International Review of Psychiatry, August 2010; 22(4): 325–329

Psychiatry and human rights in Latin America: Ethical

dilemmas and the future

FERNANDO LOLAS

University of Chile and Bioethics Program, Pan American Health Organization

Abstract
This paper addresses the context in which ethical and human right issues as they pertain to psychiatry are discussed in Latin
America. Dependency and institutional instability are singled out as pervading characteristics influencing the analysis of issues and
the design of mental health policies. According to the landmark 1990 Declaration of Caracas all countries in the region have
progressed towards implementing measures designed to improve the condition of the populations regarding mental health care and
research. Several principles are now universally accepted and, while there is still room for improvement, provision of services and
better contexts for scientific development make it possible to expect advances in the future.

The context of health care
Latin America is more than a geographical space. It is a
mixture of diverse cultures, traditions and lan-guages,
unified to some extent by a common past and the
political and institutional instability that has
characterized the continent from the very beginnings of
its independent life. As former colonies of world-wide
empires, the Spanish and the Portuguese, the countries
in the region have always been subject to the influence
of other colonial powers, the British and the American
being the most conspicuous but with the influence of
other European countries in different aspects of life.
The fact that the countries and traditions of the
continent have been under permanent influence from
other cultural contexts has greatly influenced the way
the institutions have been created, molded, and
developed. The problem of ‘identity’ and ‘authenticity’
has been relevant for Latin American scholars. The
aspiration to be original, free from external influences
and able to develop their own cultural products has
accompanied the work of intellectuals, artists, and
scholars and has created a sense of underdevelopment
and opposition against assumed conspirative attempts
from the USA and other potencies to gain control over
the life of Latin American people (Lolas, 1985). While
this influence is and has been undeniable, the opposition
against external influences assumes sometimes a
picturesque character of distrust of all and every attempt
at collaboration with scientifically more advanced
nations. A good cause, independence of thought and
feeling, becomes degraded to a series of slogans and
pseudorationalizations against foreign influence.
In the context of the topics we address here perhaps
the most pervading problem is the import of solutions to
problems not felt as such by the local populations. For
instance, ethical issues related to personal autonomy,
although important, are not felt by poor populations in
the same way they are expressed in more affluent
societies. The priorities of the vast majority of the
populations may reside in having better access to good
health care or in being able to share the benefits of
scientific progress. The ‘demonstration effect’ due to
the globalizing impact of communication media,
produces a gap within the populations, with some
privileged groups living under standards of developed
nations and the majority of the population in conditions
of poverty and lack of opportunities. This creates the
paradox of having, on the one hand, good healthcare
facilities and high-tech medical care for a minority and
on the other a huge disparity in the way the benefits of
science and technology are equitably distributed to the
populations (Alarco´n, 2003).
Mental health, despite all the ambiguities and
inconsistencies surrounding the term, may be exam-ined
through the lens provided by psychiatric care facilities,
community mental health services, preven-tive
programmes, assistance to marginalized and stigmatized
groups, prevalence of disorders, and general well-being
of the population. In a continent

Correspondence: Fernando Lolas, Interdisciplinary Center for Bioethics, University of Chile, Diagonal Paraguay 265, Office 806, Santiago, Chile.
Tel: 56-2-978 2274. Fax: 56-2-9782256. E-mail: flolas@u.uchile.cl
ISSN 0954–0261 print/ISSN 1369–1627 online 2010 Institute of Psychiatry DOI:
10.3109/09540261.2010.500864
326 F. Lolas plagued by institutional instability, corruption, polit-ical
immaturity and other societal challenges, empha-sis has
been placed on the creation of sound services and their
reform according to international stan-dards. The
history of Latin American psychiatry is rich in
initiatives at both the public and the private levels that
may improve the health of people. While this is
expressed in laws, regulations and good will, sometimes
the actual practice and the real world contradict what
otherwise might appear as advanced policy. The
establishment and maintenance of pol-icies is above all
an ethical imperative, but real life constraints have to be
taken into consideration when evaluating their outcomes
(Lolas, 2005).
The rights of people with mental disabilities
There is widespread consensus that one landmark
document for the provision of services and their reform
in the mental health field is the Declaration of Caracas,
approved on 14 November 1990 by dele-gates from 11
South American countries and reaffirmed in its basic
tenets in Sao Paulo in 2001. This declaration became
part of official Pan American Health Organization
(PAHO, regional office of the World Health
Organization) policy documents in 1997 and it is
considered an important contribution to the coalescence
between mental health care, human rights, and ethics
(Levav, Restrepo, & de Macedo, 1994).
Essentially, that document was an expression of the
need to reconsider the rights of vulnerable people and to
suggest to governments that their national laws should
consider improving the life of their popula-tions. One
essential suggestion is to change the common practice
of the psychiatric hospital to a more community-
orientated psychiatry rooted in primary care as the
strategy deemed more appropriate for improving care
and service. As expressed by experts on human rights,
that document is an essential tool for the promotion and
protection of human rights of people with mental
disabilities in the context of international documents
(Jime´nez & Va´squez, 2001).
In an unpublished document that served as a proposal
for the Caracas conference, Marin, Lolas, Kreimer, and
Fuenzalida (1990), after reminding that certain
characteristics and rights of individuals are inherent to
the human condition and not concessions of political
power, and supported by international documents and
legislations, considered several rights that might be
deemed particularly relevant to the mental health field.
Some of the rights considered, and later expanded in
different publications, include
The right of mental patients to be treated with
care, respect and dignity
frequently been addressed by advocates of human
rights. Problems associated with exploitation, inad-
The right not to be labelled as a psychiatric
patient without appropriate technical advice and
on the basis of considerations other than those
derived from the state of the art in psychiatry and
allied professions
The right to receive the best attention and
treatment according to the best technical and
ethical norms
The right to be informed about the diagnosis and
the treatment, considering appropriateness and
risks, and to give and withdraw consent for
interventions
The right not to be submitted to clinical trials or
experimental studies without informed consent
The right to privacy and confidentiality regarding
clinical status, diagnosis, and treat-ments The
right to accept or refuse spiritual or religious
support and be free to choose among religious or
ethical persuasions
The right to receive information on pathology and
prognosis appropriate to level of comprehension
The right to work and receive remuneration
The right to exercise rights unless incompe-tency
or inability is determined by experts and the law
after due process
The right that in case of committing a crime or
offence, competency be determined by a tribunal
in accordance with appropriate legal practice
The right not to be illegally discriminated against
in the exercise of rights due to health
considerations
These rights must be considered against the
background of regulations, laws, conventions, and
covenants pertaining to human rights, and special
declarations setting out ethical guidelines for the
practice of psychiatry such as the Declaration of Hawaii
(1977), updated in Vienna in 1983, and the Declaration
of Madrid (1996), documents approved by the World
Psychiatric Association (WPA) and adopted by most of
its member societies.
Permanent rights and duties: the challenges ahead
Although the literature on human rights and on bioethics
was developed with relative independence from one
another, the topics tend to overlap. The issues of
stigmatization of mental health patients, low budgets
devoted to mental healthcare and poor development of
facilities and human resources have
equate consent of individuals and populations engaged in
research, and conflicts of interest regarding financial
incentives for researchers and institutions are more
frequently dealt with in the bioethical literature. Despite
consistent and contin-uous efforts on the part of policy
makers, opinion leaders, experts, and health authorities,
many of these problems constitute permanent burdens
on Latin American communities. Overall, a relative
neglect of their needs and expectations regarding mental
health can be perceived, particularly in those forms of
psychiatric treatment consisting of confining people
against their will (Hillman, 2005; Saraceno et al., 2005).
While the impact of international regulatory doc-
uments and especially the documents elaborated by
PAHO on the reform of psychiatric care have been
important, there is still room for improvement. It is
evident in legislation and research agendas that the topic
of mental health care and mental health research has
gained relevance and recognition, but much needs to be
done to reach the goals set by the international
community and the mental health professions.
Perhaps the most pressing problems from the
standpoint of ethics relate to the adequate design and
provision of services. They should be accessible with
equity and efficient with quality. Equity and quality are
difficult to harmonize and this harmonization is a
challenge. Another challenge is to bring mental health
care closer to primary care practice. This might mean
reformulating health care training and redefining the
role of specialists in the field with profound
reformulation of medical school curricula and the
standards for the professions. Research in psychiatry is
still plagued by unsolved issues, like the use of
international guidelines and appropriate frameworks for
establishing, training, and empower-ing research ethics
committees at all levels (Lolas, 2002, 2006). Serious
attention should be devoted to an analysis of
international guidance documents as they are applied in
psychiatric settings. Legislation in the countries should
be adapted to the new demands and challenges,
considering that even if it may well not be the most
important factor legislation is an essential one in every
effort to develop sound policies and practices.
Empowering people should make it real the main
emphasis of bioethics is to empower people in order to
enter into dialogs between different stakeholders,
discourses, disciplines, and pressure or opinion groups.
This means that it should not be confined to the usual
practices of informed consent in research and healthcare
but expanded to cover all aspects of social life. It is
particularly important to recognize that whatever
328 F. Lolas
central to mental health. On the other hand, ethical
challenges are widespread in this field, ranging from
Psychiatry and human rights in Latin America 327
limitations may be present in patients with mental
disabilities, their dignity and human condition must be
respected. In no other field of medicine is the need to set
limits to intervention in the name of progress or welfare
than in psychiatry, since psychi-atric conditions are
most likely to impair ability to judge, lead to
stigmatization and abuse, and create confusion
regarding rights and duties of people in the role of
patients.
Advocacy for mental health and appropriate pro-
tection of rights of individuals with mental disabilities
should start by sensitizing the public, improving
information, and increasing knowledge among citi-zens
about mental health that should start at school and
continue in the mass media. To create a cadre of
professionals familiar with and eager to participate in
the improvement of mental health care and research is
essential, particularly at a time when the prestige of the
psychiatric profession seems to be in doubt. The strong
influence of vested interests, of political decisions
(sometimes altered by corruption and objectionable
practices) and of the pharmaceutical industry should be
acknowledged, studied, and controlled for the sake of
better health, good prevention of illness and promotion
of well-being. Conflicts of interest are and probably will
continue to be unavoidable, but professionals trained not
only in evidence-based but also on value-based mental
health should be capable of identifying them, con-
trolling them and working for the benefit of their
patients and the population as a whole. It should be kept
in mind that the region of the Americas and the
Caribbean belongs to the most inequitable in the world,
and that the great moral challenge ahead is, without
forgetting the need to encourage and develop sound
systems of research, care, and educa-tion, to reduce
inequities and unjust disparities that can be solved with
technical and human resources. This cannot be done by
simply importing solutions from other world regions; at
all times, culture, tradition, and socioeconomic
conditions should be considered essential elements in
policy formulations and in action plans. International
experience should be considered, in order to avoid
mistakes evident in other world regions and health care
systems (Desjarlais, Eisenberg, Good, & Kleinman,
1995).
Despite different legal systems and traditions, the
countries of Latin America and the Caribbean can be
considered jointly. International organizations such as
the Pan American Health Organization have been
instrumental in promoting sound public policies and
recommendations to policy makers and opinion leaders.
There is great need to reinforce the princi-ples of
international covenants and declarations that relate to
mental health, for there is no health without appropriate
consideration of social and community dimensions of
personal well-being, an aspect that is
individual rights to the right of groups and societies to
enjoy the highest attainable level of resources needed to
develop healthy lifestyles. In many countries of the
region there is awareness of the need to actively
intervene in politics and societal reforms in order for
these rights to be acknowledged and respected, a
situation that in the past has led to political involvement
of the professionals concerned. The classical bioethical
principles of autonomy, beneficence, non-maleficence
and justice must be complemented with those of
reciprocity, solidarity and truthfulness both in the
provision of health healthcare and in the establishment
of research priorities. Healthcare and research, the
foundations of appropriate mental health policy, must
be grounded on appropriate training of professionals.
Going beyond the trend to specialization and market-
orientated practice, professional education should
sensitize experts and lay people alike to the unfin-ished
aspects of health agendas, and make them aware of the
challenges posed by the Millennium Development
Goals (MDG) accepted by the inter-national community
and the public–private partner-ships that seem to hold
promise of a better integration of efforts toward the
establishment of a new, more humane, medical science.
Among the anticipated challenges for the mental
health agenda, the problem of an increasingly aged
population is to be considered. This poses not only a
problem in terms of economic sustainability but will
radically change the way we look at the mental health of
populations. It is estimated that the older mem-bers of
communities will increase their number more rapidly
than other age groups and that, consequently, the type
and range of health problems will change, including
those due to cognitive impairment, co-morbidity with
mental health ailments, and potential abuse of the aged
on the part of institutions and persons. While some
countries have passed legisla-tion specifically addressed
to the needs, rights, and duties of an ever increasing
number of older citizens, the moral implications of its
implementation are beyond the mere promulgation and
enforcement of legislation and depend on widespread
public aware-ness of its implications.
Also related to the ethical aspects of mental health
care are the growing concerns about violence in the
private and the public domains, gender inequalities, and
the sources of satisfaction that derive from the use and
abuse of chemical substances. While the usual approach
is to punish deviant behaviours and to increase
surveillance and control, it is evident that community
mental health should be informed by
profound ethical principles, widely recognized and
accepted, in order to be effective. One of the most
important developments of the last decades is the
recognition that ethics is not a monological extension of
traditional philosophical thinking but a dialogical
enterprise where deliberation, consensus-building, and
education play important roles in the establish-ment of
sound and healthy social practices (Lolas, 2001). If this
could lead, as some fear, to a de-professionalization of
society, it is of the utmost importance to change the way
in which information and knowledge are managed in
our societies. Professional dominance, as was the case
with the once attacked hegemony of the medical
profession, cannot be based solely on cognitive bases, or
on the information mastered or administered by profes-
sionals. It is the ethical underpinning of the practice of
care, of research and of advocacy that is needed and
represents the great challenge ahead.
Declaration of interest
The author reports no conflicts of interest. The author
alone is responsible for the content and writing of the
paper.
References
Alarco´n, R.D. (2003). Mental health and mental health care in Latin
America. World Psychiatry, 2, 54–56.
Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995).
World Mental Health. Problems and priorities in low-income
countries. New York: Oxford University Press.
Hillman, A.A. (2005). Human rights and deinstitutionalization: A
success story in the Americas. Revista Panamericana de Salud
Pu´blica, 18, 374–379.
Jime´nez, H., & Va´squez, J. (2001). El derecho internacional,
instrument esencial para la promocio´n de la salud mental en las
Ame´ricas. Rev Panam De Salud Pu´blica [International law: an
essential instrument for health promotion in the Americas, Revista
Panamericana de Salud Pu´blica], 9, 264–268.
Levav, I., Restrepo, H., & de Macedo, C.G. (1994). The restructuring
of psychiatric care in Latin America: A new policy for mental
health services. Journal of Public Health Policy, 15, 71–85.
Lolas, F. (1985). Sobre americanidad. Notas al Margen. Ensayos
[On americanism, In: Lolas, Fernando (Marginal notes. Essays)].
Santiago de Chile: Editorial Cuatro Vientos.
Lolas, F. (2001). Bioe´tica. El dia´logo moral en las ciencias de la
vida [Bioethics. Moral dialogue in the life sciences] (2nd). Santiago:
Editorial Mediterra´neo.
Lolas, F. (2002). Bioethics and psychiatry: A challenging future.
World Psychiatry, 1(2), 127–128.
Lolas, F. (2005). Psiquiatrı´a y e´tica [Psychiatry and ethics]. In RD
Alarco´n, G. Mazzotti & H. Nicolini (Eds.), Psiquiatrı´a (2nd) (pp.
945–952). Me´xico: El Manual Moderno.
 Psychiatry and human rights in Latin America 329
Lolas, F. (2006). Ethics in psychiatry: A framework. World America and included among the documents of the
Psychiatry, 5(3), 185–187. meeting in 1991.
Marin, U., Lolas, F., Kreimer, O., & Fuenzalida, H. Saraceno, B., Saxena, S., Caraveo-Anduaga, J.J., Kohn, R.,
(1990). Reestructuracio´n de la atencio´n psiquia´trica. Levav, I., Caldas de Almeida, J.M., et al. (2005). Los trastornos
Aspectos e´ticos y jurı´dicos [Restructuring psyhciatric mentales en Ame´rica Latina y el Caribe: Asunto prioritario para
care. Ethical and legal aspects]. Unpublished document la salud pu´blica [Mental disorders in Latin America and the
presented as background paper at the Regional Caribbean: A priority in public health]. Rev Panam De Salud
Conference for Restructuring of Psychiatric Care Latin Pu´blica, 18, 229–240.
Copyright of International Review of Psychiatry is the property of Routledge and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.