Psychology
Dr. Maha Younis
Lecture 15: Legal issues in psychiatryLegal issues in psychiatry:
The word ethics has been derived from the greek word ethikos, meaning “rules of conduct that govern natural disposition in human beings”.In simpler terms ETHICS means principles of right conduct.
To formulate guidelines in dealing with patients, their relatives and third parties in areas of:
Psychiatric diagnosis
Informed consent
Voluntary and involuntary treatment and hospitalization
Confidentiality
Respect for the patient and his human rights
Third party responsibilities
Psychiatric research.
However, one should not equate a psychiatric diagnosis with legal insanity or it should not be used to as a defence for reduced responsibility.
Because a large number of psychiatric diagnoses do not fulfil the legal condition required for insanity.
Only for clinical purposes, as it provides a reasonable guideline regarding etiology, management and prognosis.
Informed consent:
Till recently, after seeking consultation, psychiatrists generally decide treatment which they felt the best in the interest of the patient. This method in medical practice is known as medical paternalism
Most psychiatric patients do not have insight hence, not able to give consent for their treatment.
Even if they give consent it might be for the wrong reasons e.g. a manic patient may challenge the doctor to give all drugs he has. Such consent has no meaning.
Before giving consent, patient should fully comprehend the information provided and should be able to decide on the course of treatment in an understanding manner.
Information to be provided by the treating physician.
Competence of the patient to comprehend information provided.
Freedom of choice
Patient’s human rights
Human rights of a patient should be more reasonably protected and the patient should be informed about the nature of the illness and treatments available, so that he/she could partake in the decision making process.Consumer protection involvement compels the medical profession to provide detailed information for their own safeguard.
Information to be provided for informed consent
Nature of the disorder
Prognosis of the disorder without treatment and with each of alternative treatment methods.
Treatment options available.
Reasons for specific treatment being offered and drawbacks of the same.
A specific statement that the consent could be withdrawn whenever the patient wishes so.
Temporary hospitalization to regain sanity is a much preferable alternative to staying chronically sick.
Peele, Chodoff and Taubstate that “it is a perversion and travesty to deprive these needy and suffering people of treatment in order to preserve a liberty which is in actuality so destructive as to constitute another form of imprisonment”.
Patient can be treated in an emergency even without the consent
The treatment of a stuporose or acutely excited patient should not be deferred on account of non-availability of the consent.
Minors (below the age of 18 years) are not considered to be legally competent to give consent .
Any psychiatric patient can be taken to a court of law where the evidence of his being mentally sick can be produced, and order for admission can be obtained.
1% of population suffers from serious psychiatric illnesses and needs hospitalization.
Mean that 8 million persons in India need to be screened by the overburdened judiciary.
Confidentiality
Anything learned during the professional relationship should not be revealed to others without the consent of the patient.
Records of the patient should be strictly safeguarded, so that no unauthorized person can have access.
Unauthorized persons include any person other than the treating team and the family member whose consent patient has been admitted.
However after having achieved recovery, if the patient advises the therapeutic team that even the admitting family member/relative should not have access to the patient’s records , his wishes should be respected.
The employers, insurance companies, and other interested parties should be provided information after obtaining consent from the patient.
The confidentiality clause will require more careful monitoring as the new mental health act has come into operation.
The records of the patient may be inspected by the “inspectors” at any time. Some of these “inspectors” may not be professionally trained. Therefore, one must only record all the observations which seem to be relevant to diagnosis and treatment.
Several practical problems
Informing a patient of schizophrenia the exact prognosis of the illness at the initial stage may give rise to severe depression and may sometimes lead to adverse consequences.
Information or treatment options, like drugs and ECT, may not be fully understood by the patient and make decisions on the basis of certain prevailing biases and prejudices against each of these treatment methods.
Competence of patient
Competence in this context refers to the patient’s ability to understand the nature and severity of his presenting problems, and need of suggested therapeutic help and its limitations.
Whether a psychiatrically ill person is likely to possess such an ability has been debated for a long time by several researchers.
How to assess competence
By asking a few questions on the information made available to himWhether patient is able to objectively understand that he is ill and requires treatment?
Can he understand the nature of each treatment option and its consequences?
Involuntary vs. Voluntary treatment
As psychiatric patients do not consider themselves to be ill, they have to be hospitalized or treated against their will.
Patients admitted as “voluntary” or “informal” patients, by obtaining signatures on consents form without obtaining their real consent.
