CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 3 juillet 2012

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display:inline-block } .sF2E32F9B { width:36.61pt; display:inline-block } .s5F32E900 { width:208.31pt; display:inline-block }     FOURTH SECTION             CASE OF X v. FINLAND   (Application no. 34806/04)               JUDGMENT       STRASBOURG   3 July 2012   FINAL   19/11/2012   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision. In the case of X v. Finland , The European Court of Human Rights (Fourth Section), sitting as a Chamber composed of:   Nicolas Bratza, President,   Lech Garlicki,   George Nicolaou,   Ledi Bianku,   Zdravka Kalaydjieva,   Nebojša Vučinić, judges,   Matti Mikkola, ad hoc judge, and Lawrence Early, Section Registrar, Having deliberated in private on 12 June 2012, Delivers the following judgment, which was adopted on that date: PROCEDURE 1.     The case originated in an application (no. 34806/04) against the Republic of Finland lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Finnish national, X (“the applicant”), on 30   September 2004. The President of the Fourth Section of the Court decided of his own motion that the applicant’s name should not be disclosed (Rule 47 § 3 of the Rules of Court). 2.     The applicant was represented by Ms Helena Molander, a lawyer practising in Helsinki. The Finnish Government (“the Government”) were represented by their Agent, Mr Arto Kosonen of the Ministry for Foreign Affairs. 3.     The applicant alleged in particular under Article 6 of the Convention that she had not received a fair hearing in the criminal proceedings against her, in that she had not been given an opportunity to be heard at an oral hearing on the need to appoint a guardian for her for the purpose of those proceedings, and that she had not been given an opportunity to examine witnesses appearing on her behalf. She also alleged, under Articles 5 and 8 of the Convention, that she had been unnecessarily and unlawfully subjected to involuntary admission to a mental institution and forcible administering of medication. She further claimed, under Article 13 of the Convention, that she had not had an effective remedy to challenge the forcible administering of medication. 4.     On 11 May 2009 the President of the Section decided to give notice of the application to the Government. It was also decided to rule on the admissibility and merits of the application at the same time (Article   29   §   1). 5.     Having consulted the parties, the Chamber decided that no hearing on the merits was required (Rule   54 § 3). THE FACTS I.     THE CIRCUMSTANCES OF THE CASE Background and events giving rise to the criminal proceedings 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. Use of coercive measures 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. Restraining order 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. Criminal proceedings 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. Events which took place while the applicant was in 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. Arrest and detention 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 ). Psychiatric assessment in a mental institution 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. Involuntary care 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. Proceedings before the Supreme Administrative Court concerning the initial confinement for involuntary care 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.” Proceedings relating to the first decision to continue involuntary care 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. Proceedings relating to the second decision to continue involuntary care 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 fut