On the need to have "rules" to regulate covert medication.

Exhorting psychiatrists to use covert medication is not right. Unlike in pediatrics and geriatrics, a small section of schizophrenics and mood disorder patients with full awareness of their legal rights, vehemently refuse medications. In such cases "rules" are required to regulate covert medication, forced medication etc. Only that way both patients' right for autonomy and the professionals duty to administer treatment could be simultaneously taken care of. Section 19 of the Mental Health Act 1987 provides the required legal provision for this. Civil society expects psychiatrists too to function within the boundaries set by a legal framework.

Kala 2012[1] exhorts psychiatrists to take “covert medication” out of the closet and discuss it openly in academic sessions. This indeed is a welcome idea. But his suggestion to “use it rationally, without being apologetic,” has the danger that the entire profession may take it, as a “scientific sanction” to use it without any qualms. Also, those who are already over-using it, quite indiscriminately would feel quite justified in their actions.

Covert medication in Pediatrics and Geriatrics practice need not be viewed as a complex “legal” issue, as it is “allowable,” by “common law.” Many standard guidelines, like the one by the Royal College of Psychiatrists, 2004,[2] are available, which could be useful for caregivers. So long as “mala fides” is not there, while looking after helpless wards, everything is legally and ethically fine.

But the issue is different in the case of a small section of patients with schizophrenia and mood disorder. These are people who vehemently refuse medications and are also very conscious of their “legal right” to do so. Kala, 2012,[1] has cited “thought provoking real life accounts” by psychiatrists, belonging to the “e-IPS group,” about patients in their practice, who strongly objected to treatment. The “moral” of most stories is that but for the timely “covert medication” by a benevolent psychiatrist, all those patients would have ended-up in total disaster!

Latha 2010[3] in her comprehensive review has presented views of many authors, some justifying covert medication and some others, strongly criticizing it. Many, who view matters from a purely clinical angle, put forward a variety of reasons to justify the use of “coercion” and covert medication. According to Singh 2008,[4] “we must of course do no harm, but we must also dare to care”! There are many more opinions aired, such as covert medication would avoid the need for using physical restraints, forcible injection, and certification!

Indeed, without timely treatment, psychotics would deteriorate, causing irreparable harm to themselves and to those around them. This is the stark reality, which prompts many well-meaning psychiatrists to go out of their way, to “help” their patients by resorting to even “covert medication”!

For a professional, who is sensitive about patients’ self-respect, along with their personal autonomy, “covert medication” is a less acceptable option, than going for “forced medication.” In psychiatric practice, when persuasions fail, a doctor may sometimes have to use force to give medicines. He may also have to temporarily use physical restraints. In some extreme situations, like when a patient takes a dangerous stance, with a weapon in hand, “covert” or “concealed” medication may be the only available “last resort”!

But even such “going-for” covert medication, to tide over an extra-ordinary life-threatening situation, is something to be done just for that one occasion. The patient's family members should not get a chance to use it further, as a kind of routine practice, on a plea that the doctor has prescribed or used it. Only a very responsible family member must be involved in the “operation covert medication,” so that future misuse is effectively prevented.

These are all things to be done with a lot of sensitivity, where firmness has to be combined with enough kindness and concern for patients’ autonomy. Family members of patients should be told clearly, about the great harm, any kind of deception could do to inter-personal relationships, within their family. “Be honest and straight with your wards, rather than cheat them on a regular basis.” Also, everything done to tide over an emergency situation must be recorded properly in case records. If such basics are taken care of psychiatrists need not have to be bothered about their professional actions being scrutinized by someone, on a future occasion.

When viewed strictly from the legal perspective, covert medication constitutes grounds for claims of “criminal battery.” The psychiatrist and the hospital may be exposed to liability, based on a claim of civil trespass, especially if there is an adverse outcome. Shah and Basu 2010[5] have stated that controversies on “coercion in psychiatric care,” mainly center on issues of “justification” and “human rights.” “Justification” for a psychiatrist to administer treatment, based on his clinical judgment and “human rights” of a patient, to decide by himself what is good for him.

Everyone, including doctors is required to respect the personal autonomy of others, even if they are “patients.” Now the question, which needs to be dispassionately addressed is whether psychiatrists have a “professional right” to intervene in a “paternalistic” manner and treat patients, against their explicitly expressed un-willingness for it? Am I acting in a manner which is legally and ethically tenable?

Or is my action similar to that of every “do-gooder,” who acts high-handedly and then justifies it, by a time-old worn-out doctrine, that ‘the end would justify the means’? “Unless I acted in the manner in which I did, that person [sometimes a whole group of people, or even a nation!] would have perished”: this is the familiar tone of too many autocrats, in the history of mankind!

Kala 2012[1] quotes section 89 of the Indian Penal Code, to “accord” legal sanction for ‘things done in good faith’ for a “person of unsound mind,” provided that it is with the consent of the guardian. But the question is, who decides on “unsoundness of mind” and in what manner? And who is the true “guardian” of a “patient,” in a given situation? Again, who decides these things?.

A point worth recalling here is a famous dictum, which is meticulously followed in the “criminal Justice system” of all civilized countries, including India: “the innocence of an accused person is to be presumed, till the contrary is established by a due process of Law.” In the same way, in a situation where a person's “mental soundness” is crucial to decide a legal issue, the established principle in Law is, “mental soundness” of a person is to be presumed, till the contrary is established by a due process of Law.

So if a psychiatrist is to conclude that a person is “mentally un-sound,” as required to meet the criteria laid down in section 89 of the Indian Penal Code, such a “decision-making” has to go through a “due process.” Ordinarily, such a “due process” in Law requires that facts are brought out in an open court, in an “adversarial” manner and a judicial officer passes a “judgment.” This system is certainly an open and transparent one, but is widely criticized for being very cumbersome and time consuming.

Khurshid, 2006,[6] in his “Tale of two Cities” expresses discomfort in not being able to resort to covert medication, in Springfield, United States, as he used to do in New Delhi. The message he gives, in a not so subtle manner, is that by following the Rules that place “high value” on the “autonomy” of patients, the management of psychotic patients is being messed-up in the United States!

But while being critical of the “process of Law,” which determines “unsoundness of mind,” for being cumbersome, psychiatrists should not demand that the “due process” requirement should be altogether done-away-with. What we ought to strive for is to make provisions in the Law simpler. Only when decisions are reached, adhering to a “due process,” they would be acceptable, from a legal stand.

It is in this context, making a visit to our much maligned Mental Health Act 1987[7] would be worthwhile. In this Act, we have section 19, which lays down the procedure to admit mentally ill persons, under certain special circumstances. The great attraction of this provision is that, while tackling emergency situations, one could go through a “due process,” without the involvement of courts of Law and judicial officers.

As per section 19, compulsory admission of an un-willing patient could be effected on the strength of an application by a relative or friend, two medical certificates, and some brief paper work by the medical officer in charge of a psychiatric facility! Here we have a “due process,” to admit unwilling patients as per Law, without any hassles, which is something Dr. Khurshid could not get done, in the United States!

And when the Law enables a person to get admitted in this manner, to a psychiatric facility, it is only logical to expect that the same Law would make sure that he would receive treatment. This aspect has to be taken care of by State Governments, by having appropriate provisions, while they frame “Mental Health Rules,” as required by the Act.

Actually, all of those occasional “strong” and often “un- pleasant” actions, which a psychiatrist has to perform in his day-to-day practice, like forced injections, application of physical restraints on patients and even the rare action of giving “covert” medication, could be “regularized,” by including suitable provisions in Rules, to meet such contingencies also. There should not be any situation, where psychiatrists are forced to act “illegally,” to render proper treatment to their patients.

There is another useful provision in the Mental Health Act, namely Section 23, which requires police officers to act in a helpful manner, to ensure protection of mentally ill persons. This section also could be given more teeth, by including suitable provisions, while framing Rules. Things could be made more explicit, so that police officers would be required to act positively, in “prescribed” ways, to meet “real-life” situations.

Kala 2012[1] has expressed a view that professionals in India have their limitations, in coping up with patients, who are non-cooperative and resist treatment, as we have no “community mental health teams” like they have in the “developed West.” To my mind, this is an opinion, which is given without adequately taking into consideration, sections 19 and 23 of the Mental Health Act 1987 and the scope for state governments to frame rules based on those provisions.

The ground reality in India is that, large sections in the profession take a view that “we are the experts in this field; leave it to us to decide who all require forced admission and covert medication. Laws, Rules and Regulations need not be there to control us”! Here, let us keep in mind that the rest of civil society would want psychiatrists too, to function within the boundaries set by the legal frame-work, like everyone else in the country.

It is also important for the profession to keep in mind that in the present situation, where covert medication is being given to, too many patients could be drastically reduced, if psychiatrists do their duty of educating victims of functional psychosis and their families properly. This is something to be done on a regular basis as a patient has to overcome too many challenges, to go on with life, taking medicines, but keeping his self-respect and autonomy intact. The fact that Sreenivasan and Thara 2002[8] were able to report on as many as 67 Schizophrenia patients on covert medication, with the blessings of “treating” psychiatrists, should be an eye-opener to the entire profession in India!

Rao et al., 2011[9] have said that “standard operating procedures for clinical practice” is an idea, whose time has arrived. Their plea is to introduce it into routine clinical practice, not just for special situations. And for sure, the time is NOW for mental health professionals, to introduce “standard operating procedures,” in the management of non-cooperative, violent psychotics.