Joint comments from the World Psychiatric Association (WPA) and the WMA on the Special Rapporteur on Health report A/HRC/44/48

Dr. Dainius Puras,
United Nations Special Rapporteur on the right of everyone
to the enjoyment of the highest attainable standard of physical and mental health
Office of the High Commissioner for Human Rights
United Nations Office at Geneva
CH-1211 Geneva 10
Switzerland
7 August 2020
Dear Dr. Puras,
We are writing to you on behalf of the World Psychiatric Association (WPA) and the World Medical Association
(WMA) in response to your report (A/HRC/44/48), submitted to the 44th session of the United Nations (UN) Human
Rights Council, 15 June – 3 July 2020. WPA and WMA, which represent together millions of physicians around
the globe, including more than 225,000 psychiatrists, have previously submitted comments in response to the
Special Rapporteur’s report in 2017 (A/HRC/35/21).
As we noted in our prior comments, the WPA and the WMA share most of the goals reflected in the Reports of the
Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and
mental health. In particular, we strongly affirm that there is no health without mental health. We condemn without
reservation any form of abuses, violence and discrimination against patients with mental disorders and reaffirm the
ethical responsibility of physicians to respect the autonomy of all patients.
We regret that health professionals have not been consulted at any stage of the drafting process of a report which –
in our opinion – challenges severely the psychiatric profession. Both WPA and WMA have developed good working
relationships with the Special Rapporteur during his mandate and we have repeatedly affirmed our willingness to
be included in the discussion with the users and other relevant actors.
We express our great concern over the continued negative portrayal of psychiatry and psychiatrists in the documents,
and the disparagement of contemporary, evidence-based approaches to the treatment of mental disorders. We fear
that the personal views of the Special Rapporteur, which are not reflective of the vast majority of his colleagues in
the mental health professions nor of the extensive body of data that has been collected about the efficacy of
psychiatric treatments, hold the potential for causing substantial harm to the very people whose interests the Special
Rapporteur purports to promote.
At the most basic level, we reject the false dichotomy that provides the underlying foundation for the Report, i.e.,
that approaches to the treatment of mental disorders must be based either on a “medicalized” approach or on non-
medical, psychosocial interventions that take into account the social context of patients’ lives. Psychiatrists
worldwide recognize the invalidity of this dichotomy and the necessity for a combined biopsychosocial model for
understanding and treating mental disorders. The development of effective medications for the treatment of many
mental disorders, including psychoses, bipolar disorder, depression, anxiety disorders and others, has enabled
countless people to return to happy, productive lives. However, many patients also benefit from treatment with
evidence-based psychotherapies with or without the use of medication, and for many others—especially people with
severe and persistent mental disorders—interventions such as social skills training, occupational rehabilitation, and
assistance with schooling, housing, and other social needs are essential components of effective treatment.
The Report also incorrectly equates medical approaches to mental disorders with abuse of patients’ human rights.
Comments such as “Medicalization affects every aspect of the lives of persons with psychosocial disabilities; it
undermines their ability to vote, work, rent a home and be full citizens who participate in their communities” are
simply without foundation. Effective psychiatric treatment is not incompatible with scrupulous concern about
patients’ rights and respect for patients as autonomous persons—positions strongly supported by our organisations.
Note that what is said to be at issue here is usually characterized in the Report as “medicalization,” but at times
referred to “over-medicalization,” “pernicious forms of medicalization,” “mass medicalization,” “excessive
medicalization,” and “coercive medicalization,” suggesting confusion regarding the precise basis for the issue. We
regret that nowhere is a clear definition offered of what constitutes “medicalization” or the associated “biomedical
model,” which is also disparaged, or of the variants of medicalization noted in the Report.
We are worried by the inclination in the current global debate that persistently places into opposition human rights
and medical ethics. We believe that this characterization merely shifts the problem and generates prejudice and
distress for psychiatric services. It misinterprets the function of physicians as the backbone of the health care system
and indirectly undermines the expected privileged relationship between physicians and patients based on trust,
professionalism and confidentiality. The issue of ill-treatment of patients with mental illness lies mostly with the
severe deficits in support for the mental health system in many countries, and we regret that this issue is not
addressed in the report.
A particularly harmful element of the Report is its attack on the inclusion of medications for mental disorders in the
list of essential medications published by the World Health Organization (WHO). From a list of hundreds of
medications covering roughly 45 pages, the Special Rapporteur identifies only the 12 medications listed as essential
treatments for mental disorders—the collective efficacy of which is backed by peer-reviewed publications
numbering in the thousands—as in need of “re-evaluation of their risk-benefit ratios.” The real motive for this
suggestion becomes apparent a few lines later in the report where the Special Rapporteur worries that “The essential
medications list may imply that making such drugs available is equivalent to providing the appropriate standard of
care for the treatment of mental health conditions…” But of course, use of these medications when indicated is
exactly what the standard of care calls for and their removal from the WHO’s list of essential medications would
cause untold amounts of harm, especially to people in low and middle-income countries, where resources for
medications may be limited and priority is likely to be given to those designated as “essential.”
This recommendation is tantamount to rejecting—in the face of extensive evidence to the contrary—any biological
component to mental disorders in favor of the advocacy of a position that would cause concrete harm to people with
mental disorders around the world.
The World Psychiatric Association and the World Medical Association kindly ask the Special Rapporteur to
consider withdrawing his report in its current version and engaging in a broad consultation with a view to producing
a revised text reflecting the views of all the stakeholders concerned. Alternatively, we would welcome our comments
being attached to the report, as a “right of reply” from health professionals.
We would welcome the opportunity to provide additional information and participate in further discussions to
facilitate a greater understanding of these issues.
Sincerely yours,
Professor Helen Herrman AO Professor Miguel R. Jorge
President President
World Psychiatric Association World Medical Association
Copy: Ambassador Elisabeth Tichy-Fisslberger, President, United Nations Human Rights Council