A step toward safeguarding rights in compulsory psychiatric treatment: ethical reflections on Italian Constitutional Court Ruling No. 76/2025

Dear Editor,

Contemporary medical ethics affirms the physician’s duty to respect patient self-determination (the ethical principle of autonomy), meaning the patient’s consent or refusal to rehabilitative, therapeutic, or palliative interventions. Care is not an obligation but an opportunity that individuals may decline based on their personal concept of quality of life or for reasons they are not obliged to disclose to the healthcare professional. Health and well-being are inherently subjective concepts that may not align with the physician’s notion of “good”, guided by the principle of beneficence, when selecting and proposing interventions aimed at preserving health as the absence of disease and the maintenance of biological life. Even though in clinical practice ethical deliberation may involve duties such as non-maleficence (for example, intervening in an emergency when there is an imminent risk), the proportionality of interventions, and the protection of third parties from serious harm, in case of conflict between the principle of patient autonomy and the physician’s ethical duty of beneficence, the former generally prevails, since the alternative would entail coercing individuals into unwanted treatment, thereby violating personal freedom in healthcare as protected by Article 32, paragraph 2 of the Italian Constitution.

However, the same provision includes an exception governed by Articles 33, 34, and 35 of Law No. 833 of 1978, which regulates Compulsory Treatments (CT) ¹. This legislation establishes that when timely and effective outpatient care is not feasible, urgent therapeutic treatment may be imposed as an extraordinary and temporary measure on individuals with mental disorders who refuse treatment, by only as a last resort. To ethically justify the CT, and to avoid a contradiction with the principle of respecting free choice in healthcare, two arguments are typically advanced.

Firstly, it is argued that mental impairment may prevent individuals from exercising self-determination by impeding their understanding of what constitutes their own good. Consequently, when such individuals refuse treatment, their dissent is not considered an authentic expression of their will. However, it is noteworthy that when individuals with mental disorders consent to treatment, their will is not subjected to the same scrutiny. This is rooted in the subjective and debatable assumption that any “mentally sound” individual would seek treatment ². Yet the ethical principle of self-determination inherently includes the possibility that individuals may prefer to refuse treatment. For consistency, if the self-determination of persons with mental disorders is questioned, it should be questioned equally in cases of both refusal and acceptance of treatment. However, applying this logic stance would lead to recognizing their capacity for self-determination in both cases.

Secondly, treatment is imposed to address the underlying pathology presumed to cause the individual’s incapacity for self-determination, with the aim of restoring their ability to make informed decisions ³. Forced treatment is thus framed as a means to re-establish the conditions necessary for individuals to exercise their right to consent or dissent fully and consciously. However, assuming that those who refuse psychiatric care must automatically incapable of decision-making is inconsistent with clinical reality, which often reveals periods of lucidity and residual volition ⁴. Decision-making capacity may not be an all-or-nothing condition: it can be task-specific, time-dependent, and may fluctuate over the course of illness. Moreover, capacity can sometimes be supported through appropriate communication, clarification of information, and relational engagement. It is on the basis that the recent Italian Constitutional Court ruling No. 76/2025 can be interpreted. According to Italian legislation, the mayor of the municipality where CT has been requested and confirmed by two physicians, is responsible for issuing the CT order. Validation of the mayor’s order by the Guardianship Judge is a mandatory step in the CT procedure. Following the issuance of the mayor’s order authorizing CT, the Guardianship Judge must validate it within 48 hours through a reasoned decree. The reform of Article 35 of Law 833/78 now requires that the Guardianship Judge’s validation be promptly communicated to the individual concerned, allowing them to exercise their right to defense and to file an appeal if necessary. The Constitutional Court declared Article 35 of Law No. 833/1978 unconstitutional due to the absence of three fundamental safeguards: (1) communication to the patient or their legal representative of the order imposing CT; (2) the opportunity for the individual to be heard by the Guardianship Judge before validation; and (3) notification of the validation decree. According to the Court, excluding patients from procedures that entail a serious restriction of personal liberty violates fundamental rights to adversarial proceedings, information, and defense ⁵. Even when mental impairment is present, individuals retain their fundamental rights and as far as possible, must actively participate in the procedures that affect them. For this reason, the Court strongly reaffirms the principle of the necessary active participation of the individual, particularly in the context of CT, where the vulnerability of the individual and the asymmetry in the doctor-patient relationship requires heightened attention and safeguards.

Overall, the justification of CT based on the absence of self-determination  may risk relying on problematic assumptions that deserve careful ethical scrutiny.

The first concerns the asymmetric scrutiny applied to treatment decisions, whereby refusal is frequently interpreted as evidence of incapacity while consent is readily accepted as valid. If mental impairment invalidates decision-making capacity, this should apply equally, resulting in the impossibility of affirming or denying self-determination.

The second is the denial of residual or fluctuating decisional capacity, despite clinical experience and case law indicating periods of lucidity during which individuals can be engaged, informed, and provide authentic consent or dissent. Recognizing these complexities does not negate the possible need for compulsory interventions in exceptional circumstances, but it highlights the importance of procedural safeguards and careful capacity assessment. Therefore, while the recent Constitutional Court ruling may appear surprising in its call for CT procedures reform, it provides further grounds for critical reflection on the moral legitimacy of CT within an ethical framework that genuinely respects autonomy and fundamental individual rights.

In conclusion, we are aware that this reform may introduce procedural and practical challenges in the routine operations of mental health services, particularly within General Hospital Psychiatric Inpatient Units where compulsory treatments are typically administered. However, it represents a significant step forward in recognizing and protecting the fundamental constitutional rights of highly vulnerable individuals during the most delicate phases of their care pathways. These patients are often subjected to rights violations, forced treatments, and restrictive measures, and this reform aims to address these critical issues while upholding their dignity and autonomy.