Some clinicians essentially view civic engagement as a caring system that makes treatment possible. They disagree with the assumption that people with mental illness are able to exercise their agency and make decisions in their own best interests, such as taking medication or staying out of a hospital. They believe that some people with mental illness may not be physically dangerous, but may still jeopardize their own prospects for normal life. “All approaches to medical ethics, whether empirical, legal, sociological, theological or philosophical, should aim to be useful in practice. Good medical ethics should help inform and guide those directly involved in moral issues in medicine and health care. This means that, above all, good medical ethics are clinically relevant. [24] “You have to reconcile idealism and pragmatism, how much is feasible and how much you have to try. [25] It is important that medical ethics not become archaic and impracticable laws; But science-based, achievable, ethical-minded guidelines should be updated regularly. Think of an ethical problem you encountered while caring for a psychiatric patient and a family. Use the ethical decision model to decide on the best course of action. A patient admitted against his will lost the right to leave the hospital at his own request.
If an inpatient leaves before discharge, the staff are required by law to inform the police and the competent courts. Often these patients go home or visit family or friends and can be easily found. The judicial authorities then refer the patient to the hospital. Further action is not required as the original commitment is still in effect. Disability in mental illness is a condition in which the patient has shown symptomatic recovery with available treatment modalities, but has deficits that result in significant problems with personal care, interpersonal, social, and professional functions, and impaired quality of life that may require aggressive rehabilitation. [20,21] Balakrishnan et al.[22] scientifically examined various aspects of the Persons with Disabilities Rights Act, 2016,[23] particularly with respect to certification guidelines. They highlight the lack of clarity around screening tools, resource allocation and the need for inclusive education. They recommend increased concentration and restraint for patients with disabilities due to specific mental illness and learning disabilities; and decentralization of disability certification, such as certification of severe or profound intellectual disability in the primary health centre (PHC) itself. This would avoid inconvenience to end-users, reduce the workload in tertiary psychiatric centres, be cost-effective and time-consuming, and lead to increased recruitment of mental health professionals, in particular qualified psychiatrists and clinical psychologists at the PHC itself. However, this certification should be carried out by a medical committee, which necessarily consists of a qualified psychiatrist and a clinical psychologist, and not by other professionals such as paediatricians. Any PWMI is a potentially medical case, unless proven otherwise.
However, we should not be anxious in our assessment and treatment, but cautious, and be aware of the legal angle that ultimately comes down to the ethical aspects. It is of utmost importance that the fear of being accused of “violating rights” does not prevent us from providing legally sound ethical psychiatric care in the “best interest” of PWMI to address the real concerns of caregivers, especially parents, who bear the burden of patients` illness. In their article on MHCA 2017, the authors[4] critically assess the advantages and disadvantages of the new ACT. They praise the law to support PWMI`s rights (especially insurance) and recommend decriminalizing suicide and the lesbian, gay, bisexual, transgender, questioning/queer (LGBTQ) community. They also mention the non-representation of the Indian Psychiatric Society and the inadequate treatment of the caregiving burden suffered by caregivers. PWMI caregivers are true ambassadors for mental health; They sincerely understand the true service that psychiatrists have rendered in this country for many decades. There is no doubt that PWMI`s human rights must be protected at all times; However, it cannot be one-sided. There is an equal and strong need to involve caregivers in the design of mental health policies that are ethical and legal, while being adapted to their needs and the realities of this developing country, such as poverty, illiteracy, ignorance of mental illness, stigma, discrimination, etc. Given the new challenges posed by MHCA 2017, such as mental health assessment, living will, designated representative, etc., the authors stress the need to actively engage with “the media, police, NGOs, human rights activists. and the police. [4] In their article “Psychiatrists on Trial: Indian Scenario”[9], the authors discuss the legal aspects of psychiatric care when psychiatrists are called in as experts.
They believe that “psychiatric residents often do not come into direct contact with the judicial process.” There may be three reasons for this. First, many residents are trained in psychiatric units in general hospitals (especially private colleges) that are not directly affiliated with forensic psychiatric units. They have a peripheral assignment of only about 2 to 4 weeks at such centers. Second, the residents, who are doctors in training, work under the supervision of the faculty; Therefore, the honourable courts do not consider them conclusive. Third, faculty members should not involve them in the legal aspects of patient care, believing that this is not their responsibility. At my workplace, a public tertiary hospital, psychiatric residents are regularly involved in the legal aspects of patient care. Faculty must ensure that residents are actively involved in the legal aspect of patient care, such as medical committees, discharge committee meetings, certification, etc. Only if they are exposed at this stage of their career, once they have left their place of residence, will they be able to deal with such problems independently. Many of the moral and ethical dilemmas faced by caregivers stem from the conflicting principles of autonomy and charity. However, the nurse`s ability to critically assess risks and benefits helps her make decisions that benefit the affected patient.
To foster Anita`s autonomy, nurses must take risks that may go against their principles of non-malevolence and charity. However, using collaborative work practices, this case study showed that solutions can be found even in the most complex care dilemmas. The growing knowledge of the genetic basis of psychiatric disorders will raise even more ethical questions. Current evidence suggests that the etiology of most psychiatric disorders is the result of a combination of genes and environmental factors. “With rights comes responsibility!” “A person has a mental illness, is aware of it, is exercising their right not to seek treatment, commits a crime, attributes the crime to a mental illness, and does not take responsibility for the crime because it is due to mental illness.” An example in relation to disability would be that only a few patients with intact mental capacity have an idea of their mental illness, but exercise their “right to refuse treatment”. Therefore, they do not want to take responsibility for the treatment. However, in order to receive benefits, they “declare a disability” due to mental illness. How can such a person exercise their right to object to treatment? But at the same time claiming “benefits” related to his mental illness? As genetic testing becomes more readily available, the pressure on prenatal testing, screening of children and adults, selection of potential adoptees, and premarital screening will increase.
Ethical issues here relate to knowledge of genetics, the impact of this information on self-sense, limits on personal choice, and the potentially discriminatory use of genetic information to deny people access to insurance and employment (Cheung, 2009; Appelbaum, 2010). The legal and ethical context of care is important to all psychiatric nurses because it focuses on patients` rights and the quality of care they receive. However, laws vary from state to state, and psychiatric nurses should familiarize themselves with the laws of the state in which they practice. This knowledge improves caregiver and patient freedom, informs ethical decision-making, and ultimately leads to better care. Psychiatric nurses can face complex ethical situations when caring for patients and families with mental illness. As professionals, they are held to the highest standards of ethical responsibility in their clinical practice (Murray, 2007). A number of essential ethical competencies are listed in Box 8-1. These enable the nurse to provide socially responsible and personally responsible care. Beauchamp and Childress (2009) developed four basic moral principles that serve as guidelines for professional ethical decisions.