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CASE STUDY
RESPONSE Competence in mental health
research Bhargavi
Davar
Conducting psychiatric studies from the
perspective of the humanities and the social sciences is a new endeavour in the
Indian context. For this reason the ethical quandaries that may be faced in this
area are seldom discussed. A few medical institutions working in the mental
health sector have some type of mandatory ethical screening. However, such
instances are rare. In the absence of organised ethical forums, or sustained
discussion on ethics, the mental health professions have no platform where such
dilemmas can be tabled. (Among the mental health professions, I include
psychiatry, clinical psychology, psychiatric and medical social work and the
related social sciences.) The present case study (1) is therefore an important
contribution to the ethics of working with persons with psychosocial
disabilities. Such disclosures should encourage the mental health community to
bring the topic of psychiatric ethics into the public domain.
The issue of
confidentiality has been robustly dealt with by the researcher (RA), especially
the negotiations between family / relative / carer and the user of psychiatric
services.
The researcher is also keenly aware of the scope for coercion when
inducting users of psychiatric services into the study. She has employed the
strategy of explicitly stating that being involved in the study is not in any
way linked with receiving continuing care and treatment. Institutional consent
was not taken as individual consent. It is also commendable that the researcher
did not accept proxy consent by a carer. Recently, the NGO SAARTHAK filed an
intervention before the Supreme Court arguing for the omission of Section 8.1 of
the Mental Health Act, 1987, which liberally allows proxy consent in research on
persons with psychosocial disabilities. The intervention argues that no
research should be conducted without user consent.
Research and care
In such
studies, researchers are often confronted with the issue of providing care for
participants. When the researcher and the service provider are from the same
institution, there is a conflict between the researcher's interest in inducting
participants into the study, and the provider's interest in providing care to a
needy person. The issue crops up in different ways for both social science and
biomedical research.
This question did not arise for RA, as service provision
was left to the hospital where she conducted the study. However, there is the
related question, of the research's relevance to the user. The Mental Health Act
mandates that any such research should be of 'direct' benefit to the user. The
act does not define 'direct' benefit, leaving it to interpretation. RA's study
does not address the question of risks and benefits, what the direct benefits
were to the user, and whether they were considered or negotiated.
The case
study does not talk about the time spent with the participant, which can be an
important issue especially when people visit an institution in a state of acute
emotional distress.
Definitions of competence
There
appears to be some vagueness in RA's position on competence. This can be seen as
a general dilemma in the mental health research field. On the one hand, she has
accepted, as fully competent, persons who have refused to participate even
though the family has given consent. On the other hand, she has taken into
account the medical opinion ("joint consultation") of incompetence and has
chosen not to take persons (who may have consented if she had asked).
In
India, professional bodies such as the Indian Psychiatric Society have not
established standards for the medical assessment of incompetence. In the absence
of tools to decide incompetence, a medical finding of mental illness is offered
as a legal finding of incompetence. (For example, a person is held unfit for
trial because he is suffering from schizophrenia.) Legal case work in India
gives much evidence of such examples in the mental health field (2). Also, the
present discussion on the UN Convention on the Rights of Persons with
Disabilities grants full legal capacity to all persons with any type of
disability. In this situation, it is not clear how far a medical opinion of
incompetence can override a user opinion of competency, or a human rights
consideration of full capacity.
References:
1. Addlakha Renu. Ethical
quandaries in anthropological fieldwork in psychiatric settings. IJME 2005; 2:
55-56.
2. Dhanda Amita Legal order / mental disorder: draft of
the working group on the UN Convention on the rights of persons with
disabilities. New Delhi: Sage Publications; 2001
BHARGAVI DAVAR, Center for Advocacy in Mental Health, Research Centre of
Bapu Trust, B1/11, 1/12, Konark Pooram, Kondhwa Khurd, Pune 411 048 INDIA.
e-mail: info@camhindia.org wamhc@vsnl.net
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