as there is evidence that when treated with respect, patients can more easily cope with the illness they suffer and their health can even improve . To achieve this goal, an important role would have the collaboration between the various state institutions and the alignment of national policies and laws with various international instruments promoting human rights [11, 26].
Improving healthcare policies could foster access to quality health care that emphasizes respect for human rights and respect for autonomy as a core value of medical ethics, including the patient’s right to be properly informed and to contribute to decision-making process about their own care and treatment, or to establish beforehand what action to take at some point in time [1, 7, 27, 28].
The legislative framework could be improved by offering patients the opportunity to take part in the decision-making process on mental health policies or the various mental health reforms [1, 5, 7] and by promoting principles that provides hospital admission and medication based on the patient’s own desire rather than his or her obligation . Also, by improving the legal framework, promoting equal rights for people with disabilities can extend from the medical level to the social one so as to cover all aspects of life .
In order to protect the dignity of people with mental illness, a particular role is played by direct contact with the patient, the manner in which he is approached, communication being essential even when the illness of the patient seems to dissuade him from what is being communicated to him or when the way he perceives his situation is different from the doctor’s view . That is why organizing training sessions for medical staff, where they are advised to talk (“what to say”) and how to act (“what to do”) when interacting with patients with mental illness [1, 17, 29] may prove useful. These sessions could also target strategies to provide psychological support or mental health first aid  as well as correcting false conceptions that might hamper quality care .
Another solution aims at facilitating patient’s access to community life and recognizing the value of their involvement : respecting the autonomy of making decisions for themselves, ensuring access to the labor market, ensuring access to education, social support, moving from hospital care to community care [1, 9, 10] and the involvement of civil society.
The collaboration could expand internationally by conducting joint new research in various institutions that promote human rights, aimed at creating a system that can monitor inequalities in health systems, abuse or neglect of human rights, thus contributing for removing stigma and respecting the dignity of people with mental illness .
194 WHO member states have taken an important step in this direction by approving the Mental Health Action Plan 2013 to 2020 (MHAP) at the 66th World Health Assembly , in which they promote social justice through full inclusion into society of mentally ill, proposing different measures in order for them no to be marginalized anymore by society, calling for the inherent dignity when making changes in policies and services relating to mental health : “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” .
Psychiatric pathology predisposes to the violation of human dignity, being necessary to promote policies that protect the health and rights of mentally ill people through measures to reduce stigma, discrimination and marginalization, thus protecting their rights and freedoms without discrimination, the observance of the integrity and dignity of patients being both an ethical obligation and a recovery method, valid throughout the medical world.
It is necessary to draw an alarm signal to emphasize the importance of collaboration between relevant institutions at national and international level, both on the legislative and on the medical-social and community side, so that patients with psychiatric disorders can feel safe and respected in all aspects of their lives.
HANGANU Bianca 
HLEŞCU Andreea Alexandra 
BÎRLESCU Elena Andreea 
PETRE-CIUDIN Valentin 
MANOILESCU Irina Smaranda 
 “Grigore T. Popa” University of Medicine and Pharmacy of Iasi (ROMANIA).
Contributo selezionato da Filodiritto tra quelli pubblicati nei Proceedings “13th National Conference on Bioethics with International Participation - 2018”
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Contribution selected by Filodiritto among those published in the Proceedings “13th National Conference on Bioethics with International Participation - 2018”
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