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Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 1-3

Autonomy and advance directives in psychiatry patients in India – Mental Healthcare Act 2017 perspective

Additional Professor of Psychiatry, Department of Psychiatry, AIIMS, Guntur, Andhra Pradesh, India

Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Vijaya Chandra Reddy Avula
Department of Psychiatry, AIIMS, Managalagiri, Guntur - 522 501, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMH.AMH_24_20

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How to cite this article:
Reddy Avula VC. Autonomy and advance directives in psychiatry patients in India – Mental Healthcare Act 2017 perspective. Arch Ment Health 2020;21:1-3

How to cite this URL:
Reddy Avula VC. Autonomy and advance directives in psychiatry patients in India – Mental Healthcare Act 2017 perspective. Arch Ment Health [serial online] 2020 [cited 2023 Feb 8];21:1-3. Available from: https://www.amhonline.org/text.asp?2020/21/1/1/288917

  Paternalism to Shared Decision-Making Top

The autonomy of the patient is a derivative of the natural law right to self-determination. The principle autonomy emphasized the predominant role of the patient in making treatment decisions, and the doctor's role is limited to providing the information regarding the disease, its complications, types of treatment available, and prognosis. The patient can refuse the treatment in toto. The doctor is not in obligation to accept the patient's choice if it is futile or not by beliefs of the treating doctor. However, the doctor cannot impose treatment on the patient through coercion of any means. Traditionally doctors had a significant role in the treatment decisions of patients. Patients had minimal involvement in treatment decision making. It was based on the Hippocratic principle “I will use treatment to help the sick according to my ability and judgment.”[1] In the above-said principle, the physician's belief in the treatment choice that is of beneficence to the patient had superiority over the autonomy of the patient in choice of treatment. Hippocrates' principles of medical ethics do not talk about the patient's autonomy. Human rights movements post-World War II had an impact on the rights of patients in the medical field. World medical association adopted a new physician pledge as an ethical guide for the practice of medicine, at 2nd Annual conference in Geneva 1948, and the latest amendment to the pledge at its 68th annual meeting in Chicago USA. This pledge states as a physician, “I WILL RESPECT the autonomy and dignity of my patient.” This paradigm shift from doctor's paternalism to shared decision-making model, giving a primary role to the patient in his treatment choice is a result Nazi doctors atrocities during World War II.[2] This paradigm shift from doctor's paternalism to a shared decision-making model is a result of Nazi doctors' atrocities in World War II.

  Ulysses Directives Top

In mentally ill patients, autonomy has been a function of competence, and the competence of the patient has been dependent on his insight into the disease and judgmental capacity of the patient during the ill state. In psychiatric illness, the competence of the patient fluctuates during decompensation and remission of the disease. The concept of advance directives in mental illness has been adopted to patients suffering from psychiatry diseases to achieve autonomy of their treatment decisions. The advance directive concept is derived from Ulysses directives. Ulysses, the hero of Homer's Greek mythical story, after the trojan war on his long voyage back to home across the oceans, wanted to listen to what Sirens sang about him. Sirens are dangerous creatures with their enchanted voice lure the sailors into wrecking their ship to rocks on the shores of the island. Hence, he directed his crew to tie him to the mast so that he could hear the song but be prevented from misdirecting the boat, while his team was instructed to block their ears and thus keep the ship on course no matter what he later commanded them to do. Ulysses directives intend to administer the treatment which the patient has accepted while he was competent and is currently refusing due to incompetence caused by the disease.

  The Mental Healthcare Act 2017 – Advance Directives Top

The Ministry of Law and Justice on April 7, 2017, ratified “the Mental Healthcare Act 2017.”[3] Chapter III of the said Act (MHA,2017) has laid down rules and guidelines for patients, caregivers, mental health workers, and legal authorities on advance directives (AD), enabling the autonomy of the psychiatric patients. Chapter II of the article speaks about the capacity of mentally ill patients in making treatment decisions. Section 5 of Chapter II of MHA, 2017 gives powers only to the court to declare the incompetency of the patient to make treatment decisions.

Section 4 of Chapter II defines competency as understanding the information regarding treatment, present and future consequences of illness, and ability of the patient to communicate his decisions regarding treatment. Chapter III Section 9 gives the doctor to override advance directive in case of emergency, and Section 12 provides the doctor and caregiver to approach the concerned mental health board seeking relief not to follow the advance directive. The committee, after a fair hearing of the patient, caregiver, and doctor, may grant the appropriate instructions. Advance directives can only be canceled when those directives were made under coercion or current situation patient suffering is different from what is anticipated, or advance directives were made with insufficient understanding of the disease or the patient was suffering from an unsound mind at the time of decision-making, or advance directives are in contrary to existing laws. Chapter III has given adequate autonomy to psychiatry ill patients to make, modify, redact, and remake advance directives regarding the treatment they wish to receive.

  Competence of the Patient Top

Practical implementation autonomy through advance directives depends on the mental competence of the patient to make such a directive. Like the UK, the USA, and Canada, the Indian Mental Healthcare Act 2017 defines that every subject is competent to make a decision unless otherwise proved. Chapter XI Section 81(1) of the MHA 2017 has directed to appoint an expert committee to prepare guidance document to assess the competent capacity of a mentally ill individual to make his advance directives. As on date, no such material has been prepared by the central committee, while Chapter II Section 5 empowers the court to decide the competency of the patient in making advance directives. Till guidance document is issued by the central committee, the court has powers to determine the patient's capacity to make an advance directive. Mental competence or ability to decide is a continuous spectrum, more serious the medical problem higher is the mental capacity required to consent or refuse a particular treatment for that condition.

  Parties Involved in Drafting Advance Directives Top

Chapter III of MHA 2017 has put the onus of making an advance directive on the patient to preserve the autonomy of the patient. Patients are independent, but their treatment affairs are dependent on their caregivers and doctors. For example, a patient in his advance directive prefers a particular hospital or particular doctor for treatment, and if that choice is expensive for caregivers, enforcing that directive is an economic burden or approaching the board for nullification of such instruction is a procedural burden. A patient in his advance directive lists a particular drug that is not readily available, or it is not much helpful in treating the condition, the doctor is in a double conflict of convincing the caregivers and the board to nullify the advance directive. Listing all conflicting situations and making provisions in the law to avert the conflicts will make the code more cumbersome and challenging to implement. Including the doctor and trusted caregiver parties to Advance directives (AD) and getting AD preapproved by the concerned board will mitigate the technical and economic difficulties that may arise if the patient is the sole author of his AD. The board, by its participation, should prevent coercion seeping into the AD either by treating doctors or caregivers.

  Is There a Conflict between Autonomy and Advance Directives Top

An advance directive is a treatment plan written by a competent patient at a time when his symptoms of psychiatric illness are under control, and when the patient has adequate insight and judgmental capacity. The plan is prepared with an understanding of his previous episodes of decompensation and its effect on his work, social, and family life. An advance directive, in turn, is facilitating a smooth journey from illness to illness-free period as per the wishes of the patient made during his competence phase. Advance directive promotes the autonomy of the patient as long as situational modification AD is allowed under the proper supervision of review psychiatry medical boards. The first step in preserving autonomy is helping the patient to write reasonable will-based practical, available, and affordable health facilities. Imparting education of psychiatric illness in laymen terms to family members and patients also plays a vital role in drafting a proper advance directive. Modalities of treatment and their benefit, cost, and risk should be discussed with the patient and caregiver, and then, the choice of the treatment of the patient should be a part of the AD draft. The psychiatrist and family member of patient choice should also be active members for drafting AD, although their role should be limited advisory capacity. The draft should be examined by a team of experts about reasonability and feasibility of its implementation, and if draft needs modification, the patient may be directed to do the changes required, and the review board resolves if any conflicts persist.

  Conclusion Top

Advance directives preserve the autonomy of psychiatry patients. They are not in conflict with each other but are complementary to each other. The MHA 2017 has paved the way to the autonomy of patients through advance directives and nominated representatives. Concerning the above modules, the act needs further refinement to preserve the right to self-determination vis-a-vis autonomy of the patient. Autonomy and soft paternalism (shared decision model) result in the beneficence of the patient, the second core principle of medical ethics. Non-maleficence (primum non nocere), an essential part of medical ethics, persevered if the doctor adheres to a well-written AD. With regard to the justice part of medical ethics, which predominantly deals with the fair distribution of medical facilities, AD's role is limited because of extreme disparity in medical facilities based on affordability. Advance directives are a positive step toward upholding the rights of the mentally ill patient, and all hospitals or doctors dealing with psychiatric patients should encourage the patients to draft a proper advance directive.

  References Top

Jones WH, editor. Introduction to the oath. In: Translator. Hippocrates. Vol. 1. Cambridge, MA: Harvard University Press; 1923. p. 296.  Back to cited text no. 1
Declaration of Geneva. In: Wikipedia; 2019. Available from: https://en.wikipedia.org/w/index.php?title=Declaration_of_Geneva&oldid=92289518. [Last accessed on 2020 Mar 06].  Back to cited text no. 2
The Mental health Care Act 2017, no. 10 of 2017, Parliament of India; 2017. Available from: http://egazette.nic.in/WriteReadData/2017/175248.pdf. [Last accessed on 2020 Mar 06].  Back to cited text no. 3


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   Paternalism to S...
  Ulysses Directives
   The Mental Healt...
   Competence of th...
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