Date Published: October 18, 2018
Publisher: Public Library of Science
Author(s): Faraaz Mahomed, Michael Ashley Stein, Vikram Patel
Abstract: Based on interviews with a variety of participants, Vikram Patel and colleagues advocate for philosophical and practical progress toward recognizing decision-making capacity in people with psychosocial disabilities.
Partial Text: The United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) was adopted in 2007 and has since been ratified by 177 countries. It represents a paradigm shift from an impairment-focused, biomedical model of disability to a socially focused, human rights–based model. Impairment arising out of a mental health condition is termed “psychosocial disability” in this model, and laws and clinical protocols governing mental health practice are likely to be informed by the CRPD’s provisions. The Indian Mental Health Care Act of 2017 (MHCA) states that it was drafted because “it is necessary to…harmonize existing laws with [the CRPD]” . Similar processes have taken place or are in motion in 32 countries,  illustrating the CRPD’s potential impact on the lives of people living with psychosocial disabilities. This evolution also applies to intellectual disabilities and degenerative conditions (e.g., dementia). Although not covered in detail in this paper, all of these conditions are likely to be affected by the CRPD’s approach to legal capacity, as discussed below.
Twelve stakeholders were interviewed in person or over Skype. They included members of the user and survivor movement, representatives of disabled people’s organizations (DPOs) and the UN system, ethicists, clinicians, legal scholars, and policy makers. Using a purposive, deviant sampling method, stakeholders whose positions were known to be diverse based on their publicly held viewpoints were approached . Gender and geographical representivity were also considerations. Several participants held multiple identities (e.g., both clinician and policy maker or both user and DPO representative). The Harvard School of Public Health granted an exemption of Institutional Review Board approval before interviews commenced (IRB17-1943). Coding was undertaken by the interviewer (FM) and a second independent coder (JNB), who was provided with anonymized transcripts. Thematic content analysis occurred initially after seven interviews and then again after a “stopping criterion,” reflecting the decreased probability of retrieving new information, was applied following the 12th interview . Following coding of the first round of interviews, Cronbach’s alpha coefficient was 0.64, rising to 0.82 after the second round, suggesting an acceptable level of inter-rater reliability. More information on the methodology is available in the supplementary files (S1 Text, S1 Table). The results of the thematic analysis are summarized in Table 1.
The results highlighted important political and epistemological differences that impacted how the debate on legal capacity has been evolving, as well as unresolved questions around the practical application of ULC and key steps that should be taken to develop this discourse further. There appears to be broad agreement among the stakeholders interviewed that involuntary mental health treatment is heavily overutilized. Therefore, calls for “radical reduction” in nonconsensual methods, while perhaps not sufficient for some, are likely to have widespread support. This already provides a basis for important changes to be made.