ARTICLE
Ethical issues in
psychiatry
N N Wig
Psychiatry has been isolated from the mainstream of
medicine; this has been bad for the profession and worse for the mentally ill.
This article discusses some important ethical problems in the practice of
psychiatry in India.
Common ethical issues in medicine and
psychiatry
Medicine is both a science and the art of healing. The
dynamics of this combination is best reflected in psychiatry, the branch of
medicine which specialises in the diagnosis and care of those who are suffering
from mental disorders. The past five decades have seen the establishment of
general hospital psychiatric units and the rise of private sector in psychiatry,
bringing psychiatry closer to general medicine but as a result, psychiatry is
now facing many ethical issues common to several other medical specialties.
These include-but are not limited to-commercialisation, an exaggerated emphasis
on laboratory investigations and technical procedures, increasing use of
self-advertisement, 'cut backs' for investigations or services, and an unhealthy
relationship with pharmaceutical firms. The Indian Association of Private
Psychiatry (IAPP) has discussed guidelines on the subject (1).
Some ethical issues peculiar to
psychiatry
The practice of psychiatry is different from other
medical specialties in two significant respects. First, one deals with certain
groups of patients whose judgement may be impaired at times due to their mental
illness or who are unable to look after themselves. Such patients, at times, may
also become a danger to either themselves or others but may still refuse any
medical help. In such situations, therapeutic intervention or even detention in
a psychiatric facility against the patient's wishes may become necessary. This
raises various ethical and human rights issues that have been debated
extensively without arriving at a consensus.
Second, in no other medical specialty do patients
share with their doctor so many intimate details about their personal,
emotional, social or even sexual life. As a result, a special kind of
relationship, both positive and negative, develops between the patient and
psychiatrist. This particularly happens during prolonged treatment. This raises
many ethical issues depending on how the psychiatrist handles it.
National and international ethical
guidelines
The World Psychiatric Association (WPA) prepared the
Declaration of Hawaii in 1977 after extensive discussion. This was updated in
Vienna in 1983. The revision in 1996 was called the Madrid Declaration (2).
There is also a Standing Committee for ethical issues. The UN General Assembly
in 1991 specially considered the question of 'Principles for the protection of
persons with mental illness and for the improvement of mental health' (3). In
India, the National Human Rights Commission's publication, Quality assurance in
mental health, provides guidelines for the care of mentally ill in psychiatric
institutions (4).
The essence of all these recommendations is that
psychiatric patients should be treated with dignity and respect. As far as
possible, their consent must be taken for any treatment or hospital admission.
If such patients are not in a position to give their consent, close family
members should be consulted, but the interest of the patient must remain
paramount. Physical restraints, if required, must be minimum and for a temporary
period under close medical supervision. The use of chains or other degrading
devices to restrict the patient should have no place in modern psychiatry. The
patient should be kept as involuntary admission in a psychiatric hospital for
the minimum period necessary. There must be adequate provisions for the right to
appeal against forcible detention. Many of these recommendations are included in
the Mental Health Act of 1987.
Research on patients with mental
disorders
In general, it is agreed that for any medical research on
human beings, informed consent of the individual must be an essential part of
the research protocol. The difficulty in seriously mentally ill patients is that
due to their illness, many of them have their judgement substantially impaired.
They may not be in a position to judge the risks involved in various medical
research procedures. In India, where a large number of patients are poorly
educated, giving consent by signing some research protocol seems to be an
inadequate safeguard. The patients and their families inherently trust their
doctors and hence a big ethical responsibility falls on the treating doctor. A
complete ban on all research on the mentally ill may be going to one extreme.
Two safeguards are suggested. First, such research should be strictly limited to
what is in the larger interest of the mentally ill. Second, there must be
independent monitoring to ensure that ethical guidelines are followed. The
Indian Council of Medical Research must periodically review the ethical
implications of research on those who are seriously mentally ill.
The question of electroconvulsive therapy
(ECT)
The use of unmodified ECT is another subject of intense debate
in India. Some time ago, there was a lively exchange on the subject (5-8). One
section seems to favour unmodified ECT in certain circumstances, while the other
holds that unmodified ECT, without anaesthesia, has no place in modern
psychiatry. I find myself close to the latter position for the following
reasons:
With the availability of modern antipsychotic and
antidepressant drugs, the role of ECT has been greatly reduced. I know many
successful colleagues who have rarely used ECT in the past five years or so in
their private practice.
Second, there will be a few people in psychiatric
hospitals or general hospital psychiatric units who will require ECT, and it may
even be life saving in some situations. It must be ensured that ECT is provided
with anaesthesia and muscle relaxants. There should be no compromise on this
issue. If direct ECT is easily available it may be overused and misused, as
happens in many mental hospitals located remote areas.
'The convulsion looks frightening to the viewer;
this perpetuates the myth that ECT is a barbaric treatment.' (5) This statement
gives the impression that the feelings of viewers-family members, health care
staff-are not important in this matter since the patient does not remember the
fit. I do not agree. In our society, people already have strong prejudices
against psychiatric patients. Any treatment which appears to be 'barbaric' or
'frightening' to the general public will further reduce the acceptance of
psychiatry in the mainstream of medicine. For this reason alone, unmodified ECT
should be stopped.
Crossing clinical
boundaries
This subject has been extensively debated in the medical
literature in the US and Europe where there are many more psychiatrists and
psychotherapy is quite common. The psychiatrist-patient relationship can
continue for a long time and strong positive (and sometimes negative) feelings
can develop for the therapist and vice versa. It is a part of the psychiatrist's
training to handle such situations carefully. The guiding principle is always
the interest of the patient who has come for help. The WPA's Madrid Declaration
states: 'Under no circumstances should a psychiatrist get involved with a
patient in any form of sexual behaviour, irrespective of whether this behaviour
is initiated by the patient or the therapist.' (2)
'The real issues in mental
health'
I have borrowed this sub-heading from Dr Pathare's article
(6). I fully share his views in this matter. For me, the most important national
ethical issue is how to ensure that the benefit of modern psychiatry is
available to all sections of our population. Unfortunately, it is not happening
at present. Poor patients from rural or slum areas, especially women, get little
benefit from modern psychiatry. The book Out of mind, out of sight beautifully
describes the plight of homeless women with mental illness in India (8). We must
remember the distressing sight of the wandering 'lunatic' or mentally ill with
torn clothes, with nothing to eat, ridiculed by passers-by. We must ensure that
such degrading sights to human dignity disappear from India and essential
psychiatric services are available to such unfortunate patients. The best
methods, as mentioned by Dr Pathare and by many others and also recommended in
WHO's World mental health report 2001, are to provide services through primary
health care in the community, increase the number of mental health
professionals, supply essential drugs and most importantly, educate the public
to reduce the stigma and discrimination due to mental illness so that patients
and their families do not hide the mental illness but avail psychiatric services
on time (9).
References
1. Kala AK.
Presidential Address. Indian Association of Private Psychiatry, 2nd Annual
Conference, Jodhpur, November 2001.
2. World Psychiatric Association.
http://wpanet.org/home.html
3. United Nations. The protection of persons with mental illness and
the improvement of mental health care. U.N. General Assembly Resolution (1991)
A/Res/46.119.
4. National Human Rights Commission of India. Quality
assurance in mental health. New Delhi: National Human Rights Commission of
India, 1999.
5. Andrade C. Unmodified ECT: ethical issues. Issues in
Medical Ethics 2003;11:9-10.
6. Pathare S. Beyond ECT: priorities in
mental health care in India. Issues in Medical Ethics
2003;11:11-12.
7. Mirsky J. China's Psychiatric Terror. New York Review
of Books. February 27, 2003.
8. Kendra. Out of mind, out of sight.
Chennai: Banyan, 2002.
9. World Health Organization. The world health
report 2001. Mental health, new understanding, new hope. Geneva: WHO,
2001.
N N Wig, Emeritus Professor of Psychiatry,
Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Correspondence: 279, Sector 6, Panchkula 134109, India. e-mail:nnwig@glide.net.in
