Mental Health (Involuntary Procedures) (Amendment) Bill 2008: Committee Stage.

Wednesday, 2 December 2009

Seanad Eireann Debate
Vol. 199 No. 1

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Question proposed: “That section 1 be deleted.”

Senator Dan Boyle: Information on Dan Boyle  Zoom on Dan Boyle  Section 1 refers to section 58 of the Mental Health Act 2001 which relates to the practise of psychosurgery. In consultations which took place since the previous occasion on which the legislation was debated, the other sponsors of the Bill and I agreed that it needed to be more focused and should concentrate solely on the involuntary use of electroconvulsive therapy. However, we are still of the view that action should be taken to tackle the legislative provision relating to the practise of psycosurgery. This should be done in the context of a future review of the Mental Health Act 2001.

“Psychosurgery” is a more polite medical term for the practise of lobotomy. It has not been practised in this country for more than 30 years and the likelihood is it probably will not be used. We should be unhappy it is provided for in legislation but that is not the focus of the Bill. On those grounds, we propose that section 1 of the amendment Bill be deleted.

The purpose of this debate and the Bill, as we hope to progress it, concerns involuntary treatment and the inconsistencies in how people are treated medically in terms of physical ailments and psychiatrically in terms of mental ailments and the principle of, and the ability to give, consent. It is not an all-embracing attempt to change the legislation. However, it points to one important area. As we move on to the other amendments, it is important to put on record that it is not about removing, in all circumstances, the use of ECT, a controversial treatment, but of minimising its use.

There is an acceptable argument that it has been overused, misused and unfortunately has affected people in a way that may not have been intended. There have been victims of the use of this treatment. We will hear arguments as to how people have been treated successfully owing to the existence of the treatment. In striking the balance between people’s right to their own bodily functions and minds and the need to protect society and administer an appropriate course of medical and psychiatric attention, we can all agree, whatever else we agree about in terms of the general focus of this Bill, that our law is deficient and that the review of the Mental Health Act is overdue and needs to come to a quick conclusion and make appropriate changes in order that the rights of patients, in particular, can be better protected.

[70]Senator Feargal Quinn: Information on Fergal Quinn  Zoom on Fergal Quinn  I am in an area in which I am out of my depth inasmuch as I do not know a great deal about this. However, I have spoken to some people who have had involuntary treatment and it has had a very severe effect on their lives. One is torn between the disastrous personal experiences of people and the professional advice.

I have checked up on this. It is very interesting that a much refined version of lobotomy, to which Senator Boyle referred, called neurosurgery for mental disorder is still carried out in the United States and in the United Kingdom in Cardiff and Dundee hospitals for persistent severe depression, anxiety and obsessive compulsive disorders. In 2006 a neurosurgeon in Cardiff described the practice as not a panacea but added that in patients for whom all other treatment has failed, it transforms their lives if it works well. Many professionals in the area still see a place for the treatment. Nobody is disagreeing with the treatment as such.

There is an oft held perception that ECT is a high risk with little benefit but we must look beyond those pure assumptions or perceptions as to what ECT is and whether it can bring benefit to those suffering, even if they are unable to agree to the therapy at that time. It is worthwhile noting a report published in the Lancet medical journal by researchers at the University of Edinburgh and the University of Aberdeen who found ECT to be the most effective treatment for depression, particularly when the condition is accompanied by psychotic symptoms or hallucinations. However, they pointed out that there are some risks associated with ECT, including having greater anaesthesia and memory impairment. The researchers said that all effective treatments for depression, which is by nature associated with the most profound suffering, must be welcomed.

In another report in the Lancet in 2003, the United Kingdom ECT review group found ECT to be one of the most safe and effective treatments in medicine. I am going to some pains to remind Members that it is a very effective treatment. As the Irish Journal of Psychological Medicine highlighted in its editorial published this year, this proposal is meant to promote the use of advanced directives made by patients early in the course of their illness when they have capacity. The assumption is that advanced directives will prevent paternalism and promote the rights of the patient. However, the authors of the article state that a ban on involuntary ECT would render them unable to treat some of the most mentally ill people in society. They state it would lead to medical deterioration and subsequent general hospital treatment for some. It would mean a basic violation of the treatment contract because the detention in hospital of involuntary patients should be based on the principle of reciprocity for which they state they must aim to restore decision-making capacity to patients.

I agree with this view that medical practitioners must be able to have the ability to restore this decision-making capacity to involuntary patients. That is why I find it difficult to divide between the personal experiences of those who have spoken to me and the medical experience and the professionalism of the experts in that area of medicine. I am not saying we should not go ahead with this but I am expressing the concern that we should not jump into it without giving serious consideration to the very definite medical advice we have been given before we assume it is the correct thing to do.

Senator Maria Corrigan: Information on Maria Corrigan  Zoom on Maria Corrigan  I welcome the opportunity the Bill provides to debate this crucial and, at times, very distressing aspect of care for people. The amendment that a programme of electroconvulsive therapy shall not be administered to a patient unless the patient gives his or her informed consent in writing to the administration is one with which we are all in agreement where the patient has capacity to consent. This demonstrates the need to move with speed on the capacity to consent legislation which we have been expecting. Much progress has been made on it and I hope it will be brought before us. It raises a vital issue for people with mental health difficulties and people with intellectual disability in terms of the basic human right it would restore to them. We need to see that legislation as quickly as possible because without it, we would find it difficult to implement this amendment.

[71]I refer to the group of people who may not have capacity to give consent. That is where the conundrum arises. Senator Quinn referred to past research. Results are mixed but there is a very clear body of thought in the area of mental health which would attest to the effectiveness of ECT for a very limited number of patients. The conundrum for us is what process should be in place where a patient cannot give consent.

We have spoken about the idea of advanced consent. Looking at the issue of advanced consent would be very beneficial where somebody is at the initial stages of illness or has a history of illness and has the capacity to give consent when well. From my personal and professional experience, I know that for a very small number of people advanced consent would not have been an option because of the speed with which they found themselves suffering from mental health issues. The conundrum for us is what should be in place for those individuals who have not been able to give advanced consent and are not in a position to give consent at the time of proposed treatment.

The amendment proposes that we would withhold the right for ECT to be administered. I am not too sure that this is the best way forward. We must have regard for the medical advice given to us. However, perhaps we should look at the provisions, whereby two consultant psychiatrists would sign off on it and at whether a different process should be in place which would see the involvement of a strong advocate for the patient who is not a consultant psychiatrist. I am not casting aspersions on the professional integrity of consultant psychiatrists and accept they act in the best interests of their patients, but I am trying to ensure our legislation provides reassurance that rights will be protected.

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  As we are on Committee Stage, I ask Senators to speak to the section.

Senator Frances Fitzgerald: Information on Frances Fitzgerald  Zoom on Frances Fitzgerald  I welcome the focus this Bill has brought to mental health issues. Judging from the comments of the Minister of State at the Department of Health and Children at a recent meeting of the Joint Committee on Health and Children, he will need support from all sides of this House if he is to maintain funding for mental health. We are at present discussing the quality of mental health interventions and how to ensure the highest standards of care and protection in all treatments. Electroconvulsive therapy will not be familiar to most Senators because it is rarely mentioned in the public arena. Like many other psychiatric treatments it has been practised behind closed doors in the past. This debate is part of an ongoing and necessary process of bringing transparency to such treatments.

I previously suggested that the Minister of State or the Joint Committee on Health and Children should arrange hearings on the issue in order that interested parties can offer their opinions. I would like a better focus on mental health issues and the funding of services but I acknowledge the Acting Chairman’s advice that we speak directly to the section.

The Mental Health Commission’s investigation of the administration of ECT without consent is relevant to this debate. The variations in ECT administration around the country raise serious questions and explain to some extent why the Green Party has brought forward this Bill.

I would like to discuss the issue of involuntary treatment in the context of capacity legislation and a review of the Mental Health Act 2001. Similar principles should be applied in respect of standards on voluntary patients in areas such as continuing medication after three months if we are to ensure best practice in the treatment of vulnerable patients with mental health issues. The Bill will not apply to patients who are willing and able to offer consent but questions arise in regard to depriving incapacitated patients of the chance of being treated with ECT. I appreciate this is a controversial issue and that some countries have decided to discontinue ECT or have introduced advanced directives on its use. We should consider these options because I am concerned about the variations in treatment in Ireland. Advanced directives, advocacy roles or court directives could be developed to govern the use of ECT. I imagine that the numbers treated would decrease as a result.

[72]We must accept, however, that ECT remains a recognised form of treatment for certain conditions. I appreciate that some user groups and advocates of this Bill take the view that it should not be considered as a treatment. Such concerns are understandable given the nature of ECT. Equally, however, some expert researchers will attest to its usefulness. I was recently given a briefing by a psychiatrist who made a strong argument for the use of ECT as a last resort in very specific cases.

I ask for the Minister of State’s opinion on the implications of depriving incapacitated patients of the chance to be treated with ECT. In the case of a person who lacks capacity, it may be possible to deal with the question of whether the treatment may be given under the common law doctrine of necessity. The safeguards may be more limited in such a situation because the legal provisions would be vague and less protective of patients. We will have to consider the legal implications of the Bill. If certain categories of people can benefit from ECT, I ask whether the Minister of State believes it should be maintained, albeit with enormous safeguards.

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  On a point of clarification, the Minister of State may comment if he so wishes but as this is a Green Party Private Members’ Bill, Senator Boyle will be addressing Senators’ questions.

Senator Liam Twomey: Information on Liam Twomey  Zoom on Liam Twomey  I ask the Minister of State to comment on the issues I will raise. I am probably the only Member of this House who has administered ECT. It is a truly barbaric procedure but so too is major surgery. We should consider the outcome of the treatment in asking whether it is necessary. I have witnessed the recovery of people who were incredibly depressed after they were treated with ECT but I was too inexperienced at the time to know whether they would have benefited from alternative treatments. We should discuss the Bill from the perspective of whether we are for or against ECT. I am not convinced that advanced directives would be as effective as some presume because nobody decides to embark on ECT before trying all the alternatives. Patients may not have the opportunity of considering advanced directives on ECT.

If we are not going to ban the treatment, we should examine the effectiveness of the protocols governing its application. Anecdotal evidence strongly suggests that ECT is being used inappropriately and too often. Perhaps we should restrict the treatment to a limited number of institutions and consultants. When I was a senior house officer, consultants directed me to go to a ward, with an anaesthetist, to carry out ECT treatment on a patient. That was maybe too loose a way to carry out the treatment. When the Minister of State responds he may need to examine within his Department the protocols and procedures for carrying out ECT, by limiting it to certain institutions and tightening up the way it is carried out, who is informed or who allows it to go ahead.

I do not know that advanced directives will work. Advanced directives for ECT should be the same as advanced directives for any form of treatment, for example, for someone involved in a car accident or who gets a serious illness and is left comatose. The advanced directives should kick in for anybody who no longer has the capacity to decide his or her own future. That could apply to dealing with someone who has Alzheimer’s disease. None of us would decide to write an advanced directive on what should happen if we get Alzheimer’s disease. We simply get it and then it is too late. This situation is similar. We should consider whether we abolish ECT or allow it to continue in a very rigid way. The Minister of State needs to bring forward proposals on that issue and that may be what we should debate on later Stages.

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  I ask Senators to please stick to Committee Stage. We have completed Second Stage.

[73]Senator Déirdre de Búrca: Information on Déirdre de Búrca  Zoom on Déirdre de Búrca  I wish to respond to Senator Twomey’s point about whether we should support the use of ECT. The thrust of our amendment is to remove the involuntary use of ECT from the Statute Book. The question of removing it altogether is a wider one. It misses the point of our amendment. Senator Twomey said surgery is invasive.

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  The Senator is responding to the queries but Senator Mullen has indicated he wishes to speak. I did not realise that Senator de Búrca wanted to respond.

Senator Dan Boyle: Information on Dan Boyle  Zoom on Dan Boyle  The Senator is just making a point.

Senator Déirdre de Búrca: Information on Déirdre de Búrca  Zoom on Déirdre de Búrca  Yes, I am just making a point in response to Senator Twomey. He said that surgery is involuntary in that it is invasive but will he consider how acceptable it would be to the public if we were to carry out involuntary surgery because we felt it would achieve certain outcomes? That would be absolutely unacceptable. As Senator Boyle said we must examine complementary approaches to treating physical——

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  The Senator is responding to questions. Senator Mullen has yet to speak. When we return to this side the Senator, or whoever wishes to respond, may do so.

Senator Déirdre de Búrca: Information on Déirdre de Búrca  Zoom on Déirdre de Búrca  I wish to make one final point because this is important. When we raised this issue over a year ago, many who contributed said they did not know enough and wanted to defer to mental health experts, psychiatrists and so on. That was over a year ago. We have had an opportunity here——

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  I have to deal with procedure.

Senator Déirdre de Búrca: Information on Déirdre de Búrca  Zoom on Déirdre de Búrca  We have had an opportunity for hearings and to invite in experts but have not done so. We are still at the point we were at last year. No reforms or changes have been made to the Mental Health Act. Senators have made very good suggestions today about the need for people with serious mental health difficulties to have advocates, for advanced directives, considering approaches that have social and psychological dimensions rather than relying on extreme, controversial biological treatments such as ECT and its involuntary use. It is important to respond to the points other people are making here. We need to take this issue more seriously. Over a year has elapsed since we introduced this Bill and unfortunately we have made very little progress.

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  I have no problem allowing anyone respond but people must speak first, then the Senator can respond.

Senator Rónán Mullen: Information on Ronan Mullen  Zoom on Ronan Mullen  As the Green Party has withdrawn certain aspects of its original proposals in this Bill, I will confine my comments to what remains, essentially whether ECT should be permitted in the absence of the patient’s consent. I admire the animating spirit behind this initiative and believe it is right and proper that we think long and hard in terms of human rights and dignity when we consider any kind of medical procedure.

Without wishing to sound patronising, it is because people care so much that important issues are brought before us. Nonetheless, the question of consent raises a core philosophical issue. Our society correctly lays a strong emphasis on rights and that leads to our thinking about patient autonomy which is important most of the time. Rather like anti-discrimination provisions they are always right except when they are wrong. There may be circumstances in which, if we viewed this issue through a communitarian lense, or within the concept of paternalism, which is not desirable in itself because its language is wrong, it may remain a fact that in certain cases society must on occasion act in the best interests of some of its members. Therefore an untrammeled appeal to a doctrine of patient autonomy could end up operating not just against the common good but against the good of individuals in particular circumstances. That [74]is what animates my contribution, with great and sincere respect for what the Green Party proposes.

We all agree that ECT is the last resort. It is often prescribed for patients who are involuntary, unlikely to be willing or able to consent. That goes without saying. The question is whether the treatment is effective and whether the safeguards ensure that ECT is sparingly used only in cases where it is deemed to be necessary. I understand that in practice if the legal representative of the patient objects to the treatment the matter would go to the tribunal which safeguards the rights of the patient in whose best interests it acts.

In Ireland today ECT is reserved for certain circumstances, such as catatonia, treatment resistant depression or severe depression with stupor, which would likely lead to a person’s death by starvation, and in cases where the person would die if not given ECT, especially if he or she is elderly or frail. Could this be an important and essential treatment backed by some kind of evidence base? I need to think about and research it more before ruling it out completely. The patients most in need of ECT, whether those in a catatonic state or depressive stupor, are generally unable, by virtue of their condition to give consent. Therefore, changing the law so that it can be given only with consent may result in deaths.

While I am open to debating this issue I am concerned that the Bill, although well meaning, could be counterproductive and I wonder whether the opinion of the medical community has been sufficiently taken into account. Starting with Hippocrates, medical treatment has the best interests of the patient at heart. This occasionally involves the use of treatments such as this or, in rare cases, psychosurgery. Insisting that patients who are often not in a position to act in their own best interests should have a veto over ECT treatment could be a dangerous and counterproductive measure. In the words of one medical contact, if a person was capable of acting in his or her own best interests he or she would not need ECT.

Acting Chairman: Information on Kieran Phelan  Zoom on Kieran Phelan  I remind the Senator we are on Committee Stage, not Second Stage.

Senator Rónán Mullen: Information on Ronan Mullen  Zoom on Ronan Mullen  We are talking about rarely used treatments, that are strictly regulated but where a treatment is evolving, it is not the place of this House to substitute its judgment for that of medical professionals who might in the future develop a type of psycho-surgery or other treatment that could be beneficial. These matters must always operate within constitutional and legal parameters. I underline again my respect for the spirit underlying the Bill, even if I cannot support the proposed removal of the possibility of this procedure being performed without consent.

Senator Dan Boyle: Information on Dan Boyle  Zoom on Dan Boyle  I thank Members for their contributions. It is important to note we are talking about a limiting of the practice of electroconvulsive therapy. The debate relates to those subjected to the treatment, and whether a majority have been affected in a negative way, rather than helped. The existing law is failing in many respects. The safeguards for patients implemented by the Mental Health Commission are carried out too secretively. The extent to which the patient or his representatives is able to contribute that process is non-existent.

Our process is behind that found in other European countries. ECT is not practised at all in Slovenia. In England and Wales, the practices are quite similar to those in Ireland. However, Scotland has had a separate Parliament since 1999 and the Scottish Mental Health (Care and Treatment) Act 2003 gives patients with capacity the right to decide. Where people in this country have the capacity to decide, that capacity is overruled in the current situation and the treatment is administered regardless. That is a flaw in its own right. The involuntary nature of the practice when people have the ability to refuse is a major flaw in our legislation. None of us can be happy with this.

[75]The Austrian Government tried to overcome the difficulties described by Senator Corrigan by appointing a patients’ advocate who would act on a patient’s behalf. There is something similar in Belgium, where a person known as judge of peace acts under similar principles. There are laws in Denmark which allow for complaints about the administration of involuntary treatments and involuntary admissions. That is subsequent to the fact, but it has helped reduce the reliance on psychiatric measures in Denmark. Over a 20-year period to 2008, the number of beds in psychiatric institutions in Denmark halved because the Danes took what we would argue is a more humane approach. The balance at state and federal level in Germany is towards a more human rights patient-centred approach over and above what are seen to be the preferred approaches of the medical profession in administering care and attention. Ironically, ECT has been more or less taken out of the psychiatric system in Italy, which was the first country to use the practice. It is now expressly discouraged for schizophrenia and is banned as a means of achieving a rapid remission of symptoms in those who are deemed to be suffering under such psychiatric conditions.

We argue that Ireland does not have the proper balance between the rights of patients and the administration of effective standards. In the renewed programme for Government that was recently agreed, the Government committed itself to making appropriate amendments to the Mental Health Act 2001 to address concerns regarding involuntary committals and procedures. As limited as it is, this Bill is a sincere attempt to do this. It will not happen tonight, but we have edged the debate forward.

Proposals have been made on how we can involve more actors in the debate, and I accept the points made by Senator Fitzgerald. However, Senator de Búrca already pointed out that we have had that in the original debate also. I welcome the formation of an Oireachtas group on mental health, and this is possibly a good forum for such a debate to happen. However, this debate has been dominated too much by the established psychiatric profession. There is a great debate within psychiatry itself and many psychiatrists do not believe this is an effective form of treatment or that it should be administered to the extent that currently occurs. The debate has seen very little contribution on the role and rights of patients. The Minister of State has made several attempts in the ongoing review to change the situation, but this is about where we need to go with this Bill.

Senator Mullen made a point about patients’ rights and the threat to wider society. I do not accept that the use of ECT has anything to do with life saving. Psychiatrists might make arguments about mental capacity and personality disorder, but life saving procedures are medical procedures. They relate to the physical condition of the person and I do not see the situation as described by Senator Mullen.

When we are passing Bills, we must avoid legislating for the particular. The legislation in force is based on a mythical set of standards, whereby there is an extreme case in every circumstance for which the law must provide. As our law is predicated on that premise, there are too many innocent victims who fall foul of not being the extreme case, who get treatment that is not necessary but is seen to be the easiest treatment. We should not have a psychiatric system or a philosophy of psychiatry that is based on this. That is why we are moving these amendments and seeking support.

The first amendment tries to take away the debate on psychosurgery or lobotomy, which I find far more offensive, even though we have not practised it here for 30 years. That will not be the focus of the Bill. The second and third amendments deal with electroconvulsive therapy. I will wait for the contribution of the Minister of State on this, but I welcome the comments made by all Members. While there are reservations about specific aspects of what is being proposed in the Bill, there is a sincere belief there is a need to change the legislation to get the balance right. If there is a means for this House to find a way forward on the basis of this Bill, we will have done well.

[76]Minister of State at the Department of Health and Children (Deputy John Moloney): Information on John Moloney  Zoom on John Moloney  I thank Senators for their contributions. I acknowledge the sincerity of the Green Party in this debate. I also acknowledge that ECT treatment is controversial. I am glad that I do not sense any political involvement in this, as it is a genuine attempt to ensure our mental health services are reformed, which is the continuing role of a Minister of State with responsibility for mental health issues.

We are speaking specifically about involuntary treatment, which has always been the way. I must accept that it is a year since we debated this issue, but I have spent the last 15 months travelling around the psychiatric hospitals. I have done this for a number of reasons and I always made sure that the press were never notified, nor were political colleagues. I did that at all times to ensure we built a belief that we were trying reform the mental health services. On most occasions when I visit a hospital, I ask to meet the staff who deliver this treatment and visit the ECT rooms.

I am taken by the many valid points raised by Senator Fitzgerald, including that on the variation in treatment across the country. Without trying to lead to a cosy proposal I might make shortly, I made the point at the Joint Committee on Health and Children that it was no longer sufficient to make a yearly statement on mental health services. Since taking office, I have believed it is important we tie down the commitments and recommendations made on the reform of mental health services in A Vision for Change which has been running for four years and has five or six left to run. From the outside, I saw the importance of having in place a director for mental health who would have as his or her only brief the driving of the reform of mental health services. I am pleased to say Mr. Martin Rogan is now in place. However, it is not just a matter of having a person in place but of having someone who will be directly responsible for driving reforms. I have always insisted on the person in question not being responsible to the Minister, lest there be any argument about political motivation. The job description for the post of director should be to be specifically responsible to the monitoring committee charged with delivering reforms. That is now in place as part of the building blocks. The other part concerns the 14 clinical directors.

I will come to the net point shortly but I wish to establish my own credentials first. Clearly, we cannot be true in our talk of reform unless funding and capital are provided. I have made proposals in this regard to the Government. I made this point also at the Joint Committee on Health and Children; therefore, it is not just a matter of talking about talks behind closed doors. I have proposed a five-year capital programme on how we should develop and put in place all of the capital programmes required. I accept that capital programmes are not the answer to every issue and are only part of our public commitment to deliver reforms. My proposal is that whatever is raised in the mental health sector from the sale of 800 properties should go back into mental health services specifically and that there should be a clear money trail from the sale of the properties down the line to the commitments and recommendations made, whether in regard to intensive care units, intensive care rehabilitation units and the Central Mental Hospital. I wish to deal with these issues in the context of mental health service reform.

In the past year I have received many submissions from people who believe we should remove ECT, a matter which has arisen in today. There are three public positions on ECT — there are those who are totally opposed to the treatment, there are those who are in favour of it and, as I have come to realise having listened to the debate, there are those who are in favour of it, provided certain safeguards are in place. I concur with the latter. I am not here to argue the pros and cons, and that is not a cop-out because I will come to my net point shortly.

A year ago submissions and presentations were made to me on the need to remove ECT from mental health services. I was taken by the debate. I have since had the opportunity to meet those who administer the treatment, as well as those who are totally opposed to it. I [77]accept that in some cases the treatment does not work but that it does in others. While I do not want to make either case, it has been suggested ECT does not work. Only last week, however, I received a letter from a person who offered to come to a committee of the Houses, perhaps the Joint Committee on Health and Children. The person has a severe mental illness — he is catatonic — and wrote to make me aware of the fact that he put his survival down to the treatment in question.

I am making the case to convince myself in the sense that, on the one hand, I have evidence that suggests there is an argument for the retention of ECT, although I am not swayed by it, but, on the other, there is evidence on the other side of the argument. I do not use the phrase “putting this out for wide consultation” because what it means in political speak is that I let the issue run for months or even years and that the next person coming after me would have to pick up the pieces. I accept from what I have heard from the Members who have moved the motion and all who spoke is that this is a very serious issue. While I do not want to respond in contradictory terms, when the point is made that we had a year but did nothing, I must say the opposite. I will try to show the House what I mean. First, as part of the programme for Government, in which my party and the Green Party are involved, we have considered not just continuing reform of mental health services but also a review of the Act.

  6 o’clock

The second issue can be confirmed by many hospital staff. The third issue is as follows. The Mental Health Commission has promised to meet me before 10 December to outline its views on how we should deal with unwilling or unable people. A fortnight ago I met the representatives of the College of Psychiatry of Ireland. Let me make it clear to the House because I must respond to the point made, although I accept it was not meant as a criticism, the established mental health service providers are totally in favour of ECT. While this might be so, as Minister of State and with the officials who work in the Department, I am not advancing that case in any way. What we are suggesting is that this is such a huge leap — the word “courage” was used — I must have the courage to make the right decision. In that context, I will meet tomorrow the representatives of the hospital consultants.

All of this has been a process in the past year to ensure I am properly informed before I make a recommendation to the Government. I ask Members to consider that we have been genuine in our attempts to come to an informed conclusion. I have also invited the representatives of the College of Psychiatry of Ireland, as well as those who propose the abolition of ECT, to come to the Houses on one day, when those in favour of its retention and those in favour of its abolition can make a presentation to members of the joint committee. Rather than put the issue on the long finger — it is far too serious for that — I give a commitment to the House that by March I will have completed the consultation process. I will know the pros and cons and at that point it will be up to me to make a decision. I also give a commitment to the House that not only will I make recommendations — I am not a professional and bow to those who are — but also that the relevant Bills will be ready by then.

I wish to respond to some of the points made. Senator Fitzgerald made the point that mental health issues should be to the fore and that the process for ensuring this should be directed through the Joint Committee on Health and Children. I will ask the Chairman to facilitate those people who in the run-up to March want to make written submissions and, if time is available, to take some verbal presentations.

The issue is serious and the word “courage” strikes me. I will try to deal with the matter more specifically. I must also have the courage to ensure the plight of those who cannot protect themselves by securing treatment is examined. I have the courage in that context to ask that we do not make the decision on this legislation now. I ask that Committee Stage be adjourned to allow me make a genuine attempt to address the issue.

It is not a matter of trying to be cosy politically or to escape my responsibilities in this portfolio. I do not want to ignore the genuine commitment of the proposers of the motion. I [78]have been as active as a Minister of State can possibly be in this Department for the past 15 months and I have made it clear that in February I will host a public appraisal of where we are with A Vision for Change. I will deal with the level of commitments of what we will do with regional directors and, more importantly, of dealing with the capital programme.

By March I will bring forward a nationwide proposal on using local radio and personalities, including people involved in Shine and other mental health groups. We will go the regions and promote the concept of eliminating the stigma in mental health. I will do that publicly but in the meantime I ask to be allowed space to work. I will ignore nobody and take all into account. The time for decision will be March and I ask people to allow me that space. I ask the Green Party Members to adjourn the debate on Committee Stage until then.

Senator Dan Boyle: Information on Dan Boyle  Zoom on Dan Boyle  I have heard the comments of the Minister of State and my colleague and have some sympathy with what he is trying to achieve. He mentioned hospital consultants and has noted the contact he has had with the college of psychiatrists.

It is important that any consultation process defined to end by March will have all the actors involved. The Minister of State mentioned organisations such as Shine. Every mental health advocacy group and patients’ rights group should be fully involved in the process and identified as such. The process should have defined outcomes and work towards the possible drafting of heads of Bills that would tackle this question.

I am encouraged by the contributions made by many Members this evening. We have no desire to divide the House on the issue and hope Members will continue to contribute to the debate, especially through the Oireachtas group on mental health. Having heard what the Minister of State said and being cognisant of amendments submitted by other Members, I seek the agreement of those proposing amendments and the House in general to adjourn the debate on Committee Stage.

Senator Frances Fitzgerald: Information on Frances Fitzgerald  Zoom on Frances Fitzgerald  I support Senator Boyle’s comments. It is important that any consultation involves the user groups. We must also hear the views of the professionals involved in the area and it is critical that the consultation be comprehensive. We are coming from a position with psychiatry where user groups did not have the kind of voice they needed, although I am thankful this is changing. There is a way to go with the issue and the way this consultation unfolds could be important in developing that role for user groups. I congratulate those involved with the user groups because they have been pioneers in ensuring a focus on the client, patient and user of services. It is critical to get that balance as it has been missing in so many areas of life, particularly in psychiatry. It is great to see such change and we must do everything possible to encourage it.

If March is the deadline, will Ireland have ratified the UN Convention on the Rights of People with Disabilities by then? It would be a good template to measure what we are doing in the area. Will the same deadline apply to the capacity legislation and the review of the mental health legislation? We need a holistic approach to what is being discussed and there are rights issues involving voluntary as well as involuntary patients, electroconvulsive therapy, ECT, and other areas. We are asking much of the Minister of State but all of these issues are intertwined. We will get the best result if they are dealt with holistically.

Senator Maria Corrigan: Information on Maria Corrigan  Zoom on Maria Corrigan  I support Senator Boyle’s proposal to adjourn the debate on Committee Stage. I pay tribute to the work done by the Members of the Green Party in bringing this Bill forward and giving us the opportunity to focus on what needs to be done and take time to look at the issue as a whole. Senators Boyle and de Búrca were initially very clear that they were focusing on a particular area but we have had the opportunity to widen the debate.

[79]The Minister of State has commented on the review of the mental health legislation and the implementation of A Vision for Change. I compliment the Minister of State on the work he has undertaken and welcome that he has set a March deadline. To achieve what he hopes to achieve, much work remains to be done.

I appreciate that the Minister of State has mentioned the groups with which he has consulted. I add my voice to that of other colleagues in asking that the consultation be as wide as possible. In particular, there should be consultation with patient and advocacy groups as well as families. A wider range of professionals and personnel involved in the delivery of the mental health service should also be included as we can only benefit from widening that scope.

To achieve what the Minister of State hopes to achieve, we must be upfront about the issue. We need the capacity legislation and, without it, much of what we hope to do will be stymied. This legislation will be a momentous milestone in the delivery of services but if we try to proceed with any of our reforms without putting that legislation in place, we will be coming up constantly against a wall and conflict over people’s rights.

Senator Feargal Quinn: Information on Fergal Quinn  Zoom on Fergal Quinn  I add my words to Senator Boyle’s proposal. I was very impressed by the debate and it was an eye opener for me. I did not know very much about the topic, although I had met some people with experience of the issues being discussed. I also found a viewpoint being expressed by the professionals. The Minister of State has opened our eyes and minds to the challenge which is not easily met. He has explained the matter very well and I appreciate the work put into it by the Green Party and both of its Senators.

The Minister of State has committed himself to a March deadline, which is useful. The debate has been productive and I hope Senator Boyle’s proposal is accepted. The debate has opened our eyes and minds and given us a chance to air the issues. I look forward to holding the Minister of State to the March date.

Senator Phil Prendergast: Information on Phil Prendergast  Zoom on Phil Prendergast  I welcome the Minister of State. I have witnessed ECT and seen its positive effects. I can only judge it as positive from what I have known beforehand. I will not be descriptive of cases where it may not have been positive as I do not have the experience to discuss it in fine detail. I admire the way the Minister of State is going about his brief and visiting all units around the country. Psychiatry is constantly evolving and there are new treatments and management styles, some of which conflict with management practices within regular psychiatry services and, perhaps, new models of training, evaluation and how we assess progress or the lack of it. My colleagues have stated there are many differing opinions on the use of ECT and whether its use is positive or negative.

I agree completely with the process by which the Minister of State intends to bring the Mental Health (Involuntary Procedures) (Amendment) Bill to the Seanad. I am willing to co-operate with that process and facilitate the widest possible communication and deliberations with all parties in order that we will have the most comprehensive information available to inform the debate and how best we can progress what is best for those who will be affected by the decisions we make. Therefore, with other Senators, I am happy to agree to the adjournment of the debate on Committee Stage.

Senator Nicky McFadden: Information on Nicky McFadden  Zoom on Nicky McFadden  I thank the Minister of State for taking this issue so seriously. I also thank Senators de Búrca and Boyle for bringing this important legislation before the House. I appreciate the effort and work they have put into the Bill which aims to prohibit the involuntary administration of ECT. I have read a fair amount about ECT but find it confusing that some psychiatrists think it is the be all and end all, while others see it as a last resort. It is a barbaric process, but I am not a medic or psychiatrist. I find it hard to understand the reason people must be strapped down and medicated to such a degree that they convulse, their blood pressure rises and heart rate is disturbed. This therapy should be a last chance saloon. I am [80]very disturbed at the idea that people will lose their memory and about what this would mean to them and how vulnerable and fearful they must be at such a time. I am disturbed, too, by the idea that people’s spirits will be broken and they will no longer be the persons they were before they suffered from severe depression. The issue must be given serious attention. Therefore, I congratulate the Minister of State on taking the time to confer with all of the interest groups involved. I look forward to contributing to the debate when the Bill is returned to the House.

Deputy John Moloney: Information on John Moloney  Zoom on John Moloney  I thought it was a given that service users were already talking to me, but I acknowledge that I should have conveyed that information on a more formal basis. I would like to outline the basic principles we should be following from here on. I am asking for an adjournment of the debate on Committee Stage until March on the basis of what I propose. Members should know that what I propose is not an empty exercise and that they have not wasted their time in coming to Dublin today. An invitation will be issued from the Department to all service users and all those with an interest in this issue to submit their proposals before March and I will meet as many of them as possible. Since my appointment, I have made a point of meeting at least five groups a week from the mental health or disability sector. I now know most of the groups involved and it is a matter of making them aware of the purpose of this process. I am initiating a process, whereby service users will be invited to come to the Oireachtas to make their case. I will ensure we will have a suitable place, I hope the audiovisual room, where they can make their case before Members in order that we will all be properly briefed. Until I came into this job, I did not know much about this sector, but that is not to say I know much more now. We must all be given a full briefing on the issue which is currently before the Seanad but which will be put to the Dáil by way of the mental health review in the new year. I want to deal with the Bill in March.

I would like to respond to the specific points raised by Senator Fitzgerald. I agree that the idea is to be ready with capacity legislation on all of the reform programmes. We should be thinking of devoting next year to a consideration of mental health issues. There are many proposals we should continue to promote. We must give total responsibility to the new director for the reform programme on a day-to-day basis, rather than to a Minister. I do not wish to lay all of the blame on the new director, but it is important that both he and the 14 clinical directors are permitted to bring forward the reform programme in the next five years. This means we must have an implementation plan with teeth.

I have mentioned that we will have a meeting for service user executives on 22 December. The Mental Health Commission is also preparing its report on its position which is expected in the period from 10 to 12 December. It is important I receive everybody’s position on the issue. I recognise fully the call made by the Senator for the full involvement of service users and that will happen. The process I envisage forms part of the reform of mental health services. Everybody I meet in the House talks about the need to ensure the mental health service is on a level with acute services and that it receives the same level of support. Since I came into the Department 12 months ago, I have received a clear message from the debate in both the Seanad and the Joint Committee on Health and Children that we need clear targets. That is the reason I have set a timeframe, to which I have committed totally in order that we will bring forward the reappraisal of A Vision for Change in February. On that day I want to acknowledge publicly where the reform programme is working well and to be honest and point to where it is not working well. More importantly, I will challenge the regional directors who receive funding from the Department to demonstrate how the funding is being used in moving from the institutionalised model of mental health services to the community model.

Leaving aside the important issue of ECT, the challenge for all of us is to ensure we will no longer have people living in our old psychiatric hospitals. We need a real commitment in this [81]regard if we want to ensure proper reform. Today I met representatives of the Clúid organisation and expect to meet representatives of the Irish Council for Social Housing shortly. I am meeting these organisations to try to reduce the overall cost of delivering on A Vision for Change. I want to involve the voluntary housing sector in moving at least 80% of patients from psychiatric hospitals into supported housing. This is not a matter of trying to deliver reform on the cheap. It is important that we recognise the HSE must be tied into this process. Whoever leaves an old mental hospital must have the support of a community mental health nurse, occupational therapist or whatever service is required. These supports cannot be separate from each other.

Even if we had the best service in the world and the capital programme required, which we do not, we must still have people who are prepared to use the mental health services. The biggest challenge we face is the removal of the stigma attached to mental health issues. The past 15 months have not been wasted in this regard. I watched the interview with Michael Murphy on Ryan Tubridy’s show and attended his book launch and told him how courageous he was in speaking out. I believe getting the media involved is important in helping to remove the stigma and have invited the newscasters to become involved in the process. I am pleased to tell Senators that Ms Eileen Dunne and Mr. Michael Murphy came here to meet me a fortnight ago and have agreed to act as advisers when we meet editors in local radio stations some time in February in the hope of having a weekly programme on mental health issues to ensure we look after our mental well-being. It is most important that we establish a service that will cover the issues that affect people. We can talk all we want about money and the capital programme, but we want to ensure we deal with the basic issues involved. Treatments must be provided and we must recognise the need to provide services for those who may not be able to speak for themselves.

This is a two-way process in the House. I recognise the genuineness of the Senator’s position and ask her to recognise ours. I also ask that the debate on Committee Stage be adjourned to give us an opportunity to come back to the House having fully deliberated on and listened to all of the various opinions expressed in this controversial debate. If I were to make such a significant jump without being satisfied I had heard all of the professional voices, it would be a leap too far. I, therefore, ask for a period of three months to continue our deliberations.

Senator Dan Boyle: Information on Dan Boyle  Zoom on Dan Boyle  I thank the Minister of State for the confirmation and clarification of his proposals which give some hope that there will be progress in the immediate future.

I thank the Members who have participated in the debate to date. Their contributions show the value of and the necessity for the Seanad as a Chamber which is capable of acting independently. If we have raised an issue which will be considered in detail and in respect of which changes can be made, we have justified our purpose in being here this evening.

Progress reported; Committee to sit again.

An Leas-Chathaoirleach: Information on Paddy Burke  Zoom on Paddy Burke  When is it proposed to sit again?

Senator Dan Boyle: Information on Dan Boyle  Zoom on Dan Boyle  Ag leath-uair tar éis a deich maidin amárach.


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