A/HRC/43/41/Add.3 treatment of persons with “severe mental disorders” on the basis of lack of capacity to consent, need for treatment, and/or danger to self or others. Permitted coercive interventions include involuntary admission, shielding and isolation, mechanical and chemical restraints, forced intake of drugs, restricted contact with the outside world and outpatient commitment. The Health and Care Services Act (ch. 9) and the Patients’ and Users’ Rights Act (ch. 4) also allow for the use of coercion and force against persons with intellectual disabilities and those deemed unable to consent. Many national and international human rights experts and bodies have extensively criticized these provisions and their implementation. 67. During the visit, the Special Rapporteur was informed that, despite efforts to reduce the number of coercive measures employed, they had remained steady over the years. In 2018, a year after the Mental Health Care Act was amended, there were 7,849 involuntary admissions to psychiatric hospitals compared to 7,704 in 2017. The number of patients aged more than 16 with one or more decisions on coercive orders issued for them also increased, from 1,995 in 2017 to 2,164 in 2018.16 The total number of coercive admissions for the first quarter of 2019 amounted to 2,520, i.e. 16 per cent of a total of 15,934 admissions to mental health care. 17 Furthermore, electroconvulsive therapy continues to be applied without free and informed consent on the basis of the principle of medical necessity in criminal law, despite the general prohibition of treatment that constitutes a serious intrusion in section 4-4 (2) of the Mental Health Care Act. Coercion of persons with intellectual disabilities, autism and dementia is also widespread and of concern. For instance, in a report of August 2019, the Equality and Anti-Discrimination Ombud found serious weaknesses in the administrative review of decisions on coercive measures against persons with intellectual disabilities in the county of Hedmark. 18 68. The Special Rapporteur acknowledges the leadership of the Ministry of Health and its commitment to reducing coercion. In that context, in 2017 the Government appointed a law commission to review and propose amendments to the regulation of coercion in the health and care services contained in four laws, in order to enhance legal safeguards and reduce the use of coercion. 19 In June 2019, the commission submitted a report proposing a new act on the limitation of coercion, which contains important proposals and conclusions. However, unless a human rights-based approach is integrated throughout, it will fall short in protecting the rights of persons with disabilities. Coercive measures are not only contrary to human rights law, but evidence shows that they are ineffective in protecting individuals and can prevent them from seeking support. 69. Instead of regulating exceptions to the use of coercion, discussion should focus on systemic changes to prevent and end coercion. That includes the development of community-based services and the provision of support, including supported decisionmaking and non-coercive responses to mental health crises. As demonstrated by the very successful experience of two different coercion-free services the Special Rapporteur visited in Norway – the basalt exposure therapy department of Vestre Viken Hospital Trust in Blakstad and the medication-free department of Åsgård Psychiatric Hospital in Tromsø – it is possible to provide quality mental health and psychosocial support without using any form of coercion in even the most complex cases. The Special Rapporteur’s report on disability-specific forms of deprivation of liberty contains further useful guidance (A/HRC/40/54). 16 17 18 19 14 See www.helsedirektoratet.no/statistikk/statistikk/kvalitetsindikatorer/psykisk-helse-forvoksne/tvangsinnleggelser-i-psykisk-helsevern-for-voksne (in Norwegian). See https://statistikk.helsedirektoratet.no/bi/Dashboard/028e6f20-6846-46df-9f3b7cf1e2c011d8?e=false&vo=viewonly and www.helsedirektoratet.no/statistikk/statistikk/kvalitetsindikatorer/psykisk-helse-for-voksne (both in Norwegian). See www.ldo.no/globalassets/brosjyrer-handboker-rapporter/rapporter_analyser/tvang-2019/tvangog-makt-mot-personer-med-utviklingshemming-etter-helse--og-omsorgstjenesteloven-kapittel-9.pdf (in Norwegian). See www.regjeringen.no/contentassets/46b1d575199f4322b113887452e8b382/nou-2019-14.pdf (in Norwegian).