Utviklingen av registrert tvangsbruk

Erfaringer med tvangslovgivningen

Regjeringen nedsatte fredag Tvangslovsutvalget. Helse- og omsorgsminister Bent Høie skal ha ros for å handle raskt. Det er på tide å samle våre erfaringer med tvangslovgivningen.

Rundt 2000 personer med utviklingshemning blir årlig underlagt registrert tvang etter helse- og omsorgstjenestelovens kapittel 9. I tillegg er det et ukjent antall som har tvangsvedtak etter pasient- og brukerrettighetslovens kaittel 4A. NFU har jobbet for å få en gjennomgang av tvangslovgivningen og praktiseringen av denne. Dette skyldes dels saker som er høyst urimelig bruk av tvangsvedtak, drift i lovforståelsen, forutsetninger for lovverket som ikke lenger eksisterer og det at dagens lovverk neppe er i samsvar med FN-konvensjonen om rettighetene til mennesker med utviklingshemning.

Det pågår utvilsomt mye uregistrert bruk av tvang og makt. Hvor store mørketallene er, vet vi ikke noe om. Ut i fra tilsynsrapporter og henvendelser til NFU kan det synes som om mørketallene har vært rimelig konstante de siste ti årene.

De svært alvorlige torturlignende sakene som fikk presseoppslag på 1970, 1980 og 1990-tallet, ser vi ikke lenger. Noe har utvilsomt skjedd på feltet og tvangslovgivningen har hatt positive bidrag. Det kan være like alvorlige saker i dag som på 1970-tallet, men sakene er neppe av samme type.

Lite inngripende tiltak

Et ikke ukjent fenomen er at tjenesteyter ikke griper inn og forhindrer opplagt uheldige hendelser med den begrunnelsen at de ikke har lov til å bruke tvang og makt. Men verken veiledning eller overtalelse er tvang eller makt. Vanlige husregler krever heller ikke vedtak etter helse- og omsorgstjenestelovens kapittel 9. Men effektiv veiledning og overtalelse, krever tjenester, kompetanse og stabilitet blant tjenesteyterne. Slike systemer har mange kommuner hatt store problemer med å etablere.

Mange har hørt om klorflasken og rengjøringsmidler som oppbevares i et låst skap. Jeg hørte om et vedtak som sa at støvsugeren skulle låses inn i boden etter bruk. Det er vanskelig å betrakte denne typen tiltak som spesielt inngripende i den enkeltes frihet. Det er en unødvendig sløsing å la slike tiltak gjennomgå samme omfattende saksbehandling som alvorlig og inngripende tiltak. En enkel registreringsordning kunne være tilstrekkelig. Selv om de fleste ville verdsatt at støvsugeren ble satt på plass etter bruk, vil summen av mange og lite inngripende tiltak kunne skape en svært avmektig situasjon.

Manglende rettsikkerhet

Rettsikkerheten i tvangslovgivningen er truet på svært mange måter, kanskje ikke først og fremst gjennom lovverkets ordlyd, men folks bevisthet og systemene som bygger opp under lovverket.

Sentralleddet i NFU bistår i mellom 300 og 500 klagesaker på ulike områder per år. De fleste henvendelsene kommer i form av en bekymring over endringer i tjenestetilbudet som oppfattes som uheldig eller urimelig. Kunnskapen om rettigheter og rettsikkerhet er svært lav. Det hjelper lite å ha gode formelle klagemuligheter når en mangler kunnskap eller kompetanse til å benytte seg av rettighetene.

Tvangsvedtak stadfestet av Fylkesmannen, kan påklages Fylkesnemnda for barnevern og sosialsaker. Etter hva jeg forstår, er det ytterst sjelden at klagemuligheten benyttes. Det vil være naivt å tro at tvangsvedtakene stadfestet av Fylkesmannen er så ufeilbarlige som klagetallene tilsier.

Domstolsbehandling av tvangsvedtak er enda sjeldnere enn klager til Fylkesnemnda. NFU advarer stort sett mot å bringe saker for domsstolene. Få dommere og advokater er kjent med feltet. Utfallet av en domsstolsbehandling kan være mer vilkårlig enn om en alternativt forsøker å få endret vedtaket gjennom andre kanaler hvor kunnskapen er større.

Skal NFU kunne bistå i en klageprosess, så krever det at en kontakter NFU. Mange har dessverre ikke den muligheten. Har en ikke nære pårørende som engasjerer seg eller bistår, så vil nok mange med en utviklingshemning ikke være i stand til å benytte seg av den rettsikkerheten som ligger i lovverket.

Mange kvier seg for å klage på vedtak. Prosessen er krevende, langtekkelig og mange frykter  hevnreaksjoner. Ansatte som varsler om uverdige eller ulovlige forhold, synes heller ikke å ha spesielt stor rettsikkerhet.

Det å øke kunnskapen på feltet, er ingen enkel oppgave, men dagens ordninger med klagerett, gir en lav grad av reell rettsikkerhet. Domstolene bør tilføres kunnskap om feltet og en bør stimulere til varslig om utilbørlig bruk av tvang og makt.

Alternativ til tvang

Det finnes mange eksempler på at behovet for tvangstiltak forsvinner eller avtar vesentlig når tjenestene organiseres i form av brukerstyrt personlig assistanse (BPA). Forholdet kan neppe tilskrives annet en betydningen av individuelt tilpassede tjenester.

I flere tilfeller hvor det anvendes inngripende tvangstiltak, synes behovet for tvangstiltak å være knyttet til bestemte steder eller situasjoner. I slike tilfeller bør en absolutt stille spørsmål med tilretteleggingen.

Boforholdene til mennesker med utviklingshemning er i stor grad blitt institusjonalisert, ofte i større institusjonslignende bofellesskap enn det som ble bygget ut under siste halvdel av HVPU. Enkelte steder har en også etablert "Autismeboliger", dvs. bofellesskap for personer med hyppige og alvorlige utageringer. Vi mangler oversikt over konsekvensene av disse endringene, men både enkelteksempler og generell betraktninger kan trekkes i retning av at det er skapt livssituasjoner som kan skape mistrivsel og gi behov for tvangstiltak.

Når en vurderer tvangsvedtak, så er det rimelig sjelden at mer grunnleggende forhold knyttet til livssituasjonen vurderes som alternativer. Alternativene som vurderes er ofte begrenset til tjenesteyternes mulige handlinger, ikke til personens trivsel og livssituasjon. Det å sikre et stabilt personell som forstår personen med funksjonsnedsettelser og som personen føler seg trygg på, kan ofte være tilstrekkelig for å unngå tvangsbruk.

Faglig forsvarlighet

Faglig forsvarlighet må være mer enn munnhell. På mange felt kan det være ytterst vanskelig å finne standarder eller omforente holdninger om hva som er faglig forsvarlig: Hvor tett og hvor lenge er det forsvarlig å følge etter folk? Når er det faglig forsvarlig å låse folk inne? Hvor mye kan folk prate i mobiltelefon innen for faglig forsvarlige rammer? Hvilke samboere er det faglig forsvarlig å ha? I flere tilfeller med svært inngripende tiltak, kan en stille spørsmål med om en forveksler det forsvarlige med det uforsvarlige. En bør absolutt stille spørsmål med hvilke kriterier som benyttes av fagmiljøene for å kvalifisere tilnærminger som faglig forsvarlige.

Regional variasjon i tvangsvedtak

Andelen av mennesker med utviklingshemning som har tvangsvedtak varierer svært mye mellom fylkene. I Finnmark er det ca. 1,85 % som har tvangsvedtak. I Hedmark er andelen 11,61 %. Vi vet ikke hva forskjellen skyldes, men det er nærliggende å tro at holdningene til intervensjoner eller det å fatte tvangsvedtak kan variere en del mellom fylkesmennsembetene og habiliteringstjenestene. På fylkesnivå er det relativt få personer involvert i tvangsvedtakene. En bør stille spørsmål med hvilke nasjonale korrigerende signaler som finnes overfor de få personene som er involvert på feltet. En fordel med en diagnoseuavhengig lovgivning er at miljøet som arbeider på feltet blir større. Tettere koblinger på tvers av fylkene eller enheter som dekker flere fylker, kan også være bidrag til å sikre flere involverte og en større regional likhet.

Om ikke å passe inn vår samfunnsorden

Mennesker med utviklingshemning er stort sett avhengige av tjenester gjennom hele livet. Kommunene er og må ha ansvaret for tjenestene. Men en stor utfordring med kommunene, er at politikerne vanligvis har svært liten kjennskap til politikken overfor mennesker med utviklingsheming, lovverket og våre internasjonale forpliktelser. Politikerne kjenner i liten grad til livssituasjonen til mennesker med utviklingshemning. Det samme gjelder rådmannen og det meste av den kommunale forvaltningen. Når sentrale saker for mennesker med utviklingshemning er på kommunestyrets dagsorden, er det stort sett knyttet til budsjettsaker eller fysisk planlegging i forbindelse med etablering av en omsorgsbolig. Det er lett å stille kritiske spørsmål til en ordning hvor styrerne har en svært tynn kunnskap om forholdene de skal styre. Det er vanskeligere å finne løsningen, men noe kan nok gjøres med informasjonstiltak. Klarere statlige retningslinjer kan også være påkrevd. Uansett er det uforståelig når en registrerer at selv tilsyn som avdekker alvorlige forhold er ukjente for styrerne.

Manglende kunnskap og innsikt er også et stort problem i domsstolene. Få saker om bruk av tvang og makt har vært domstolsbehandlet og få jurister har nevneverdig kjennskap til feltet.

Diskriminering

Diskriminerende holdninger består i gruppetenkning, fordommer og at en anvender andre regler og normer overfor gruppemedlemmene enn for andre. Slik opplever en ofte når det gjelder tvang og makt, spesielt i de alvorlige og inngripende sakene. Det finnes knapt grenser for hvor mye en kan begrense friheten til mennesker med utviklingshemning. Inngripende tiltak kan vedvare gjennom store deler av voksenlivet og tiltakene kan være vel så inngripende som fengsel. En så stor makt, skal en være varsom med å gi enkeltpersoner i forvaltningen. Heldigvis er slike forhold ikke blant de mest utbredte når det gjelder tvangsbruk, men rettsikkerheten kan være temmelig fraværende i de sakene hvor behovet for rettsikkerhet er størst.

Menneskerettighetene er universelle. FN-konvensjonen om rettighetene til mennesker med nedsatt funksjonsevne sier i hovedsak at menneskerettighetene også gjelder for mennesker med funksjonsnedsettelser. Når en har universelle prinsipper å bygge på, bør en kunne etablere et universelt tvangsregelverk uavhengig av diagnoser og funksjonsevne.

Jens Petter Gitlesen

18 juni 2016

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