Mental health law in Turkey: legislation pending

Abstract

In Turkey, mental health professionals, together with patients and carers, have been involved in the drafting of the Mental Health Bill which is presently under consideration by Parliament. While the Mental Health Law is pending, various pieces of legislation are being used for different types of involuntary admission. The prospective Mental Health Law is of paramount importance for doctors, patients and families.

The Mental Health Law in Turkey is still at the proposal stage and has not yet been enacted (Psychiatric Association of Turkey, 2007). This has significant repercussions. Various groups, including clinicians, patients and carers, are affected and take on major responsibilities to compensate for the lack of specific mental health legislation. Currently, clinical practice is heavily influenced by cultural factors, such as carers’ attitudes towards people who are mentally ill and the family’s resources. However, there is nonetheless a legal framework to compensate for the lack of specific mental health legislation. The Ministry of Health (2011) has a mental health action plan that prioritises finalisation of the Mental Health Law. The proposal is still pending discussion in Parliament.

Turkey has a long history of providing mental health treatment in in-patient settings. As early as 500 years ago, at the time of the Ottoman Empire, mental illness was recognised as a physical ailment and physicians treated patients in therapeutic settings using holistic approaches that included music therapy. Several mental health institutions were established in the early 19th century. The first regional psychiatric state hospital was set up after the foundation of the Republic of Turkey in 1923. Currently, university, state, military and private hospitals provide in-patient psychiatric treatment.

In Turkey, family members are the main providers of care and are usually the legal guardians of patients with mental illness. Most people with severe mental illnesses live with their families and the number of homeless patients with schizophrenia is lower in Turkey than in other European countries. On the other hand, family-related factors have a large influence on the course of treatment and admission rates of patients with schizophrenia in Turkey. Thus, patients from families who are less functional are likely to be admitted more often (Taktak et al, 2000).

The proposed Mental Health Law

The Psychiatric Association of Turkey began work on draft legislation in 1998 and the first proposal was released in 2006, after a specialist task force was appointed (Psychiatric Association of Turkey, 2007). The task force had representation from 15 professional organisations, including the Psychiatric Association of Turkey, the Turkish Medical Association and numerous charities formed by patients and carers. The proposed Bill supports not only patients’ rights to treatment but also clinical governance in mental health settings. The Bill defines voluntary and involuntary admissions, how an independent psychiatrist is to be involved in decision-making, how the courts should be informed of long-term involuntary admissions and patient care after discharge. It has been regarded as an unusual but valuable opportunity that a new law is being created afresh (Arikan et al, 2007).

Current practice

In current practice, the family should consent to the involuntary admission if the patient lacks capacity at the time of assessment. This also means that the family can either refuse admission or discharge the patient by withdrawing consent, against medical advice. This system places clinicians, patients, carers and the general public in a vulnerable position. The question of whose responsibility it is when things go wrong is an important one. There are examples, albeit few, of unfavourable and at times tragic results. Patients can be left untreated. Clinicians also suffer from not being able to provide optimum treatment and the carers have to take on overwhelming responsibilities.

While specific legislation for involuntary admissions is still lacking, psychiatric units are making use of an article in the Turkish Civil Code (Ministry of Health, 2011). Article 432 sets out the requirements for involuntary admission: the patient must have a mental illness and pose a danger to the public. The same article covers infectious diseases, intellectual disability and alcohol or drug misuse or vagrancy. It further states that patients should be discharged as soon as they are fit. The article has not been prepared for or tailored to the needs of people who are mentally ill, their well-being or rights; rather, the focus is on the ‘safety of the public’ (Sercan, 2007).

Until 2008, Article 432 had been rarely used by the legal authorities or mental health professionals. Since then, with the support of the Mental Health Law initiatives taken by the Psychiatric Association of Turkey and also with the support of several clinical directors of psychiatric state hospitals who contacted their local courts, this piece of legislation began to be used within routine clinical practice. Currently, psychiatric state hospitals and most of the university hospitals use Article 432. If the judge decides that a patient meets the criteria set out in the Civil Code, then permission is given and Article 432 is used for involunatry admission. However, there are still ongoing difficulties, such as delays in court decisions, problems with the appeal procedure and communication problems with regard to discharge. Although the active use of Article 432 in psychiatric practice has effectively established a legal framework and thereby reduced the uncertainties for psychiatrists, patients and carers, it can be regarded only as a subsidiary regulation until the Mental Health Law is passed.

Other forms of involuntary admission, particularly for patients who are involved in criminal acts, are regulated by the Turkish Criminal Law. The Criminal Court can decide on a compulsory admission of a patient who has a history of offending. This is only for up to 3 weeks, as part of an assessment process of criminal responsibility (Criminal Procedure Law, Article 74). If the forensic psychiatric assessment concludes that the patient does not have criminal responsibility due to a mental illness, the patient does not receive a conviction and is instead compulsorily admitted to a psychiatric ward. The relevant article of the Turkish Criminal Law (Article 57) also defines discharge processes and the frequency and the reporting of compulsory follow-up visits following discharge (Sercan, 2007). The Mental Health Law is expected to be compliant with the relevant articles of Turkish Criminal Law, although further amendments might be required when the Mental Health Law is debated in Parliament (Psychiatric Association of Turkey, 2007).

Consent should be obtained from parents for the admission of anyone under 18 years of age. When there are no parents involved in the care of the child, as in the case of children living in children’s homes or foster homes, social services have legal responsibility and should give consent. Under the Child Protection Law, a child is entitled to safeguarding, to receive healthcare, to adequate shelter and to an education. This law is used in the best interests of the child to enable the child to receive adequate treatment, including in-patient and out-patient psychiatric care when necessary.

Turkey provides an example of how different pieces of legislations can be used for involuntary admissions while the proposed Mental Health Law is pending discussion in Parliament. In the meantime, mental health professionals in conjunction with patients and carers continue to campaign for the Mental Health Law.