Psychiatric Annals

Psychiatry and the Problem of Human Rights: Ethical Issues

Howard P Rome, MD

Abstract

The World Psychiatric Association, as a collegia! body, will celebrate its 25th Anniversary at a meeting to be held in Copenhagen in August 1986. As a significant part of itsproceedings.it will review in an historical perspective (he aflairs of international psychiatry of the past quarter century. The salience of ethical problems in regard to civil rights of persons alleged to be patients in need of psychiatric hospital care will be a prominent feature of the meeting.

Inasmuch as a detailed clinical history is essential to untangling the skein of events which constitute the elements of eihical-psyehiatric problems, the following account is presented.

Professor Walter Ullman. a distinguished medievalist, in a series of lecfures that were given at the Johns Hopkins University said: ''There are probably few topics in modern social and political thought which arouse greater interest than the status, function and power of the individual within the State, within the organized body of citizens." He went on to say there is "a fairly general agreement, at least within the Western orbit, on the autonomous independent status of the individual within society . . . Man as an individual has certain inalienable rights which no power of government can take away, and with which no government may with impunity interfere."

Professor Ullman documented the point that since the Middle Ages, there has emerged a vital difference between the individual as a mere subject and the individual as a citizen, the latter status being what Dante called the most precious gift which God had conferred on man - "his freedom."

Thus it is that in relatively recent times, the role of the psychiatrist as a professional with responsibilities both to his patients and to society has been seriously challenged by those who see the potential for abuse. More than any other discipline in medicine, psychiatry is intimately involved with social values and consequently with ethical considerations in which such ambiguous issues as competence, responsibility, and dangerousness may be fraught with prejudice and personal bias. So it is that human rights - ethical issues - arose as a concern of international psychiatry.

John Stuart Mill, in his 1859 essay "On Liberty," recognized this politicization when he wrote: "In former days, when it was proposed to burn atheists, charitable people used to suggest putting them in the madhouse instead; it would be nothing surprising nowadays were we to see this done, and the doers applauding themselves because, instead of persecuting for religion, they had adopied so humane and so Christian a mode of treating these unfortunates, not without a silent satisfaction at their having thereby obtained their deserts."

My first personal acquaintance with this alleged misuse of psychiatric facilities by psychiatrists was in March 1971. I had received a letter from Dr. Norman Hirt of Vancouver which indicated that "for some years" some Russian psychiatrists had been involved in the incarceration of "dissident young people, artists, writers, as well as older citizens who are involved with civil rights. "This, Hirt went on to say. was "without recourse to law or adequate psychiatric investigation." Further, he pointed out that "with the history of the Nazi Holocaust, which in part began with the misuse of medical people by political factions, that there is some fear that similarly, there be misuse of psychiatric technology in mental hospitals anywhere in the world for political and repressive needs." As lhe then Chairman of the Section of Psychiatry of the British Columbia Medical Association, he prepared a brief, after assembling additional information. which led to a final resolution by the Executive Council of the Canadian Psychiatric Association.

Doctor Hirt…

The World Psychiatric Association, as a collegia! body, will celebrate its 25th Anniversary at a meeting to be held in Copenhagen in August 1986. As a significant part of itsproceedings.it will review in an historical perspective (he aflairs of international psychiatry of the past quarter century. The salience of ethical problems in regard to civil rights of persons alleged to be patients in need of psychiatric hospital care will be a prominent feature of the meeting.

Inasmuch as a detailed clinical history is essential to untangling the skein of events which constitute the elements of eihical-psyehiatric problems, the following account is presented.

Professor Walter Ullman. a distinguished medievalist, in a series of lecfures that were given at the Johns Hopkins University said: ''There are probably few topics in modern social and political thought which arouse greater interest than the status, function and power of the individual within the State, within the organized body of citizens." He went on to say there is "a fairly general agreement, at least within the Western orbit, on the autonomous independent status of the individual within society . . . Man as an individual has certain inalienable rights which no power of government can take away, and with which no government may with impunity interfere."

Professor Ullman documented the point that since the Middle Ages, there has emerged a vital difference between the individual as a mere subject and the individual as a citizen, the latter status being what Dante called the most precious gift which God had conferred on man - "his freedom."

Thus it is that in relatively recent times, the role of the psychiatrist as a professional with responsibilities both to his patients and to society has been seriously challenged by those who see the potential for abuse. More than any other discipline in medicine, psychiatry is intimately involved with social values and consequently with ethical considerations in which such ambiguous issues as competence, responsibility, and dangerousness may be fraught with prejudice and personal bias. So it is that human rights - ethical issues - arose as a concern of international psychiatry.

John Stuart Mill, in his 1859 essay "On Liberty," recognized this politicization when he wrote: "In former days, when it was proposed to burn atheists, charitable people used to suggest putting them in the madhouse instead; it would be nothing surprising nowadays were we to see this done, and the doers applauding themselves because, instead of persecuting for religion, they had adopied so humane and so Christian a mode of treating these unfortunates, not without a silent satisfaction at their having thereby obtained their deserts."

My first personal acquaintance with this alleged misuse of psychiatric facilities by psychiatrists was in March 1971. I had received a letter from Dr. Norman Hirt of Vancouver which indicated that "for some years" some Russian psychiatrists had been involved in the incarceration of "dissident young people, artists, writers, as well as older citizens who are involved with civil rights. "This, Hirt went on to say. was "without recourse to law or adequate psychiatric investigation." Further, he pointed out that "with the history of the Nazi Holocaust, which in part began with the misuse of medical people by political factions, that there is some fear that similarly, there be misuse of psychiatric technology in mental hospitals anywhere in the world for political and repressive needs." As lhe then Chairman of the Section of Psychiatry of the British Columbia Medical Association, he prepared a brief, after assembling additional information. which led to a final resolution by the Executive Council of the Canadian Psychiatric Association.

Doctor Hirt attempted to gel a comparable action taken by the American Psychiatric Association, and that was the purpose of his letter to me. He had been referred to me by Dr. Leo Alexander who had had some experience with medicine's abuse of human rights, having participated as an expert in the Nuremberg-Nazi Trials.

In January 1971, the Board of Directors of the Canadian Psychiatric Association had accepted this report recognizing thai the information concerning such practice was as "hard" as can be expected, short of firsthand investigation which, it judged, would not be allowed. The Canadian Psychiatric Association directive specifically indicated communication of the problem and i Is response to medical associations of other countries, the World Health Organization, and the World Psychiatric Association.

The first opportunity for the Council of International Affairs of the American Psychiatric Association to formally receive and review the details of these allegations was at the Fall Meetings in 1971. The Council proposed to the Board of Trustees lhe adoption of a formal resolution condemning such practices.

At the December 1971 Board of Trustees meeting, the following resolution was passed: "The American Psychiatric Association firmly opposes misuse of psychiatric facilities for the detention of persons solely on the basis of their political dissent, no matter where Jl occurs."

The V World Congress of Psychiatry was to be held in Mexico City on November 28th. 1971 to December 4, 1971. At its meeting prior to that lime, the Executive Committee of the World Psychiatric Association, convened in Washington in May 1971, had received a confidential memorandum from its Secretary General. It concerned ethical problems. In it, the Secretary General summarized all the ethical activities which in his words, "have been ot concern to the World Psychiatric Association, since its formation and since the new officers of the Executive Committee were elected in 1966." He made note of a >-day symposium that was held in London in November 1969 on the topic "The Uses and Abuses of Psychiatry." in August 1970. his office received a letter dated August 26. 1970 concerning the problem of political dissidents commuted to psyehialric hospitals in the Soviet Union. During a visit to Leningrad in September 197Ü. in an informal fashion, this matter had been discussed with Soviet colleagues by Dr. Denis Leigh. Secretary General. Doctor Hirt had written lo him on March 21, 1971 asking that the problem be put in a document to the World Psychiatric Association. In a reply on April 6, 1971, Doctor Leigh indicated the matter would be put to the Executive Committee at its meeting in Washington in May 1971.

It was on Sepiember 14, 1971 lhai the Secretary General had informed the representai i ve of the AllUnion Society of the allegations which were being made againsl a number of Russian doctors belonging to their Society and, therefore, were members of the World Psychiatric Association. On October 13, 1971, Professor Snezhnevsky. the representative of the All-Union Society, was sent a complete file of lhe documents supplied by Mrs. Eleanor Ailken, the Hon. Secretary of the Working Group on the Internment of Dissenters in Mental Hospitals.

As a member of the Committee of lhe World Psyehialric Association I too received a letter from Mrs. Aitken dated November 10. 1971, requesting that "the matter bo fully and widely discussed at the forthcoming conference in Mexico . . ."

I was not lhcn a member of the World Psychiatric Association's Executive Committee. However, I have carefully reviewed the minutes of that meeting and can find no direct mention of the aclion taken. The matter was discussed: all the relevant documents were distributed to each member of the Executive Committee at that lime.

It had been suggested at the meeting of the Executive Committee held in Leningrad on September 24, 1970 that:

The WPA must have certain principles clearly established and adhered to regarding the meetings comprising the World Congress: a) The WPA is a professional organization, and is noi concerned with nntionui und/or international politics: h) the WPA has certain membership criteria. Non-members are not freely eligible for entry to meetings of the WPA. Careiul consideration must be given to the admission of a non-member; c) any person seeking to introduce poli t ies into any session of the Congress must immediately be ruled oui of order by lhe Chairman of lìmi session: dì any other questions arising out of local considerations might be diseussed at this meeting.

At the V World Congress a complaint alleged to have been made by a Member Society, the Canadian Psychiatric Association, was found Io be false. The Secretary General's report continues, "In fact, no single complaint from any National Member Society about any other National Member Society was, or ever has been, received by the WPA meeting in Mexico City." The then Executive Committee considered anew the whole matter, as did the Committee of the Association (the Committee consisting of 26 individuals drawn from many parts of the world).

It was decided that nowhere in the Statutes was there listed any mechanism whereby one National Member Society might make a complaint against another Member Society. No complaint had been received and. therefore, the nuit ter couíd not be discussed further.

During 197 1, the Executive Committee had actively considered the formation of a Committee to study the Ethical Aspects of Psychiatry. The Secretary General had made a study of Ethical Codes as applied to medicine and psychology; had consulted with the United Nations Commission of Human Rights, wilh the Council of Europe and its Commission of Human Rights, with a Council for International Organization of Medical Sciences, and through il with UNESCO, with (he WHO, and with Amnesty International as well as with National Member Societies.

The Secretary General requested the Executive Committee of the WPA to consider the formation of a Committee dealing with the ethical problems of psychiatry. Alter agreement by the Executive Committee, the proposal was put to the Committee and to the representatives of the National Member Societies in the General Assembly, the ultimate governing body of the WPA, convened in Mexico City during the V World Congress. The proposal was rejected; not a single Member Society voted for the proposal.

History is necessarily selective, in this account of the salient events of the Vl World Congress of Psychiatry, I have chosen as relevant background what I feel are a few of the more significant events and statements that antedated the Congress. My thought is that it is necessary to be aware of the values in conflict in order to properly interpret what has happened and assess the future. It is the political ambience that has made the issue of human rights, and its derivative medical-psychiatric ethics, attain such importance in recent limes. It is the polarizing aspect of the ongoing world wide confrontation between the two superpowers: the US and the USSR.

The atrocities that led to World War (I were exposed at Nuremberg. They focused attention on an issue of human rights that was unique, For the first time in the long and honorable history of medicine, physicians were indicted and found guifty of conscious and deliberate violations of their ancient Hippocratic Oath. In retrospect, the fact that physicians planned and participated in such reprehensible behavior seems to have initiated the distrust and suspicion that since has haunted the profession as it embarks on projects lhal also involve life and death issues.

Medical ethics, which since the definitions of Thomas Pereival in 1803. with minor modifications, has been construed primarily as a code of etiquette regulating the tenets of professional courtesy among physicians, now has again assumed its larger Hippocratic scope and consequently will henceforth play a mosi important role in the lives of physicians and patients alike.

Professional organizations sensed and responded to these pressures. The need was felt for making ethical position-statements public. These were binding on their members. They may be seen also as efforts to restore medicine's waning stature.

For example, the Declaration of Geneva adopted by the General Assembly of the World Medical Association at Geneva, Switzerland in September 1948, among others of its stipulations required a novitiate secki/ig to be accepted asa member of the medical profession to solemnly pledge: "The health of my patient will be my first consideration." Further, "1 will not permit considerations of religion, nationality, race, party politics, or social standing to intervene between my duty and my patient."

Following this, an International Codcof Medical Ethics was adopted by the 3rd General Assembly of the World Medical Association in London in October 1949. It is an expanded and detailed version of the traditional duties of doctors in general, the duties of doctors to the sick, and (he duties of doctors to each other. Next came the Declaration of Helsinki which contained recommendations guiding medical doctors in biomédical research involving human subjects. This was adopted at the 18th World Medical Assembly in Helsinki. Finland in 1964, and revised by the 29th World Medicai Assembly in Tokyo in 1975. In its introduction, it alluded to the previous declarations and codes mentioning again that "Any act or advice which could weaken physical or mental resistance of a human being may be used only in his interest." Then there followed, after this introduction, 12 basic principles, six items concerned with medical research and professional care, and four items that dealt with non-therapeutic biomédical research. The Declaration of Sydney adopted by the 22nd World Medical Assembly in Sydney. Australia in August 1968 was a statement on death. The Declaration of Oslo, adopted by the 24th Medical Assembly in Oslo in 1970, was a statement on therapeutic abortion. The Declaration of Tokyo, which is staled to be guidelines for medical doctors concerning torture and other cruel, inhuman, or degrading treatment, or punishment in relation to detention and imprisonment, was adopted by (he 29th World Medical Assembly convened in Tokyo, October 1975.

Inasmuch as this particular Declaration has relevance lo what has been alleged by persons charging the Soviet Union with the abridgment of their rights, it is germane to this historical review. In part, it says:

For the purpose of this Déclaration, torture is defined as lhe deliberale, systematic, or wanton infliction of physical or mentili suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield inforniation, to make a confession, or for any other reason.

And then there are six i terns stipulated in the Declaration.

The Parliamentary Assembly of the Council of Europe at its 27th Ordinary Session in (anuary 1976. adopted Resolutions 615 on the Rights of the Sick and Dying, and repeated the Recommendation 779 in which the Assembly considered that "the rapid and continuing progress of medical science creates problems, and may even pose certain threats with respect to lhe fundamenials of human rights and the integrity of sick people." It invited the responsible bodies of the medical profession in the member stales "Io examine critically the cvileria upon which decisions are currently based . . ."

Then too, on the initiative of Amnesty International, there was held a Symposium on Medical Ethics and Abuses of Psychiatry for Political Purposes in Geneva in April 1975. The Symposium noted thai:

Whatever the differences in diagnostic criteria for mental illnesses in different countries, recourse to psychiatric treatment such as incarceration or the compulsory administration of medicine, when carried out in violation of human rights, and particularly, as a means of repression of religious or political dissenlers, can onl> be qualified as a crime . . . they (therefore) callón medical associations and conferences no longer to hesitate, despite threats of withdrawal by member countries, expressly to condemn these abuses of psychiatry wherever they occur, and to boycott the doctors involved and the organizations which refuse the necessary investigations.

In addition, the participants resolve lo contribute, through the creation of an Initiating Committee, to the establishment oi' an international standing body whose task will be to denounce and prevent these abuses.

They asked "all medical and psychiatric societies to adopt a position of principle to give their assent to the establishment of such a body, which will be politically neutral and composed ofdoctors. jurists, and other persons competent in the field of Human Rights."

Having noted that until now. and particularly during the Mexican Congress, the World Psychiatric Association and the World Federation for Mental Health have been powerless to take necessary measures, the participants decided Io initiate the establishment of a body capable of carrying ou t impartial inquiries, condemning illegal and ethically unjustifiable methods, and defending colleagues who maintain their professional integrity in the defense of policy pressure.

All of lhese documents are variations and elaborations on (he original Universal Declaration of Human Rights, adopted by the General Assembly of the United Nations on December IU. 1948. It was proclaimed as a common standard of achievement for all peoples and all nations, to the end thai every individual and every organ of society, keeping this Declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and progressive measures, national and international, to secure lheir universal and effective recognition and observance, both among the peoples of Member States themselves and among the people of the Territories under their jurisdiction.

Thereafter followed 30 articles which al firmed the fundamental Human Rights of all oi'ihc peoples of the United Nations.

With these statements, what then was the problem thai was posed to lhe General Assembly of the World Psychiatric Association?

The matter was presented formally as item 11 on the Agenda of the General Assembly of the World Psychiatric Association meeting during the Vl World Congress convened in Honolulu, Hawaii, on August 29. 1977 and meeting again on August 31, 1977. The Assembly received from its Executive Committee a Resolution which had been passed at the Quarterly Meeting of lhe Royal College of Psychiatrists on May 14. 197b. The Resolution read:

The Royal College of Psychiatrists repeats its support for the steps taken by Council against the abuses of psychiatry in the Soviet Union and requests Council to do all in its power at the next World Congress of the World Psychiatric Association to secure the passage of the following Resolution or one closely similar: The World Psychiatric Association, taking noie of extensive evidence of the systematic abuse of psychiatry for political purposes in the USSR, joins in the condemnation of those practices which has already been made by the British Royal College of Psychiatrists as well as oiher bodies.

Item 11 (b) on the Agenda was a communication dated June I, 1977. which had been received from the Royal Australian and New Zealand College of Psychiatrists. It informed the Executive Commillee of the Resolution passed by the General Council which read:

That General Council moved lu amend the Resolution of the Royal College of Psychiatrists as follows: 'That the World Psychiatric Association lake note of the abuse of psychiatry for political purposes, and that il condemn those practices in all countries in which they occur, and call upon professional organizations of psychiatrists in those countries to renounce and expunge those practices from their countries; and that the WPA implement this Resolution in ihe first instance in reference to the extensive evidence of ihe systematic abuse of psychiatry for political purposes in ihe USSR . . .'

Item 11 (c) was a request from the American Psychiatric Association contained in a telegram dated August 2. 1977 by its President (lack Weinberg, M. D.):

As the official delegate to the General Assembly representing the American Psychiatric Association, 1 request that the following motion be placed on the Agenda for consideration by the General Assembly at the Vl World Congress of Psychiatry in Honolulu. Hawaii August 28th through September 3, 1977.

'The World Psychiairic Association opposes the misuse of psychiatric skills, knowledge, and facilities for the suppression of dissent wherever it occurs and will establish a Committee to investigate abuse of psychiatry, to review all notices or complaints which are officially addressed to the President of the WPA regarding the political abuse of psychiatry, and if sufficient evidence warrants, may. 1) investigate allegations of violation of the WPA policy regarding abuse of psychiatry by seeking additional written information and/or personal testimony from whatever sources deemed necessary, and/or by site visits; and 2) recommend such corrective actions as seem appropriate to (he Executive Committee of the WPA.

'The Members of the Committees shall be appointed by [he President and approved by the Executive Committee. The Committee to Investigate Abuse of Psychiatry is further charged to insure that all of its deliberations are carried out in a manner which affords fair and equitable representaiion from the WPA member societies in the country where the alleged violation(s) occurred.

'The WPA shall establish a special fund which will receive donations from individuals and organizations for the expressed purpose of financing the activities of the Committee to Investigate Abuse of Psychiatry. All expenditures of monies from this fund must be approved in advance by the World Psychiatric Association Executive Committee and follow the general WPA policy for expenditure of funds.'

Please let me know what additional steps I need to lake to insure that the above motion is included on the General Assembly Agenda.

The above items were transmitted to the General Assembly I rom (he meet ing of the Commiitee of the World Psychiatric Association with a letter from the President of the All-Union Society of Neuropathologists and Psychiatrists, dated September 1. 1977, and addressed to Professor P.). Pichot, President of the WPA; Professor P. Berner, Secretary General of the WPA; Professor Howard P. Rome, Past-President of the WPA; Professor Denis Leigh, Past-Secretary General of the WPA: Professor Shervert H. Frazier, President of the VI World Congress of Psychiatry.

It stales the position of the Ail-Union Society. Essentially this has been ils position and contention since these charges of abuse were raised in 1971 at the V World Congress. I feel it is essential that the USSR position be presented in full in its own words, accordingly;

Dear Sir;

The Delegation of the USSR Society of Neuropathologists and Psychiatrists to the Vl World Congress of Psychiatry finds it necessary to draw your attention, as well as the attention of the National Member Societies, to ihe following.

For several years, certain political circles of several Western countries were conducting, through the mass media, an extensive hostile propaganda campaign directed against the stale system existing in the USSR. In ihis campaign, irresponsible and unjustified charges were made in connection with alleged cases of placement of mentally healthy individuals into psychiatric hospitals of the Soviet Union for political reasons, and of persecution of 'political dissidents. To make these allegations more plausible, a clamorous hysterical campaign has been organized around those individuals, who were earlier treated in Soviet menial hospitals, and later emigrated from the country. These individuals arc now exhibited io the public in different countries; they make public statements; their demands to meet Western politicians are widely publicized; their attacks on the internal law enforcement rules in the USSR are presented as a definite proof of the 'Soviet crimes,' eie . . .

During this campaign, which has been especially intensified in connection with the VI World Psychiatric Association Congress in Honolulu, irresponsible appeals were made demanding denunciation not only of Soviet psychiatrists, but actually attempting to put on trial all psychiatry of the world.

There is no need to say that motives of organizers of this campaign have nothing to do with professional and humane pin-poses of international cooperation of scientists and of physicians of difieren! countries, and with the interests of really sick people.

Regretfully, certain Western psychiatrists have become involved in this political campaign and found it possible to make unfounded judgments about allegedly 'criminal' practices of their Soviet colleagues in the absence of reliable, professional information.

For the clearly understandable reasons, the USSR Society of Neuropathologists and Psychiatrists, although taking no t ice of the unjust itied allegations, strictly followed the principles oí medical confidentiality and ethics and avoided public discussions of the menta! siate oí the individuals involved in the above-mentioned anti-Soviet campaign.

At the same time. Soviet psychiatrists, on a number of occasions, have informed their foreign colleagues about all of the issues of professional interests, including the principles and methods of conductment of forensic psychiatric expertise in the USSR. Many Western psychiatrists visited scientific curative psychiatric institutions of the USSR, including the Institute of Psychiatry of lhc USSR Academy of Medical Sciences. Bekhterev Institute of Psychoneurology, many mental clinics and hospitals, and Serbsky Institute of f-'orensic Psychiatry.

Since considerations of professional ethics did not allow Soviet psychiatrists to publish openly case histories of those mental patients, who were widely used in the West for purposes of anti-Soviet propaganda as presumed victims of Soviet psychiatry, these case histories were only made available to foreign psychiatrists participating in the International Symposium on Schizophrenia conducted in the Soviet Union in I973.

In 1977. in order to establish lhe truth, the USSR Society of Neuropathologists and Psychiatrists submitted condensed medical case histories of individuals mentioned in the Western press to the Executive Committee of the WPA whh lhe request to circulate them lo National Psychiatric Member Societies of the WPA on the condition of full professional confidentiality and mutual trust, However, since the Members of the Hthical Committee of the WPA expressed doubts as to the possibility to keep these case records confidential with such wide distribution, the USSR Society did not insist on its request, and only later had to demand that these case records were distributed among the delegales of the General Assembly of the VI World Congress of Psychiatry.

It has been explained that in these cases psychiatrists were dealing with individuals who, although committed actions classified by the Soviet legislation as crimes against the Stale, had suffered from mental fatigue even during juvenile age or adolescence, and in this connection were examined and treated by psychiatrists. In oiher eases, the suspicion of mental disease emerged during the court procedures of other legal investigations. Such cases as well as those when some mentally disturbed individuals, possessed by their delusional ideas, may become "prophets" or "sick passionate idealists" which sometimes may act inductively on mentally healthy people, are well known to psychiatrists in many countries.

Therefore, coming to the Vl World Congress of Psychiatry in Honolulu, the delegation of the USSR Society of Neuropathologists and Psychiatrists expected that the necessary measures had been taken to permit the objective and scientific discussion of important issues of the present-day psychiatry and did not expect to yield to the pressure of forces attempting to use psychiatry for purposes of political propaganda aimed at provoking dissent and hostility between people.

Unfortunately, however, the atmosphere of the Congress did not contribute to fruitful and constructive discussions. From the very beginning, the work of the Congress was affected by the elements attempting Io streamline it along political antiSoviet lines. This follows in particular from the distribution in the lobby of the Congress of slanderous anti-Soviet literature and of various statements and appeals directed against the Soviet psychiatry. This follows also from attempts to present the alleged victims of Soviet psychiatry to Congress participants. A particularly noisy campaign was organized in connection with the "Open Session" which represented a political show, rather than the scientific discussion of important ethical issues. One cannot overlook also that some papers of delegates from Israel. South Korea, etc., at some sessions of lhe Congress can be classified only as a direct slander againsl other countries, absolutely non-permissible at a world scientific nonpolitical conference.

As concerns the consideration of the draft resolutions proposed by the U.K. Royal College of Psychiatry and by the Australian College of Psychiatry and seconded by the American Psychiatric Association, the Soviet delegation regrets to stale thai this discussion was taking place under the conditions of pressure on the Soviel delegation who was given an opportunity to ask only a lew questions addressed to the delegates of Great Britain, Australia, and the United Slates.

Unsatisfactory answers to these questions have shown that the accusations with respect to Soviet psychiatry were completely unfounded. At the same time, (he Soviet delegate has not received an opportunity to present explicitly all ihe available arguments, supporting the stand of Soviet psychiatry, and to illustrate (he unfounded nature and tendentiousness of the proposed resolution inspired by the slanderous political campaign fanned (Oi' more (han 6 years. Suel? atmosphere of the General Assembly has shown the obsolete and undemocratic nature of its work the more so. that ihis Assembly presented the first serious opportunity during the last 5 fob years to psychiatrists of all member societies to obtain the firsthand information about alleged abuses of psychiatry in ibe cases of the so-called dissidents.

The additional motion of the American Psychiatric Association was discussed contrary to the WPA Statute, since it was submitted to the Executive Committee less than I month before the beginning of the Congress- Meanwhile, the Soviet proposal of a draft resolution aimed at the prevention of abuse of mental patients for the purposes of political propaganda aimed at provoking dissent and hostility between peoples (also submitted to the lixeculive Committee of the WPA on the last day) was not even announced to the Assembly. TIi e Soviet delegation from the very beginning spoke up against !he existing system of the voting based on an anii-democratieal principle depending on the amount of dues paid and considered the use of such an archaic principle of voting inadmissible for the WPA. During the actual voting of the resolution of the Royal College and of the amendment of the Australian College. 33 out of 55 national delegations voted against this resolution. However, the non-objective system of voting and a confused procedure of conn ting the votes permitted to carry the resolution of the Royal College, however, only by two voles, whereas three ballots corresponding to eight votes were declared invalid. Notwithstanding this result, the use of an obsolete principle of voting permits us to consider the formal results of voting null and void. The USSR Society of Neuropathologists and Psychiatrists considers the moves made by the U.K. Royal College of Psychiatry, the Australian College of Psychiatry, and the American Psychiatric Association as absolutely contrarv to the objectives of the WPA. whose noble aims are to advance inquiry into the aetiology, pathology, and treat men ? of menial j|[ness, and to strengthen relations between psychiatrists working in different fields and between psychiatric societies existing in different countries.

It is contrary to the codes of medical ethics approved in different countries at different times and regulating the main principles or relations between physicians and patients, physicians and societies, as well as between physicians themsc'/ves. Finally it is absolutely contrary to (ht1 relevant decisions and resolutions of the Work) Health Organization, specifically the resolution WHu 15.51 concerning "The Rule of ;i Physician in Preserving and Strengthening of Peace." which declares that physicians and other medical personnel in ihe exercise of lbeir profession;)) duties, delivery of care and support lo their patients, are called upon to perform a meaningful role in the maini ain ing and furthering of ihe world peace, contributing to the eradication or at least to the amelioration of anxiety and confusion.

The delegation of the USSR Society of Neuropathologists and Psychiatrists to the Vl World Congress of Psychiatry wants to express its deep confidence thai the psychiatrists of all countries would agree that in the modern world, persons suffering from mental diseases represent one of the most vulnerable population groups and thai all possible measures must be undertaken for the protection and improvement of the health of each individual and of the society.

We draw the attention of all the psychiatrists to ihe inadmissible eases of deliberate exploitation of mentally sick persons IOr the purpose of political propaganda aimed to fan the dissent and hostility between the peoples and the states, and urge psychiatrists of different countries in case of emigration of mentally sick persons toother countries for one reason or another to deliver to these persons the necessary therapeutic and preventive aid and Io exchange relevant professional information in strict conformity with the requirements of medical ethics and observance of professional confidentiality, being guided exclusively by the interests and protection of the health of the patients.

The USSR delegation to the Vl Congress requests (his letter be distributed to the delegation of all Member Societies of the WPA.

Signed: The Soviet Delegation to the Vl World Congress of Psychiatry.

The facts of the vote taken by the General Assembly are the following, These are from the Organization and Statutes, By-Laws; 111, General Assembly (10) that reads: "The President shall then request the General Assembly to vote upon the number of votes to be allocated to sueh Societies in accordance with the following rules: a) The delegate of a Member Society shall be entitled to one vote for caeh 100 subscribing members of their Society up to a maximum of 50 votes."

Appendix B to the Agenda of the General Assembly is the financial survey of the Member Societies, It lisls in columns the dale of joining, the name of the Member Society, the number of members in 1977. and the subscriptions in US dollars for the years 1972, 1973, 1974. 1975, 1976, and 1977.

Il was this specific requirement that determined the number of votes of the delegates. Parlamentry procedure followed the protocol used by the United Nations. It determines thai an amendment be voted first. Il it carries then it precludes a vote on the original resolution. Voting on the amendment of the Royal Australian and New Zealand College of Psychiatry, which according to protocol took precedence over the resolution of the Royal College of Psychiatry, was as follows: Yes - 90; No - 88; Abstaining - 8. The number of Societies voting "Yes" was 19; lhe number of Societies voting "No" was 33: the number of Societies abstaining was 8.

The voles on (he American Psychiatric Association's resolution were as follows: The number of votes voting "Yes" was 121; lhe number of votes voting "No" was 66; the number abstaining was 4. The number of Member Societies voting "Yes" was 28; the number of Member Societies voting "No" was 26; the number of Member Societies abstaining was 1.

There arc a number of points in the USSR document of September I, 1977 [hai need and deserve qualification. To be sure as has been indicated in an increasing fashion since 1971, there have been charges repeatedly levied at the state system existing in the USSR. Then too, the Western press. particularly that of Britain, has been most vocal in its charges and documentation.

Since 1970, the Soviet Human Rights Committee formed in Moscow has appealed io the West to take measures to prevent what it called "The corruption of psychiatry for political ends."

Vladimir Bukovsky's A Manual Psychiatry for Dissidente gives the following definition.

The diagnosis of 'sluggish schizophrenia' was used by lhe Soviel psychiatrists io validate psychiatric hospiializution. This diagnostic formulation was refuted by British, Australian, and American psychiatrists whose contention it was that 'sluggish schizophrenia' was a facade Io justify the imprisonment of political dissidents.

'Sluggish schizophrenia' is understood lo be a form oi' disease in which ill its symptoms arc 'barely' or Only slightly' manifest while symptoms as explicit as the presence of hallucinations are absent altogether. Its normal symptoms are unsociability, sluggishness, loss of interest in life, mild attacks of pessimism and melancholia, concentration on inner experiences, inadequale thoughts and actions, stubbornness and inflexibility of convictions, suspiciousness. etc . . .

Professor John K. Wing, in a paper published in the British Medical Journal on March 9, 1974 (p. 433-436) discussed the diagnosis of schizophrenia in Moscow. The USSR prevalence is five to seven per 1000. while most U.K. studies suggest three to ibur per 1000. It is Professor Wing's opinion that the Snezhnevsky school oí diagnosis is mainly responsible for this increased frequency. He continues: "American psychiatrists would diagnose as latent, pseudoneurotic, or pseudopsychopathic schizophrenia."

Then too, according to Wing, there are three main conceptual differences to take into aecount. There is nothing in Western criminal law equivalent to the Soviet category of crimes against the Slate. Thus, the seriousness with which such actions are viewed is quite outside our experience, but it is a fact of life in the Soviet Union. According to Wing:

This difference is basically political. Assuming for the moment lhai the Soviet psychiatrists have made their diagnosis in guod faith, lhe question looks quite different to them: Is a person who is suffering !Vom u slowly developing form of schizophrenia responsible IOr an action which is likely to land him, at the very least, in a labor camp for 3 years? The Soviel doctor claims that he is acting humanely and that, in essence, the part he plays is no different from that of the American psychiatrist who saved Ezra Pound from execution.

It should be noted that Professor Wing is a recognized world authority ?p psychiatric classification and has been intimately involved in the development of the International Puoi Study of Schizophrenia that was sponsored and subsequently published by the World Health Organization in 1973.

During the Annual Meeting of the American Psychiatric Association in Toronto, Canada in May 1977. Waller Reich, a member of the faculty at Yale University School ol Medicine, also presented a similar version of the mild subtypes of Sovietdefined schizophrenia. Hc obtained this information from interviewing a group of emigre Soviet dissidents between 1972 and 1977. He also conducted interviews with about a half dozen Soviet psychiatrists who emigrated to the West.

According to Reich, the Moscow School overturned the traditional Soviet concept of environmental etiology and replaced it with an approach thai assumes, what Reich called, "a thorough going genelicism and a very broad catalogue of mild symptoms and common personality types that are included within its newly expanded clinical boundaries."

According to the Snezhnevsky formulation, each of three forms runs a "course" which is an aspect of a genetically based spectrum: continuous, periodic. and shifting. The sluggish or mild typo has the qualities of neuroses with what in this context is termed "reformist delusions." ie. poor adaptation to the socio-political environment.

I was a member of the group of foreign psychiatrists who participated in lhe Soviet demonstration of their procedures at lhe Serbsky Institute in October of 1973.

The facts are these: The Wl1A. indeed, did hold a Symposium on Schizophrenia. Il was held in Yerevan, Armenia and Tbilisi, Georgia in October 1973. While in Armenia and Georgia, we who attended were given invitations to visit the psychiatric facilities in Moscow following the close of the Symposium. The meeting was planned for October 15. There would he an opportunity to visit the Serbsky lnsiiiute and lhe inviUition ibal was circulated continues:

followed by a full and free professional discussion of lhe alleged abuse of psychiatry in the Soviet Union. Case histories will be discussed, and a Commission of Inquiry will be seen at work. This meeting will be followed by a WPA press conference tit the Serbsky Institute dealing with lhe Symposium. " Aspects of Psyehia try." All speakers and chairmen of the Symposium arc invited, asare representatives of the World Press. At the enti of this discussion, a statement will be made by lhe WPA regarding some ethical aspects of psychiatry.

On the 12th of October in Tbilisi, 20 foreigners met on several occasions (and the following is a quotation from the prepared document that was never released as intended io the World Press who were present);

... to consider their host's offer to arrange a further meeting in Moscow after the conference. This meeting would have the object of discussing the allegations ihat have recently been made about Soviel forensic psychiatry. The group decided to accept host's offer. The participating scientists would take part in their individual capaciu and not as representatives of any organi za i ion. The group wished to make two points clear: 1) ihe laci ihai members of the group are willing to attend the meeting does not in itself imply any prior acceptance or rejection of the allegations; 2) such complex and difficult problems cannot be adequately evaluated in I day. It is, therefore, unlikely (hat a clear-cut statement of approval or disapproval will be made at the end ol'lhe meeting. The intention is to begin what is hoped to be a series of professional discussions.

This was signed by 20 foreigners: USA - 5; Sweden - 1; UK - 3: Switzerland - 2: Denmark - 3: Mexico - 1; Senegal - 1; Federal Republic of Germany - 2: Japan - 1: Nigeria - 1.

There were others present who, for reasons of their own, did not sign the statement. A few, however, accepted the Soviet invitation. There were others who neither signed nor accepted the invitation.

It is also necessary to establish the context in which this opportunity presented itself. The Symposium, " Aspects ol'Schizophrenia." was to be one of the two Annual Regional Meetings which the Executive Committee of the WPA holds. It was in two sessions - the first, October 8-9, 1973 in Yerevan, and the second, October 11-12. 1973 in Tbilisi.

The Symposium had been arranged as is the custom by the Secretary General several years in advance of the actual meeting. Hc was responsible for inviting some 31 participants from outside the USSR.

In the US in anticipation of ibis meeting, l)ie Board of Trustees of the APA meeting on September 10, 1973 sent a telegram signed by the President. Dr. A.M. Freedman, statingafter reviewing briefly its position vis-a-vis the alleged confinement of political dissidents in psychiatric hospitals, that:

. . . the American Psychiatric Association calls on Soviel colleagues to meet with a delegation of distinguished US psychiatrists in an appropriale professional selling thai will assure professional confidcntialiiy. to discuss involuntary psychiatric confinement, and specific cases where abuse has been alleged and recognizing thai ii may be necessary io consider individual patients.

We also recognize that charges about the political uses of psychiatric confinement can be made againsl any country. Therefore, our delegation would be prepared to discuss alleged misuse of involuntary confinement in the United Slates and other countries.

The growing suspicion the world over thai lhe profession of psychiatry lends i ? self to abuses of this genre is cause for alarm by psychiatrists everywhere. If such abuses exist, they ,should he publicly exposed and corrected with all possible dispatch. We very much hope that Soviet colleagues will join us in this effort, especially irt the light of lhe joint agreements beiwecn our nations on scientific cooperation.

This letter had reference to the agreement that was signed during the Moscow Summit Meeting by President Nixon in May 1972. As part of the USUSSR accord establishing joint research efforts in cancer, environmental health, and heart disease. there was a comparable research on schizophrenia explored but not signed by the Russians.

Deborah Shapley, in an editorial in Science on March 8. 1974 (183:932-936). gives the reasons for this "split on schizophrenic program."

Shapley summarized the concern expressed by the scientists of the National Institute of Mental Health that "the Soviet authorities (would) use the menial hcallh exchanges IOr propaganda purposes Io whitewash their psychiatric system." Al that time the Bukovsky papers were made part of the Congressional Record by a subcommittee of the Senate Committee on the Judiciary which held hearings on the abuse of psychiatry in the Soviel Union on September 26, 1 972 (Government Printing Office Washington. D.C. 1 972 Stock No. 5270-01653).

There was finally a concluding memorandum of the Joint US-USSR Working Meeting signed by Dr. Bertram Brown, the Director of the National lnslilutc of Mental Health and Professor A. V. Snezhnevsky. the Director of the Institute ol Psychiatry of the Academy of Medical Sciences of the USSR on |une I4. 1974. This collaborative undertaking was to continue "working programs on clinical standardization and classification of the forms of schizophrenia"; to continue "an accumulation of experimental material in the field of immunopathology of schizophrenia"; to elaborate new methodological lechniques for the study of hereditary nature of schizophrenia ; to continue an exchange of biological material for the study of enzymatic activity in schizophrenia; to elaborate joint methodological approaches for the study of individuals with a high hereditary risk for schizophrenia; to determine biologically and genetically the criteria for a predisposition to schizophrenia.

"This collaboration should be developed on the basis of an exchange of clinicians and scientists from or sponsored by the National Insti tute of Mental Health and the Institute of Psychiatry, USSR."

With these unsettled elements in the background, il is obvious why the delegations of scientists from the National Institute of Mental Health did not participate in the post-Symposium discussions that were held in Moscow.

To further politicize the situation, the National Academy of Sciences on September 8 authorized its President, Dr. Philip Handler, to send two cablegrams to Mslislav V. Keldysh. the President of the Soviet Academy of Sciences, expressing "deep concern" over the harrassment of Andrei D. Sakharov, the outspoken Soviet physicist who is a member of both the American and Soviet Academy. This was accompanied by an action by Congressman Wubur D. Mills who was Chairman of the House Ways and Means Committee which deals with trade legislation. Congressman Mills said he would oppose liberalization of trade with the Russians "if the price is to be paid in the martyrdom of political dissidents such as Mr. Sakharov and Alexsandr Solzhenitsyn who had recently won the Nobel Prize."

Moreover, the British Press had been publicizing the data smuggled out of the Soviel Union attesting this misuse of psychiatric facilities. For example, on September 9. Sir Martin Roth, the President of the Royal College of Psychiatrists, wrote a letter to the tiditor of the Guardian explaining the position of the Royal College saying that:

We expect British psychiatrists who have been chosen to attend this Conference not to remain sileni on ihe political exploitation of the humane science and practice of psychiatry.

Indeed, I am aware that a number of hYiiish and other participants intend to examine ihe validity of the diagnoses pronounced by some Soviet psychiatrists in the cases of Medvcdev, Grigorcnko, Yakhimovich, Ciorbanevskaya, Fainberg. Borisov. and Sehikanuvsky arid the ethical problems posed by such psychiatric practices in their papers. I consider personally that, as members of a profession thai is concerned first and foremost with the integrity and well being of the human being for whom it is their privilege to care, it is their duty to do precisely this . . .

I must onec again clear away any remaining misconceptions about the role of the Royal College of Psychiatrists in this matter. We and our predecessors have in recent years organized joint meetings with Canadian. American, and French psychiatric associations. We have not arranged any with Soviet psychiatric societies nor do we intend to do so in the foreseeable future.

The Royal College played no part in arranging (his Conference or in choosing Russia as a place in which it should be convened nor was its Council consulted at any stage about the program. The decisions were taken by the World Psychiatrie Association and we have no official representative on the Executive Committee of thai body.

Yet if Professor Nazhdarov believes, as reported, thai the world scientific community has rejected the alleged abuses of psychiatry in Russia as 'part of an anti-Soviet propaganda campaign.' he must he misinformed or indulging in wishful illusion. The World Assembly, which is the only body of the World Psychiatric Association in a position to pronounce on such issues, is ordinarily convened only during international Congresses of psychiatry which take place at intervals of approximately 6 years.

At the last meeting in Mexico, many of the delegales were unclear about the purpose of the Assembly, unaware of what was to be discussed until they arrived in Mexico and, therefore, without any clear brief from international organizations concerning abuses of psychiatry for political purposes. The Canadian delegation, which had submitted the protest about Soviet practices, mysteriously wiihdrew its resolution at the last moment.

Many representatives were deeply disturbed by the Medvedev's book which was on sale al the Congress and strongly criticized the practices described therein. The entire Soviet delegation absented themselves from the Assembly. Those of us less aware in December 1971 than we arc now about the slate of certain dissidents in Soviet Russia were anxious io question the Soviet delegates in a setting of the World Assembly on these matters, but found ourselves unable to do so. It would be stretching the facts, to say the least, to regard the proceedings of the Assembly as having in any way condoned the perverted abuses of psychiatry about which we have been hearing with increasing frequency in recent years.

Tine Resolution adopted by rny Council on January 24ih WEIS in general terms condemning the use of psychiatry for political purposes wherever it may occur. We tried to achieve a united stand with psychiatrists in other countries, and. therefore, to prompt international organizations, the World Psychiatric Organization and the World Health Organization included, itito action. Ii was desirable to adopt an attitude of political impartiality and to avoid general condemnations where only the misdeeds of a small number of handpicked individuals were possibly in question.

However, within our College, we are committed (irst and foremost to a common compassionate concern for the mental health and dignity of the individual. We have a special obligation to try to relieve the sufferings of those who appeal- to be oppressed by an offensive and unacceptable application of the skills of psychiatrists; the problem is lo arrive at the most effective means for securing these ends.

Our Resolution was not our last word and our actions will be influenced by the responses elicited. My Council will be returning to the subject al ils next meeting.

Signed: Sir Martin Roth. President, Royal College of Psychiatrists.

There were thirteen of us who consented to visit the Serbsky Institute. Our Soviet hosts attempted to explain in detail their standard forensic psychiatric procedures. Inasmuch as we were not able to interview the palicnt who was presented, none of us could comment on the details of what we were shown and told. Neither could we examine in a meaningful way what were purported to be the clinical records of those patients who were said to be the political dissenters. Dr. Denis Leigh volunteered to go to interview General Grigorenko who was interned in another hospital. The General was suspicious about the interpreter who was provided as well as Doctor Leigh, and in consequence refused Io use the interpreter as a trusted intermediary. Inasmuch as he could not speak English nor Doctor Leigh understand Russian, the unsatisfactory encounter was quickly concluded with no opportunity for any meaningful interchange. Consequently, the same state of affairs existed for the remainder of our visiting group.

A TASS reporter did, indeed, speak with Dr. Ramon de la Fuente and me as we were leaving our hotel on October J 7th. BLI! in iheiimemem primed in TASS on October 17, 1975. the juxtaposition of our general statements expressing our reception at the Symposia were interwoven with the details of the operations of the Serbsky. The net result was a total distortion that alleged our approval of what was presented. This, was precisely what the group had expressed in the precautionary statement which we had signed in Tblisi saying that we were in no position to express an unofficial, much less an official, opinion on what would transpire following our meeting in Moscow. Not able to speak Russian. read the documents that were circulated, or personally interview the patient who was presented, we could not and did not endorse the actions that were represented. Both Doctor de la Fuente and I, after learning about this article, expressed our resentment at this propagandiste use of our attempts to be courteous for the hospitality shown us.

The foregoing is a most abbreviated version of the politicization of international psychiatry - its distortions, its background, and circumlocutions.

In March 1974 in the Journal of Neorupathology and Psychiatry of the Korsakov Institute, it was reported "The members of the Executive Committee expressed their satisfaction with the discussion which had taken place and with the friendly atmosphere in which it had been conducted, It was agreed that all five of the so-called dissenters who had been discussed at the meeting had been suffering from mental illnesses at the times when they had been examined by psychiatric commissions."

Charges and refutations such as these formed the background of the Vl World Congress of Psychiatry.

10.3928/0048-5713-19860701-12

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