The paper by Galderisi et al¹ raises an array of ethical challenges, each of which would warrant an extended response. Here I will focus on a few overarching issues.

First, it is extremely heartening to see the paper's engagement with the Convention on the Rights of Persons with Disabilities (CRPD). This has not always been the case: engagement from psychiatrists has in the past been frosty at best. The emphasis on autonomy, dignity and involvement of people with lived experience (PWLE) of psychiatric systems in care, treatment and decision-making about them is of a type that would have been uncommon twenty years ago in this sort of paper. The acknowledgement that compulsion has been and continues to be significantly over-used in psychiatry internationally, buttressed by the establishment of a working group at the WPA on developing alternatives to compulsion, suggests a significant shift in attitudes. As the paper notes, the 2020 revisions to the WPA Code of Ethics continue the movement of previous Codes towards a world where PWLE are not psychiatric objects but citizens warranting respect and dignity – a core value of the CRPD. The discussion in the paper puts some flesh on those bones from a psychiatric perspective.

As the authors acknowledge, this engagement will not satisfy those adopting a strong view of the CRPD. However, the paper does provide the hope for a productive dialogue among the diverse array of CRPD commentators about how services and support should be provided. If this takes place with a view to the values that the parties share, there is real potential for change in peoples’ lives. That would be potentially significant.

The challenge is how to get these newer attitudes into effect on the ground. History is not promising in this regard. Much of the encouraging language of the 2020 WPA Code of Ethics had its roots in the earlier Declaration of Madrid, originally passed by the WPA in 1996, and even the Declaration of Hawaii passed in 1983. Those documents also spoke of therapeutic relationships founded on “mutual agreement” and trust. The Declaration of Madrid expressly enjoined psychiatrists to “devise therapeutic interventions that are least restrictive to the freedom of the patient”. The patient was to be “accepted as a partner by right in the therapeutic process”, and the psychiatrist was to “empower the patient to come to a rational decision according to his or her personal values and preferences”. Even when the patient lacked capacity, the document enjoined that “no treatment should be provided against the patient's will, unless withholding treatment would endanger the life of the patient and/or those who surround him or her”.

All too frequently, twenty-eight years after the Declaration was adopted, this continues not to be the experience of PWLE. That is reflected in their writings. Numerous reports of international inspectorates – the Council of Europe Committee for the Prevention of Torture² and the United Nations Subcommittee on Prevention of Torture³ being the most obvious examples – and national non-governmental organizations make this clear. Too frequently, the principles of ethical documents have little impact on the lives of those affected. Galderisi et al acknowledge this when they say that “many mental health professionals are unaware of [the WPA Code's] principles”. It is fair to ask how far changing the language of a Code which has no or little traction will actually change things.

Galderisi et al go on to state that “everyone in theory agrees” with a transition away from paternalist care and towards the new vision of patient involvement and autonomous decision-making, but “in practice there is resistance”. Given the persistence of the old approaches, it is fair to ask whether in fact “everyone in theory agrees” with the new ones. Some of the inspectorate reports and the experience of law and policy reformers would suggest that sometimes the resistance comes from the majority of professionals in some countries. How do we engage professionals who really do not want to get with the programme?

Certainly, nudging towards good practice is an appropriate strategy, but a certain scepticism is appropriate. Good practice statements, manuals and guidance have been around for decades. As noted, it is not obvious that they have had an adequate impact. Certainly, the WPA initiative with the World Health Organization on implementing alternatives to coercion⁴ is a positive step; but will it really be taken up by the practitioners who have thus far seemed resistant to change? It is at best doubtful.

As Galderisi's paper notes, legal reforms may help. We have seen that in the provision of research ethics committees in the countries that have introduced them (by no means all, internationally). While one can certainly debate the appropriateness of the processes that these bodies use, and the merits of individual decisions, they do have their effects. In some circumstances, law can work.

I am a lawyer, so I am obviously not going to argue against the provision of good laws governing mental health provision; and yes, new laws can provide a marker of change that gives good practice more space to flourish. Equally, though, as someone who has done a good deal of international work and read a lot of mental health law, I think I have never seen a statute so rigidly drafted that it can preclude bad practice if practitioners want to exercise undue control.

This suggests that individual accountability is the key issue. How is that to be enforced? Law may be of little help here. Often, domestic courts look at overall standards within a country and, if a doctor's practice is broadly consistent with a significant minority of his/her colleagues, the court will decline to be involved.

Medicine is generally a self-governing profession. Will national professional bodies provide sticks with the carrots, both leading from the top in terms of the promotion of ethics, and also censuring practitioners who do not meet the international standards? This seems doubtful. Even in countries with quite developed complaints systems, it is hard to imagine a governing body censuring a practitioner for lacking respect for the views and preferences of a PWLE, or being too quick to exercise compulsion. Galderisi's paper notes that only 15 out of the 143 Member Societies of the WPA have formal ethical documents. This does not inspire confidence that the standards envisaged in the 2020 WPA Code will be given priority in most of the world.

How should we deal with failure to engage at the level of national organizations? In principle, human rights bodies such as the European Court of Human Rights could insist on standards of medical ethics that are consistent with the developments in the field of human rights, but thus far they have been remarkably reluctant to do so. Would the WPA or similar international organizations be prepared to exert political pressures, such as naming and shaming? This seems also doubtful, and is a high-risk strategy since it destroys goodwill between the organization and the national body.

That said, failure to intervene means that nothing will actually change on the ground. And it is on the ground that the changes need to happen.

Galderisi 等人的论文¹提出了一系列伦理挑战，每一个挑战都需要长期回应。在这里，我将重点讨论几个总体问题。

首先，看到该文件与《残疾人权利公约》（CRPD）的接触是非常令人振奋的。情况并非总是如此：精神科医生的参与在过去充其量是冷淡的。强调具有精神病学系统生活经验（PWLE）的人在护理、治疗和决策中的自主性、尊严和参与，这在二十年前的此类论文中是罕见的。承认强迫在国际精神病学中已经并将继续被严重过度使用，并在 WPA 成立了一个开发强迫替代方案的工作组的支持下，表明态度发生了重大转变。正如该文件指出的，2020 年对 WPA 道德准则的修订延续了之前的准则，朝着一个世界迈进，在这个世界中，PWLE 不再是精神病学对象，而是值得尊重和尊严的公民——这是 CRPD 的核心价值观。论文中的讨论从精神病学的角度对这些骨头进行了一些充实。

正如作者承认的那样，这种参与不会让那些对《残疾人权利公约》持有强烈看法的人满意。然而，该文件确实为 CRPD 的不同评论者之间就如何提供服务和支持进行富有成效的对话提供了希望。如果这一切都以双方共同的价值观为基础，那么人们的生活就有真正改变的潜力。这可能具有重要意义。

挑战在于如何将这些新态度付诸实践。历史在这方面并不乐观。 2020 年 WPA 道德准则中的许多鼓励性语言都源于早期的马德里宣言，该宣言最初由 WPA 于 1996 年通过，甚至于 1983 年通过的夏威夷宣言。这些文件还谈到了建立在“相互同意”和信任。 《马德里宣言》明确要求精神科医生“制定对患者自由限制最少的治疗干预措施”。患者应“在治疗过程中被接受为正确的合作伙伴”，而精神科医生则应“使患者能够根据他或她的个人价值观和偏好做出理性的决定”。即使患者缺乏行为能力，该文件也禁止“不得违背患者意愿提供治疗，除非拒绝治疗会危及患者和/或他或她周围人的生命”。

然而，在《宣言》通过二十八年后，PWLE 的经历却常常不再如此。这反映在他们的著作中。国际监察机构（欧洲委员会防止酷刑委员会²和联合国防止酷刑小组委员会³是最明显的例子）和国家非政府组织的大量报告明确了这一点。很多时候，道德文件的原则对受影响者的生活几乎没有什么影响。 Galderisi 等人承认这一点，他们说“许多心理健康专业人员不了解 [WPA 准则] 原则”。公平地说，改变没有或几乎没有吸引力的准则的语言实际上会改变什么程度。

Galderisi 等人接着指出，“理论上每个人都同意”从家长式护理转向患者参与和自主决策的新愿景，但“实际上存在阻力”。鉴于旧方法的持续存在，我们可以公平地问，事实上“理论上每个人都同意”新方法。一些监察报告以及法律和政策改革者的经验表明，有时阻力来自一些国家的大多数专业人士。我们如何吸引那些真正不想参加该计划的专业人士？

当然，推动良好实践是一种适当的策略，但一定程度的怀疑也是适当的。良好实践声明、手册和指南已经存在了数十年。如前所述，它们是否产生了足够的影响并不明显。当然，WPA 与世界卫生组织关于实施胁迫替代方案的倡议⁴是积极的一步；但迄今为止似乎抵制变革的实践者真的会接受它吗？这充其量是值得怀疑的。

正如加尔德里西的论文指出的那样，法律改革可能会有所帮助。我们已经在引入研究伦理委员会的国家（绝不是所有国家，国际上）的规定中看到了这一点。虽然人们当然可以争论这些机构所使用的程序的适当性以及个人决策的优点，但它们确实有其影响。在某些情况下，法律可以发挥作用。

我是一名律师，所以我显然不会反对管理心理健康服务的良好法律的规定；是的，新的法律可以提供变革的标志，为良好实践提供更多的发展空间。但同样，作为一个做过大量国际工作并阅读了大量精神卫生法的人，我认为我从未见过如此严格起草的法规，以至于如果从业者想要实施不当控制，它可以防止不良做法。

这表明个人责任是关键问题。如何执行？法律在这里可能没什么帮助。通常，国内法院会考虑一个国家内的总体标准，如果医生的做法与其大部分同事大体一致，法院将拒绝介入。

医学通常是一个自治的职业。国家专业机构是否会在胡萝卜加大棒的同时，从高层领导推动道德规范，并谴责不符合国际标准的从业者？这似乎值得怀疑。即使在投诉制度相当发达的国家，也很难想象管理机构会因为执业者缺乏对 PWLE 的观点和偏好的尊重，或者太快地实施强制而对其进行谴责。 Galderisi 的论文指出，WPA 143 个会员协会中只有 15 个拥有正式的道德文件。这并不能激发人们对 2020 年 WPA 规范中设想的标准将在世界大部分地区得到优先考虑的信心。

我们应该如何处理国家组织层面未能参与的问题？原则上，欧洲人权法院等人权机构可以坚持与人权领域的发展相一致的医学道德标准，但到目前为止，他们非常不愿意这样做。 WPA或类似的国际组织是否准备好施加政治压力，例如点名和羞辱？这似乎也值得怀疑，并且是一种高风险策略，因为它破坏了该组织与国家机构之间的善意。

也就是说，不进行干预意味着实际情况不会发生任何实际变化。改变需要在实地发生。