Professor Dainius Pras:

I thank members for their good questions. On the issue of access to abortion, I have outlined the minimum requirements or standards the United Nation proposes. Personally, I find them confusing. Actually they create new problems. Of course, I would be in favour of the recommendation that we, as experts, have provided in the statement, but I recognises what happens in real life. With regard to having special circumstances, those states that choose to have restrictive laws are recommended to do as outlined, at the least. I agree that almost all of the cases mentioned are such that if we try to imagine how the system would work - there are countries where the type of legislation in question is in place - we note that problems would be created not only for women but also for doctors, for example. They have to decide.

Especially in mental health but also in physical health, medicine is not as exact a science as maybe we would like it to be. Therefore, on the question of what is the criteria to differentiate between the right to health and the right to life, as a medical doctor, I should not agree to be involved in this exercise because it will be always subjective. This is particularly so with mental health, where we do not have any single biological marker. If we take any sample of blood or biopsy, we will never find anything to indicate if it is, let us say, depression or not depression, and if it is a high risk of suicide or a low risk of suicide. To further complicate matters, in the countries which have high rates of suicide, these are not because of severe depressions but rather as a result of a very high number of mild depressions which make this number of suicides high. Most suicides are from mild depressions, not severe depressions, because there are so many mild depressions.

We understand that all these ethical issues are related to prenatal diagnostics of, let us say, chromosomal diseases or abnormal development of the child. This is a huge issue to be discussed. For example, it is a more clear position that we have to inform families and to support any decision. If, in the first trimester, Down's syndrome is diagnosed, we should respect any decision. If they decide to terminate the pregnancy or if they decide to have this child, it is not for us to apply pressure for one side or the other, although this happens. I know some colleagues who would like all these women to terminate pregnancies in such cases and I do not understand why. It is not their business so to say. It is up to families to decide what decision they make.

I agree that these minimal standards create new legal, ethical and other issues for women and for doctors. When travelling in these countries where they do not have these even minimal requirements, I have seen how the thinking of doctors is changing. In one country there was a case of a ten year old girl who was pregnant as a consequence of rape and my formulation was she was forced to pregnancy and motherhood, but the doctors with whom I discussed it could not see any problem. The doctors told me the girl was okay and there was no harm to her physical and mental health. I was thinking the doctors were wrong but who will judge whether I am right or this doctor is right? In that context - maybe it is some survival strategy - it depends on cultural and legal contexts. Doctors are human beings and they adapt. I could share also other stories about this so-called "dual-loyalty" when doctors, as doctors, should think one way but the law suggests to them to think another way. It is a complex situation for doctors.

If I may move to the second question, it is about this interesting situation in global mental health when there is common agreement between experts that there is a global mental health crisis but some experts emphasise a so-called "global burden of mental disorders" and other experts like me emphasise a global burden of obstacles in the realisation of the right to mental health. People have always had mental health conditions. We do not now have some epidemics. It is just that we may collect information better. The problem I see is overuse of biomedical interventions for different reasons. Biological psychiatry promised 30 years ago to solve effectively problems, and maybe even to cure mental health conditions with modern medications, and now there are not so many promises. We see that psychotropic medications may be effective but may be also not effective, and they are overused. For example, to treat mild and moderate depressions, one does not need anti-depressants. Anti-depressants are usually needed for severe depression.

Deputy O'Connell raised a question about therapies. I am presenting the global view. Again, I am here not to assess the Irish situation but to merely inform about global situation. There are many countries, including in eastern Europe, where psychosocial interventions have never been covered. If a woman or a family with child will go to the mental health services, they will always receive medications, whether they are needed or not needed. It is merely that there is a long tradition to biomedicalise mental health and it is still this way. We can find compromise with inexpensive more short-term and not-so-very-sophisticated psychosocial interventions which can be cost-effective and not so expensive. The main point is that we should address more social and structural determinants of health, such as poverty and equality, and violence, instead of medicalising consequences. It often happens that those who are suffering from unbearable conditions in their lives, if they go to mental health services, will be diagnosed as if it is a chemical imbalance. In today's presentation, I allowed myself to use this. I think it is more often a power imbalance than a chemical imbalance. Too often, it is the consequences of different social and environmental determinants, including the fact that many societies tolerate and condone violence against women and against children and then they are surprised why there are so many mental health issues. I do not want say that medications are not needed. I merely want to signal also in this report that sometimes biomedical interventions are overused, not to speak about institutionalisation. In many countries, there are many people enclosed in residential institutions. Under my report to the Human Rights Council, I will merely remind it that psychosocial interventions and public health interventions are not a luxury. They can be very effective. They are not less effective than medications.

A more complex question followed. I mentioned and then Deputy O'Connell mentioned power asymmetries. Power asymmetries means that if, in general medicine, there was agreement globally, in law and ethics, to move from paternalistic relations between doctor and patient to partnership, this has not happened in psychiatry. In psychiatry, the doctor still make decisions for basic elements of life of users of mental health services and when one has such monopoly of power, it is difficult not to misuse this power.

This power asymmetry does not help to empower users of mental health services, and we need to address that. I am looking for states which could be champions. I want to discuss the matter with the leadership of the psychiatric profession and to move to more innovative mental health services, which would reduce this power asymmetry.

I will respond to a question on broader issues of women's health. I agree that there are many equally important issues regarding women's health, including physical health. The UN is doing its best, but I have to remind the committee that I do not represent the UN. We special rapporteurs often like to criticise the UN and the World Health Organization, WHO. We have such a right because we are independent experts and the UN and WHO were perhaps too slow to react to emerging new priorities. The first priority was communicable diseases and the global response to the HIV-AIDS crisis was quite good. Indicators suggest we are now in the middle of the way. This very ambitious sustainable development goal to eliminate AIDS by 2030 is an example of where the human rights approach was really used in practice. I do not know the motives, and perhaps it was out of fear, but many countries moved to effective policies to address HIV-AIDS and reduce discrimination against these people. There are new priorities now, as states are starting to understand, in the form of non-communicable diseases and mental health.

Sustainable development goals, SDGs, signal that these problems are equally important for all countries, including high income countries, while millennium development goals, MDGs, as the committee remembers, were more focused on the developing world. Europe was maybe not so interested in SDGs because major problems have been solved by European countries. All 17 sustainable development goals, including goal 3, to promote health and well-being, are equally important. These include the health of women, demographic shifts where there are huge numbers of children, adolescents and young people in many countries, and also issues of a large population ageing. These shifts should be addressed by countries implementing practical health policies. Some countries are doing this better and some are doing worse. I agree that there are many issues relating to women's health which need to be addressed better to reduce this gap and these gender inequalities which still exist where women in many countries cannot access health care and girls cannot receive education.

This is also related to the next question which Deputy Kelleher raised, about research across the globe. He mentioned oppression from which women in particular suffer because of different political systems, if I understood correctly. I agree and share this concern that the global picture is not very good. Many countries threaten to take more populist decisions and do not pay enough attention to human rights, as it was in 1948, for example, when the Universal Declaration of Human Rights was unanimously approved. Now we need more arguments to convince everyone why we need full respect for all human rights. I see some countries exercise human rights and the right to health care in a selective way when I go to them. Some rights for some people are okay, and some rights for other people could be ignored. This leads to further inequality, social exclusion and I do not imagine that we can reach the agenda for 2030 and its very ambitious sustainable development goals in this way. I agree that there are many issues globally which need to be addressed in a more serious way. I am doing this on behalf of my mandate, which is about a right to health care. Sometimes, some countries remind me that when I go abroad that I may overstep my mandate since the right to health care may not be exercised without other rights. I do not think I do.