East Asian Arch Psychiatry 2018;28:122-8 | DOI: 10.12809/eaap1825 Theme Paper Compulsory Admission in Hong Kong: Balance between Paternalism and Patient Liberty B Siu, EC Fistein, HW Leung, L Chan, CK Yan, A Lai, KK Yuen, KK Ng Abstract In Hong Kong, compulsory admission is governed by the Mental Health Ordinance Section 31 (detention of a patient under observation), Section 32 (extension of period of detention for such a patient), Section 36 (detention of certified patients), and the sections in Part IV for hospital order, transfer order, and removal order. Mental health professionals adopt both legal criteria and practice criteria for compulsory admission. The present study discusses the harm principle, the patient’s decision-making capacity, the multi-axial framework for compulsory admission, and the balance between paternalism and patient liberty. Key words: Hong Kong; Involuntary treatment, psychiatric; Mental health services; Patient admission Dr Bonnie WM Siu, MBChB, MRCPsych, FHKCPsych, FHKAM (Psychiatry), practitioner is a person registered in accordance with the FRCPsych, Department of Forensic Psychiatry, Castle Peak Hospital, Hong Medical Registration Ordinance and needs not to be a Kong SAR, China. 2 Dr EC Fistein, PhD, MRCPsych, School of Clinical Medicine, University of psychiatrist. The applicant needs to have seen the patient Cambridge, United Kingdom. personally within 14 days of application and states the Mr HW Leung, BSc, MBA, Department of Forensic Psychiatry, Castle Peak reasons for detention. Form 2 contains written opinions Hospital, Hong Kong SAR, China. Ms Lanly SY Chan, BSc, MBA, Department of Forensic Psychiatry and Old Age of a registered medical practitioner who has examined the Psychiatry, Castle Peak Hospital, Hong Kong SAR, China. patient within 7 days. Form 3 is completed by a district judge Ms CK Yan, BSc, MSc (Management in Health Care), Department of Forensic or magistrate to authorise removal of a patient to a mental Psychiatry, Castle Peak Hospital, Hong Kong SAR, China. Ms Anita CH Lai, BSc, MSc (Nursing in Clinical Leadership), Department of hospital for detention and observation. Before application, Forensic Psychiatry, Castle Peak Hospital, Hong Kong SAR, China. reasonable steps should be taken to inform the relatives of Mr KK Yuen, MSc, BN, Department of Forensic Psychiatry, Castle Peak patients, and patients should be informed that they have the Hospital, Hong Kong SAR, China. Mr KK Ng, BSc, MSc (Nursing), Department of Forensic Psychiatry, Castle right to see the district judge or magistrate. Peak Hospital, Hong Kong SAR, China. Section 32 is a one-off extension of detention of not more than 21 days upon expiry of Section 31. The Address for correspondence: Dr Bonnie WM Siu, Department of Forensic Psychiatry, Castle Peak Hospital, 15 Tsing Chung Koon Road, Tuen Mun, New opinion of two registered medical practitioners on the Territories, Hong Kong. necessity of further detention for observation, investigation, Tel: 24567111; Fax: 24631644; Email: [email protected] and treatment is required in Form 4. The form will be Submitted: 26 March 2018; Accepted: 23 July 2018 countersigned by a district judge and forwarded to the medical superintendent of the mental hospital in which the patient is detained. Section 36 authorises further detention of a patient in Introduction a mental hospital or in the Siu Lam Psychiatric Centre, upon expiry of a hospital order or a sentence of imprisonment. In Hong Kong, the Mental Health Ordinance (MHO) governs It requires two registered medical practitioners to examine the civil aspect of compulsory admission.1 Section 31 of the the patient separately or together and conclude that: (1) the MHO authorises detention of a patient in a mental hospital patient is suffering from mental disorder; (2) of a nature for <7 days or in a place of safety (accident and emergency or degree that is appropriate to receive medical treatment department) for <48 hours. The grounds for application are: in hospital; and (3) for the health or safety of the patient (1) the patient is suffering from mental disorder, (2) of a or for protection of others; and (4) such treatment cannot nature or degree that warrants detention in a mental hospital be provided unless the patient is detained. Additionally, for observation (with or without treatment), and (3) for the patients who are neither suffering from mental illness nor interests of the patient’s health or safety or protection of psychopathic disorder may not be certified under Section others. 36 unless they are abnormally aggressive or their conduct Application of detention requires completion of three is seriously irresponsible. To detain such patients, two forms. Form 1 may be made by a relative of the patient, registered medical practitioners should complete the Form a registered medical practitioner, or a public officer in 7 and forward it to a district judge to countersign who the Social Welfare Department. A registered medical agrees that it would be dangerous to the voluntary patients 122 © 2018 Hong Kong College of Psychiatrists. CC BY-NC-ND 4.0 Compulsory Admission in Hong Kong or others if they are discharged from the mental hospital. 20 July 2017, the total number of inpatients was 751; of For the criminal aspect of compulsory admission, these, 337 (44.9%) were admitted compulsorily. Psychiatric part IV of the MHO governs the admission of mentally diagnoses were categorised according to the ICD 10th disordered persons in criminal proceedings, transfer of revision.6 The most common diagnosis was severe mental mentally disordered persons under sentence, and remand of illness (n=184), followed by mental retardation (n=56) mentally incapacitated persons. Section 45 grants powers to and pervasive developmental disorders (mainly autistic the courts or magistrates to issue a hospital order to detain spectrum disorders) [n=16] (Table 2). On 17 July 2017, 69 a patient in Siu Lam Psychiatric Centre or a mental hospital patients (73.9% males) aged 21 to 80 (mean, 49.8) years for a specified or unspecified period. Section 52 is for were compulsorily admitted under Section 36. The most removal to a mental hospital of a person serving a sentence common principal diagnosis was schizophrenia (68.1%), of imprisonment. Section 53 is for removal to a mental followed by personality disorder (10.1%) and mental hospital of other prisoners (eg, remand prisoners). Persons retardation (8.7%). The most common reasons for detention who has been admitted to a mental hospital, pursuant to was insight problem (65.2%), followed by psychotic Sections 45, 52, 53, shall be treated as if they had been symptoms (55.1%) and risk of aggression (53.6%) [Table detained in a mental hospital in accordance with Section 3]. 36, except that the power of the medical superintendent to permit absence on trial shall not be exercised; the persons Compulsory admission (legal criteria) shall not be discharged without the consent of the Chief Executive. The rates of compulsory admission vary considerably in different jurisdictions and are influenced by the legal criteria Compulsory admission rate in Hong Kong and practice criteria of mental health professionals.7-9 In some countries, compulsory admission is permitted as a The rate of compulsory admission is an indicator of preventative measure against self-harm or suicide.3 In underlying characteristics of mental health care laws.3 The others, compulsory admission is restricted to those judged decision-making process is influenced by multiple factors to pose a danger to themselves or others. In England and such as the practice of compulsory admission by different Wales, detention is also authorised when deemed necessary mental health care professionals.4,5 There are great variations for the health or safety of the patient. Risk (of continued ill- in the compulsory admission rates as a percentage of all in- health, deterioration, or physical harm) may not be the only patient episodes across different European Union countries, criterion to consider. Dangerousness and grave disablement from 3.2% in Portugal in 2000 to 30% in Sweden in 1997.3 are grounds for compulsory admission, but there ought to be In Hong Kong, between 2012/3 and 2016/7, there additional grounds such as treatability and lack of insight.10 were 3657 compulsorily admissions and readmissions In England and Wales, ongoing detention for treatment is (57% for males) to the Castle Peak Hospital, accounting authorised only if appropriate medical treatment is available for 26.9% of all admissions (Table 1). Most compulsory for the condition, whereas in Scotland, medical treatment to admissions occurred in age-groups 21-35, 36-50, and 51-65 stop deterioration of condition or to treat some symptoms years. Most compulsory admissions were authorised under must be available, and the patient must be significantly Forms 1, 2, and 3 (Section 31), followed by Section 36. On impaired to make decisions about treatment.8,9 Table 1. Compulsory admissions to Castle Peak Hospital from 2012/2013 to 2016/2017. Parameter No. or No. (%) of patients 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 Admission 2680 2695 2650 2792 2770 Voluntary 2029 (78.7) 2018 (74.9) 1995 (75.3) 2011 (72.0) 1878 (67.8) Compulsory 651 (24.3) 677 (25.1) 655 (24.7) 781 (28.0) 892 (32.2) Sex Male 394 (60.5) 397 (58.6) 371 (56.6) 442 (56.6) 480 (53.8) Female 257 (39.5) 280 (41.4) 284 (43.4) 339 (43.4) 412 (46.2) Age group, y ≤20 5 9 8 11 28 21-35 119 146 136 189 235 36-50 208 185 177 222 226 51-65 197 194 186 200 200 66-80 76 78 99 97 137 ≥81 46 65 49 59 66 East Asian Arch Psychiatry 2018, Vol 28, No.4 123 B Siu, EC Fistein, HW Leung, et al Table 2.