Randi Sigurdsen og Bjørn Roar Vagle

Argumenterer for Tvangslovutvalgets forslag

Bjørn Roar Vagle og Randi Sigurdsen støtter flertallet i tvangslovutvalget og er positive til utvalgets lovforslag.

Tvangsbegrensningsloven – vil styrke rettssikkerheten for personer med utviklingshemning

Av Bjørn Roar Vagle og Randi Sigurdsen, medlemmer av Tvangslovutvalget og NFU, henholdsvis seniorrådgiver Undersøkelseskommisjonen for helse- og omsorgstjenesten og professor, Det juridiske fakultet, UiT Norges arktiske universitet.

Leder Jens Petter Gitlesen har i flere innlegg på NFUs nettside kritisert Tvangslovutvalgets forslag til ny tvangslovgivning – Tvangsbegrensningsloven (NOU 2019: 14). Gitlesen har, sammen med undertegnede, vært medlem av Tvangslovutvalget. Gitlesen er én av to som tok generell dissens fra lovforslaget, mens undertegnede tilhører flertallet. Felles for lovutvalget er imidlertid et ønske om strengere krav for å kunne benytte tvang.

I innlegg 8. juli skriver Gitlesen at utvalget ikke har søkt informasjon eller innsyn i tvangssaker som gjelder personer med psykisk utviklingshemning. Dette er feil. For det første har Gitlesen bidratt med slik informasjon. I tillegg har undertegnede begge lang erfaring som foreldre til barn med utviklingshemning og vi har yrkesmessig arbeidet med dette saksfeltet i mange år. Vagle har jobbet nesten 20 år i den direkte tjenesteutøvingen, hvorav syv år som leder for habiliteringstjenesten i Helse Stavanger. Også utvalgsleder, professor Bjørn Henning Østenstad har i mange år arbeidet med spørsmål om bruk av tvang overfor personer med utviklingshemning. Vi er derfor flere som har bidratt med kunnskap om livsvilkårene og om bruk av tvang overfor mennesker med en utviklingshemning. Tvangslovutvalget hadde også et langt møte med en ung mann som var/er under et restriktivt tvangsregime. Vi har hatt møte med tjenesteytere i flere kommuner og med habiliteringstjenester/spesialisthelsetjenester, og vi har gjennom anonymiserte vedtak fått innsyn i kontroversielle tvangsvedtak.

Tvangslovutvalget har med andre ord hatt et rikt tilfang av informasjon om hvordan dagens lovverk om bruk av tvang overfor personer med utviklingshemning praktiseres, og hvilke omfattende tvangsregimer enkelte personer erfarer.

Trenger vi et lovverk om tvang?

Det primære formålet med et lovverk om tvang er ikke å åpne opp for tvangsbruk. Gjennom å anerkjenne at noen tiltak er å anse som tvang, skapes oppmerksomhet om hva som skal til for å hindre tvangsbruk. Faktorer som bidrar til å forhindre bruk av tvang er trygg og god omsorg, stabile relasjoner, tilpasset kommunikasjon, bygge opp under selvbestemmelse og frivillighet. Med andre ord skal det arbeides for generelt gode levevilkår for å forhindre at mangler på disse områdene gir utslag i utfordrende atferd som i neste omgang kan bli møtt med tvangstiltak. Bare som en siste utvei skal tvangstiltak benyttes, og kun dersom konsekvensene av ikke å gripe inn er svært alvorlige.

Til tross for bestrebelser for å unngå bruk av tvang, vet vi at behov og preferanser varierer kolossalt. Noen personer motsetter seg å gjennomføre nødvendige gjøremål, som hvis de ikke utføres kan gi alvorlig fare for skade på personen selv. Eksempelvis kan noen nekte nødvendig helsehjelp fordi de ikke forstår informasjon som blir gitt om at de har en alvorlig sykdom. Behovet for å gjennomføre tannbehandling er for enkelte uforståelig og oppleves kun som et ubehag, og må på grunn av motstand gjennomføres under narkose. Et gyldig samtykke til undersøkelsen foreligger ikke når personen ikke forstår hva som skal skje.

Andre personer kan komme til å utføre handlinger som er skadelig for dem selv eller andre. Det kan ha sammenheng med at de har reaksjonsmønstre som det ikke lykkes med å forebygge årsakene til, som f.eks. sterk redsel for hunder. Ved et møte med hund, kan noen finne på å løpe rett ut i veien og risikere å bli drept. Da må tjenesteyterne gripe tidlig inn. Det finnes også personer med utviklingshemning som har vansker med å forstå hva som er akseptabel sosial omgang, f.eks. overfor barn, eller har annen svært problematisk atferd i det offentlige rom.

Det er altså noen som trenger tett oppfølging av personalet om de ønsker det eller ikke, for å hindres i å forårsake situasjoner som kan innebære en nærliggende og alvorlig fare for personen selv eller andre. Dette er vanskelige problemstillinger. I noen tilfeller makter ikke tjenesteapparatet å forebygge eller finne fram til egnede frivillige tiltak. Alternativet til tvang vil da være å unnlate å gi personen nødvendig omsorg og eventuelt la politiet "ordne opp".

Tvangslovutvalgets forslag sammenlignet med dagens kapittel 9 i helse- og omsorgstjenesteloven

Lovforslaget inneholder ingen henvisning til diagnoser. Dagens diskriminering ved at et lovverk kun gjelder personer med utviklingshemning, vil opphøre. Definisjon av tvang er strammet inn. Noen av tiltakene som i dag anses som tvang overfor personer med psykisk utviklingshemning uten at vedkommende motsetter seg det, vil ikke omfattes av lovforslaget. Personer med utviklingshemning skal selv kunne samtykke til en del tiltak som i dag regnes som tvang. Dersom en person med lett utviklingshemning og fysisk funksjonsnedsettelse i dag ønsker å ha baby-call om natten for å tilkalle personalet, vil det kunne bli forstått som et inngripende varslingssystem som skal regnes som et tvangstiltak. Et annet eksempel på tiltak som i dag reiser spørsmål om det er et tvangstiltak, er når en person med utviklingshemning ber personalet om å oppbevare mobiltelefonen om natten.

Fjerning av diagnosekrav og større vekt på selvbestemmelse bidrar etter vår mening til å styrke menneskerettighetene til personer med utviklingshemming

Tvangslovutvalget mener at hovedvekten av rettssikkerhetstiltak må gjelde tiltak som personen motsetter seg. Men der det er tvil om det foreligger motstand, skal det legges til grunn at så er tilfelle. Dessuten vil forslag til tvangsdefinisjon innebære at når betydelig inngripende tiltak benyttes overfor personer med store formidlingsvansker, er det alltid å regne som tvangstiltak som utløser rettssikkerhetsmekanismene. Det er også alltid tvang dersom vesentlig informasjon om et tiltak holdes skjult for å unngå motstand.

Jon har moderat utviklingshemning. Han løper ofte ut på egenhånd og finner på masse han ikke burde ha gjort. Blant annet stjeler han mye i den lokale nærbutikken og han oppsøker barn i en barnehage som blir redde for han. Han har noen ganger blottet seg. Fastlegen til Jon vil gi han Nozinan som gjør at han roer seg mer hjemme. Jon får bare beskjed om å ta medisinen, uten noen forklaring. Slik «samarbeider» han lettest.

Med tvangslovutvalgets forslag er dette tvangstiltak overfor Jon. Kommunen må blant annet vurdere om Jon har nok og kvalifiserte tjenesteytere, om han har et meningsfullt skole- eller arbeidstilbud, hvilke fritidstilbud han har. Dersom denne type forbedringer i hans livssituasjon ikke er tilstrekkelig til å forhindre at Jon løper ut, må de be om bistand fra spesialisthelsetjenesten (habiliteringstjenesten) og de må involvere nærmeste pårørende. Utkastet til tvangsbegrensningslov styrker rettssikkerheten, sammenlignet med dagens regler. I dag er medisinering med psykofarmaka et forsømt område i omsorgen for personer med utviklingshemning.

En kort oppsummering av lovforslaget:

• Det overordnede formålet med lovforslaget er å begrense bruk av tvang – tvang skal være absolutt siste utvei. Derfor foreslås det strengere krav til å finne alternative tiltak som kan forhindre tvangsbruk. Utvalget løfter fram retten til et tilrettelagt tilbud uten tvang som en side ved retten til helse- og omsorgstjenester.

• Helhetstenkningen rundt individet må styrkes for å få ned bruken av tvang. I dag kan en person være underlagt tvangstiltak med hjemmel i flere lovverk, med ulike vilkår for når tvang kan anvendes og ulike klage- og overprøvingsordninger. Derfor er det foreslått én felles tvangslov. At det i dag må fattes ulike typer vedtak oppleves ofte utfordrende for tjenestene. I dag må f.eks. tannstell med motstand hjemles i et kapittel 9 vedtak, mens det må fattes et eget vedtak om tannbehandling under narkose (etter kapittel 4A i pasient- og brukerrettighetsloven som gjelder alle voksne personer som mangler samtykkekompetanse).

• Lovforslaget bygger på likebehandling av mennesker. Det er deres behov for tiltak som er det sentrale – ikke deres diagnose. Lovforslaget gjelder også barn, med noen særregler.

• Voksne personer med utviklingshemning har beslutningskompetanse, men som for alle andre, noen har det på alle livsområder, andre kan ha begrensninger på enkelte områder. Dette må vurderes individuelt.

• Selvbestemmelsen for voksne personer må styrkes. Det er derfor foreslått utprøving av modeller for beslutningsstøtte.

• CRPD er én blant flere menneskerettskonvensjoner som det må tas hensyn til ved spørsmål om bruk av tvang i velferdsøyemed. Som alle andre rettslige dokumenter må CRPD tolkes. At CRPD-komiteens tolkning av konvensjonen har stor betydning er udiskutabelt, men det er ikke den eneste kilden til tolkning av konvensjonen. Andre organer, bl.a. FNs Menneskerettskomité, deler ikke fullt ut CRPD-komiteens syn, noe dette lovutvalget har vært forpliktet til å ta hensyn til.

• Lovforslaget er fortrinnsvis knyttet til tjenester, ikke til hvor en person bor. I dag er det flere steder fast praksis for å hindre personer som bor i bofellesskap utgang fra sin bolig deler av døgnet. Dette er frihetsberøvelse og krever hjemmel i lov. Tvangslovutvalget har derfor foreslått at om en person skal forhindres i utgang fra egen bolig, må nærmere vilkår være oppfylt. Tiltaket kan kun gjelde personer som ikke er i stand til å klare seg utendørs om natten på grunn av omfattende orienteringssvikt.

• Det må legges mer vekt på rettssikkerheten ved de mer inngripende tiltakene ved å blant annet styrke kontroll- og overprøvingsordningene. Fylkesmennene skal bl.a. holde oversikt over alle vedtak som gjelder samme person, noe som vil kreve at ulik fagkompetanse må involveres når en person erfarer flere tvangstiltak. I tillegg foreslår Tvangslovutvalget opprettelse av tvangsbegrensingsnemnder med et klart mandat: å se kritisk på tvangsbruken. Tvangsbegrensningsnemndene skal dersom det ikke allerede foreligger klage, gjennomføre høring innen 30 dager i saker som gjelder de mest inngripende tiltakene. Tvangsbegrensningsnemndene skal også gjennomføre stedlig tilsyn.

Ja, det vil skje endringer i hvordan rettssikkerheten for personer med utviklingshemning ivaretas, men samlet sett vil det etter vår oppfatning skje klare forbedringer med en ny tvangsbegrensningslov.

25 august 2019

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