EHRM, 02-10-2012, nr. 41242/08

The applicant was born in 1975 and lives in Dunakeszi.

At the time of introducing the application, the applicant, a university dropout and unemployed, lived on financial support from his mother and grandmother.

On 12 September 2006 the applicant's mother consulted her psychiatrist, Dr M., complaining of suffering from distress due to the ‘strange behaviour’ of her son. According to the mother's medical file, she stated that the applicant ‘kept wandering in town’, ‘did not have any friends’ and ‘did not look after himself’. In response, Dr M. informed her of the possibilities either to commit the applicant to a psychiatric hospital for emergency treatment or to initiate a procedure for obtaining his mandatory institutional treatment, if necessary.

On 6 November 2006 the mother informed Dr M. that the reason for her having previously moved out of their common flat was the applicant's ‘strange behaviour’ and that she was afraid of returning. On 4 December 2006 Dr M. noted in the mother's medical file that she was discussing with her the problems concerning the applicant, whom his mother perceived as psychotic.

During their subsequent consultations, the mother repeatedly mentioned to Dr M. that the reason for her anguish was that the applicant had not taken up a proper job and still lived on financial support from his family. In her medical file Dr M. reiterated the view that the mother's problem originated in her son's conduct perceived as psychotic by the mother.

On 17 September 2007 the applicant was called on to meet Dr M. They discussed the applicant's dropping out of university and his inability to meet his mother's expectations. Dr M.'s diagnosis was ‘paranoid schizophrenia under observation’.

Subsequently Dr M. gave the applicant an appointment for a psychological examination, which took place on 22 September 2007. On that day, Dr L. examined the applicant and found that he was characterised ‘by schizoid isolation, sensitive attitude and paranoid behaviour’.

Further sessions involving the applicant, Dr M. and Dr L. took place on 24 and 28 September and 3 and 5 October 2007. At these sessions he expressed his interest in politics and voiced hopes of being elected Mayor of Budapest. Dr M. was trying to find out the reasons for his social isolation and convince him about the need to reconcile his projects with reality. The applicant missed two sessions scheduled for 12 and 19 October 2007.

Having noted that the applicant's ideas had remained megalomaniac, on 24 October 2007 Dr M. confronted the applicant with her view that his social isolation was due to a psychiatric disorder.

On 31 October 2007 the applicant renounced further counselling by Dr M. About the same time, he also stopped seeing Dr L.

On 5 and 6 November 2007 the mother complained to Dr M. that she, in despair because of the applicant's condition, was unable to pay her utility bills, exorbitant due to the applicant's habit of using too much water for ‘ritual bathing’. Dr M. explained to her that the applicant was expected to seek treatment voluntarily.

Since the applicant did not do so, on 26 November 2007 Dr M. requested the Dunakeszi District Court to order his mandatory institutional treatment. This application consisted of a pre-printed form stating that there was a possibility that the applicant's conduct would become dangerous because of a mental disorder. Dr M. completed the form by adding that the applicant's mother asked her for assistance since she had the suspicion that her son was mentally ill, that the applicant had contacted Dr M. upon notice, that he had not worked for eight years, was supported by his mother, lived an isolated life, and did not get in touch with anyone, and finally that he was short-tempered towards his mother, who had moved away from the flat as the patient's behaviour was threatening.

On 11 December 2007 the Dunakeszi District Court held a hearing. For the purposes of the ensuing proceedings, a guardian ad litem was appointed for the applicant. The District Court heard Dr M. In her testimony, she repeated in essence the elements contained in the application for mandatory treatment. She stated that she had suspected that the applicant might have a psychiatric illness when, on 12 September 2006, the mother had told her that the applicant had refused to use a micro-wave oven for fear of radiation, and that she had concluded that the applicant was psychotic on 24 September 2007 when he had mentioned his hope of being elected Mayor of Budapest.

Dr M. related that, in addition to the applicant's mother, his grandmother and her partner, living next door to the applicant, were also concerned about his odd conduct. She stated that she had the suspicion that the applicant suffered from paranoid schizophrenia. She also mentioned that the applicant had on several occasions visited a psychologist, Dr L., who had observed stress and paranoid symptoms which, however, did not amount to a pathological or psychotic mental state, although the applicant had been capable of disguising his symptoms.

Dr M. specified that she had instituted proceedings for the applicant's mandatory treatment after he had refused to be counselled by her.

The District Court then heard the applicant. It noted that his replies were disoriented and erratic. He was asked questions about his lifestyle and hobbies, his relationship with his grandmother, his willingness to take up a job as well as any illnesses he had. He said he was considering the necessity of a job and of seeking advice from social workers or medical help from health professionals, excluding Dr M.

During the hearing the court ordered a forensic psychiatrist, Dr H., to prepare a medical opinion about the applicant's condition. This psychiatric evaluation was done during the break in the court hearing, in approximately forty minutes. Neither the guardian ad litem nor the applicant had the opportunity to learn about the expert opinion prior to the resumed hearing. Dr H. did not produce any written opinion at this stage; she presented her testimony to the court verbally following the break. Its written version was faxed to the court on 13 December 2007.

Dr H. considered that the applicant suffered from delusional schizophrenia, characterised by grandiose delusions, bizarre elements of lifestyle and partial insight into his condition. She specified that she considered the applicant's treatment necessary since otherwise his health would decline, whereas therapy might improve his condition. She was of the view that the applicant could not take care of himself, by which he represented a significant danger to himself. She was not convinced that the applicant would voluntarily seek outpatient care but suggested that a decision on compulsory treatment be postponed for six months, in order to observe the applicant's conduct. The judge pointed out that no such option was allowed under the relevant law.

On 18 December 2007 the District Court held another hearing, at the beginning of which Dr H.'s report was handed over to the applicant and his guardian ad litem. Dr M. was summoned but failed to appear. The guardian argued in essence that the applicant's behaviour was not dangerous and that he posed no significant threat either to himself or others. He noted that neither Dr M.'s nor Dr H.'s testimony contained elements pointing to the applicant's representing any danger.

On the same day the District Court ordered the applicant's mandatory institutional treatment. Relying on the medical opinions, it accepted that he suffered from schizophrenia with grandiose delusions and was satisfied that he posed a danger to his own health by failing voluntarily to subject himself to psychiatric treatment and by not looking after himself. The court affirmed that ‘appropriate medical treatment would improve [the applicant's] condition’ and that, if untreated, his health would decline. It observed the applicant's statement about his willingness to seek medical help voluntarily but was not convinced that he would actually do so.

The court's decision was based on sections 188(b) and 200(1) of the Act no. CLIV of 1997 on Health Care (‘the Health Act’) and on the Supreme Court's leading case (EBH2004.1130) (see below paragraphs 32–33).

On 27 December 2007 Dr H. submitted to the court her opinion in hard copy. On the same day the applicant contacted the MDAC seeking advice on possible remedies against the court order. He was advised to appeal against the decision. During the second-instance proceedings, the applicant continued to be represented by the guardian ad litem appointed for him by the District Court, whereas MDAC provided him with additional legal advice.

On 14 January 2008 the guardian ad litem appealed to the Pest County Regional Court. He argued that the conditions for mandatory treatment as required by the Health Act were not fulfilled, since the evidence provided by the two psychiatrists involved did not prove the applicant's significant dangerous character but consisted of no more than vague predictions of an eventual deterioration in the applicant's condition. The decision was not in conformity with the Health Act, since the District Court had established the applicant's dangerous character relying on his lifestyle rather than a mental illness and its symptoms; in fact, the forensic expert had merely suspected the presence of a mental disorder and her opinion did not contain a proper diagnosis or substantiate that the degree of the applicant's mental illness warranted mandatory treatment.

On 12 February 2008 the Regional Court dismissed the applicant's appeal and upheld the first-instance decision, endorsing in essence its reasoning. This decision was served on the applicant on 4 March 2008; the time-limit to file a petition for review by the Supreme Court accordingly expired on 3 May 2008.

On 27 March 2008 the applicant's treatment commenced at Vác Hospital. On admission, he was held in the closed ward of the psychiatric department. Two weeks later he was transferred to the regular ward of the department.

On 25 April 2008 the geographically competent Vác District Court conducted a review of the applicant's hospitalisation. Relying on the opinion of forensic expert Dr T. — according to whom the applicant, whose condition had improved, suffered from schizophrenia hallmarked by residual symptoms of a psychotic state, but represented no direct danger and was willing to accept voluntary treatment — it held that the conditions for mandatory treatment were no longer met in the applicant's case and ordered his release.

On 6 May 2008 the MDAC attempted to obtain a copy of the petition for review from the court for their records and found out that it had never been lodged by the applicant's guardian ad litem, despite his exclusive entitlement and his promise to do so.

The relevant provisions of the Health Act read as follows:

Section 188

Section 197 — Voluntary treatment

Section 198

Section 199 — Urgent hospitalisation

Section 200 — Compulsory treatment

Supreme Court leading case no. EBH2004.1130 contains the following passages:

The Government submitted the following elements concerning the law on the subject matter of the application in various European jurisdictions.

According to the findings of the Final Report of a Research Project financed by the European Commission in 2002 on the ‘Compulsory Admission and Involuntary Treatment of Mentally Ill Patients — Legislation and Practice in EU Member States’, the legal criteria qualifying a person for involuntary placement in a psychiatric facility differ widely across the Member States of the European Union. The research focused on 15 EU Member States but its findings can be generalised as regards all 47 Member States of the Council of Europe, only the number of States belonging to different models varies.

When determining the criteria for compulsory admission, a basic conflict between a medical model and a civil liberties approach can be identified. These two approaches can also be characterised as the ‘parens patriae’ approach or the ‘police powers’ approach, respectively. The medical model emphasises the need for treatment as a sufficient prerequisite for the involuntary confinement of a mentally ill patient. Supporters of the medical model consider compulsory admission to be essential and inevitable to secure treatment for patients whose mental illness interferes with their capacity to accept treatment on a voluntary basis. Similarly, the ‘parens patriae’ approach is the public-policy power of the State to act as the parent of an individual who is in need of protection but cannot protect himself. On the basis of this power, State authorities may make decisions regarding mental health treatment on behalf of one who is mentally incompetent to make the decision himself. A strict human-rights approach accepts forced hospital admission only when a mentally ill person threatens to do harm to others or himself. This is the only criterion (‘dangerousness criterion’) justifying or permitting someone to be admitted involuntarily. This is similar to the police-power approach which authorises and requires the State only to interfere in order to protect the public order and the rights and safety of others.

The first and common condition for compulsory admission is the existence of a ‘mental disorder’. This term is generally not defined by legislation and is given a wide definition in practice. Among the States covered by the comparative analysis, only Denmark restricts this condition to ‘psychosis’. The same restricted meaning is given to this term in practice in Finland. Schizophrenia is generally included in the notion of psychosis. Therefore it can be concluded that schizophrenia is regarded in the Member States of the Council of Europe as a mental disorder of a kind or degree warranting compulsory confinement.

As to the further conditions of compulsory admission, danger to oneself or to others is not an essential prerequisite everywhere. It is completely absent as a criterion in Italy and Spain. A serious threat of harm to the person himself and/or to others is an essential prerequisite for compulsory admission in Austria, Belgium, Germany, Luxembourg, Sweden and the Netherlands. Many States, including Denmark, Finland, France, Greece, Ireland, Portugal, the United Kingdom and Latvia apply both the dangerousness criterion and the need-for-treatment criterion, as alternatives, to admit mentally ill patients involuntarily. The dangerousness criterion is not applied in a uniform manner in the Member States of the European Union. Some States qualify the level of danger required for admitting a person involuntarily, others do not. The defined thresholds, however, are rather vague, requiring that the danger to health or safety of the person concerned or to the public be ‘serious’, ‘immediate’, ‘significant’ or ‘substantial’. Some countries include only public threats, while others add the element of possible harm to the patient himself. In some jurisdictions, the risk of deterioration of the patient's health is expressly mentioned in the law (Denmark, Finland, Portugal, Latvia and the United Kingdom (in respect of certain psychiatric conditions)), but it is not clear whether and to what extent the risk of deterioration is included by judicial interpretation in the danger to one's own health in other States. Among those countries that stipulate the need for treatment as a criterion, Finland, France, Ireland, Portugal and Spain additionally emphasise the lack of insight by the patient.

Guardianship rules may also affect the conditions of involuntary admission and treatment of patients with mental disorders. In Germany, there are 16 different admission laws (Unterbringungsgesetz) in force in the public laws of the Länder and one guardianship law (Betreuungsgesetz) in force in the federal civil law, regulating the detention of mentally ill persons under certain circumstances. The public-law aspect is fundamentally determined by a decision of the Federal Constitutional Court, confirming an overall ‘right to be ill’ and largely exempting the society from responsibility for improving the condition of citizens by infringing upon their personal freedom. The function of public law is to avert danger to public order and security relating to mentally ill persons, whereas that of guardianship law is to secure appropriate personal, medical and economic care for those in need due to disability or illness. Such persons are taken care of by a court-appointed guardian who can decide on the necessity of psychiatric treatment, including hospitalisation.

Similarly, in Luxembourg, the Mental Health Act authorises compulsory admission only if the person suffering from severe mental disorder is dangerous to himself or to other persons, whereas the Act on the incapacity of adults (guardianship) is regarded as serving the protection of mentally ill persons.

The same dichotomy is reflected in the law of France where different conditions are applicable depending on the initiator of compulsory admission: if it is initiated by a ‘third party’ (a relative or other private party), the person suffering from mental disorder rendering his consent impossible must be in a state that requires immediate care and constant supervision in a hospital, whereas if it is initiated by the police, it must be shown that the person whose mental disorder jeopardises law and order or public safety may cause danger to others.

In Ireland, if a police officer has reasonable grounds for believing that a person suffers from a mental disorder and that there is a serious likelihood of that person causing immediate and serious harm to himself or to others, the police may take the person into custody. If confinement is initiated by other persons, it is sufficient that a registered medical practitioner be satisfied that the person is suffering from a mental disorder.

In Denmark, compulsory admission is justified if the psychotic patient is either dangerous to self/others or if the prospect for recovery will diminish substantially if detention in a psychiatric ward will not take place. The involuntary admission of a patient to a Danish psychiatric ward will always be for a therapeutic reason; the placement of incurably mentally disordered people without medical aims is illegal. The Act on guardianship is applied to placement in nursing homes of incurably mentally disordered people.

In Finland, involuntary treatment is allowed both due to ‘need for treatment’ and ‘dangerousness’. For the purposes of ‘need for treatment’, the possible deterioration of the mental illness is expressly referred to. The process of ordering compulsory confinement is organised as a primarily medical decision-making one, similarly to Ireland and Luxembourg.

In Greece, in addition to preventing acts of violence against himself or others, a person suffering from a severe psychiatric disorder can be admitted and treated involuntarily when this disorder makes the patient unable to look after his own well being, and (or) treatment is expected to improve his condition and reverse the deterioration of his mental health.

In Portugal, compulsory admission can be ordered by a court either if the person concerned represents real danger to himself/others as the result of a mental anomaly and he refuses treatment or if the absence of adequate treatment would entail a risk of further deterioration, of which the person himself is unaware.

In the United Kingdom (England and Wales), the criteria for detention (admission for assessment or treatment) specify that it must be necessary either in the interests of the patient's health, or his safety, or for the protection of other persons. In the case of treatment orders of those with psychopathic disorder or mental impairment, there is a further condition, namely that treatment must be ‘likely to alleviate or prevent a deterioration’ of the condition in question. Compulsory admission for treatment is justified only if appropriate treatment is available for the person concerned.

In Latvia, psychiatric assistance without the consent of a patient is provided for not only if the patient behaves violently or threatens to cause personal injuries to himself or to another person but also if the patient with a mental health disorder has disclosed an inability to care for himself (or for a person under his guardianship) and his health might unavoidably and seriously deteriorate.

Romanian law also allows for compulsory hospitalisation of a mental patient on account of the risk of a serious deterioration of his health.

In sum, the majority of the Member States of the European Union perceive the risk of deterioration of the patient's health as justifying his compulsory hospitalisation if he refuses to receive treatment voluntarily. In those States where compulsory hospitalisation is more restricted, guardianship laws are applied to provide treatment to persons suffering from a mental disorder without their consent.

As regards the condition that the person detained under Article 5 § 1 (e) must be reliably shown to be of unsound mind, the expertise required to assess the medical criteria for admitting a person involuntarily are heterogeneous across the Member States of the European Union. The laws of several States permit doctors other than trained psychiatrists to be involved in the initial medical assessment of the persons concerned not only in emergency cases but also during routine involuntary placement procedures (and thorough assessments are performed by psychiatrists only when a patient is admitted to a psychiatric facility), whereas the expert testimony of a psychiatrist is mandatory in the remaining countries (Austria, Greece, Ireland, the Netherlands, Portugal, Spain, the United Kingdom and some of the 16 German Länder). Most Member States (Austria, France, Finland, Greece, Ireland, Italy, Luxembourg, Portugal, Spain, Sweden and the United Kingdom) require the opinion or certificate of more than one expert (but not necessarily all of them being a psychiatrist and not necessarily prior to ordering compulsory admission); the opinion of one expert is sufficient in Belgium, Denmark and the Netherlands. In Denmark, Finland, Ireland, Luxembourg and Sweden, the decision is left to psychiatrists or other health care professionals, whereas in 10 other States the decision is made either by judges, prosecutors, mayors or other agencies independent from the medical system (e.g. social workers in the United Kingdom).

Several States require that less restrictive treatment options be considered before ordering compulsory hospitalisation. In Belgium, compulsory admission is applicable only when there is no other adequate treatment option. In practice, this is equivalent to the patient's refusing voluntary treatment. In the United Kingdom (England and Wales) the criteria for detention specify that the patient must be suffering from a mental disorder ‘of a nature or degree’ which makes it ‘appropriate’ for the patient to receive assessment or treatment in hospital. In effect, this means that treatment in the community must be impractical or impossible, the latter being most commonly because the patient cannot be relied upon to be compliant with assessment or treatment on a voluntary basis. Compulsory outpatient treatment as a possible less restrictive alternative to compulsory hospitalisation is mentioned in the laws of only four Member States (Belgium, Luxembourg, Portugal and Sweden).

The applicant submitted that from the academic literature it was evident that Western European countries recognised dangerousness and incapacity to consent to treatment as two separate issues in their mental health systems. Most provided for involuntary treatment separately on both grounds (e.g. the United Kingdom), some only on the basis of incapacity (e.g. the Netherlands), but they did not conflate the two issues.

In a decision of 23 March 2011 - 2 BvR 882/09 — the German Federal Constitutional Court accepted a constitutional complaint lodged by a convicted felon committed to a psychiatric hospital as a measure of correction and prevention, holding that the relevant legislation in Rhineland-Palatinate was unconstitutional. The Federal Constitutional Court summarised the case as follows:

The Federal Constitutional Court held in particular as follows:

[Unofficial translation by the European Court's Registry:]

The case summary continues as follows:

Article 12 of the United Nations Convention on the Rights of Persons with Disabilities reads as follows:

Equal recognition before the law

The United Nations Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (adopted by General Assembly, resolution 46/119 of 17 December 1991) contain the following passage:

Principle 16 — Involuntary admission

The World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems (10th Revision) (ICD-10) defines paranoid schizophrenia as follows:

F20.0 Paranoid schizophrenia

The applicant complained that his involuntary psychiatric treatment amounted to an unjustified deprivation of liberty in breach of Article 5 § 1 (e). The Government contested this view.

Article 5 § 1 provides as relevant:

Article 41 of the Convention provides: