CASE OF X v. FINLAND
Remainder inadmissible;Violation of Article 5 - Right to liberty and security (Article 5-1 - Deprivation of liberty;Article 5-1-e - Persons of unsound mind);Violation of Article 8 - Right to respect for private and family life (Article 8-1 - Respect for private life);Pecuniary damage - claim dismissed;Non-pecuniary damage - award
George Nicolaou;Lech Garlicki;Ledi Bianku;Matti Mikkola;Nebojša Vučinić;Nicolas Bratza;Zdravka Kalaydjieva
6. The applicant is a paediatrician, born in 1943, who continued in private practice after her retirement. 7. On 30 November 1995 a mother brought her daughter, V., born in 1993, to the applicant’s practice to be examined, suspecting that the girl had been sexually abused by her father. The applicant examined her and took photographs. 8. On 13 June 2000 the girl was taken into public care because of her mother’s mental health problems and was placed in a family support centre. 9. The events now in issue began on 16 December 2000, when the mother failed to return V. to the family support centre after spending time with her. It appears that the centre was going to close during the Christmas holidays and it was alleged during the domestic proceedings that the girl had indicated to her mother that she was unwilling to go to her father’s home for the holidays. 10. V. fell ill and was taken to the applicant’s practice by her mother on 26 December 2000. When she left the practice V. remained with her mother until she was found by the authorities on 22 April 2001. 11. On 18 April 2001 the applicant was arrested as a suspect in the deprivation of V.’s liberty, which had allegedly begun on 16 December 2000 in [town A]. The applicant’s home and practice were searched the same day. On 20 April 2001 the District Court (käräjäoikeus, tingsrätten), having heard the applicant in person, remanded her in custody, considering it likely that she would otherwise complicate the resolution of the case and continue to engage in criminal activity. 12. By five separate decisions between May and September 2001, given at the request of the police, the District Court granted permission to obtain information about calls to and from telephones used by V.’s mother and a third suspect during different periods between 15 December 2000 and 22 April 2001. The information gathered showed that calls had also been made from and to a telephone in the applicant’s possession. 13. V. was found on 22 April 2001. On 25 April 2001 the applicant was released. Following her release, the applicant complained on several occasions, inter alia, about the District Court’s decision of 20 April 2001 remanding her in custody, and requested an investigation of, inter alia, the actions of a number of police officers during her arrest and related events. 14. On 11 May 2001 the police issued an interim restraining order in respect of the applicant, the terms of which were that she was not allowed to visit certain places frequented by V. Those places were specified in the decision. 15. On 1 June 2001 the District Court found that it was unlikely that the applicant would or could continue to harass the girl or commit an offence against her. It therefore quashed the restraining order. 16. On 18 April 2002 the public prosecutor preferred charges against V.’s mother, the applicant and a third person. The applicant was charged with seriously depriving V. of her liberty during the period from 16 December 2000 to 22 April 2001 or, in the alternative, aiding and abetting the commission of that offence. The applicant had allegedly, through her opinions, advice and actions, contributed to the mother’s decision to abduct her child on 16 December 2000 in [town A] and, after the mother had abducted her child and taken her at Christmas 2000 at the latest to [town B], the applicant had, with the mother’s consent, unlawfully isolated V. As the deprivation of liberty had lasted a long time, had been planned and premeditated and had endangered the girl’s emotional development, the offence was considered aggravated. 17. In her written reply to the charge the applicant denied that she had in any way had an impact on the mother’s actions. She had only provided medical treatment for V. It had not been shown that the suspicions of sexual abuse were unfounded. 18. On 17 July 2002 and 22 January 2003 the applicant unsuccessfully made an application to the Office of the Prosecutor General (valtakunnansyyttäjä, högsta åklagaren), requesting that the public prosecutor be replaced by an impartial one and alleging a number of irregularities in the performance of his duties. 19. On 21 August 2002 the District Court appointed a public defender to represent the applicant – Ms M.K., a member of the Bar – as the representative chosen by the applicant – Mr J.R., a civil engineer – was not considered capable of representing her, given the gravity of the alleged offence. The applicant contested the appointment of Ms M.K. in a written representation, without however naming a lawyer of her choosing, although invited to do so. On 21 October 2002 the Court of Appeal (hovioikeus, hovrätten) rejected the applicant’s representation. 20. At a preliminary hearing on 19 September 2002 the District Court ordered, against the applicant’s wishes, that the case be examined in camera as it concerned sensitive issues relating to a child’s life. It also held that the applicant was unable to defend herself, given the nature of the case. The applicant unsuccessfully complained to the higher courts about this decision. 21. The case was heard over four days, beginning on 22 October 2002. The applicant informed the court that she considered that her public defender, Ms M.K., who was present at the hearing, was not entitled to plead on her behalf. The applicant declared that she would defend herself. 22. The District Court heard statements from the applicant and the two other defendants. It also heard V.’s father, representing V., and ten witnesses. On 24 October 2002 the court rejected as irrelevant a request by the applicant that V., Mr J.R., a police inspector and two lawyers be heard as witnesses regarding the applicant’s deprivation of liberty and the alleged misinterpretation of the facts by the public prosecutor, which the applicant described as criminal. The applicant then reiterated her request, stating that the witnesses should testify about the background to the offence with which she was charged. The District Court also rejected that request, noting that she had not given any reasons which would have justified hearing the witnesses she proposed. 23. On 25 October 2002 the District Court ordered the applicant and V.’s mother to undergo a psychiatric assessment under Chapter 17, Article 45, of the Code of Judicial Procedure (oikeudenkäymiskaari, Rättegångs Balk) and section 16(1) of the Mental Health Act (mielenterveyslaki, mentalvårdslagen), and adjourned the proceedings for the assessment to take place. The applicant then went into hiding. 24. Dr K.A., a psychiatrist, noted in a written medical opinion of 30 December 2002 that he had met the applicant twice, on 14 November and 30 December 2002, and that in the two conversations he had had with her he had not observed any signs of mental disorder and that, in his opinion, she was not in need of involuntary care. He emphasised, however, that he had not carried out a psychiatric assessment, as such an assessment could only take place in a hospital and not in a private consulting room. 25. Niuvanniemi Hospital, one of the two State mental hospitals, informed the applicant that it was ready to receive her from 2 January 2003. At the applicant’s request, the assessment was postponed first to 20 January 2003 and then to 12 March 2003. The applicant failed, however, to appear at the hospital. 26. By a letter dated 8 January 2003 the applicant proposed Mr P.S. as her new representative. On 13 January 2003 the District Court appointed Mr P.S., a member of the Bar, as the applicant’s new public defender. 27. On 25 March 2003 the District Court ordered the applicant’s arrest and detention in absentia on the ground that she was seeking to evade trial, as she had not appeared at Niuvanniemi Hospital. The applicant was represented at the hearing by Mr P.S. The applicant lodged a complaint, alleging insufficient grounds for detention and procedural errors. On 28 April 2003 the Court of Appeal dismissed the complaint as unfounded. On 16 June 2003 the Court of Appeal dismissed a further complaint by the applicant without considering its merits. The applicant later lodged a third complaint, which was dismissed as unfounded by the Court of Appeal on 18 March 2004. The Supreme Court refused requests by the applicant for leave to appeal. 28. On 9 October 2003 the Court of Appeal rejected a complaint by the applicant in connection with the order that she undergo a psychiatric assessment, finding the applicant’s allegations of procedural errors in the District Court proceedings unsubstantiated. On 30 March 2004 the Supreme Court refused leave to appeal. 29. After receiving a request from Mr P.S. to withdraw, on 5 May 2004 the District Court, having given the applicant an opportunity to be heard in writing, appointed Mr M.S., a member of the Bar, as her new public defender. On 23 June 2004 the Court of Appeal rejected a complaint by the applicant against this decision, finding that she was unable to defend herself and that Mr M.S. was not biased as she had alleged. It also rejected a request by the applicant for an oral hearing as manifestly unnecessary. On 27 June 2005 the Supreme Court refused leave to appeal. 30. On 15 June 2004 the Court of Appeal rejected a complaint by the applicant that, inter alia, the District Court Judge who had ordered her psychiatric assessment was biased. A request by the applicant that its decision be supplemented was rejected by the Court of Appeal on 12 July 2004. On 27 June 2005 the Supreme Court refused leave to appeal. 31. By a letter dated 2 September 2004 the District Court informed the applicant that it would hold an oral hearing on 20 September 2004 concerning her detention. The applicant was informed that other aspects of the criminal charges against her would not be dealt with at that hearing and no evidence would be taken other than on her detention. 32. On 20 September 2004 the District Court issued a further order for the applicant’s arrest and detention, finding that she was still seeking to evade trial. She was represented at the hearing by her public defender Mr M.S. On 9 November 2004 the Court of Appeal dismissed a complaint by the applicant concerning the decision of 20 September 2004 without considering its merits, as it had been drawn up by Mr J.R., who did not fulfil the requirements set out in Chapter 15, Article 2, of the Code of Judicial Procedure. It was noted that a public defender had been appointed to represent the applicant. A further complaint by the applicant was dismissed by the Supreme Court on 29 September 2005 without consideration on the merits. 33. On 12 October 2004 the applicant was arrested. 34. On 15 October 2004, having heard the applicant in person, the District Court remanded her in custody, finding that she was aware of the psychiatric assessment to be conducted and the subsequent arrest warrants. The court stated that the applicant had been evading trial, of which the assessment formed a part. The applicant was ordered into police custody and from there to a mental institution to be designated by the National Forensic Medical Authority (terveydenhuollon oikeusturvakeskus, rättsskyddscentralen för hälsovården). 35. On 11 November 2004 the applicant was taken to Vanha Vaasa Hospital, the other State mental hospital, for a psychiatric assessment, the duration of which was initially to be two months. The assessment was carried out by Dr A.K. a specialist in psychiatry, adolescent psychiatry and forensic psychiatry. During the assessment the applicant was interviewed by Dr A.K. on ten occasions. She also saw two psychologists, G.W-H. and A.K-V. She refused to undergo somatic and neurological examinations and special examinations, such as magnetic resonance imaging of the brain. She also refused laboratory tests and psychological tests. 36. On 3 January 2005 Dr A.K. gave his written opinion to the National Forensic Medical Authority on the basis of the assessment conducted between 11 November 2004 and 3 January 2005. His conclusions were that the applicant was suffering from a delusional disorder and had not been criminally responsible at the time of the alleged offence. Dr A.K. also found that the criteria for involuntary confinement, set out in section 8 of the Mental Health Act, were met and that the applicant could not be heard at the trial. Her capacity to look after her own interests was diminished by her mental illness, and she was thus in need of a guardian for the criminal proceedings. 37. On the same date the applicant asked the National Forensic Medical Authority for a second opinion. On 5 January 2005 that authority informed the applicant that ordering a psychiatric assessment of a defendant in a criminal case was outside its authority, and she should therefore direct her request to the court. 38. By an interlocutory decision of 20 January 2005 the Forensic Psychiatry Board of the National Forensic Medical Authority (terveydenhuollon oikeusturvakeskuksen oikeuspsykiatristen asioiden lautakunta, nämnden för rättspsykiatriska ärenden vid rättsskyddscentralen för hälsovården – hereafter “the Forensic Psychiatry Board”) requested Dr A.K. to supplement his opinion, as far as possible, by giving the applicant psychological tests and by submitting such background information as would enable a comparison to be made between the applicant’s ability to manage in her earlier life and her ability to manage at the time of the alleged criminal events. Dr A.K. was also invited to provide detailed reasons why he considered that the criteria for involuntary care were met and why outpatient treatment was not considered sufficient. The results of the supplementary examination were to be submitted to the National Forensic Medical Authority as soon as possible. 39. The supplementary examination was completed on 4 February 2005. The applicant again refused psychological tests by the hospital staff, doubting their impartiality. In his report, dated the same day, Dr A.K. found that the applicant was suffering from a psychotic delusional disorder and that her condition had already been present prior to the events leading to the criminal charges. The applicant had observed indications of sexual abuse which other experts had not been able to detect. In Dr A.K.’s opinion, the applicant was in need of involuntary psychiatric treatment in order to recover from her disorder, which mainly related to judicial matters, but also to a delusion of grandeur as to the correctness of her own actions. Further, as a doctor she was endangering other people’s well-being by prescribing them treatment which put their health at risk. Because the applicant had for a long time evaded psychiatric assessment, and as she opposed treatment, outpatient treatment would not be sufficient. In conclusion, Dr A.K. considered that the applicant was paranoid and that she had made accusations against various authorities about continued abuse of office. She had become entangled in the tiny details of her own case without being able to perceive the wider picture. He considered that her delusional disorder had reached the level of psychosis, which distorted her conception of reality. Owing to her illness, she did not understand the unlawfulness and repercussions of her actions and she had been psychotically deluded when she had taken part in the deprivation of a child’s liberty. Moreover, she was in denial of her illness. 40. The applicant sent a number of letters to the Forensic Psychiatry Board, in which she criticised the psychiatric assessment conducted by Dr A.K., among other things. She also submitted to the Board Dr K.A.’s divergent medical opinion of 30 December 2002 (see paragraph 24 above). 41. On 17 February 2005 the National Forensic Medical Authority submitted its opinion on the psychiatric assessment to the District Court under section 16(3) of the Mental Health Act, finding that the applicant had not been responsible for her actions at the time of the offence. 42. On 23 February 2005, the psychiatric assessment being complete, the District Court ordered the applicant’s release from detention. She was, however, to remain in hospital for treatment, as ordered on 17 February 2005 by the Forensic Psychiatry Board. 43. On 17 February 2005 the Forensic Psychiatry Board ordered, on the basis of Dr A.K.’s proposal, that the applicant receive involuntary treatment in Vanha Vaasa Hospital. It considered that she was suffering from a delusional disorder, which had affected her for years and which made her incapable either of seeing a matter from a viewpoint other than her own or of questioning the correctness of her own conclusions. She suspected that the authorities had “ganged up” on her. During the psychiatric assessment she had tried, as a medical doctor, to take a stand regarding the treatment of other patients on the ward. The delusional disorder, if not treated, would considerably worsen her mental illness or seriously endanger her health and the health of others. No other mental health services were considered adequate, having regard to the fact that the applicant did not consider herself to be mentally ill. The decision referred to sections 8, 17(1) and 17a of the Mental Health Act. 44. The applicant considered that she was not in need of mental health treatment, and wished to obtain a second opinion on her need for treatment. However, at the beginning of February 2005 the hospital refused to allow a Dr M-P.H. to visit her during the ongoing psychiatric assessment. 45. The initiation of medication was discussed with the applicant on 21 March 2005. She was given the opportunity to take medication orally, but she repeatedly refused to do so. Owing to the applicant’s resistance, the administering of medication began with involuntary injections of Zyprexa. As the applicant had made it clear that she would not cooperate, it was decided to continue her medication by giving long-acting injections of Risperdal Consta every two weeks, starting on 31 March 2005. The basis of the decision was explained to the applicant and she was also given information about the drug. The issue of medication was discussed with the applicant on several occasions after that. She was encouraged to take it orally, but she persistently refused. 46. As the applicant’s core symptoms persisted after two and a half months of medication, it was decided on 22 June 2005 to increase the dosage of Risperdal Consta from 25 milligrams to 37.5 milligrams. It was reduced to 25 milligrams again from 16 November 2005. 47. The applicant alleged that when she had questioned the forcible administering of medication, she was informed that it was intended to cure her telephone surveillance delusion. The applicant argued that the surveillance had taken place and that there had been no delusion on her part. 48. On 7 July 2005 the applicant claimed to have been assaulted in connection with the forcible administering of medication. She had resisted, as she considered the medication unnecessary, whereupon she had been dragged by her arms and legs to her room. When she was put on the bed her thigh had hit the edge of the bed. She had reported the incident to the police, who had asked a medical doctor, Dr S.Ö., to examine her, which he did on 28 July 2005. In his medical opinion of 5 August 2005 he noted that the applicant had a 10 cm bruise on her thigh, which could have been caused in the manner described by the applicant. 49. On 22 July 2005 the head physician of the hospital decided to continue the applicant’s involuntary treatment. 50. In a written statement of 17 August 2005 to the Administrative Court the head physician of Vanha Vaasa Hospital, M.E., noted that the applicant was still in denial of her illness and very strongly opposed medical treatment. She was literally fighting back, and this had resulted in several difficult situations when attempts were being made to proceed with the administering of medication in a manner which would be safe for both the applicant and the hospital staff. 51. It appears that in August 2005 enquiries were made about a possible transfer of the applicant to a different hospital in her home town. However, that hospital did not consider itself able at that point to accept responsibility for the applicant’s care. 52. The applicant alleged that she was still suffering side effects from the medication. The applicant’s patient records indicate that the alleged side effects could not be objectively verified. The applicant refused to undergo further medical examinations whereby any side effects could be detected. 53. On 3 October 2005 the applicant was visited by Dr E.P., a general practitioner at an occupational health care centre. In his opinion of 5 October 2005 Dr E.P. emphasised that he did not specialise in psychiatry and he could not therefore take a stand as to the diagnosed delusion on the basis of one visit. He noted, however, that the applicant had been lucid and well-orientated. During their conversation he had not observed any signs of psychosis or delusion. In his capacity as a general practitioner, he considered that the conditions for involuntary treatment were not met. 54. On 22 October 2005 the applicant was visited by a psychiatrist, Dr M-P.H., who in a written medical opinion of 25 October 2005 considered, as an outsider, that the choice of medication for the applicant (37.5 milligrams of Risperdal Consta injected into the muscle every two weeks) seemed excessive, given the patient’s age and state of health. Furthermore, he considered that the involuntary and forced medication fulfilled the constitutive elements of assault. In conclusion, he considered that open-care measures were possible and that the danger posed by the applicant to herself and others had been considerably exaggerated, and accordingly that the criteria for involuntary care were not met. 55. It appears from the applicant’s patient records that from November 2005 at the latest she was no longer physically resisting the injections, although she was still verbally opposing her medication. 56. On 19 November 2005 the hospital decided to move the applicant from the closed ward to an open one. 57. On 24 November 2005 the applicant agreed to blood tests. 58. On 21 December 2005 the applicant again saw Dr M-P.H., who in a written medical opinion of 21 December 2005 considered that the conditions for involuntary care were not met. 59. The applicant spent Christmas at home. She had with her a dose of Risperdal Consta, which she injected during her holiday with the assistance of a nurse. 60. On 9 January 2006 it was decided, by mutual agreement with the applicant, that the medication should be terminated, as she was not at all motivated to take it. 61. On 20 January 2006 the head physician of the hospital took a further decision to continue the applicant’s involuntary care. 62. On 27 January 2006 the applicant was discharged from hospital. 63. On 30 May 2006 Dr M.E. considered that the grounds for continuing the involuntary care under section 8 of the Mental Health Act no longer existed, whereupon the treatment was officially terminated by a decision of the National Forensic Medical Authority of 22 June 2006. 64. On 23 February 2005 the applicant appealed to the Supreme Administrative Court (korkein hallinto-oikeus, högsta förvaltnings-domstolen) against the decision of 17 February 2005 by the Forensic Psychiatry Board, arguing that there was no legal basis for the involuntary care. She alleged that Dr A.K. had erred in his assessment. She relied, inter alia, on the above-mentioned medical opinion of Dr K.A., who had seen her twice, in November and December 2002, and who had not found any signs of mental illness on the basis of those meetings. She alleged that there was no other reason for the forced medication than the hospital doctors’ attempt to conceal their incorrect diagnosis. 65. On 4 March 2005 the Supreme Administrative Court found no reason to stay execution pending its proceedings. 66. On 30 June 2005 the Supreme Administrative Court prohibited Mr J.R. from acting as the applicant’s representative. Under Chapter 15, Article 10a(2), of the Code of Judicial Procedure the applicant was invited to inform the court of her choice of counsel. Subsequently, the applicant was represented by Ms H.M., counsel chosen by her. She was granted legal aid. 67. On 30 August 2005 the Supreme Administrative Court decided to hold an oral hearing in the case. 68. On 29 and 30 September 2005 the applicant requested the court to postpone the oral hearing until she had obtained an impartial medical opinion and until she had recovered from the side effects of her medication. On 3 October 2005 she informed the court that she had fallen ill and again requested that the hearing be postponed. 69. On 4 October 2005 the Supreme Administrative Court held an oral hearing and received the testimony of, inter alia, the applicant and six witnesses proposed by her. The applicant was represented by Ms H.M. 70. The court refused the applicant’s request for a stay of the proceedings pending the submission of fresh medical opinions. The court considered this unnecessary given the fact that the issue to be decided was whether the applicant had been in need of involuntary care at the turn of the year 2004 to 2005. The validity of the impugned decision had already expired, as more than six months had elapsed since it had been given. It was difficult to see how a fresh examination could affect the court’s assessment. 71. On 7 October 2005 the applicant submitted to the court a medical opinion by Dr E.P. dated 5 October 2005. 72. On 13 October 2005 the Supreme Administrative Court dismissed the applicant’s appeal. Having first noted that the impugned decision met the formal requirements and that the applicant’s complaint of partiality on the part of Dr A.K. and the members of the Forensic Psychiatry Board could not be upheld, it went on to note that the question to be decided was whether the criteria for involuntary care under section 8 of the Mental Health Act had been met on 17 February 2005, when the Board had given its decision. The question of whether a person was mentally ill was a factual question to be decided on the basis of medical evidence, having due regard to the correctness of the decision-making procedure applied. 73. The court considered that Dr A.K., a specialist in psychiatry since 1990, was an experienced psychiatrist. His opinion and the opinion of the Board were based on a professionally qualified and reliable medical assessment. 74. As to the subject matter the court reasoned, inter alia: “... Dr A.K. interviewed the applicant on ten occasions and was then able to make observations on her. Drs A.K. and M.E. explained at the oral hearing that the diagnosis of delusion was affected by the absoluteness of the applicant’s views on incest. They stressed that incest diagnoses required examinations by doctors specialising in gynaecology and also child psychiatry examinations. The applicant is a specialist in paediatrics. In particular, Dr M.E. gave evidence that in his discussions with the applicant she had refused to take into account the possibility that there had been no incest, although she admitted in general that doctors could also be mistaken. The fact that witnesses J. and S. gave evidence that the applicant had explained her situation in a pertinent manner did not undermine the view of Drs A.K. and M.E. The doctors gave concordant evidence that the discussions with the applicant were pertinent as long as her view on the alleged incest was not contradicted. At the oral hearing it became evident that witnesses J. and S. had not disputed the applicant’s views, but had mostly listened to what she had to say. S. indeed gave evidence that she had checked the information provided by the applicant against other sources, but as she had concluded that the views of the applicant were tenable, she had naturally not come into conflict with her. Witness P. had not taken a stand as to whether or not the applicant had a delusional disorder. He had only judged whether or not open-care measures were possible. According to Dr A.K., the diagnosis of delusion had also been affected by the applicant’s continuing suspicion of authority and of medical and psychological examinations. Dr M.E. also gave evidence about the numerous appeals made by the applicant and how her world centred on them. The applicant had refused a somatic and neurological examination, magnetic imaging and psychological tests because she believed that the tests would be carried out by biased and prejudiced persons. The applicant has the right to refuse to be examined in respect of her mental health. On the other hand, it is justifiable to question the basis for the absolute refusal to undergo the examinations offered and whether the refusal may be based precisely on thinking typical of a delusional disorder. Having regard to these considerations, it cannot be said that the diagnosis of delusional disorder was based on improper or arbitrary grounds, although the applicant has explained her refusal of examinations by stating that she had the right to do so, and her writing of legal submissions by stating that it was necessary to do so. At the oral hearing the applicant admitted that a deluded person would probably not be aware of her own illness. At the oral hearing the applicant’s son, Dr E., a doctor in general practice, gave evidence stating that he understood, given his mother’s absolute and rigid behaviour, that she had been diagnosed as delusional. He could not, however, be certain of the correctness of the diagnosis, since he had seen his mother only a few times in recent years. On the basis of the documents in the file and the information received at the oral hearing, and on the above grounds, the Supreme Administrative Court finds that reliable evidence has been provided for the diagnosis of delusional disorder in the decision of the Forensic Medical Authority. A diagnosis of delusional disorder as such does not, however, suffice to warrant involuntary treatment. In addition, its effects on the person concerned and on others must be assessed. The decision of the National Forensic Medical Authority was that the applicant was in need of involuntary treatment and that, if not treated, her mental illness would considerably worsen and seriously endanger her health and the health of others. According to information received, when the decision on treatment was taken regard was had to the repercussions for the applicant’s life if her conflicts with the authorities and raising of associated issues were to continue. At the time it was considered that the applicant was not able to think matters through and that ordering treatment could help her to continue life in a calmer way. These considerations must be held to be pertinent to an assessment of the need for the involuntary treatment for the sake of the applicant’s own health. The fact that after about six months of treatment and medication the head physician, Dr M.E., in his explanation of 17 August 2005, and the witnesses put forward by the applicant, in their statements, expressed divergent conclusions does not justify calling into question the assessment of the National Forensic Medical Authority regarding the need for treatment on 17 February 2005 for the sake of the applicant’s health. The National Forensic Medical Authority did not consider that, if not treated, the applicant would seriously endanger the safety of others. However, it held that the health of others could be seriously endangered. It should be taken into account that the applicant could have an influence on other people, owing to the authority which she enjoys by reason of her status as a paediatrician. She may engender in other people suspicions which lack real foundation, causing them to act hastily, inappropriately or even criminally. The possibility of this kind of influence is not lessened by the fact that the applicant is retired. Nor would the possibility of influence be prevented by the mere withdrawal of the applicant’s licence to practise medicine, because the influencing is exerted on a psychological level and also in contexts other than that of a doctor’s consulting room. The nurse assigned to the applicant, P., gave evidence to the effect that the applicant was not dangerous to other people. Although in his witness statement he also raised the issue of whether the applicant had given other patients dangerous advice, P.’s testimony can be regarded as a common judgment of a person’s dangerousness, such as violent behaviour or similar. This is not the case when it comes to the applicant. On the contrary, all the witnesses have concordantly testified that she tries to do good things and tries to help others. The doctors treating her have made similar statements. This intention does not, however, obviate the possibility that the actions of the person could cause harm to others. In this case there are sufficient grounds for holding that, if not treated, the applicant could have seriously endangered the health of others. Other mental health services are inadequate, having regard to the fact that the applicant is in denial as regards her illness. That being the case, it can be held that the applicant would try to avoid treatment and would refuse examinations. Conclusion The Supreme Administrative Court finds, on the basis of the documents in the file and the information received at the oral hearing, that it has been reliably and objectively shown that the applicant was, at the time of the decision of the National Forensic Medical Authority, mentally ill within the meaning of section 8 of the Mental Health Act. Owing to her mental illness, she was in need of treatment and, if not treated, her mental illness would have considerably worsened or seriously endangered her health and the health of others. Other mental health services would not have been adequate. The conditions for ordering the applicant to undergo involuntary hospital treatment were thus present. The decision of the National Forensic Medical Authority ordering treatment was based on the Mental Health Act and was made in accordance with the procedure laid down by law. Nor is the decision unlawful.” 75. On 22 July 2005, on the basis of a medical observation report by the doctor treating the applicant and the applicant’s medical records, the head physician of Vanha Vaasa Hospital decided to continue her treatment. It was noted that the applicant had, inter alia, criticised the treatment being given in the hospital and had tried to play a role in other patients’ treatment in her capacity as a doctor. She had also given them instructions concerning medication, even after she had been forbidden to do so. Open-care measures were considered insufficient, because the applicant was in denial of her illness and completely lacked motivation in relation to her treatment. 76. The decision of 22 July 2005 was submitted for confirmation to the Administrative Court (hallinto-oikeus, förvaltningsdomstolen). The applicant also appealed against that decision to the same court, requesting an oral hearing. 77. On 31 October 2005, having obtained a statement from the head physician of Vanha Vaasa Hospital and the applicant’s comments on it, the Administrative Court dismissed the applicant’s appeal. It observed that the applicant’s condition had improved during treatment and that there had been discussions about a possible transfer to a psychiatric hospital in her home town. The court noted that the applicant was not suicidal and thus not endangering her own health, nor was she violent towards others. She was able to discuss day-to-day matters in a pertinent and polite manner as long as no one contested her views. However, she was still denying her illness, which manifested itself in her opposition to medical treatment and all further medical examinations offered her. The denial of the illness and lack of motivation in relation to treatment led the court to the conclusion that the applicant would most likely neglect treatment outside the hospital, which would severely aggravate her illness and endanger her health. As her delusion was related to her medical profession and her patients, lack of treatment could also put the health of others at serious risk. The Administrative Court also dismissed the applicant’s request for an oral hearing as manifestly unnecessary, making reference to the hearing held by the Supreme Administrative Court on 4 October 2005. Moreover, the court considered that the main issue, that of whether the applicant’s condition had improved to the extent that grounds for involuntary treatment no longer existed, could be adequately resolved on the basis of the case file alone. 78. The applicant appealed further to the Supreme Administrative Court, citing, inter alia, the medical opinion of 30 December 2002 by Dr K.A., the medical opinion of 5 October 2005 by Dr E.P., and those of 25 October 2005 and 21 December 2005 by Dr M-P.H. 79. On 16 May 2006 the Supreme Administrative Court, having obtained a fresh statement from the head physician of Vanha Vaasa Hospital and the applicant’s comments on it, upheld the lower court’s decision, on mainly the same grounds. It rejected the applicant’s request for an oral hearing, finding oral evidence on circumstances which prevailed after the adoption of the impugned decision of 22 July 2005 irrelevant. 80. On 20 January 2006 the head physician of Vanha Vaasa Hospital took a further decision to continue the applicant’s involuntary care, based on a medical observation report by another hospital physician. It was noted that the applicant’s condition had improved and that she was currently cooperating with hospital staff. While her sense of reality still failed her as far as the criminal charge against her was concerned, she was able to discuss the matter pertinently and without agitation. She was no longer regarded as dangerous to herself or others and planning for her future transfer to outpatient care was considered justified. 81. That decision was submitted to the Administrative Court for confirmation. The applicant appealed against that decision also. 82. On 20 April 2006, having held an oral hearing, the Administrative Court found that the applicant was still suffering from psychotic delusions and that her illness was of a chronic nature. According to the court, the cessation of treatment would therefore significantly aggravate her illness. The court also took into account the marked improvement in the applicant’s condition, which had made it possible to plan her gradual transfer to outpatient care. It was noted that the applicant’s medication by injection had been terminated at the beginning of January. The court considered that it had been important for safety reasons to observe the effects of the withdrawal of medication in the hospital and, therefore, other forms of care would have been insufficient at the time. 83. It is not known whether the applicant lodged a further appeal with the Supreme Administrative Court. 84. During her stay in Vanha Vaasa Hospital the applicant made representations to the National Forensic Medical Authority, which by letter of 15 July 2005 noted that it had commenced an investigation of the actions of the medical staff involved in the applicant’s treatment. It did not however have the authority to monitor health care establishments. It informed the applicant that that authority lay with the social and health affairs department of the relevant State Provincial Office (lääninhallitus, länsstyrelse). Nor did the National Forensic Medical Authority have the authority to intervene in the administering of medication or to order the medication to be discontinued. It could, however, assess retrospectively the appropriateness of a doctor’s professional activity. 85. Between January and July 2005 the applicant lodged a number of other requests with the National Forensic Medical Authority concerning, inter alia, her psychiatric assessment and treatment in Vanha Vaasa Hospital. On 12 January 2007 the National Forensic Medical Authority gave its decision in respect of those complaints. It relied on the judgment of 13 October 2005 by the Supreme Administrative Court in finding that the confinement of the applicant in involuntary care had been justified. As a general remark it was noted that the primary and sometimes only symptom of a delusional disorder was a false belief which the patient holds to and attempts to act upon. The delusion was continuous, clear and systematic, and could be very persistent and steadfast. It was common for a patient suffering from a delusional disorder not to manifest any other anomalous behaviour. A special form of delusion was what was known as a querulous delusion, which was characterised by continual claims for rectification, complaints and legal proceedings, driven by psychotic thinking, with the aim of restoring the person’s injured self-esteem. A delusional disorder was treated with therapeutic consultations and antipsychotic medicines. Lack of motivation for treatment and an inadequate response to treatment posed fundamental risks to the successful outcome of medical treatment. As regards the applicant’s treatment, and the forced administration of medication in particular, the National Forensic Medical Authority found no indication of conduct deviating from appropriate and commonly accepted medical practice, so her representations could therefore be considered erroneous. The decision was not subject to appeal. 86. By letters dated 8, 11, 25 and 26 July 2005 Ms H.M. approached the Chancellor of Justice on the applicant’s behalf, requesting him to take action concerning the involuntary treatment of the applicant. Having regard to the provisions concerning the division of duties between the Chancellor of Justice and the Parliamentary Ombudsman, those letters were transmitted to the latter authority. By a letter dated 27 September 2005 Ms H.M. was informed of the Ombudsman’s decision not to deal with the case, as it was already pending before other authorities, namely the Supreme Administrative Court, the National Forensic Medical Authority, and the police. 87. The applicant reported three Vanha Vaasa Hospital doctors to the police, alleging, inter alia, serious deprivation of liberty. On 27 January 2006, having obtained written statements from the National Forensic Medical Authority, the police found that no offence had been committed and closed the investigation. 88. The applicant also made representations to the State Provincial Office, which sent the regional medical officer and health care inspector to Vanha Vaasa Hospital to interview the applicant and the hospital staff involved in her treatment. The regional medical officer also met the applicant’s representative. Furthermore, the authority acquainted itself with the applicant’s medical records and other documents related to the case and obtained written statements from hospital staff and the applicant’s comments on them. In its decision of 26 June 2006 the State Provincial Office noted that the issues raised by the applicant had previously been thoroughly examined by the National Forensic Medical Authority, which had found no irregularities. In the light of its own examination of the case, the State Provincial Office did not find that there was any reason to take further measures. The decision was not subject to appeal. 89. In its decision of 17 February 2005 the Forensic Psychiatry Board found that the applicant’s capacity to look after her own interests in the criminal proceedings was reduced by her mental illness and that she was therefore in need of a guardian. The applicant contested this, arguing that she was well. 90. On 23 February 2005, referring to the above statement by the National Forensic Medical Authority, the District Court informed the applicant by letter that it had decided under Chapter 12, Article 4a of the Code of Judicial Procedure to appoint a guardian for her in respect of the ongoing proceedings. It was noted that counsel M.S., who was considered to be suitable for the task, had given his consent. The applicant was provided with the opportunity to give her opinion on the matter by 3 March 2005. She was also informed that the court would hold a further oral hearing on 14 March 2005 and that her attendance at that hearing was not obligatory. 91. By a letter dated 24 February 2005 the applicant opposed the appointment of a guardian without giving further reasons. She demanded that all documents concerning that matter be faxed to Mr J.R. and sent to her by post. 92. On 2 March 2005 the District Court appointed the applicant’s public defender, Mr M.S., guardian. It was noted in the decision that the applicant was against the appointment of a guardian. 93. On 20 June 2005 the Court of Appeal rejected the appeal signed by the applicant, noting that she was, in the opinion of the National Forensic Medical Authority, in need of a guardian, owing to her mental illness. The court did not find reasons to hold otherwise. Nor did it hold an oral hearing as requested by the applicant. The court did not examine a writ of appeal signed by Mr J.R., as he did not fulfil the requirements under Chapter 15, Article 2 § 1, of the Code of Judicial Procedure. Nor did it examine the appeal lodged by the applicant’s daughter, as she had failed to give notice of her intention to appeal as required by Chapter 25, Article 5 § 1, of the said Code. 94. The applicant, represented by Ms H.M., sought leave to appeal, requesting an oral hearing. She argued that Mr M.S., whom she had never met, had not acted in her best interests. For instance, he had failed to request an oral hearing in the Court of Appeal although the applicant had asked him to submit a request to that effect. Nor had he questioned the correctness of the psychiatric assessment. She also submitted that she was in good health and not in need of a guardian. 95. On 30 September 2005 the Supreme Court refused leave to appeal. 96. On 10 March 2005 the applicant submitted to the District Court a list of eighteen witnesses she wished to examine before the court concerning, inter alia, the events in December 2000 and the alleged serious deprivation of liberty. She also sought to have Drs H.L. and M-P.H. heard as medical experts. She further identified a number of documents to be adduced as written evidence. 97. On 14 March 2005 the District Court held the final hearing in the criminal case. The applicant arrived at the court house but left before the hearing began. According to the applicant, she did so because Mr J.R., whom she had wanted to have heard as a witness, had been removed from the premises by force. 98. The District Court proceeded with the hearing, in which the applicant was represented by her guardian, Mr M.S. The latter did not contest the accuracy of the medical opinion on the applicant’s psychiatric assessment. Nor did he refer to other medical opinions on the applicant’s mental health. He pleaded on the applicant’s behalf that she could only be regarded as an accessory to the offence in her capacity as a doctor. He did not find it necessary to hear witnesses. 99. In its judgment of 8 April 2005 the District Court found V.’s mother responsible for serious deprivation of liberty between 16 December 2000 and 22 April 2001. The applicant was found responsible for aiding and abetting V.’s mother in the commission of that offence between 26 December 2000 and 22 April 2001. The court did not pass sentence on them as they were not responsible for their actions at the material time. However, it ordered them to pay damages and legal costs. 100. As regards the background to the case, the court noted that V. had been examined from 1995 onwards as a result of her mother’s suspicions that she had been sexually abused. The public prosecutor L.K. had decided on 19 April 1999 not to prefer charges against the father, as there was no evidence that an offence had taken place during the period from 1994 to March 1996. On 21 April 1998 the public prosecutor M.P. waived charges against another person, as there was no evidence that an offence had taken place in July 1997. On 4 June 2001 the public prosecutor L.K. waived charges against the father, as there was no evidence that an offence had taken place during the period from September 1998 to June 2000. In June 2000 the mother took V. to a university hospital for examination. Those examinations did not support her suspicions of sexual abuse. On 13 June 2000 the girl was taken into emergency public care because of her mother’s mental health problems and was placed in a family support centre. An ordinary care order was made in July 2000. Meanwhile, on 26 June 2000 the mother removed the girl from the centre without permission and they were found later that day in a town some 100 km away, whereupon the girl was returned to the centre by the police. On 3 April 2001 the Court of Appeal granted the father sole custody of the girl, who was to see her mother during supervised visits three times a week. 101. As to the applicant’s actions, the court noted that she had expressed a number of opinions which could not be regarded as medical opinions. She had predominantly functioned as an aide to the girl’s mother, making suggestions on what measures to take. The applicant had been aware of the fact that the girl had been taken into public care and on 18 December 2000 the police had told her that the girl was missing. The court found it established that V. and her mother had come to meet the applicant on 26 December 2000. Since that date the applicant had found accommodation for them and transported them in her car. The applicant had allowed the mother’s mail to be redirected to her address. The court noted that it had not even been suggested that the applicant had been in [town A] on 16 December 2000. 102. By a letter dated 12 April 2005 Mr M.S. informed the applicant that, as her guardian, he had notified the District Court of the applicant’s intention to appeal against its judgment. He asked the applicant to state her opinion on the judgment in writing and informed her that he would be in Vaasa on 26 April 2005, should the applicant wish to meet him in person. It appears that no meeting took place. 103. Mr M.S. subsequently appealed on the applicant’s behalf, arguing that the charge should be rejected on the grounds of lack of intent. In her capacity as a doctor, the applicant had only wished to protect the mother and the child as she was firmly convinced that the girl had been sexually abused. The guardian took the view that the case could be examined by the appellate court in a written procedure. On 9 May 2005 Mr M.S. sent a copy of the notice of appeal to the applicant for information, noting that it corresponded, in the main, to the draft he had sent her earlier, on 2 May 2005. He also noted that the applicant had not made any comments on that draft. 104. In her own writ of appeal the applicant requested an oral hearing, at which she wished the court to hear the same eighteen witnesses she had requested in the proceedings before the District Court. She also questioned the motives of the public prosecutor in bringing charges for an aggravated offence. The applicant had acquired a copy of his notes to the proceedings, in which it was implied that a psychiatric assessment was the only means of treatment, which, in turn, was the only means of stopping the terrorising of the father and the child and the misuse of justice. The applicant later lodged a number of additional submissions with the appellate court. 105. On 31 August 2005, relying on Chapter 26, Article 14 § 2, point 4, of the Code of Judicial Procedure, the Court of Appeal refused the applicant’s request for an oral hearing as manifestly unnecessary. As regards the subject matter, the court upheld the lower court’s judgment, finding no reason to deviate from it. Under Chapter 25, Article 12 § 2 of the Code, the court dismissed the applicant’s own belated representations without examining their merits. 106. The applicant, represented by counsel of her choosing, Ms H.M., requested leave to appeal. 107. On 14 February 2006 the Supreme Court refused leave to appeal. 108. On 24 October 2005 the National Forensic Medical Authority decided that the applicant’s ability to work as a doctor and her health should be examined. 109. By an interim decision of 17 March 2006 the National Forensic Medical Authority prohibited the applicant from practising her profession during 2006. 110. The applicant was assessed in an open ward of the psychiatric clinic at Helsinki University Hospital from 6 September to 6 October 2006. 111. The resultant medical opinion of 10 October 2006 did not note any specific psychiatric disorder affecting the applicant. It was noted, however, that a full examination could not be conducted because the applicant refused to surrender documents from Vanha Vaasa Hospital concerning her medical history. It was considered that the fact that she had suffered from a narrowly focused delusional disorder would hamper her ability to function as a sound expert in sexual abuse cases. She should thus concentrate on general paediatrics. 112. On 29 January 2007 the National Forensic Medical Authority revoked its decision of 17 March 2006, but ordered that the applicant should not deal with suspected child abuse cases in her private practice. The applicant appealed against that decision to the Administrative Court and the Supreme Administrative Court. Those appeals were dismissed on 24 September 2008 and 24 August 2009 respectively. 113. The applicant states that she is again seeing patients at her surgery. 114. The Constitution (Suomen perustuslaki, Finlands grundlag; Law no. 731/1999) provides in its relevant parts: “Section 7 - The right to life, personal liberty and integrity Everyone has the right to life, personal liberty, integrity and security. No one shall be sentenced to death, tortured or otherwise treated in a manner violating human dignity. The personal integrity of the individual shall not be violated, nor shall anyone be deprived of liberty arbitrarily or without a reason prescribed by an Act. A penalty involving deprivation of liberty may be imposed only by a court of law. The lawfulness of other cases of deprivation of liberty may be submitted for review by a court of law. The rights of individuals deprived of their liberty shall be guaranteed by an Act ... Section 10 - The right to privacy Everyone’s private life, honour and the sanctity of the home are guaranteed ...” 115. Chapter 3, Article 4, paragraphs 1 and 2, of the Penal Code (rikoslaki, strafflagen, Law no. 515/2003) provide: “Prerequisites for criminal liability are that the perpetrator had reached the age of fifteen years at the time of the act and is criminally responsible. The perpetrator is not criminally responsible if at the time of the act, owing to mental illness, severe mental deficiency or a serious mental disturbance or a serious disturbance of consciousness, he or she is not able to understand the factual nature or unlawfulness of his or her act or his or her ability to control his or her behaviour is decisively weakened for that reason (lack of criminal responsibility).” 116. At the relevant time Chapter 17, Article 45, of the Code of Judicial Procedure (oikeudenkäymiskaari, Rättegångs Balk, Law no. 571/1948) read: “The court may, where it is deemed necessary, order a psychiatric assessment of the defendant. Such an assessment may not be ordered against the defendant’s will save in cases where he or she has been placed in detention pending trial or is charged with an offence punishable by a term of imprisonment of more than one year. (494/1969) Separate provisions apply to psychiatric assessment and admission to a mental institution for such an assessment.” 117. That provision was amended by Law no. 244/2006, which took effect on 1 October 2006. According to the amended provision, a psychiatric assessment of the defendant may be ordered if the court has, in an interim judgment, found the defendant guilty as charged, such an assessment is justified, and the defendant agrees to the assessment or he or she has been placed in detention pending trial or has been charged with an offence punishable by more than one year’s imprisonment. At the request of the prosecutor, the defendant or his or her guardian, the court may order a psychiatric assessment earlier, during the pre-trial investigation or prior to the main hearing, if the defendant has pleaded guilty to the charge or if the need for such an assessment is otherwise clear. 118. The relevant parts of the Mental Health Act (mielenterveyslaki, mentalvårdslagen, Law no. 1116/1990), as in force at the material time, provided as follows: “Chapter 1 ... Section 2 - Direction and supervision ...In each province the planning, direction and supervision of mental health work is the responsibility of the State Provincial Office. The State Provincial Office shall, in particular, supervise the use of limitations on the right of self-determination referred to in Chapter 4 (a) of this Act. (1423/2001) ... Section 6 - Treatment given in State mental hospitals Psychiatric assessments referred to in section 15 are conducted in State mental hospitals. On the recommendation of a hospital in a hospital district, individuals who are mentally ill or suffering from other mental disorders and whose treatment is particularly dangerous or difficult can be admitted to a State mental hospital. On the recommendation of a hospital in a hospital district, individuals who are not mentally ill or suffering from the other mental disorders referred to in subsection 1 may also be treated in a State mental hospital if appropriate treatment cannot be provided in a hospital within the hospital district. Decisions on admitting to a State mental hospital a person accused of a crime or a person whose sentence has been waived because of his or her mental condition are made by the National Forensic Medical Authority, as provided for in section 17. In other cases decisions on admitting a patient to a State mental hospital, discontinuing treatment and discharging the patient are made by the head physician of the State mental hospital. (1504/1999) ... Chapter 2 Section 8 – Criteria for compulsory treatment A person can be ordered to undergo treatment in a psychiatric hospital against his or her will only (1) if the person is diagnosed as mentally ill; (2) if the person needs treatment for a mental illness which, if not treated, would become considerably worse or seriously endanger the person’s health or safety or the health or safety of others; and (3) if all other mental health services are inapplicable or inadequate ... Chapter 3 Section 15 - Admission to hospital for psychiatric assessment If the court orders a person accused of an offence to undergo a psychiatric assessment under Article 45 of Chapter 17 of the Code of Judicial Procedure, the person accused of the offence may be admitted to a hospital for psychiatric assessment and detained there against his or her will notwithstanding Chapter 2 of this Act. Section 16 (1086/1992) - Psychiatric assessment After ordering a person who is accused of an offence to undergo a psychiatric assessment, the court must forward the associated documents to the National Forensic Medical Authority without delay. The National Forensic Medical Authority shall decide where the psychiatric assessment is to be carried out and, if it is to be carried out outside hospital, by whom. The psychiatric assessment shall be completed and a statement on the mental condition of the person accused of the offence shall be submitted to the National Forensic Medical Authority not later than two months after the start of the psychiatric assessment. If there are reasonable grounds for so doing, the National Forensic Medical Authority may extend the period of the assessment by a maximum of two months. When it has received the said statement, the National Forensic Medical Authority shall issue its own statement to the court concerning the mental condition of the person accused of the offence. Section 17 - Involuntary treatment after psychiatric assessment If the conditions for ordering a person accused of an offence to undergo treatment against his or her will are met on completion of a psychiatric assessment, the National Forensic Medical Authority shall order the person to undergo treatment against the person’s will. (1086/1992) The person may be detained for treatment against his or her will on the basis of the decision of the National Forensic Medical Authority for a maximum of six months. Before the end of this period a statement on the observation of the patient shall be produced indicating whether or not the conditions for referring the person for treatment against his or her will are still met. A decision on whether treatment should be continued or discontinued shall be made in writing by [the head physician in charge of the psychiatric care or, if that physician is ineligible or unavailable, by another physician assigned to the task, preferably one specialising in psychiatry], before the treatment has continued for six months. A decision to continue the treatment shall be made known to the patient without delay and shall be immediately submitted for approval of the [court], and the [court] shall assess whether the conditions for ordering treatment against the patient’s will still exist. A decision to discontinue the treatment shall also be made known to the patient without delay and shall be submitted immediately to the National Forensic Medical Authority for approval. The National Forensic Medical Authority shall either confirm the decision to discontinue the treatment or, if the conditions for treatment against the patient’s will still exist, order the patient to undergo treatment. (1504/1994) On the basis of a decision to continue treatment, the patient may be detained for treatment against his or her will for a maximum of six months. If it seems probable at the end of this period that continuing the treatment is still necessary, measures shall be taken in accordance with subsection 2. (1504/1994) If it appears during the treatment of a person whose treatment is compulsory that the conditions for ordering the patient to undergo treatment against his or her will do not exist, measures shall be taken in accordance with subsection 2. (1504/1994) Section 17 a (383/1997) – Specialised psychiatric hospital treatment The National Forensic Medical Authority shall decide on initiating involuntary treatment of a person accused of a crime; the treatment shall take place in a hospital which has the facilities and particular expertise required for the treatment of the patient. When the patient’s need for treatment changes, the physician referred to in section 11 shall immediately take measures to transfer the patient to a hospital which can provide the treatment the patient requires. The need for treatment in a State mental hospital shall, however, be assessed within six months of the beginning of the treatment, in collaboration with the hospital district in whose area the patient’s home municipality is located. Chapter 4a Section 22 a (1423/2001) - ... general conditions for limiting fundamental rights .... A patient’s right of self-determination and other fundamental rights may be limited by virtue of the provisions of this Chapter only to the extent necessary for the treatment of the illness or for the person’s safety or the safety of others, or to safeguard some other interest laid down in this Chapter. The measures shall be undertaken as safely as possible and with respect for the patient’s dignity. When choosing and determining the extent of a limitation on the right of self-determination special attention shall be paid to the criteria for the patient’s hospitalisation ... Section 22 b (1423/2001) - Treatment of mental illness A patient must be treated, as far as possible, in an atmosphere of mutual understanding. A care plan must be drawn up when treatment is being provided. In treating a patient with mental illness the only medically acceptable methods of examination and treatment are those which, if not used, would seriously jeopardise the health and safety of the patient or others. The physician attending the patient decides on the treatment and examinations which are to be given regardless of the patient’s wishes. The attending physician also decides whether to hold or tie down the patient and whether to take other similar measures for the period of the treatment, or whether to take other short-term restrictive measures necessary to give treatment ... Chapter 5 ... Section 24 (1504/1994) – Appeal An appeal may be lodged with the [court] against the decision of a hospital physician to order a person to have treatment or to continue treatment against the person’s will ... Section 25 - Enforcement and interruption of enforcement A decision to order a patient to undergo treatment against his or her will or to continue such treatment, or to take possession of personal property or to limit contacts, shall be enforced immediately irrespective of whether or not the decision has been submitted to another authority for confirmation or an appeal has been lodged. (1423/2001) After a decision has been submitted to another authority or an appeal lodged against it, the authority in question or appellate authority may forbid the enforcement of the decision or order it to be stopped. Section 26 - Urgency of the proceedings Submissions or appeals relating to treatment given against a patient’s will, and matters relating to mental health assessment, must be dealt with urgently ...” 119. According to the preparatory documents relating to section 22b of the Mental Health Act (Government Bill HE 113/2001 vp), a care order issued for the involuntary hospitalisation of a psychiatric patient is understood to contain an automatic authorisation to treat the patient, even against his or her will. Although the doctors may seek to obtain a person’s consent prior to the treatment, there is no obligation to have such consent in written form or to seek such consent from the patient’s relatives or guardian. If a patient refuses to give his or her consent or withdraws consent previously given, the provision allows the forced administration of medication. This is in the interest of the patient in order to secure his or her constitutional right to necessary care in a situation in which the patient is not personally able to make a decision about the treatment on account of his or her illness. 120. Section 7(3) of the Administrative Courts Act (hallinto-oikeuslaki, lagen om förvaltningsdomstolarna, Law no. 1424/2001) provides that in administrative courts an expert member participates in the consideration of, and decision on, matters concerning the order of involuntary care and continuing involuntary care of a person referred to in the Mental Health Act. 121. The relevant provisions of the Health Care Professionals Act (laki terveydenhuollon ammattihenkilöistä, lagen om yrkesutbildade personer inom hälso- och sjukvården, Law no. 559/1994), as in force at the material time, read as follows: ... Section 15 - Obligations related to professional ethics The work of health care professionals has the objective of promoting and maintaining health, preventing illness, curing those who are ill and alleviating their suffering. In their professional activities, health care professionals must employ generally accepted, empirically justified, methods, in accordance with their training, which should be continually supplemented. Each health care professional must weigh the benefits to the patient of their professional activity against its possible hazards ... Section 24 - Guidance and supervision The general guidance of health care professionals lies with the Ministry of Social Affairs and Health. The National Forensic Medical Authority is responsible for the guidance and supervision of health care professionals ... Within a province the activities of health care professionals are guided and supervised by the State Provincial Office ... 122. The Decree on the National Forensic Medical Authority (asetus terveydenhuollon oikeusturvakeskuksesta, förordningen om rättskyddscentralen för hälsovården, no. 1121/1992, with subsequent amendments) contains provisions concerning, inter alia, the Forensic Psychiatry Board within that authority. Article 12 of the Decree, as amended by Law no. 432/1997 and in force at the relevant time, provided that the Board dealt with and decided on matters concerning the mental state of a person charged with an offence, or matters related to the ordering of treatment of such a person, or a person not sentenced to a punishment because of his or her mental state, in psychiatric hospital care, and the cessation of such treatment. The Board was composed of a chairman, who had to be an official of the National Forensic Medical Authority, and three other members. One of the members had to be an expert in the field of law, and two members, one of whom also had to be a representative of municipal health care, had to be an expert in the field of psychiatry. 123. State Provincial Offices ceased to exist on 1 January 2010, and their tasks have been transferred to various other authorities. Prior to that rearrangement within the administration, the provisions regulating the tasks of the State Provincial Offices were to be found in some 130 different statutes. General information about the tasks and powers of that authority may be found in the Government Bill HE 154/2005 vp concerning, inter alia, certain amendments to the Mental Health Act. According to that document, the State Provincial Offices were to exercise guidance and supervision of State mental hospitals, among a number of other institutions and services. This was implemented, inter alia, by way of distribution of information, on-site inspections and dealing with complaints. In 63% of the decisions given by State Provincial Offices in 2004, in their capacity as supervising authorities, no appearance of inappropriateness to a degree which would have justified their taking measures was found; 18% of the cases dealt with resulted in the attention of a health care professional being drawn to the matter, and an admonition was given in 5% of the cases. 124. The relevant parts of Chapter 2, section 1 of the Criminal Procedure Act (laki oikeudenkäynnistä rikosasioissa, lagen om rättegång i brottmål, Law no. 689/1997) provide as follows: “A person suspected of an offence has the right to defend him or herself in pre-trial investigations and at the trial ... A public defender shall be appointed for the suspect of the court’s own motion when: (1) the suspect is incapable of defending himself or herself; (2) the suspect, who has not retained a public defender, is under 18 years of age, unless it is obvious that he or she has no need of one; (3) the public defender retained by the suspect does not meet the qualifications required of a public defender or is incapable of defending the suspect; or (4) there is another special reason for the same.” (107/1998) Chapter 2, section 2 (1) reads: “A person appointed under section 1 ... as public defender ... must be a public legal-aid attorney or an advocate. If there is no suitable public legal-aid attorney or advocate available or there is another special reason to do so, another person with a degree of [Master of Law] who by law is qualified to act as an attorney may also be appointed as public defender ... The person to be appointed as public defender ... must have an opportunity to be heard on the appointment.” (260/2002) 125. Chapter 12, Article 4a, of the Code of Judicial Procedure (Law no. 444/1999) reads: “If a party is incapable of looking after his or her interests in court proceedings owing to illness, mental disorder, ill health or another similar reason, the court before which the case is pending may of its own motion appoint a guardian for that party for the purposes of the proceedings. The provisions of the Guardianship Services Act shall apply to such guardian. Unless the court decides otherwise, the appointment of the guardian shall remain in effect before an appellate instance where the matter is pending on appeal.” 126. Section 5 of the Guardianship Services Act (laki holhoustoimesta, lagen om förmyndarverksamhet, Law no. 442/1999) provides that a suitable person who consents to the appointment is eligible as a guardian. In the assessment of the suitability the skills and experience of that person, among other things, and the nature and extent of the task shall be taken into account. 127. Chapter 8 of the Code of Judicial Procedure (Law no. 768/2002) lays down provisions concerning the procedure to be followed in dealing with petition-based cases (hakemusasia, ansökningsärendet) in the District Court. Those provisions apply also to such petition-based cases which the court may take into consideration of its own motion (Article 1 § 2). A petition-based case shall be examined in chambers or at a hearing. If a party, a witness or another person is to be heard in person, a hearing must be held. A hearing must also be held if the matter has been contested and a party requests a hearing or if the court considers a hearing necessary for the matter to be resolved (Article 3). If a party is to be reserved an opportunity to be heard in a petition-based case, the court must invite him or her to submit a written statement (Article 5). A petition-based case may be dealt with in connection with related criminal proceedings, if that is possible without impeding the proceedings (Article 9 § 2. 128. Chapter 26 of the Code regulates the appeal procedure in the Court of Appeal. Article 14 of that Chapter (Law no. 165/1998) reads as follows: “An oral hearing shall be held in the Court of Appeal if a party to a civil case or the injured party or the defendant in a criminal case so requests. However, an oral hearing need not be held for the reason referred to in subsection 1, if: (1) in a civil case amenable to settlement, the opposing party has consented to the appellant’s request for a change; (2) in a criminal case only the appellant has requested a full hearing and it is the appeal decision which makes the ruling on the case; (3) the person requesting a main hearing is satisfied with the decision of the District Court and the decision is not changed to his or her detriment; (4) the appeal is manifestly ill-founded; (5) the matter is to be decided in the case is procedural only; or (6) a full hearing is for another reason manifestly unnecessary. The provisions in paragraph 1 and in paragraphs 2 § 1 and 2 §§ 3--6 also apply, in so far as appropriate, when hearing an appeal lodged in a petition-based case.” 129. According to the relevant Government Bill (HE 33/1997 vp) the term “ill-founded” in Chapter 26, Article 14 § 2, point 4, of the Code refers to a situation where it is impossible for the grounds presented in the appeal to lead to the changes requested. An appeal is also ill-founded where the grounds for it do not correspond to the generally known facts. The provision may also be applied in criminal cases where, inter alia, the defendant requests an acquittal relying on matters which he or she would present at the oral hearing but which could not have any impact on a decision in the case. No consideration is to be given to the gravity of the offence or the sentence imposed when that provision is applied. 130. Chapter 26, Article 15 § 1 of the Code (Law no. 165/1998) reads: “The Court of Appeal shall hold an oral hearing, regardless of whether one has been requested, if a decision on the matter turns on the credibility of the testimony admitted in the District Court or the findings of the District Court in a judicial inspection, or on new testimony to be admitted in the Court of Appeal. In this event, the evidence admitted in the District Court shall be readmitted and the inspection carried out again in an oral hearing, unless there is an impediment to this.” 131. Chapter 6, section 5 § 2 of the Criminal Procedure Act stipulates, inter alia, that it is a court’s task to ensure that a case is dealt with in a coherent and orderly manner. It shall also ensure that the proceedings are conducted appropriately and that no irrelevant issues are introduced. 132. Paragraph 41 of the CPT report concerns the consent of a patient to treatment given in a mental hospital. It reads as follows: “Patients should, as a matter of principle, be placed in a position to give their free and informed consent to treatment. The admission of a person to a psychiatric establishment on an involuntary basis should not be construed as authorising treatment without his consent. It follows that every competent patient, whether voluntary or involuntary, should be given the opportunity to refuse treatment or any other medical intervention. Any derogation from this fundamental principle should be based upon law and only relate to clearly and strictly defined exceptional circumstances. Of course, consent to treatment can only be qualified as free and informed if it is based on full, accurate and comprehensible information about the patient’s condition and the treatment proposed; to describe ECT as "sleep therapy" is an example of less than full and accurate information about the treatment concerned. Consequently, all patients should be provided systematically with relevant information about their condition and the treatment which it is proposed to prescribe for them. Relevant information (results, etc.) should also be provided following treatment.” 133. The CPT visited Finland from 7 to 17 September 2003, the Niuvanniemi State Mental Hospital being among the establishments visited. In paragraph 144 of its report, published on 14 June 2004, the CPT made the following remark: “As regards safeguards, the procedures concerning the mental examination of persons accused of a crime and the initial placement of such persons offered, overall, adequate guarantees of independence and impartiality as well as objective medical expertise. By contrast, the manner in which an order for treatment in respect of both civil and forensic patients was being renewed would merit a reassessment. The CPT considers that the periodic review of an order to treat a patient against his/her will in a psychiatric hospital should involve a psychiatric opinion which is independent of the hospital in which the patient is detained.” 134. On its next visit to Finland, between 20 and 30 April 2008, the CPT visited, inter alia, the Vanha Vaasa State Mental Hospital and another psychiatric establishment. In its report, published on 20 January 2009, the CPT made, inter alia, the following remarks and recommendations: “ ... 126 - In both establishments, the use of psychiatric medication appeared appropriate. As regards the Vanha Vaasa Hospital, the current rhythm of formal multidisciplinary clinical review (twice a year) is not sufficient. Staff representing different specialties (psychiatrists, nurses, psychologists, occupational and work therapists, social workers) should all meet and discuss each patient’s condition and progress on a more frequent basis. The CPT recommends that steps be taken in the light of these remarks ... 140 - Involuntary hospitalisation of a psychiatric patient continued to be construed as automatically authorising treatment without his/her consent. In practice, doctors in the two psychiatric establishments visited sought to obtain patients’ verbal consent to treatment, but there was no written proof that such informed consent had been given. Further, a patient’s refusal or subsequent withdrawal of consent to treatment did not result in an external independent psychiatric review as to whether treatment could be provided against the patient’s will. In addition, patients could not appeal against such decisions to a court. The CPT recommends that a special form relating to informed consent to treatment, signed by the patient and (if he is incompetent) by his legal representative, be introduced at the ... and the Vanha Vaasa Hospital (as well as in all other psychiatric establishments in Finland). The relevant legislation should be amended so as to require an external psychiatric opinion in any case where a patient does not agree with the treatment proposed by the establishment’s doctors; further, patients should be able to appeal against a compulsory treatment decision to the court ...”