Introduction
All Irish citizens living in Ireland have a constitutional right to vote in all referenda and elections in Ireland (www.citizensinformation.ie). Resident British citizens can vote in local, European and Dail elections while EU citizens can only vote in local and European elections. A person’s name must be entered on the electoral register in order to exercise their right to vote. A person may be eligible for a postal vote if they are unable to attend a polling station owing to physical disability, because of occupation or if in prison as a result of a court order(www.citizensinformation.ie).
Alternatively, those who live in hospitals and nursing homes and have an illness that prevents them from going to a polling station may apply to be on a special voters list (www.citizensinformation.ie). A medical certificate is required with the application. At the time of an election, notice will be given and a special presiding officer will call to the hospital accompanied by a garda and allow the individual to vote in private.
Patients in acute hospitals who are registered to vote and are unable to attend in person are eligible for a postal vote provided they have registered in advance as a postal voter. Most patients admitted to an acute psychiatric unit will not have registered in advance as a postal voter and therefore will need to attend the polling station in person. However, patients who are in hospital for longer periods could register as postal voters or be on the special voters list and in our view this should be discussed with patients.
Patients in psychiatric units in Ireland are legally entitled to vote but to our knowledge many patients are unaware of their right to vote. There is no formal procedure for voting among the in-patient mentally ill in Ireland. We carried out a survey to learn how many patients on an acute psychiatric admission unit within a general hospital were aware of their right to vote in the General Election on Friday 25 February 2011 and how many did so. We provide recommendations that would facilitate voting among in-patients.
Aims
To investigate the voting practices of patients on an acute psychiatric unit in the Irish General Election 2011.
Objectives
∙ To investigate the level of patient awareness of their voting rights in hospital.
∙ To investigate how many patients were informed by the ward staff of their voting rights in the 2011 General Election.
∙ To investigate how many patients exercised their right to vote.
Method
On 28 February 2011, 3 days after polling day, all patients on an acute psychiatric ward were invited to take part in an oral survey carried out by a registrar in psychiatry. Patients who were judged to be too unwell by the clinical team were excluded from the study The ward is a general adult psychiatric ward and has no high dependency or intensive care facility. Ethical approval was not required as the study was considered to be an audit but all patients were informed in writing of the authors plan to publish the results of the survey anonymously.
Each participant was asked four questions:
1. Are you registered to vote?
2. Are you aware of your voting rights as an in-patient?
3. Were you informed by the ward staff of your right to vote in the general election?
4. Did you vote? If no, please give reason for not voting.
We asked each patient’s responsible consultant and their keyworker if they had discussed with patients their wish to vote before polling day. We also enquired about a hospital policy on voting rights and procedures for in-patients. We contacted the relevant authorities for guidance on voting rights for in-patients in psychiatric units.
Results
There were 29 in-patients on polling day and 22 of these patients remained in hospital on the day that the survey was conducted. A total of 20 patients were judged by the clinical staff to be suitable to take part in the survey. One patient was medically unstable and another patient was judged to be too hostile. All 20 patients judged to be suitable to participate agreed to be interviewed.
Only two patients voted. Both of these patients were on overnight leave when they voted, so strictly speaking, neither patient was actually on the unit on polling day. None of the clinical team had discussed with their patients their wish to vote before polling day even though three of the patients were in hospital for more than 3 months. There was no patient information available on the unit about voting and there was no general hospital protocol to facilitate patient voting.
Discussion
Our survey showed that only 10% of in-patients voted and these patients were on overnight pass. This compares with a general election turnout of ~70% (www.oireachtas.ie). A total of 45% of patients who were registered to vote were unaware of their eligiblility to vote because of their in-patient status. This lack of patient awareness is consistent with previous studies. A recent study (McIntyre et al. Reference McIntyre, Khwaja, Yelamanchili, Naz and Clarke2012) of psychiatric in-patients voting practices in a London catchment area during the General Election 2010 showed that 88% of patients who had not registered to vote did not know they were allowed to vote or how to register. In an earlier study (Humphreys & Chiswick Reference Humphreys and Chiswick1993) of elderly psychiatric and medical in-patients in the United Kingdom it was revealed that while 80% of the patients wanted to vote, only 8% managed to do so.
Our survey showed that there was no ward or hospital policy on patient voting and no members of staff had discussed with patients in advance of election day their right to vote. A staff survey (Rees Reference Rees2010) was carried out in a psychiatric unit in the NHS to investigate the knowledge of in-patients’ voting rights among healthcare staff. A total of 89% of staff agreed that voluntary patients had a right to vote but only 63% of respondents agreed that patients detained under an admission order had a right to vote. Almost all respondents stated that they had not been given information on patients’ voting rights leading up to the recent election. A lack of awareness among hospital staff about patient eligibility to vote may partly explain why none of the participants in our survey were informed of their voting rights.
What about the patient’s capacity to vote? The Mental Health Commission provided a written response stating that every citizen has the constitutional right to vote. It is the responsibility of the Approved Centre to facilitate patient voting. We contacted the Irish Advocacy Network Ltd. who provide Peer Advocacy and who obtained the following information from the Mental Health Commission for one of their clients:
‘The core issue in-patient voting is if the person has capacity. The test of legal capacity in this regard is whether at the time of voting the person can understand in broad terms what he/she is doing and the effect of this. This includes understanding the choice to vote or not’.
‘The question of capacity will be one of fact for the presiding officer at the polling station… In effect there is little to prevent a person from voting if they have a basic understanding of what they are doing and being in hospital should not prevent persons from doing so….’ ‘However if someone is very ill etc it is likely that they might be deemed not fit to leave regardless of the capacity to vote. So the welfare and safety of the patient would override other considerations under our law on negligence. One could consider support etc to maximise the right to vote so accompanying a person etc would be part of that’.
In sum, the decision to permit a patient to leave hospital in order to vote rests with the treating consultant and the patients well-being is paramount.
Our survey shows that there is lack of patient awareness about their entitlement to vote in hospital. The likelihood of voting depends in part on a persons social setting and support (Redley et al. Reference Redley, Hughes and Holland2010).
We recommend that a protocol should be developed in each hospital and each patient should be informed of their right to vote as part of their admission. The patient’s treating team should also discuss their wishes with them. In Australia, where voting is mandatory, electoral visitors ensure that in-patients are registered and facilitated to vote. Advocacy could play a useful role in facilitating patients to vote in Ireland. Long stay patients should be encouraged to register as postal voters if they are unable to attend in person and should be advised to register the hospital as their place of residence if they no longer have a home or are awaiting accomadation.
Hospital patients are among those most affected by healthcare policies and their rights as citizens are diminished if they are denied the opportunity to vote because of lack of information.
Limitations
The survey took place 3 days after polling day and therefore some patients had already been discharged from the unit who may have voted and are not included in the survey. We also acknowledge that this is a small survey and it would be interesting to learn about hospital voting practices and policies in other areas of Ireland.
Acknowledgements
The authors thank Siobhan Comerford for her administrative support and our patients who participated in the survey.
