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, 6, 7, 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).