2011: Restrictions of freedom
The 1966 Compulsory Mental Care (Certain Cases) Act was replaced by:
- The Compulsory Mental Care Act (SFS 1991:1128)
- The Forensic Mental Care Act (SFS 1991:1129)
The care of people suffering from mental disorders is covered by the general provisions of the Health and Medical Service Act (SFS1982:763). The Compulsory Mental Care Act covers mental care combined with custodial and other coercive measures. The Forensic Mental Care Act applies in cases which are not covered by the Compulsory Mental Care Act such as people who have been ordered by court to receive mental care or who have been arrested, remanded in custody or admitted to a unit for forensic psychiatric examination or to a correctional institution.
In the introduction to the English translation of this law, the Ministry of Health and Social Affairs (1993) described the objectives of this legislation as follows:
"The new legislation has the effect of strengthening legal safeguards for patients and augmenting judicial control. In addition it makes better provisions for the protection, laid down by the Constitution Act, against deprivation of liberty and forcible bodily interference, and it brings the rules on compulsory mental care into line with the 1983 recommendations of the Ministerial Committee of the Council of Europe.
The new legislation is intended as a more adequate response than LSPV to the development of psychiatry during the past decade in favour of close restrictions on coercive care.
Mental care shall as far as possible be provided on a voluntary basis. Compulsory mental care is only to be resorted to when there is no possibility of care on a voluntary basis.
The purpose of compulsory care shall be for the patients to become capable of voluntary participation in continuing care."
The conditions for involuntary internment
Under the Compulsory Mental Care Act (SFS 1991:1128) a person can be interned if:
S/he is suffering from a serious mental disturbance and on account of his/her mental state and his/her personal circumstances, the patient generally has an absolute need of mental care which cannot be provided for in any other way than the admission of the patient to a medical institution for qualified psychiatricall day care, and
S/he objects to such care, as is referred to above or, on account of his/her mental state, is manifestly incapable of expressing his/her consent to care.
It is stated that when appraising the need for care under this paragraph, it should be considered whether the patient constitutes a danger to the safety or physical or mental health of another person.
The procedure for involuntary internment
On the basis of a special medical examination conducted by an authorised doctor, a medical certificate (care certificate) must be issued and forwarded without delay to the medical institution where the question of involuntary internment is to be considered. The examination must only be performed if there is reasonable cause for doing so. The certificate should show that there is reason to suppose that the above-mentioned preconditions have been fulfilled. It should also include an account of the nature of the mental disturbance and any other circumstances which necessitate care.
An admission order is then issued and within four days the patient is taken to the care institution, where it must be decided within 24 hours whether s/he is to be admitted against his/her will. During this time, the doctors on duty have the right to prevent the patient from leaving the hospital.
A chiefmedical doctor in a mental care unit decides on compulsory admission. This cannot be the same doctor who issued the care certificate.
A patient who is in voluntary care can be admitted into compulsory care by the chiefmedical doctorif the conditions have been fulfilled and it is feared that the patient on account of his/her mental disturbance may inflict serious injury upon him/herself or some other person. For such decisions, a care certificate must be issued by anotherdoctor. In such cases, the chief medical doctor must apply to the county administrative court within four days requesting permission for the continuation of compulsory care.
The duration of involuntary internment
If the internment lasts for more than four weeks, the chiefmedical doctor must apply to the county administrative court for permission to extend the internment. An account of the care and treatment needed must be appended to the application. If the application is granted the internment may be extended by four months. Afterwards, if internment is still necessary, a further period of six months can be granted and this is renewable. If the court rejects the application, compulsory care must cease immediately.
The right to appeal
The patient may appeal to the county administrative court against the decision of chiefmedical doctor’s order for compulsory care. Before the court hears the appeal, a statement is requested from the chief medical doctor on the circumstances which led to the compulsory care and details of the support and treatment which was planned for the patient. Unless further investigation is required, the case should be tried within eight days of the appeal.
Under paragraph 30 of the Compulsory Mental Care Act (SFS 1991:1128) a patient advisor (known as a supporting person) shallbe appointed at the request of the patient. A patient adviser can be appointed in other circumstances if the patient does not object. The appointment of the supporting person is governed by the provisions of the Act on Patients’ Committees (SFS 1998:1656).
The role of the supporting person is to support the patient in personal matters for as long as s/he is receiving compulsory care. The supporting person is entitled to visit the patient in the institution. S/he cannot improperly divulge or utilise matters coming to his/her knowledge in the course of the assignment and relating to the patient's health status or personal circumstances in general.
The restriction of personal liberty
Paragraph 20 of the Compulsory Mental Care Act (SFS 1991:1128) deals with isolation. A patient may not be isolated from other patients unless this is necessary. This could be due to aggressive or disruptive behaviour which seriously impedes the care of other patients. An isolation order can be made for up to eight hours and can be prolonged for a further eight hours. Under special circumstances the duration of eight hours can be extended. As with restraint, an isolation order can only be made by the chiefmedical doctor and isolation for more than 8 hours must be notified to the National Board of Health and Welfare without delay.
The National Board of Health and Welfare previously issued general guidelines on "the use of protective measures for people with dementia in special accommodation for service and care” (SOSFS 1992:17 and 1997:16).According to these guidelines, a person with dementia cannot be locked up to prevent him/her from leaving a building. However, the installation of a device which makes it difficult to open a door is permitted as it is intended to delay and not prevent the person from leaving. Similarly, an alarm system can be installed, but if the alarm goes off staff must merely try to persuade the person to return to his/her room. The general guidelines were recently cancelled. However, the National Board of Health and Welfare gives the same advice.
Restraint and other coercive measures
The use of coercive measures is covered by the Compulsory Mental Care Act (SFS 1991:1128). In paragraph 19 of this act, it is stated that if there is immediate danger of a patient seriously injuring him/herself or another person, the patient may be briefly constrained by means of a belt or similar device. The order for restraint must be made by the chiefmedical doctor. Care personnel must be present during the period for which the patient is kept under restraint. This period can be prolonged if necessary, but in such cases the National Board of Health and Welfare should be informed without delay.
The need for sufficient personnel
To avoid coercive measures, it is necessary to have sufficient personnel in dementia care. After a successful campaign by Demensförbundet (The National Dementia Association) the Swedish Parliament has requested guidelines on the number of personnel in nursing homes for people with dementia. The Government has entrusted the National Board of Health and Welfare to elaborate such guidelines. Demensförbundet would like recommendations on minimum staffing levels, preferably covered by law. However, there is strong opposition to minimum levels from the organisation representing counties and municipalities. In this connection, it is important to have trained personnel, adapted premises and principals who are present.
A controversial commission has presented proposals regarding coercive and protective measures. According to Demensförbundet and others, the proposals of the commission undermine the civil rights of people with dementia and their relatives/carers. The proposals are currently being discussed by the Government. Demensförbundet has directly pointed out to the minister responsible the negative consequences of the proposals of the commission,
The Health and Medical Personnel Act (SFS 1998:531) has been replaced by the new Patient`s Safety Act (SFS 2010: 659). In accordance with the act, the National Board of Health and Welfare takes the appropriate measures to deal with situations in which the care provided does not satisfy the criteria for good care and the safety of patients.
Abuse is covered by the Social Services Act (SFS 2001:453). Chapter 14, paragraph 3 states:
“Every person, active in the social services, who observes or becomes aware of serious abuse or of an obvious risk of abuse with regard to activities against or which may be against individuals within the social services, shall report the matter immediately to the social welfare committee.
The above provisions also apply to professionals in private practice of a similar kind. The report shall be submitted to the party responsible for the activity.
In Sweden, driving licences are granted for life. The renewal procedure is a mere formality involving a change of photograph every ten years. However, a medical examination is required for the renewal of driving license for heavy vehicles after the age of 45.
Under the 1998 Driving Licence Act (SFS1998:488), doctors are obliged to report patients who are obviously unfit to drive. Chapter 10 paragraph 2 states:
"If a doctor, when examining a driving licence holder, concludes that this person is obviously medically unfit to hold a licence, the doctor shall report this to the Swedish Transport Agency Before reporting, the doctor shall inform the licence holder. There is no obligation to report if there is reason to believe that the licence holder will conform to the doctor's instructions to refrain from driving a vehicle for which a licence is required."
There are regulations and guidelines for the practical application of this in the statutes of the Swedish Transport Agency (TSFS 2010:125). Chapter 10 in these statutes covers dementia and other cognitive disorders.
According to the statutes of the Swedish Transport Agency, dementia constitutes an obstacle for the possession of a driving licence. When dementia is considered mild, possession of a license for a normal car and motorcycle can be granted.
In the "general advice" section, it is stated that dementia should be considered mild if the patient, despite a notably deteriorated ability to function professionally and socially, nevertheless can lead an independent life with a relatively sound sense of judgement.
It is also stated that dementia is determined either on the basis of a diagnosis made according to conventional medical practice, or on an assessment, based on the information available, that the criteria for such a diagnosis have been fulfilled. Such criteria are those which are specified in a criteria-based system for the classification of diagnoses e.g. Diagnostic and Statistical Manual of Mental Disorders (DSM) or the international Classification of Diseases (ICD).
In the case of mild dementia, a certificate should be prescribed by a doctor and a review carried out at appropriate intervals to determine whether the person should be allow to have a driving licence.
 The 1966 Compulsory Mental Care Certain Cases Act
Last Updated: Wednesday 14 March 2012