September 18, 2026
By Katarzyna Widlas-Klimsiak
How should the European Court of Human Rights (ECtHR, the Court) reconcile, under the European Convention on Human Rights (ECHR), a State’s obligation to secure appropriate psychiatric care with the limits that autonomy and consent place on imposing such care? Three recent judgments illuminate different sides of this problem.
In Spivak v Ukraine (application no. 21180/15, 5 June 2025), the applicant challenged compulsory neuroleptic medication, the procedures governing his treatment and confinement, and conditions in a high-security psychiatric hospital. Albertani v Italy (application no. 15994/20, 4 June 2026) and Andrea Ciotta v Italy (application no. 368/21, 4 June 2026) concerned detention in ordinary prisons unable to provide the therapeutic care that the domestic authorities considered necessary.
Read together, the cases support a distinction that should be made at the outset. A State may be required to make services adapted to a person’s needs and an individualised therapeutic programme available. It does not follow that every component of that programme may be imposed. The adequacy and availability of care and the authority to administer a particular intervention without consent are connected, but neither determines the other.
Mr Spivak was arrested in December 2011 after an alleged attempted murder. A forensic assessment found that he had not previously suffered, and was not then suffering, from a mental illness. Instead, he had experienced a temporary twilight state of consciousness at the time of the alleged offence. The experts recommended compulsory hospitalisation under ordinary supervision. A domestic court instead ordered his placement in a high-security psychiatric hospital, where he was later diagnosed with an organic personality disorder (§§ 5–18). During the almost two years he spent in the hospital, from 6 December 2012 to 28 October 2014, Mr Spivak received neuroleptic medication against his will, in changing forms and dosages and without a predetermined course. He alleged that it was used to punish him and control his behaviour. He could not independently challenge either the medication or his continued confinement. He also complained about overcrowding and other inadequate conditions.
The Court found violations of Article 5 §§ 1 and 4 ECHR (right to liberty and security). Mr Spivak remained detained for four days after the decision terminating the coercive medical measures became final. Reviews of his confinement also failed to meet basic requirements of justice: the first three hearings took place in his absence, the courts did not examine the hospital’s submissions critically, and Ukrainian law did not permit him to initiate review proceedings (§§ 136–149).
The Court also found a violation of the prohibition of torture and inhuman or degrading treatment under Article 3. Applying the principle stated in Herczegfalvy v Austria (1992), it reiterated that a measure convincingly shown to be therapeutically necessary in accordance with established principles of medicine cannot, in principle, be regarded as inhuman or degrading. Medical necessity must nevertheless be convincingly demonstrated, and safeguards against abuse must be effective in law and in practice (Spivak, § 168; Herczegfalvy, § 82).
In Spivak, the Court described free and informed consent as ‘a cornerstone of personal autonomy’, of particular importance in psychiatric confinement (§ 174). Although health or public safety may sometimes justify treatment without consent, the intervention must be appropriate, necessary and subject to rigorous oversight capable of preventing abuse (§§ 175–176).
The Ukrainian framework did not meet that standard. The placement order operated in practice as authority to treat. Mr Spivak could not challenge the medication specifically or obtain an effective alternative psychiatric assessment; his objections were not examined independently; and six-monthly review of the overall coercive measure could not provide timely protection (§§ 177–189).
A treatment plan existed, but it did not clarify the medical purpose of Mr Spivak’s confinement, the treatment prescribed or the expected outcome. Changes in medication coincided with his insistence that he was mentally healthy, his questioning of continued hospitalisation and treatment, and his complaints about confinement. The hospital treated those objections as manifestations of illness without adequately explaining the clinical connection (§§ 190–199). The Court found no convincing proof that his continued confinement and neuroleptic treatment were necessary (§ 200). The forced administration of neuroleptics for almost two years, together with the lack of effective safeguards, amounted to inhuman and degrading treatment (§§ 201–202). It separately found an Article 3 violation concerning hospital conditions and an Article 13 violation for the absence of an effective remedy.
The judgment should not be overstated as creating a new, free-standing doctrine separating hospitalisation from treatment. It nevertheless supports a treatment-specific inquiry: the lawfulness of confinement cannot, by implication alone, establish authority to impose a particular drug, dosage or method of administration.
The Italian cases address a different problem: detention in prison settings unable to deliver the care that the domestic authorities considered necessary.
Ms Albertani had been convicted in 2011 of offences including the murder of her sister and attempted murder of her mother. Psychiatric assessments found her partly unable to understand and control her actions and considered her dangerous. She was placed in a judicial psychiatric hospital. When the security measure expired, a judge found that her psychiatric condition, depressive symptoms and substantial risk of self-harm remained incompatible with prison (§§ 7–8). Following the closure of Italy’s judicial psychiatric hospitals, she was transferred to prison despite warnings that this would interrupt her therapeutic pathway. She complained under Article 3 that the prison was unsuitable and could not provide appropriate treatment, and under Article 5 that her detention was unlawful and incompatible with her health needs. Medication and psychiatric and psychological monitoring were available, but the necessary psychotherapy could not be delivered to the required extent (§§ 13–15 and 19–20).
The Court declared the Article 3 complaint concerning the period after 24 April 2019 inadmissible for non-exhaustion: following a Constitutional Court judgment published that day, Ms Albertani should have renewed her request for an alternative measure. It examined the earlier period and found that the psychotherapeutic care provided in prison had been insufficient, in violation of Article 3 (§§ 60–65 and 80–84). It also found violations of Article 5 §§ 1 and 4 and Article 13 taken in conjunction with Article 3.
Mr Ciotta was placed in pre-trial detention in April 2020 after being charged with harassing his former partner. In prison, he was diagnosed with a delusional disorder. On 10 July 2020, a court replaced detention with provisional placement in a Residence for the Execution of Security Measures (residenza per l’esecuzione delle misure di sicurezza, REMS); a therapeutic community was later accepted as an alternative. Because no REMS place was available, he remained in prison until 23 February 2021. He was then held briefly in a public psychiatric unit under police supervision and entered the therapeutic community on 2 March 2021 (§§ 7–39).
Mr Ciotta alleged that his continued imprisonment was unlawful, incompatible with his condition and prevented appropriate care. He had initially refused pharmacological therapy and underwent compulsory medical treatment in a psychiatric unit from 16 to 25 May 2020. He later accepted medication and received close psychiatric and psychological monitoring in prison (§§ 8–11). The Court did not determine whether the May intervention was justified; its Article 3 analysis concerned the adequacy of subsequent prison care. The programme identified by the domestic authorities could not be implemented there. After transfer to a therapeutic community, Mr Ciotta received psychotherapy, psychoeducation, rehabilitation, resocialisation activities and support for social reintegration (§§ 27–41 and 102–108). The Court reiterated that examinations, consultations and medication do not automatically establish appropriate care. What matters is access to a comprehensive and individualised therapeutic strategy; its absence may amount to ‘therapeutic abandonment’ (abandon thérapeutique). It found a violation of Article 3 (§§ 102–109).
The Court distinguished three periods. It found no violation of Article 5 § 1 between 26 April and 9 July 2020. For the period from 10 July 2020 to 21 February 2021, the lack of a REMS place could not justify his continued imprisonment after the domestic placement order. His subsequent deprivation of liberty from 22 to 25 February 2021 lacked any legal basis. The Article 5 § 1 violation therefore covered the overall period from 10 July 2020 to 25 February 2021 (§§ 133–140). The Court also found violations of Articles 5 § 5, 6 § 1 and 34. Under Article 46, it identified a systemic problem in the non-enforcement of REMS placement orders. It indicated general measures aimed at improving coordination between the competent authorities, ensuring sufficient REMS capacity and developing concrete and effective alternatives to deprivation of liberty (§§ 196–210).
Both judgments build on the Court’s ruling in Rooman v Belgium [GC] (2019): detention on account of mental disorder must take place in a suitable medical environment and be accompanied by real therapeutic measures forming part of an individualised programme. Formal access to professionals, consultations and medication may not suffice (Rooman, §§ 208–211).
The Italian cases concern the State’s duty to organise and provide appropriate care; Spivak concerns the justification and supervision of treatment imposed against a person’s will. Both respond to power exercised over persons under institutional control, but they require different legal inquiries.
Taken together, the judgments make it useful to distinguish two analytically separate inquiries. First, has the State made available care that is suitable, sufficiently comprehensive and adapted to the person’s needs? Second, if a particular intervention is administered without valid consent, does it have an adequate legal basis, an individualised and evidence-based justification, and effective safeguards? The Court did not announce this as a formal test. It is a treatment-specific framework for explaining why a positive answer to the first question cannot predetermine the second.
This distinction is reflected in the way the Convention provisions operate. Article 5 governs the lawfulness of detention; under Article 5 § 1(e), the therapeutic purpose of detention and the suitability of the institution are linked to appropriate treatment. Article 3 may be violated because suitable care is absent or because imposed treatment lacks convincingly demonstrated necessity and protection against abuse. Non-consensual medical intervention may additionally engage Article 8 through physical and psychological integrity, autonomy and medical self-determination (see X v Finland (2012), §§ 212–221), although Spivak did not examine a separate Article 8 complaint.
Spivak does not displace the principle stated in Herczegfalvy: non-consensual treatment convincingly shown to be therapeutically necessary cannot, in principle, be regarded as contrary to Article 3. Its contribution lies in closer examination of the legal framework, Mr Spivak’s medical record, the reasons offered for his continued confinement and medication, and the available review procedures, rather than acceptance of clinical recommendations at face value. This approach is consistent with subsidiarity. National authorities remain primarily responsible for clinical choices, but domestic courts must subject the supporting evidence and safeguards to genuine scrutiny. The ECtHR reviews Convention compliance; it does not select the clinically preferable treatment.
In Albertani and Andrea Ciotta, medical reports and domestic decisions established that prison care was inadequate. The judgments examined whether the care was objectively suited to each applicant, but did not consider whether the applicants had participated in designing or evaluating their therapeutic programmes. That silence should not be treated as a finding that they were entirely excluded from decision-making.
The Convention on the Rights of Persons with Disabilities (CRPD) provides a relevant normative benchmark for asking whether individualised care also respects the person’s autonomy and participation. Autonomy and freedom to make one’s own choices are general principles (Article 3(a)), while Article 25(d) requires care of equal quality on the basis of free and informed consent. The CRPD Committee’s General Comment No. 1 recognises the obligation to provide access to support in exercising legal capacity (para. 16), requires that such support respect the person’s rights, will and preferences (para. 17), and replaces best-interests determinations with the ‘best interpretation of will and preferences’ where necessary (para. 21). It also states that forced psychiatric treatment violates equal recognition before the law and rights to personal integrity and freedom from violence, exploitation and abuse (para. 42).
The difference between the regimes must remain visible. The ECtHR accepts that treatment without consent may comply with the ECHR where necessity is convincingly demonstrated and effective safeguards exist. The CRPD Committee rejects disability-based denial of legal capacity and forced psychiatric treatment. The Committee’s interpretation does not bind the ECtHR in applying the ECHR, but it can inform questions that the Court’s requirement of individualised care could address more explicitly.
Although the Court did not take this step in the three judgments, the Committee’s approach suggests that individualisation could encompass the person’s objectives, objections and preferences; the information and decision-making support provided; and realistic, less intrusive alternatives. This participatory understanding would better ensure that care is individualised to the person rather than merely to a diagnosis or institutional setting. It would not require Strasbourg to write treatment plans. In accordance with subsidiarity, national authorities would retain primary responsibility for services and clinical decisions; the Court would examine whether Convention rights were respected and whether decisions were supported by evidence, reasons and effective safeguards. Such scrutiny should remain tied to the person: refusal should not automatically be treated as a symptom, professional opinion should be examined rather than repeated, and deficiencies in services should not be recast as proof that coercion is medically necessary.
The three judgments do not establish a comprehensive doctrine, but they identify complementary requirements. Care must be real rather than nominal: it requires an appropriate environment, an individualised therapeutic strategy and services capable of implementing it. The requirements are cumulative rather than competing. Calling an intervention therapeutic cannot replace proof that imposing it without valid consent is lawful, necessary and open to effective review. Andrea Ciotta also shows why a systemic response cannot be limited to adding institutional beds. REMS capacity may prevent unlawful imprisonment, but the Court also emphasised coordination and community-based alternatives. A rights-compliant system must deliver meaningful care without making imprisonment, institutionalisation or coercion the default route through which care becomes available.
European mental-health law need not choose between autonomy and care. It must prevent the duty to provide appropriate support from becoming a presumption that every recommended intervention may be imposed, while ensuring that respect for autonomy is not used to justify therapeutic abandonment.
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