ANSWER
The Mental Healthcare Act of 2017 (MHCA 2017)[1] expressly mentions the rights of patients with mental illnesses (PWMI) and establishes the ethical and legal responsibilities of mental health professionals and the government. PWMI rights are equal to human fundamental rights and must be discussed openly because they belong to a vulnerable group in terms of evaluation, treatment, and research. Such rights are reflected in psychiatric care ethics, which include respect for autonomy, the principle of nonmaleficence, beneficence, and justice, confidentiality (and disclosure), boundary violations, informed consent (and involuntary treatment), and so on. [2,3] I’ll talk about the ethical, legal, and other issues surrounding the manuscripts published in this issue of the journal.
THE MENTAL HEALTHCARE ACT OF 2017
The authors[4] critically evaluate the pros and cons of the new ACT in their article pertaining to MHCA 2017. They applaud the act for supporting PWMI rights (particularly insurance) and advocating for the decriminalization of suicide and the lesbian, gay, bisexual, transgender, questioning/queer (LGBTQ) community. They also mention the Indian Psychiatric Society’s non-representation and the inadequate treatment of the caregivers’ burden of care. PWMI caregivers are true mental health ambassadors; they truly understand the genuine service that psychiatrists have provided in this country for many decades. Without a doubt, the human rights of PWMI must be protected at all times; however, this protection cannot be one-sided. There is an equal and strong need to involve caregivers in developing mental health policies that are ethically and legally sound while also tailoring to their needs and the ground realities of this developing country, such as poverty, illiteracy, stigma, discrimination, and so on. In light of the new challenges posed by MHCA 2017, such as mental health capacity assessment, advance directive, nominated representative, and so on, the authors emphasize the importance of actively collaborating with “the media, police, NGOs, human rights activists… and police.” [4]
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GO TO: ETHICAL PROBLEMS
The definition of ethics is “a set of moral principles, particularly those relating to or affirming a specific group, field, or form of conduct.”
[5] Technically, ethics discuss morality and desirable ways of behaving, but they are not legally binding on an individual. However, when it comes to medical ethics, these are mandatory (rather than desirable) requirements upon which a physician must act. Country-specific regulations govern the legal aspects of patient care, which are in turn governed by medical ethics. For example, when an Indian psychiatrist is accused of “wrongdoing,” it is determined whether he violated “medical ethics”[6] or national laws. [1] Thus, a psychiatrist’s ethical and legal responsibilities are inextricably linked.
Confidentiality and transparency
In mental health, the patient-physician relationship is bound by the moral and ethical sanctity of confidentiality. This is one of the psychiatrist’s primary responsibilities. [1,6] In clinical practice, however, the PWMI may waive this confidentiality clause in certain circumstances. PWMI are mostly accompanied by caregivers in India. Few PWMI prefer that their information and diagnosis be shared with such caregivers. Considering this to be implied consent, such disclosure was previously done in the absence of explicit written informed consent. A typical scenario would be a woman who has been receiving treatment for psychiatric illness for the previous ten years suddenly shows up at her treating psychiatrist and discloses that she recently married and now plans to conceive. Her spouse also wishes to speak with her about the diagnosis, treatment, and the need for and safety of psychotropic medications during pregnancy. Unfortunately, the disclosed information may be used for any purpose (including divorce), and the lady may sue the treating doctor for breach of confidentiality. As a result, because the lady wants her information shared with her spouse and the confidentiality clause will be violated, written informed consent should be obtained from her, including permission to disclose how much, and this should be documented in the patient’s notes. Such written consent from the patient may protect the psychiatrist in court.
It would be interesting to learn about the sociodemographic factors that influence such disclosure. Gupta et al. [7] studied remitted psychiatric patients. Patients’ unwillingness to share their concerns with others was significantly associated with their age, gender, and educational level. These factors, according to the authors, should be considered when making ethical decisions.
Inadequate information about forensic patients with mental illnesses
Diagnosis is critical for effectively managing psychiatric patients, and it is based on adequate history from significant others, as psychiatrists cannot rely solely on mental status examination. There is a lack of adequate history when individuals are admitted involuntarily through Honorable courts and prisons into tertiary level public hospitals. This is more common with people who have been referred from prisons. Discussions are attempted with the prison medical officer and caregivers. The caregivers are either untraceable or unwilling to discuss their situation. Furthermore, due to a lack of knowledge about mental disorders, the only history obtained from the medical officer is of the patient being irritable or making suicidal threats. This is insufficient for making a diagnosis. Thus, in a forensic psychiatric setting, a lack of adequate history is a major issue. Thus, the management of such patients is primarily based on inpatient observation. In recent years, there has been a greater emphasis in India on training of judiciary and prison medical officers, which is a positive step. There is also an urgent need for a judicial policy mandating the presence of caregivers and/or family members when referring such individuals to psychiatric hospitals.
With this context in mind, a retrospective chart review of female forensic inpatients was performed.
[8] Approximately 73.9% of the sample was referred from prisons, while 26.1% were referred from the Honorable courts. In light of the alleged crime, 21.7% of subjects were referred for fitness to stand trial evaluation. The vast majority (30.43%) were charged with the murder of a close family member, such as a husband or child. Approximately half of the study sample had an illness at the time of the crime, according to a retrospective analysis. About 30.4% of the people were diagnosed with psychotic disorders, and 47.8% were diagnosed with a mood disorder. 87% of patients showed a significant clinical improvement, which is encouraging. It remains to be seen whether the gains made, particularly for those referred from prisons, will last in the long run. Also, how do such patients fare after being discharged from psychiatric hospitals and released from prisons due to treatment nonadherence and other prognostic factors? This study only looked at female forensic patients; how do male forensic patients fare?
LEGAL PROBLEMS IN PSYCHIATRIC CARE
Psychiatrist testifies in court
The authors of “Psychiatrist in Court: Indian Scenario”[9] discuss the legal aspects of psychiatric care when psychiatrists are called as expert witnesses. According to them, “psychiatry residents frequently do not get first-hand exposure to Court proceedings.” There could be three reasons for this. For starters, many residents receive their training in General Hospital Psychiatry Units (particularly in private colleges) that are not directly connected to forensic psychiatry units. They have a 2-4 week peripheral posting to such facilities. Second, because residents are doctors-in-training who work under the supervision of faculty, the Honorable courts do not consider them competent to testify. Third, faculty members may avoid involving them in legal aspects of patient care because they believe it is not their responsibility. Residents in psychiatry are routinely involved in legal aspects of patient care at my workplace, a tertiary level teaching public hospital. The faculty should ensure that the residents participate actively in the legal aspects of patient care, such as medical boards, discharge committee meetings, certification, and so on. Only when they are exposed at this stage of their careers, once out of residency, will they be able to manage such issues on their own.
The outcome of insanity petitions
The psychiatrists appear in court as expert witnesses and give evidence, but they are unaware of what happens next. I applaud the investigators for pursuing a previously unexplored topic in the Indian context, namely insanity pleas. [11] If an accused has evidence that he was receiving treatment prior to the crime, the treating psychiatrist is likely to be summoned; the treating psychiatrist was summoned in 32 of 67 cases (47.76%). The time interval between the “visit to a psychiatrist” and the subsequent “date of crime” ranged from 1 to 1800 days, which is concerning because a PWMI could commit crime immediately after the consultation. Furthermore, if there is documentary evidence of mental illness, there is a higher chance (P 0.012) of acquittal on mental illness grounds. The accused was not acquitted on the grounds of mental illness in either the 24 cases where the Honorable Court did not feel the need for psychiatrist’s evidence or the six cases where the psychiatrist opined that there was no mental illness. Furthermore, 16 out of 56 accused (28.57%) were acquitted on the basis of mental illness, according to psychiatrists (P = 0.002). Out of a total of 102 cases, 18 (17.65%) were acquitted on the basis of mental illness. The Honorable High Courts’ decision was mostly in line with the lower Court’s decision and heavily relied on documentary evidence of mental illness. The opinion of psychiatrists was an important factor, which is very encouraging. The findings strongly suggest that proper documentation is required.
Patients with mental illnesses who abscond
When PWMI escape from psychiatric hospitals, particularly closed wards, the hospital staff bears an enormous burden in terms of legal ramifications. Absconders may not take care of themselves and may endanger themselves, others, and property. Despite the fact that absconding from psychiatric hospitals or nursing homes is quite common, no Indian data are available in the published literature, most likely due to the fear that it will reflect negatively on the staff and hospital administrators. Though this is a tragic event, we should not be discouraged from investigating it because absconding is common in any closed setting, including high secure prisons[12], general hospitals[13], and psychiatric hospitals worldwide,[14,15,16], and in India[17].
It is encouraging to see that an article addressing this important, albeit unaddressed, issue has been published.
[18] Absconding behavior was observed in 4.5% of the in-patients. They were mostly men with schizophrenia or mood disorders and a substance-use disorder, with impaired insight and high perceived coercion being predictors of absconding behavior. Twenty-two percent of the nine absconders committed suicide. A previous history of self-harm and wandering away from home in those who have absconded suggests that this should be investigated as part of the history taking process. This study concentrated on open wards where PWMI consent for admission and caregivers who remain are in charge of patient care. It is important to investigate absconding behavior in the closed ward setting, where PWMI are admitted involuntarily (via courts and prisons) without caregivers, putting more “responsibility” on hospital authorities. There is an urgent need to implement policies to prevent such incidents, such as rationalizing pharmacotherapy, using restraints and seclusions according to guidelines,[1] electroconvulsive therapy for agitated patients, strengthening hospital security by constructing stronger wards with tall walls and fencing, adequate personnel, sophisticated gadgets, and alarms, timely discharge from the hospital, and so on. It also emphasizes the need for in-prison mental health services where forensic patients can be managed safely. [19]
Few of my psychiatry colleagues suggested using metal bracelets (kadas that are religiously acceptable) with details engraved (names, phone numbers, and address of patient and caregiver); bands; and implants, gadgets, watches, and chips with GPS location device and tracke However, these must be used after obtaining written informed consent, and concerns have been raised about the cost, the need for battery charging, the fact that they can be thrown away, the fact that the technology is not yet advanced enough for universal application, and so on. Other concerns raised included ethical and legal issues, stigma, restrictions on civil liberties, invasion of privacy, impairment of capacity, practicality, and so on. Tattoos with the caregiver’s name, phone number, and address appear to be a reasonable option because they cannot be discarded and may have a fashion statement, with the future suggestion being tattoos with radioactive (but safe) traceable ink material that can be tracked (in a conversation with Live CME Psychiatry WhatsApp group members: 2019 Feb., 06). However, based on ethical and legal guidelines, these should be discussed further before being implemented.
DISABILITY BENEFIT FOR PEOPLE WITH MENTAL ILLNESS
In mental illness, disability is defined as a state in which the patient has shown symptomatic recovery with available treatment modalities, but has deficits that cause significant problems with self-care, interpersonal, social, and occupational functioning, and impaired quality of life, and may require aggressive rehabilitation.
[20,21] Balakrishnan et al.[22] conducted a thorough review of the Rights of Persons with Disabilities Act, 2016,[23], focusing on the certification guidelines. They highlight the ambiguity surrounding screening tools, resource allocation, and the need for inclusive education. They advocate for increased focus and reservation for patients with disabilities caused by mental illnesses or specific learning disorders, as well as decentralization of disability certification, such as certification of severe or profound intellectual disability at the primary health center (PHC). This would avoid inconvenience for end users, reduce workload at tertiary level psychiatric centers, be more cost-effective and time-consuming, and lead to increased recruitment of mental health professionals, particularly qualified psychiatrists and clinical psychologists, at PHC. However, such certification should be performed by a medical board that must include a qualified psychiatrist and clinical psychologist, rather than by other professionals such as pediatricians.
“Rights come with responsibilities!” “A person has a mental illness, is aware of it, exercises his right to refuse treatment, commits a crime, attributes the crime to the mental illness, and claims no responsibility for the crime because it was caused by the mental illness.” In the context of disability, an example would be that few patients have intact mental capacity and insight into their mental illness, but they exercise their “right to refuse treatment.” As a result, they refuse to accept responsibility for seeking treatment. However, in order to receive benefits, they must “claim disability” on the basis of mental illness. How can such a person exercise his right to refuse treatment while also claiming “benefits” related to his mental illness?
The poverty of our patients may sometimes override our clinical assessment; however, it is the responsibility of the state to care for its citizens’ financial status. Psychiatrists should only be concerned with mental illness and its consequences. As a result, even a wealthy individual who suffers from a mental illness should be eligible for disability benefits. Disability benefits must be paid regardless of PWMI’s financial situation. There is a limited budget for disability benefits, and improper certification may prevent benefits from being granted to truly deserving PWMI; such individuals should be carefully evaluated. This is especially important in general hospital psychiatry units where nonpsychiatric medical professionals may be unaware of the true concept of disability caused by mental illness and thus may fail to understand why a particular procedure is being followed by the psychiatrists. We must educate them on the legal complexities of dealing with PWMI.
Visit: CONCLUSION
Unless proven otherwise, every PWMI is a potentially medicolegal case. However, we must be cautious rather than fearful when evaluating and treating them, and we must be aware of the legal angle, which ultimately boils down to ethical considerations. It is critical that the fear of being accused of “violation of rights” does not prevent us from providing legally sound ethical psychiatric care in the “best interests” of the PWMI, as opposed to responding to genuine concerns of caregivers, particularly parents who bear the brunt of their patients’ illness.
“All approaches to medical ethics, empirical, legal, sociological, theological, or philosophical, should strive to be practically useful… Good medical ethics must assist in informing and guiding those directly involved in moral issues in medicine and healthcare. This means that good medical ethics is clinically relevant above all.” [24] “There is a need to balance idealism with pragmatism in terms of what is feasible and what should be attempted.” [25] It is critical that medical ethics do not become archaic, impractical laws, but rather scientifically sound, implementable guidelines that take the ethos into account, and that these are updated on a regular basis.
QUESTION
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Visit http://www.aha.org/advocacy-issues/communicatingpts/pt-care-partnership.shtml and review the American Hospital Association’s Patients’ Bill of Rights. Discuss how health care professionals can ensure that patients’ rights are upheld and protected.
Word limit 400-500 words