Ethics and Law

BACKGROUND

The fundamental concept and understanding of ethics started to be evolving for the last half a century when American Psychiatric Association (APA) developed a code of ethics in 1970. The World Psychiatric Association (WPA) developed it in 1977 and the Indian Psychiatric Society (IPS) adopted it at the Annual National Conference of IPS (ANCIPS), Cuttack in 1989.[1,2]

The committee members which comprises Prof. J. S. Neki, Prof. D. N. Nandi, Prof. A. K. Agarwal, Dr. V. N. Vahia and Dr. J. K. Trivedi and others formulated the code of ethics in ANCIPS Cuttack 1989. This guideline covered the various aspects of duties and responsibilities of a psychiatrist as a practitioner, scientist as well as dealt with their social responsibilities. The professional competence of being a life-time learner even has been echoed in the recently formulated Competency-Based Medical Education issued by Medical Council of India, now National Medical Commission. The benevolence of the patients and their welfare, maintaining highest moral standards and safeguarding the interests of the patient had been given top priorities. The initial draft formulated by the pioneers of IPS.[3] The details of the draft are summarized in Table 1.

Table 1.

Ancillary rules of consent formulated by expert group of Indian Psychiatric Society

1. The consent is required for every medical examination

2. Before any invasive procedure consent will be required which ranges from surgery to blood transfusion

3. The consent should be, free, direct, clear, unambiguous and voluntary without any undue influences

4. An adult person can’t be detained in hospital forcibly. The secret informations of the patient can’t be divulged by all means to others

5. Even in criminal cases the accused or victim can’t be examined forcefully without the consent except in emergency situation in presence of police officer not below the rank of sub inspector

6. Female victims should be examined by only lady RMP (Registered Medical practitioner) (Sec 53, CrPC, 1973.)

7. The blood, urine and breath samples shouldn’t be collected without consent

8. The mentally ill patient can be treated against his/her will whereas the same is not valid for non mentally ill person who has the right to refuse the treatment

9. A prisoner can’t be treated forcibly, consent for criminal abortions are invalid

10. A person above 18 years can give valid consent to i) suffer any harm as a result not intended to cause death or grievous hurt, (ii) act done in good faith & for its benefit. A child less than 12 years age and an insane or intoxicated person can’t give valid consent (Sec. 90, I.P.C.)

11. The consent by no way is a defense in professional negligence

12. The selfish motives for financial gain, research, publication, own interest from the part of therapist must be abandoned

The purpose of updating the guidelines has become an eventuality to establish high-quality ethical standards of current practices in changing era. The therapists should have the required skills, knowledge, training, and supervised experiences as well as they should be aware of the emotional state of the patients. They should also take opinion from their professional colleagues, other experts, and specialists whenever necessary.

Ethics and law are the different forms of rules by which humans are expected to behave themselves in the society. Ethics represents internal system of controls, and Law refers to an external mechanism of control. Both these controls ar essential for optimal behavior, which includes seeking and dispensing treatment.

Salient points

The fraud and abuse of psychiatry (such as upgrading, Ganging, Touting, Self advertisement, unavailability, publishing research or report to press, unethical drug trials, teaching unprepared topics, not upgrading self through CMEs, selling of sample medicines, prescribing unscientific drug formulations, practicing quackery, dichotomy or fee-splitting, offering or receiving kickbacks, steering the patient to a particular pharmacy, non-capping, out of proportion, and illegitimate claim for professional services) must be dealt on a serious note to maintain highest possible ethical and professional standards.

Ethics is the term used interchangeably with science of morality which represents a body of knowledge that contains principles or standards for value-based human behavior whereas law refers to a system of rules which are enforced through social institutions or the state. Empathetic mode has been the universal method of deciding ethical questions. It is done by placing oneself in the place of the other person and then deciding whether he would like it or not.[4] The guiding principles of Ethics are all that is “good” or “right” have varied with respect to the time, place and the context whereas Laws of the land are made more on the reality considerations based on what is required, aspired for and is practically possible. The term “Ethics” was derived from the Greek word ethikos, which means “rules of conduct that govern natural disposition in human beings.” To put simply, ETHICS means principles of right conduct. In oxford dictionary, it has been defined as “moral principles that govern a person’s behavior or an activity. The ethics is inclusive of active participation in amoral community which deals with problem solving activity is an educational process. However, it does not include personal reliance, expert authorities, interminable disputes, or the dilemma.[5,6]

Philosophical foundations of the ethical principles

Utilitarianism (consequentialism) which states “the ends justify the means.” That is, whatever be the method used, if the final outcome of any act turns out to be “good,” then the act is considered justifiable.

Deontologism (rule-based ethics), which states that every act has to be done according to particular rules or laws. Irrespective of the outcome, these rules have to be followed, and violation is not acceptable at any time. Both these apparently contrasting viewpoints on ethics have their individual pros and cons but can be taken together. It is the “Rule-based utilitarianism” which forms the pillar of modern medical ethics. Besides utilitarianism and deontologism, virtue-based ethics is having a resurgence in medical ethics. It posits that to safeguard against ethical problems, certain attributes or “virtues” are essential for health care professionals which are related to their field.[3]

Salient points

There are certain ethical theories, for example, (i) Deontology-which is the basis of all actions. (ii) Teleology-actions can be judged on the consequences. (iii) Utilitarianism-“general welfare” instead of “individual welfare.”

TIMELINE

The earliest code of ethics could be found in Charaka Samhita. In 5^th century BC, the Code of Medical Ethics was postulated by Hippocrates. Down the lane, it was the mistreatment of human subjects in Nazi experiments led to the development of Nuremberg code (1949) which includes voluntary consent, withdrawals of human subjects from the study, and balance between benefits and risks. In the declaration of Helsinki (1964), it was unanimously decided for the first time that greater care is needed to protect the individual Human rights and was set a standard in Medical Research Ethics. The Tuskegee syphilis study (1932-1972) withholding treatment of syphilis to negro males, Willowbrook hepatitis study (1956-70) by allowing hepatitis and depriving intellectually disabled children the protective gamma globulin and Jewish Chronic Disease Hospital (JCDH) study in Brooklyn (1963) where cancer cells injected to noncancerous patients without their consent are some of the dark zones of unethical research in previous century. This was followed by 18^th Declaration of Helsinki (1964) which has been modified for five times and ultimately incorporated in 58^th WMA (World Medical Assembly) in 2000. The ancient code of ethics and its trajectory is summarized in Table 2.

Table 2.

Chronological development of different codes of ethics

a. Code of Hammurabi (2000 B.C.)

b. Sun Simiao code, King of Chinese Medicine (682)

c. Medical Ethics or a code of Institutes adapted from the professional conduct of physicians and surgeons (Thomas Percival 1740-1804)

d. International Code of Medical Ethics (Geneva Declaration of the WMA 1948)

e. Declaration of Sydney (1968)

f. Declaration of Oslo (1970)

g. Declaration of Medical Ethics (by AMA, 1973) especially applicable to Psychiatry

h. WPA code of Ethics (1977)

J. Declaration of Madrid by WPA in 1996

WPA – World Psychiatric Association; AMA – American Medical Association

Code of ethics in Psychiatry was introduced by the APA in 1973. WPA introduced a code of ethics in 1977. In 1979, Tom Beauchamp and James Childress issued the first Edition of “Principles of Biomedical Ethics.” Declaration of Madrid was done by WPA in 1996. Later, a committee was allotted by the IPS to prepare the code of ethics for the Indian Psychiatrists. It was approved in ANCIPS, Cuttack in 1989. Further, Medical council of India has published its ethical rules in 2002.[5]

Recommendations

The ethical principles guiding research are (i) respect for human dignity, (ii) respect for free and informed consent, (iii) respect for vulnerable persons, (iv) respect for confidentiality and privacy, (v) respect for justice, (vi) judging for potential harms and benefits, (vii) minimizing harm, (viii) maximizing benefits.

There are lacunae of resident training decades back in ethics, research, and law in tertiary medical colleges (both in Government and private institutions), especially while working in General Hospital Psychiatry Units. The most of the residents do not have any first-hand knowledge of appearing in the court of law, and forensic psychiatry training should be prioritized in PG training. It is recommended that residents should be involved to attend medical boards, discharge committee meetings, certification procedures.[5]

There are other unethical practices mentioned anecdotally, which are summarized in Table 3.

Table 3.

Common examples of unethical practices

Providing less time in OPDs and IPDs of government Hospital and more time in private clinic	In hospital not discharging duties in optimum manner	Intentionally treating patients potentially having frequent relapses and recurrences
Abusing, coercing, threatening, blackmailing patients with respect to the privacy	Providing wrong evidence in court	Issuing false certificates for sick benefit, pension, attendance in court, insurance, and passport
Criticizing the prescriptions of other or same subject specialists	Proper and timely referral not being done	Withholding information of notifiable diseases
Opening medicine shop for sale and gaining profit	Refusal to consult patient on religious ground	Consultation of patients in drunked state where judgement is poor

OPDs – Out patient departments; IPDs – In patient departments

In view of the development of Bioethics jurisprudence of India, it can be stated that bioethics has now emerged as professional discourse nowadays, and with changing milieu and domains of research these significant points have been added on.

Ethics and morals are everybody’s concern. Human rights are said to be universal, inviolable, and indivisible. It is a matter of perception, interpretation, and experience. This makes bioethics a fertile area for inquiry, comparison, conceptualization, and application. Lawyers know little of science and technology, particularly the frontier science of biomedical research. However, law cannot be totally avoided so long as technology can be abused and exploitation can happen in the name of experimentation.[7,8]

Medical ethics are defined as moral principles which guide the members of medical profession in their dealing with each other, their patients and state. These ethical codes guide each others to regulate their relationships. The medical etiquette is self-induced duties upon each other.[9]

Four widely accepted principles of health care ethics, extracted from Beauchamp and Childress publications.[10] This is summarized in Table 4.

Table 4.

Principles of medical ethics

Benefiance - Do good. A psychiatrist should act in the best interest of the patient	Nonmalfeasance=Do not harm. A psychiatrist should not prescribe a drug or any form of treatment that will harm the patient
Autonomy=Freedom, here the patients can take an independent decision.	Justice=Equity and fairness

1. Principle of respect for autonomy

2. Principle of nonmaleficence

3. Principle of beneficence

4. Principle of justice.

CODE OF ETHICS FOR PSYCHIATRISTS IN INDIA (INDIAN PSYCHIATRIC SOCIETY 1989)

IPS, the largest professional body of psychiatrists in India with current membership strength more than 7000, formulated code of ethics in 1989 which is guided by the following principles.[11]

1. Responsibility

The psychiatrist must know that he carries a high social responsibility because he deals with disturbed human behavior and intimacies of life. He would also serve the society through observation, investigation, experimentation, and research.

2. Competence

Psychiatrists are responsible for their continued education and should understand that lifetime learning is needed.

3. Benevolence

Patient’s interest and their health should be given the prime importance in professional practices.

4. Moral standards

Consider all the moral codes and expectations of the community they serve and will not let their behavior in anyway damage their profession.

5. Patient welfare

They will not treat any case that does not fall within their competence.

6. Confidentiality

The psychiatrists should safeguard the information obtained from their patients, relatives, and informants during their clinical work, teaching, or research.

Ethics and morals are concerns of all of us, and human rights are said to be inviolable, indivisible, and global which is a matter of perception, interpretation, and experience. Thus bioethics is a fertile area for application with comparison, conceptualization, and inquiry. The science and technology, the frontier of biomedical research is not known to the lawyers in general; however, technology can be abused, and exploitation can happen in the name of experimentation.[12]

GOOD PSYCHIATRIC PRACTICE (CODE OF ETHICS)

College report CR 186 of Royal College of Psychiatrists suggests 12 principles in 2014.[13]

1. The essential dignity and humanity of every patient should be maintained by the treating psychiatrist

2. Psychiatrists shall not exploit patients’ vulnerability

3. Patients should receive the best attainable care for their treating psychiatrist

4. Psychiatrists shall maintain the confidentiality of patients and their families

5. The valid informed consent must be obtained from the patients undergoing procedures

6. The best available treatment options should be discussed and provided to the patients and their caregivers

7. The misuse of professional skills should not be done for personal or monetary gain

8. While doing research work, the psychiatrist should follow national and international guidelines and should not disclose the identity of their patient and publish photographs without the consent of the patient

9. They should continuously develop, maintain and share their knowledge, expertise, and skills with medical colleagues, trainees, and students through CME program and medical conferences

10. Psychiatrists have a duty to attend to the mental health and well-being of their colleagues, including trainees and students

11. Above all, the professional integrity should be maintained

12. Psychiatrists shall work to improve mental health services and promote community awareness of mental illness and its treatment and prevention and reduce the effects of stigma and discrimination.

On March 27, 2017, Lok Sabha unanimously passed the Mental Healthcare Act 2017 and was approved by Honorable President of India on April 2017. In MHCA 2017, the legal and ethical aspects related to admission, discharge, consent to treatment, the capacity to consent, and role of the nominated representative (NR) are clearly set forward.[14]

The Ethics Subcommittee of the IPS issued version 1.3 of the code of ethics for Indian Psychiatrist in December 2018. It stipulates 13 principles which include patient’s well-being, competence in the field of practice, professionalism, maintaining discretion, collaborating with colleagues when needed, maintaining patient rights and confidentiality, updating knowledge regularly, acting appropriately if a colleague or professional acts unethically, upholding the dignity of the medical profession, raise awareness about mental illness among the general public, abiding to ethical principles of academic conduct when involved in medical education and in research.[15]

GOALS OF PSYCHIATRIC ETHICS

To provide competent, compassionate, and respectful care.

Being honest with patients and colleagues.

Act within the boundaries of law.

Consider the rights and autonomy of patients.

Be accountable to the community and society.

ETHICAL ISSUES SPECIFIC TO PSYCHIATRY

Diagnosis, Psychiatrist-patient relationship, Involuntary admissions, Confidentiality, Boundary violations, Informed consent, Human rights, etc.

A psychiatrist is the connecting link between the individual and the society. He needs to abide with the ethics and law, to fulfill his dual responsibility.

The aberration of normal behaviors cannot be equated as abnormality and mental illnesses. The human behaviors classified as autonormal, heteronormal, auto pathological, and heteropathological depending on the societal norms, cultural context, belief system, and situational as well as environmental factors [Table 5]. There are still grey areas of research, and continuous upgradation of diagnostic criteria is always under process.

Table 5.

Concept of normality in mental health

Autonormal	Autopathological
Heteronormal	Heteropathological

Medical ethics can be defined as moral principles which guide the members of the medical profession in their dealing with each other, their patients and state. These ethical codes guide each other to regulate their relationships. The medical etiquette is self-induced duties on each other.

They should obey and follow the IMC Act 1956. There had been very few published articles as found in electronic searches by the reviewers. It was not found to be a favorite topic for discussion by the Indian authors, only six articles directly related to ethics as found in a review article published in the Indian Journal of Psychiatry in 2010.[16]

In general, a relationship is built up by two autonomous individuals who can evaluate the pros and cons and decide whether to continue or break the relationship in the long run. However, the psychiatrist-patient relationships have other angles to consider. Due to their emotional vulnerabilities and potentiality of the development of transference reaction, a psychiatrist should have to vigilant and sensitively deal with their patients. At the same time, it is prudent to judge whether their own counter-transference could have a biased assessment and therapeutic influences while treating a mentally ill patient.[15]

Informed consent

The concept of informed consent has also been challenged as there are schools of thought that this has come as a consequence of defensive practice from the UK due to rowing litigations. Sill there are myths and misconceptions prevailing that mental illnesses are caused by possession of demon, evil spirits, supernatural powers, wrongdoings, and misfortunes, psychotropic medicines are addictive, ECT may cause more harm than illnesses and be applied as a mean of punishment, etc., Even there are biases and prejudices that come into play in the court of law during capacity assessment. The inform consent should not be a blanket consent as it is practiced in our country widely. The procedures of the consent are not followed properly and not sufficiently discussed with the patient. It is imperative to take consent for each procedure separately.

The voluntary informed consent is essential for research involving human subjects, which include (i) description of the nature of research, (ii) disclosure that the consent is voluntary and the individual can withdraw consent at any time, (iii) description of pros and cons of the research, (iv) description of how the confidentiality issues will be protected, description of compensation, (v) detail information that the researchers will share with the participant and (vi) the contact personals name with contact number who will be responsible for liaison with the research activities.

Confidentiality

Major exceptions to confidentiality:

1. Consent obtained: The patient has given consent to share information to family members, insurance company, employer, or anybody else

2. Tarasoff duty: When the patient’s act has potential to harm others, it is the duty of treating psychiatrist to inform appropriate authority

3. Emergency situations: The onus is on treating psychiatrist with documentation that there had been emergency situation beyond reasonable doubt which has necessitated him or her to breech the confidentiality

4. Mandatory reporting: In case of child abuse or violation of the right to protection of woman

5. Court orders: The patient must be informed and if the patient refuses the permission, that has also to be informed to the court

6. Under litigation: If the patient had initiated legal proceedings the psychiatrist has the right to share information before the court of law which is relevant to the case.

Principles to follow while breaching confidentiality:

1. Informing the patient and obtain written consent preferably

2. Disclose the relevant part only that is utmost important to share

3. Documentation with proper notes what the rationale for this decision was.

Competence and responsibilities

The competence and responsibilities of a therapist are immense. They should be aware of their responsibilities toward self and clients.[17]

They should maintain their own functioning and accountability to monitor their own performances as summarized in Table 6.

Table 6.

Competence and responsibilities of a therapist: dimensional concept

Competence of a therapist: The acquired skill, knowledge, qualification or capacity which depends on the level of knowledge, experience and supervised skills	Responsibilities of a therapist: The therapists on ethical point of view are aware of their responsibilities toward clients
Responsibilities to the client: Therapy should be undertaken only with professional intents and contracts involving clients should be realistic. Therapist should avoid harm and promote autonomy and maintain professional boundaries	Responsibilities to self as a therapist: The onus is on therapist to maintain their own effectiveness, resilience and ability to help clients. The therapist should undertake their own therapy when their capacity will be impaired

Infamous conduct

The behavior and practices of a doctor which is considered as disgraceful and dishonorable which can be judged as abuse of professional position is called Infamous conduct, which includes 6 “A” s, for example, Adultery, Advertisement, Abortion (criminal), Associations with unqualified persons in professional matters, Alcohol, and Addiction. This includes 1. Dichotomy (Fee spitting), 2 Engagement with touts, 3. Immoral and criminal acts, 4. Refusing treatment on the basis of race, caste, creed, religion, 5. Not doing mandatory reporting in alleged Rape and communicable diseases like AIDS, 6. Issuing false certificates, 7. Prescribing schedule H drugs violating NDPS act, 8. Refusing treatment in emergency, 9. Violation of PCPNDT act 1994, 10. Human rights violation, 11. Publication of photos and case reports without consent (Disclosure of identity).During consultation unnecessary referrals, consultations and professional jousting should be avoided.

Privileged communication

It is a statement made bonafide on any subject matter by a doctor to the competent authority as a duty protects the community or state at large. The interest of public cannot be held at jeopardy or risk for sole interest of a particular patient who may endanger the safety of larger sections of society.

Professional negligence

Professional negligence can be defined as the absence of reasonable care and skill or willful negligence of a medical practitioner in the treatment of a patient, which may cause bodily injury or death of the patient. The doctor is liable of professional negligence when there is failure to discharge the duty, dereliction, direct causation, diagnosis (4’D’s).

The professional negligence can be of two types, (i) Civil negligence and (ii) Criminal negligence. However, professional misconduct cannot be equated with professional negligence. In negligence, the absence of care and skill with damage has to be proved, and trial has to be done in court of law, whereas in misconduct the act is considered disgraceful, and trial is being done by state medical council. The difference between Civil and Criminal negligence are summarized in Table 7.

Table 7.

Basic differentiating features of civil and criminal negligence

Civil negligence	Criminal negligence
Simple act of care and skill	Gross violation and deviation from standard of care which endangered patient’s safety
No specific or gross violation of act or law	Clear violation of law dealt with IPC section 304 A
The onus to prove lies on balance of probabilities	The proof has to be sufficient beyond reasonable doubt
Consent and contributory negligence acts as a good defense	Essentially not
Trial is being done in civil court	Trial is being done in criminal court
Punishment by compensation only	Punishment is by imprisonment and/or fine
The doctor can be tried twice for the same offence	The doctor cannot be tried twice here

Contributory negligence

The concurrent damage of patient and or attendant, which added on doctor’s negligence, which has caused the eventual damage (e.g., failure to give adequate history, neglecting follow-up).

Medical maloccurrence

It happens due to bio-physiological variations of individual responses due to tolerance, idiosyncrasy, etc. (e.g., Steven Johnson’s syndrome caused by Lamotrigine).

Misadventure

This can be therapeutic, diagnostic, and experimental. When certain drugs are administered, and procedures are being done despite the extreme risk and lacking any scientific evidences (antisnake venom, anticancer drugs) or certain procedures mostly outmoded these days (Barium enema causing poisoning and rupture).

Calculated risks and product liabilities

When certain procedures can have inevitable risks, but the doctor should write proper justification and preventive measures taken. Similarly, certain physical agents (pacemaker, prosthesis, etc.,) may become malfunctioned as wear and tear or faulty manufacture.

Res ipsa loquitur

The fact that speaks itself that is in the absence of negligence, the injury or damage would not have occurred ordinarily. The doctor had exclusive control over injury-producing treatment or machinery, and the patient was not guilty of contributory negligence (e.g., leaving swab in the abdomen, mismatched blood transfusion etc.).

Novus actus interveniens

The terminology is applicable when the doctor is not only responsible for his own actions but also the logical consequences of the action.

Vicarious liability

This is applicable when the employer is not only held responsible for own’s negligence but also for the negligence of the employees, which is called “Respondant superior” (let the master answer). This should be applicable under the scope of employment and while on job.

Borrowed servant doctrine

It is applicable to an employer for a borrowed employee serving under multiple employer, especially applicable for professionals such as junior doctors, interns, nursing staffs, and pharmacists. However, the surgeon is not held responsible usually for the negligence of anesthetist and vice versa.

Medical etiquette

The essence of the medical etiquette is that the psychiatrist should treat their colleagues with utmost respect and care. A patient can be referred to a competent professional or institutions or individuals of the same or different specialties by a psychiatrist for a second opinion or further treatment. It is the self-imposed duty on each other, the conventional laws of courtesy observed between the members of the medical profession. In case of applying some unconventional treatment of a disorders psychiatrist should refer their patient to his/her colleague for a second opinion.

The movements to encompass the mental health problems like the other medical illnesses under insurance cover are gaining momentum, and some successes are now visible. The psychiatrist should inform their patients at the very beginning of the treatment about their professional obligations.

MCHA 17 and human right issues

The word Human Rights in a broader way means “those claim which every individual has or should have upon the society in which he/she lives.”

The MCHA 2017 specifically dealt with human right issues of PWMI (patients with mental illness). The ethical and legal safeguard and framework have been constituted for this vulnerable group in evaluation, management, and research perspectives. The basic tenants of ethical standard of care Beneficence, non-malaficence, autonomy, and justice for mentally ill patients have also taken care of. The confidentiality issues and boundary violation-related matters have also been judged with due weightage.[17]

Rights of the mentally ill as per mental health care Act 2017

1. The right to get considerate and competent treatment

2. The right to be informed about the treatment

3. The right to give consent

4. The right to privacy

5. The same fundamental rights as other citizens, including the right to a decent life as normal as possible

6. Protection against exploitation and discriminatory, abusive, or degrading treatment

7. Assistance including legal aid to protect their rights.[18]

DEFINITION OF BOUNDARY

A boundary may be defined as the “edge” of appropriate professional behavior, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role. In other words, It is the physical, psychological, and social space occupied by the patient in the clinical relationship.[19]

Boundary issue types

Gutheil and Gabhard identified two types of boundary issues-boundary crossings and boundary violations. A boundary crossing is a deviation from classical therapeutic activity which is harmless, nonexploitative, and possibly supportive of the therapy itself.[20]

On the other hand, a boundary violation is potentially harmful to the patient and the therapy. It constitutes exploitation of the patient. Boundary crossings and violation may arise from the therapist or from the patient. This might lead to non-sexual or sexual boundary crossings or boundary violations.[21]

Though all health professionals need to be aware of boundary issues, psychiatrist have an additional responsibility for various reasons, as mentioned below.[22]

• Knowledge about boundary issues is important for effective healthcare for prevention of BVs by oneself and in reducing harm to patients

• Psychiatric patients are more vulnerable to BVs

• BVs can lead to further emotional problems; therefore, unless the treating therapist is aware that BVs, he or she is unlikely to recognize or handle it effectively

• The doctor/therapist who violates sexual boundaries needs to be confronted and may need psychiatric or psychological evaluation

• In psychiatry, as the therapeutic relationship is prolonged and more personal as many confidential matters are discussed, there is likelihood of developing strong emotional bonds. This may lead to nontherapeutic activity

• False allegations by patients are not uncommon in India

• The ethical issues in managing boundaries have to be taught, discussed, and supervised.

REASONS FOR BOUNDARY VIOLATION

• Negligence of “transference and counter-transference”

• Personality, illness, and life situation factors in some patients and doctors

• Deficits in training about boundary issues

• Lack of knowledge on “dual relationships” risks between doctors and patients.

MEASURES TO BE TAKEN

• Educate all the health care professionals, patients, and caregivers

• Make certain supervision in clinical practice

• Develop clear ethical guidelines

• Motivate hospital/health management/medical societies in India to implement the guidelines

• Ensure legal advice for all involved – patient victim, offending doctor, and “third party doctors.”

Guidelines for doctors on Sexual boundaries Version 3.4 (IPS)

The Bangalore declaration group had formulated this guideline which had been uploaded to the Medical Council of India website, the excerpts had been given below.[23]

1. Sexual relationships between doctors and patients invariably harm both

2. Code of conduct for doctors and patients irrespective of gender

3. Doctors should not exploit the doctor–patient relationship for personal, social, business, or sexual gain

4. Even if the patient attempts to initiate the sexual relationship, it will be against good medical practice for a doctor to enter into such a relationship

5. Any sort of non-consensual sexual activity would account to sexual abuse/molestation/rape, and doctors would be answerable to the law of the land

6. Taking sexual history and performing appropriate physical examination should be done sensitively and documented properly

7. Treatments which require sedation (like electroconvulsive therapy), a nurse should be present

8. Even a relationship with a former patient is unethical. As of now, IPS puts the time frame as “one year at the very least, after the termination of the doctor–patient relationship”

9. As NSBVs can “slip into” SBVs, it is crucial for all doctors to cautious about warning signals

10. Social media should be used responsibly

11. Doctors should not exploit the doctor–patient relationship for sexual gain. These guidelines are for the safety of both patients and their family members

12. Any breach in following the guidelines, if reported to the IPS will be referred to the Ethics Committee

13. Similar care should be extended by the doctors while interacting with students, colleagues, and other professionals

14. False allegations can occur, and the doctors should remain alert

15. The IPS recognizes that SBVs are not restricted to any particular group of doctors, indeed not restricted to doctors alone, but occurs in all professional groups.[24]

MHCA 17, new visionary, new changes

The decriminalization of suicide and protecting rights of lesbian, gay, bisexual, transgender, questioning/queer (LGBTQ) community with respect to IPC 306 and IPS 377 are a step ahead towards the futuristic goal. The new challenges with MHCA 2017 with respect to mental health capacity assessment, banning ECT less than 18 years of age, advance directives, nominated representative, etc., have thrown new challenges, and the psychiatrists are on the process of examining pros and cons in their practical field of work over last three years after the implementation of this legislation.

One should work in the existing legal framework and should follow the law of the land. Therefore, ethical and legal issues are intertwined as well as bidirectional. The confidentiality builds the foundation stone for the doctor–patient relationship, and breach of confidentiality is both illegal and unethical except in exceptional situation (Tarasoff duty, Privileged communication). Young ladies with higher socioeconomic and educational status are more significantly associated with unwillingness to voluntarily disclose, which makes them guarded in initial settings.[25]

The procedures of involuntary admission had evolved gradually over the years with utmost care given to the human right issues which is summarized in Table 8.

Table 8.

Chronology of management of involuntary admission

Mental Health Act ‘87	Madrid Declaration ‘96	Hawaii Declaration, 88
Major situations when it’s necessary for involuntary admission are	Involuntary intervention is a great infringement of the human rights. Specific criteria and safeguards are required	No procedures must be performed or treatment given against patient’s will unless the patient lacks capacity
(i) Patient is dangerous to self and others
(ii) Possibility of improvement following hospitalization
(iii) Patient is incompetent

The specialized training with respect to mental health in prison set up is required. The inmates, patients, individuals having severe psychosis, dementia, and intellectual disability have more chance of having absconding behavior, and they can be provided with metal bracelets (“kadas”) which are most acceptable religiously which can be engrossed with name, address, contact numbers, and GPS trackers.[26]

The disability benefit for PWMI has to be provided in accordance with Rights to Persons with Disabilities Act, 2016. The deficits have been subclassified on self-care, interpersonal, social, and occupational functioning and in turn, impaired quality of life domain. The decentralization of certification procedure at PHC (primary health care staff) is now a reality.[27,28,29]

The conflicts of interest often arise when the primary interest such as patient’s welfare and validity of research is subsequently being influenced by secondary interest (financial gain, promotion of brands of pharmaceutical companies, etc.).

Minimizing disruption of care in pandemic days

The Telemedicine Practice Guideline has already been issued, which increases the responsibility of a psychiatrist, especially when it comes to the issues related to confidentiality and boundary violations. In person consultations, though have specific advantages as Indian patients are more boosted up by “Darshan” of their doctors which also helps to build therapeutic relationships. However, in the days of a pandemic the patients are being encouraged to follow Telemedicine for the safety of both the patients and their doctors. APA termed it as life saving physical distancing measures to be followed if at all in person consultation is required in the office of a psychiatrist.

In the current Telemedicine guideline, the voluntary consultation by video, audio calls, text messages and E-mails are considered as implied consent. However, the exemptions of concepts are there, for example, in emergency situation, therapeutic privilege (when the necessary information may potentially harm the patients), incompetence due to mental illnesses, in minors and when as a waiver patient explicitly accepts all the decisions of the treating team. The former Medical Council of India (now replaced by Board of Governors) recommended that all the professionals should join their respective societies to constantly update their knowledge and should work in their own ambit. A neurologist treating a psychiatric patient and vice versa routinely other than in emergency situation are essentially unethical. There are other explicit unethical practices in these noble practices also but the nefarious activities by a negligible few blacksheeps could not be generalized.

CONCLUSIONS

Even today in medical practice, the doctors enjoy paternalism and it’s the need of the hour to maintain highest professional ethical standards to avoid controversy in the era where information are spreading at the fastest pace. The sensitization process should begin in undergraduate education and winded up in post-graduation training keeping in mind our own culture, standards of living, cultures, ethos, and values.

1. Ethical aspects of psychiatry practice should be learned and updated to all from time to time

2. The clinician should learn most suitable and best fit model

3. The ethical guidelines are continuously evolving and one has to work in this framework

4. One should not do any act which one should not like to receive from others

5. The essence of all these recommendations is that psychiatric patients should be treated with dignity and respect

6. One should work in the existing legal framework and should follow the law of the land. Therefore ethical and legal issues are intertwined as well as bidirectional. The confidentiality builds the foundation stone for the doctor patient relationship and breach of confidentiality is both illegal and unethical except in exceptional situation (Tarasoff duty, Privileged communication etc.).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.