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.