Application of the Paternalism Principle to Constitutional Rights: Mental Health Case-Law in Ireland

In adjudicating on matters relating to fundamental constitutional or human rights, courts make important statements about the principles which apply. The principles articulated will have a profound impact on the outcomes of such cases, and on the development of case-law in the relevant field. In the fields of medical law and mental health law, various courts have moved away from deference to medical decision-making and paternalism to a person-centred rights-based approach. However, courts in Ireland have continued to interpret mental health law in a paternalistic fashion, praising paternalism as if it is particularly suitable for mental health law. This raises profound questions about judicial attitudes to people with mental health conditions and judicial reluctance to confer full personhood on people with disabilities. This article outlines case-law in Ireland regarding paternalism in mental health law and discusses the consequences for constitutional rights in Ireland.

Mental Health Law

The debate about whether mental health law should be abolished or reformed emerged during the negotiations of the Convention on the Right of Persons with Disabilities (‘CRPD’) and has raged fiercely for over a decade. It has resulted in an impasse between abolitionists, States Parties, and other reformers and a literature which has devolved into ‘camps’. Mental Health Law: Abolish or Reform? aims to cut through the confusion using the tools of human rights treaty interpretation backed by a deep jurisprudential analysis of core CRPD concepts—dignity (including autonomy), equality, and participation—to gain a clearer understanding of the meaning of the CRPD and what it requires States Parties to do. In doing so, it sets out the development of both mental health law and the abolitionist movement including its goals and how and why it has emerged now. By digging deeper into the conceptual basis of the CRPD and developing the ‘interpretive compass’, the book aims to flesh out a broader vision of disability rights and move the debate forward by evaluating the three main current abolition and reform options: Abolition with Support, Mental Capacity with Support, and Support Except Where There is Harm. Drawing on jurisprudential and multi-disciplinary research from philosophy, medicine, sociology, disability studies, and history, it argues that mental health law should not be abolished, but should instead be significantly reformed to minimize coercion and maximize the support and choices given to persons with mental impairments to realize of all of their CRPD rights.

The History, Justification, and Purpose of Mental Health Law

Chapter 2 examines the historical development of mental health law in England (which is similar to the rest of the common law world, including America, Canada, and Australia) and uses that history to consider the justification, purpose, and need for mental health law from Ancient Greece to the present. Contrary to the claims of abolitionists that mental health law has essentially always stayed the same, it demonstrates a history of continuous legal and systemic reform in mental health law. Rather than an over-zealous and interfering state keen to exercise social control over persons with mental impairment, it instead depicts a state which for the most part reluctantly only became involved in the care of persons with mental health problems when informal care by family and friends failed or was non-existent, to prevent abuses by private operators, and as an incident of its administration of the criminal law. When set against the background of the fashions, cycles, and recurring themes of mental health law, the call of abolition can be conceptualized as simply the latest fad in its evolution. Further, many of the issues which arise from mental health problems will continue to exist even without mental health law. Mental health law can be positive and negative, including defining and protecting rights and allocating resources. The chapter cautions against being too optimistic about the promises of sweeping revolutionary changes which have never really delivered (deinstitutionalization or the ‘abolition’ of the asylum being the most poignant example), in favour of solid incremental change.

The Interpretive Framework and the Reform (as opposed to the Abolition) of Mental Health Law

Having rejected the abolition of mental health law in Chapters 4 to 7, Chapter 8 explores the possibility of the reform of mental health law. It explains the Mental Capacity with Support and Support Except Where There is Harm models. It applies the interpretive compass of inherent dignity (including autonomy), equality, and participation to both models and compares them to the Abolition with Support model. It argues in favour of the Mental Capacity with Support model as being compatible with the CRPD (despite the contrary arguments from abolitionists) and more transparent than Abolition with Support. It proposes improvements to the Mental Capacity with Support model. It discusses wider reforms to the mental health system, social reforms, and how reform is possible without abolishing mental health law first.

Conclusion

Chapter 9 summarizes the arguments in each chapter, discusses my conceptual framework and methodology, and brings together all of the issues discussed in the book to a focussed and practical conclusion. It justifies why I argue that contrary to the arguments of abolitionists, mental health law should not be abolished, but be reformed by decreasing coercion and increasing social support to persons with mental impairments to maximize their dignity (including autonomy), equality, and participation in accordance with the overall object and purpose of the CRPD.