25 - Health
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on the Equalization of Opportunities for Persons with Disabilities
Adopted by the United Nations General Assembly, forty-eighth session, resolution 48/96, annex, of 20 December 1993
Rules 2, 3
Rule 2 – Medical care
States should ensure the provision of effective medical care to persons with disabilities.
• States should work towards the provision of programmes run by multidisciplinary teams of professionals for early detection, assessment and treatment of impairment. This could prevent, reduce or eliminate disabling effects. Such programmes should ensure the full participation of persons with disabilities and their families at the individual level, and of organizations of persons with disabilities at the planning and evaluation level.
• Local community workers should be trained to participate in areas such as early detection of impairments, the provision of primary assistance and referral to appropriate services.
• States should ensure that persons with disabilities, particularly infants and children, are provided with the same level of medical care within the same system as other members of society.
• States should ensure that all medical and paramedical personnel are adequately trained and equipped to give medical care to persons with disabilities and that they have access to relevant treatment methods and technology.
• States should ensure that medical, paramedical and related personnel are adequately trained so that they do not give inappropriate advice to parents, thus restricting options for their children. This training should be an ongoing process and should be based on the latest information available.
• States should ensure that persons with disabilities are provided with any regular treatment and medicines they may need to preserve or improve their level of functioning.
Rule 3 – Rehabilitation
States should ensure the provision of rehabilitation services to persons with disabilities in order for them to reach and sustain their optimum level of independence and functioning.
• States should develop national rehabilitation programmes for all groups of persons with disabilities. Such programmes should be based on the actual individual needs of persons with disabilities and on the principles of full participation and equality.
• Such programmes should include a wide range of activities, such as basic skills training to improve or compensate for an affected function, counselling of persons with disabilities and their families, developing self-reliance, and occasional services such as assessment and guidance.
• All persons with disabilities, including persons with severe and/or multiple disabilities, who require rehabilitation should have access to it.
• Persons with disabilities and their families should be able to participate in the design and organization of rehabilitation services concerning themselves.
• All rehabilitation services should be available in the local community where the person with disabilities lives. However, in some instances, in order to attain a certain training objective, special time-limited rehabilitation courses may be organized, where appropriate, in residential form.
• Persons with disabilities and their families should be encouraged to involve themselves in rehabilitation, for instance as trained teachers, instructors or counsellors.
• States should draw upon the expertise of organizations of persons with disabilities when formulating or evaluating rehabilitation programmes.
World Programme of Action Concerning Disabled Persons
Adopted by the United Nations General Assembly, thirty-seventh session, Resolution 37/52 of 3 December 1982
Prevention of impairment, disability and handicap
The technology to prevent and control most disablement is available and improving but is not always fully utilized. Member States should take appropriate measures for the prevention of impairment and disability and ensure the dissemination of relevant knowledge and technology.
Coordinated programmes of prevention at all levels of society are needed. They should include:
• Community-based primary health care systems that reach all segments of the population, particularly in rural areas and urban slums;
• Effective maternal and child health care and counselling, as well as counselling for family planning and family life;
• Education in nutrition and assistance in obtaining a proper diet, especially for mothers and children, including the production and utilization of foods rich in vitamins and other nutrients;
• Immunization against communicable diseases, in line with the objectives of the Expanded Programme of Immunization of the World Health Organization;
• A system for early detection and early intervention;
• Safety regulations and training programmes for the prevention of accidents in the home, in the workplace, on the road and in leisure-related activities;
• Adaptation of jobs, equipment and the working environment and the provision of occupational health programmes to prevent the generation of occupational disabilities or diseases and their exacerbation;
• Measures to control the imprudent use of medication, drugs, alcohol, tobacco and other stimulants or depressants in order to prevent drug-related disability, particularly among schoolchildren and elderly people. Of particular concern also is the effect upon unborn children of imprudent consumption of these substances by pregnant women;
• Educational and public health activities that will assist people in attaining life-styles that will provide the maximum defence against the causes of impairment;
• Sustained education of the public and of professionals as well as public information campaigns related to disability prevention programmes;
• Adequate training for medical, paramedical and other persons who may be called upon to deal with casualties in emergencies;
• Preventive measures incorporated in the training of rural extension workers to assist in reducing incidence of disabilities;
• Well-organized vocational training and practical on-the-job training of workers with a view to preventing accidents at work and disabilities of different degrees. Attention should be paid to the fact that outdated technology is often used in developing countries. In many cases, old technology is transferred from industrial countries to developing countries. The old technology, inappropriate for the conditions in developing countries, together with insufficient training and deficient labour protection, contributes to an increased number of accidents at work and to disabilities.
Member States should develop and ensure the provision of rehabilitation services necessary for achieving the objectives of the World Programme of Action.
Member States are encouraged to provide for all people the health care and related services needed to eliminate or reduce the disabling effects of impairment.
This includes the provision of social, nutritional, health and vocational services needed to enable disabled individuals to reach optimum levels of functioning. Depending on such factors as population distribution, geography and stages of development, services can be delivered through the following channels:
• Community-based workers;
• General facilities providing health, education, welfare and vocational services;
• Other specialized services where the general facilities are unable to provide the necessary services.
Member States should ensure the availability of aids and equipment appropriate to the local situation for all those to whose functioning and independence they are essential It is necessary to ensure the provision of technical aids during and after the rehabilitation process. Follow-up repair services and replacement of aids that are obsolete are also needed. 101 It is necessary to make certain that disabled persons who need such equipment have the financial resources as well as the practical opportunities for obtaining them and learning to use them . Import taxes or other procedures that block the ready availability of aids and materials which cannot be manufactured in the country and must be obtained from other countries should be eliminated. It is important to support local production of aids that are suited to the technological, social and economic conditions under which they will be used Development and production of technical aids should follow the overall technological development of a specific country.
To stimulate local production and development of technical aids, Member States should consider establishing national centres with a responsibility to support such local developments. In many cases existing special schools, institutes of technology, etc., could serve as a basis for this. Regional cooperation in this connection should be considered.
Member States are encouraged to include within the general system of social services personnel competent to provide counselling and other assistance needed to deal with the problems of disabled persons and their families.
When the resources of the general social service system are inadequate to meet these needs, special services may be offered until the quality of the general system has been improved.
Within the context of available resources, Member States are encouraged to initiate whatever special measures may be necessary to ensure the provision and full use of services needed by disabled persons living in rural areas, urban slums and shanty towns.
Disabled persons should not be separated from their families and communities. The system of services must take into account problems of transportation and communication; the need for supporting social, health and education services; the existence of primitive and often hazardous living conditions; and, especially in some urban slums, social barriers that may inhibit people's readiness to seek or accept services. Member States should assure an equitable distribution of these services to all population groups and geographical areas according to need.
Health and social services for mentally ill persons have been particularly neglected in many countries. The psychiatric care of persons with mental illness should be supplemented by the provision of social support and guidance to these persons and their families, who are often under particular strain. Where such services are available, the length of stay and the probability of renewed referral to institutions are lessened. In cases where mentally retarded persons are additionally afflicted with problems of mental illness, provisions are necessary to ensure that health care personnel are aware of the distinct needs related to retardation.
Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care
Adopted by the United Nations General Assembly, forty-sixth session, Resolution 46/119 of 17 December 1991
Principles 6-14, 22
Principle 6 - Confidentiality
The right of confidentiality of information concerning all persons to whom these Principles apply shall be respected.
Principle 7 - Role of community and culture
• Every patient shall have the right to be treated and cared for, as far as possible, in the community in which he or she lives.
• Where treatment takes place in a mental health facility, a patient shall have the right, whenever possible, to be treated near his or her home or the home of his or her relatives or friends and shall have the right to return to the community as soon as possible.
• Every patient shall have the right to treatment suited to his or her cultural background.
Principle 8 - Standards of care
• Every patient shall have the right to receive such health and social care as is appropriate to his or her health needs, and is entitled to care and treatment in accordance with the same standards as other ill persons.
• Every patient shall be protected from harm, including unjustified medication, abuse by other patients, staff or others or other acts causing mental distress or physical discomfort.
Principle 9 - Treatment
• Every patient shall have the right to be treated in the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the patient's health needs and the need to protect the physical safety of others.
• The treatment and care of every patient shall be based on an individually prescribed plan, discussed with the patient, reviewed regularly, revised as necessary and provided by qualified professional staff.
• Mental health care shall always be provided in accordance with applicable standards of ethics for mental health practitioners, including internationally accepted standards such as the Principles of Medical Ethics adopted by the United Nations General Assembly. Mental health knowledge and skills shall never be abused.
• The treatment of every patient shall be directed towards preserving and enhancing personal autonomy.
Principle 10 - Medication
• Medication shall meet the best health needs of the patient, shall be given to a patient only for therapeutic or diagnostic purposes and shall never be administered as a punishment or for the convenience of others. Subject to the provisions of paragraph 15 of Principle 11, mental health practitioners shall only administer medication of known or demonstrated efficacy.
• All medication shall be prescribed by a mental health practitioner authorized by law and shall be recorded in the patient's records.
Principle 11 - Consent to treatment
• No treatment shall be given to a patient without his or her informed consent, except as provided for in paragraphs 6, 7, 8, 13 and 15 below.
• Informed consent is consent obtained freely, without threats or improper inducements, after appropriate disclosure to the patient of adequate and understandable information in a form and language understood by the patient on:
a. The diagnostic assessment;
b. The purpose, method, Likely duration and expected benefit of the proposed treatment;
c. Alternative modes of treatment, including those less intrusive; and
d. Possible pain or discomfort, risks and side-effects of the proposed treatment.
• A patient may request the presence of a person or persons of the patient's choosing during the procedure for granting consent.
• A patient has the right to refuse or stop treatment, except as provided for in paragraphs 6, 7, 8, 13 and 15 below. The consequences of refusing or stopping treatment must be explained to the patient.
• A patient shall never be invited or induced to waive the right to informed consent. If the patient should seek to do so, it shall be explained to the patient that the treatment cannot be given without informed consent.
• Except as provided in paragraphs 7, 8, 12, 13, 14 and 15 below, a proposed plan of treatment may be given to a patient without a patient's informed consent if the following conditions are satisfied:
a. The patient is, at the relevant time, held as an involuntary patient;
b. An independent authority, having in its possession all relevant information, including the information specified in paragraph 2 above, is satisfied that, at the relevant time, the patient lacks the capacity to give or withhold informed consent to the proposed plan of treatment or, if domestic legislation so provides, that, having regard to the patient's own safety or the safety of others, the patient unreasonably withholds such consent; and
c. The independent authority is satisfied that the proposed plan of treatment is in the best interest of the patient's health needs.
• Paragraph 6 above does not apply to a patient with a personal representative empowered by law to consent to treatment for the patient; but, except as provided in paragraphs 12, 13, 14 and 15 below, treatment may be given to such a patient without his or her informed consent if the personal representative, having been given the information described in paragraph 2 above, consents on the patient's behalf.
• Except as provided in paragraphs 12, 13, 14 and 15 below, treatment may also be given to any patient without the patient's informed consent if a qualified mental health practitioner authorized by law determines that it is urgently necessary in order to prevent immediate or imminent harm to the patient or to other persons. Such treatment shall not be prolonged beyond the period that is strictly necessary for this purpose.
• Where any treatment is authorized without the patient's informed consent, every effort shall nevertheless be made to inform the patient about the nature of the treatment and any possible alternatives and to involve the patient as far as practicable in the development of the treatment plan.
• All treatment shall be immediately recorded in the patient's medical records, with an indication of whether involuntary or voluntary.
• Physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others. It shall not be prolonged beyond the period which is strictly necessary for this purpose. All instances of physical restraint or involuntary seclusion, the reasons for them and their nature and extent shall be recorded in the patient's medical record. A patient who is restrained or secluded shall be kept under humane conditions and be under the care and close and regular supervision of qualified members of the staff. A personal representative, if any and if relevant, shall be given prompt notice of any physical restraint or involuntary seclusion of the patient.
• Sterilization shall never be carried out as a treatment for mental illness.
• A major medical or surgical procedure may be carried out on a person with mental illness only where it is permitted by domestic law, where it is considered that it would best serve the health needs of the patient and where the patient gives informed consent, except that, where the patient is unable to give informed consent, the procedure shall be authorized only after independent review.
• Psychosurgery and other intrusive and irreversible treatments for mental illness shall never be carried out on a patient who is an involuntary patient in a mental health facility and, to the extent that domestic law permits them to be carried out, they may be carried out on any other patient only where the patient has given informed consent and an independent external body has satisfied itself that there is genuine informed consent and that the treatment best serves the health needs of the patient.
• Clinical trials and experimental treatment shall never be carried out on any patient without informed consent, except that a patient who is unable to give informed consent may be admitted to a clinical trial or given experimental treatment, but only with the approval of a competent, independent review body specifically constituted for this purpose.
• In the cases specified in paragraphs 6, 7, 8, 13, 14 and 15 above, the patient or his or her personal representative, or any interested person, shall have the right to appeal to a judicial or other independent authority concerning any treatment given to him or her.
Principle 12 - Notice of rights
• A patient in a mental health facility shall be informed as soon as possible after admission, in a form and a language which the patient understands, of all his or her rights in accordance with these Principles and under domestic law, which information shall include an explanation of those rights and how to exercise them.
• If and for so long as a patient is unable to understand such information, the rights of the patient shall be communicated to the personal representative, if any and if appropriate, and to the person or persons best able to represent the patient's interests and willing to do so.
• A patient who has the necessary capacity has the right to nominate a person who should be informed on his or her behalf, as well as a person to represent his or her interests to the authorities of the facility.
Principle 13 - Rights and conditions in mental health facilities
• Every patient in a mental health facility shall, in particular, have the right to full respect for his or her:
a. Recognition everywhere as a person before the law;
c. Freedom of communication, which includes freedom to communicate with other persons in the facility; freedom to send and receive uncensored private communications; freedom to receive, in private, visits from a counsel or personal representative and, at all reasonable times, from other visitors; and freedom of access to postal and telephone services and to newspapers, radio and television;
d. Freedom of religion or belief.
• The environment and living conditions in mental health facilities shall be as close as possible to those of the normal life of persons of similar age and in particular shall include:
• In no circumstances shall a patient be subject to forced labour. Within the limits compatible with the needs of the patient and with the requirements of institutional administration, a patient shall be able to choose the type of work he or she wishes to perform.
• The labour of a patient in a mental health facility shall not be exploited. Every such patient shall have the right to receive the same remuneration for any work which he or she does as would, according to domestic law or custom, be paid for such work to a non-patient. Every such patient shall, in any event, have the right to receive a fair share of any remuneration which is paid to the mental health facility for his or her work.
Principle 14 - Resources for mental health facilities
• A mental health facility shall have access to the same level of resources as any other health establishment, and in particular:
a. Qualified medical and other appropriate professional staff in sufficient numbers and with adequate space to provide each patient with privacy and a programme of appropriate and active therapy;
b. Diagnostic and therapeutic equipment for the patient;
c. Appropriate professional care; and
d. Adequate, regular and comprehensive treatment, including supplies of medication.
• Every mental health facility shall be inspected by the competent authorities with sufficient frequency to ensure that the conditions, treatment and care of patients comply with these Principles.