THE ROLE OF ETHICS IN MH SECTOR STRENGTHENING
BY BHARGAVI V DAVAR

The Scope of the Domain
Ethics, one of the applied disciplines of philosophy, is the study of values. Bringing a value discussion into the mission work is a significant departure from other policy initiatives as well as gain. For the mission, too, it becomes important to be self conscious about the values that it is promoting through the strategy paper.

Ethics is a self-reflective and self regulatory process that can be used by professionals and others to resolve value dilemmas in service delivery. Use of effective instruments and mechanisms within institutions will enable ethical problem solving in the service setting itself. Self-regulatory processes maintain dignity and value base of the profession. If such mechanisms are available, where everyday moral dilemmas are resolved immediately, the need for seeking redress and punitive action through external regulation becomes that much diminished. Standards of MH practice and a proactive peer pressure to maintain those standards are thereby established. Failure to address ethical issues within service delivery will only result in greater dependence of users and consumers on more normative and punitive external systems of regulation, such as law.

Medical ethics (e.g. ethical dilemmas with respect to sex determination or organ trade) has acquired a sophistication of its own in India, due to persistent efforts of health activism and advocacy. However, psychiatric ethics is not integrated into this tradition, as perhaps, the issues are somewhat different. Other than a smattering of Indian psychiatric literature on ethics, a huge gap exists in this domain, which needs to be filled.

In the context of the broader view the Mission takes of the Sector, the scope of the domain cannot be restricted to psychiatric ethics. A stakeholder view of ethics is assumed here as a guiding principle and we shall strive to approach the domain with this principle. Policy advocacy documents from other countries are looking at more comprehensive ethical frameworks, which is inclusive of community participation, rather than just the normative framework of medical ethics.

The stakeholders in the MH sector are the following: MH professional, family, community, patient and policy maker. There is also diversity to the MH professional cadre, increasing the challenge of this domain. Inclusion of user and consumer voices, hitherto unorganized constituencies, within the domain adds to the challenge, as does bringing an ethical point of view within community and NGO work in MH.

LIimitations of the Domain
In India as well as in Gujarat, there is a scarcity of discussion and research data in ethics in the mental health sector. Policy or service approaches to mental health have not openly engaged with the question of values underlying such initiatives.

The primary reason for the absence of “datafying” in ethics is the fact that appropriate competencies are not available in the country for conducting research or for building capacities. Even in the health sector, professional ethicists are very difficult to find. Very few courses are offered on the ethical aspects of health / mental health work. Such inputs are also not a part of the medical education curriculum. The level of awareness about ethical issues in service planning and delivery is quite poor in India.

The second reason is that the western methods of logical reason and philosophical argumentation about values are probably not considered as culturally appropriate in our country. The strength of the Indian traditions of philosophy and its values are evident in some of the pioneering visionaries of Indian psychiatry. However, papers on values in the MH sector have remained at the unstructured, subjective or the philosophical level. Values are offered as pregiven or as a priori, and not as a matter of dialogue and choice. References are also made to spiritual values such as moksha (enlightenment), which may be elitist, as it pertains only to upper caste hindu values. It may not be equally applicable to all religious or caste groups. Also, it may not actually be applied in the service context, as instrumentation such concepts is very difficult.

The third important reason for this absence of discussion on values is the near total lack of mobilization of users and consumers to make a demand upon policy makers and service planners. There is no bottom up pressure for systems reform, nor are users and consumers given any negotiating space within service settings. A very significant segment of the stakeholders have not been given a “voice” with respect to the ethical basis of MH sector.

Objectives
This chapter marks out the domain of ethics in the MH sector. Ethics is the study of values and its instrumentality within institutional decision-making. This chapter stresses the need to research, create awareness and discussion on ethics that will involve all stakeholders. It gives the broad concept, approach and guideline for a discussion of ethical values and value dilemmas within policy environments by using an example. The need for skill building and instrumentation in ethics, or operationalising ethical ideas within policy environments, is underscored. Special problems of dealing with ethical issues in the MH Sector are discussed. The report offers some examples of approaches where the user / consumer’s role is strengthened in planning MH services. A stakeholder perspective is also essential in strengthening the value base of the MH sector. International documents and consumer forums point to the importance of using “best practice” models in the MH sector today.

Analysis
The overall analysis of the ethical aspects in the MH sector leads to the SWOT table presented below.

Table 2 SWOT Analysis Ethical aspects in the MH Sector

Strengths Changing values of new MH professionals Increased user self-determination Increased visibility of advocacy Recent litigation and PILs Growing partnerships between professionals and users / consumers Vision and values of pioneeres in Indian MH

Weaknesses Uninformed by research Top-down approach Culturally elitist Not consumer / user centric Low receptvity of sector Low provider accountability Service provision not transparent Resistance from Providers Consumer / user apathy

Opportunities Emerging role of the public Regulatory efforts from GoI and GoG Research opportunities International lobby for systems reform International treatises and declarations signed by India

Threats Lack of pressure from law / regulation Market influences Poor linkage with regulation framework Low interest and capacities in ethical problem solving

Recommendations

Promoting a “care for ethics”
A culture of ethical thinking, or a “care for ethics” should be promoted in all MH policy environments. A care for ethics must pervade all institutional structures as well as the diversity of professionals.

Developing instrumentation in ethics:
Appropriate instruments and mechanisms are to be created within institutions to ensure that value dilemmas of different stakeholders are addressed. The instruments would cover:
Core areas of service delivery (costs, drug supply, outcomes)
Best practices in treatments (ECT, medication, psychotherapy, counselling),
Patient ethics (consent, confidentiality, transparency, doctor-patient relationship),
Gender ethics (appropriate touch, relationships with clients, sexual abuse) and
Institutional ethics (using and sharing information, research, assessments, evaluations).

In terms of mechanisms, we propose that:
A bill of rights and freedoms of persons with psychiatric disability is drafted.
Implementation mechanisms and functional linkages with regulatory systems be strengthened.

The Indian Psychiatric Society and other such professional bodies have an important role to play in all of this.

Research and Awareness
Ethics education and capacity building on dealing with ethical dilemmas is suggested to be included in medical, clinical psychology and social work curricula. Research must be undertaken on the role of ethics and values in clinical decision making, value dilemmas of different stake holders, value exchange in service delivery, consumer expectations and satisfaction, treatment outcome / remission research and best practices (Gordon, 1986).

User / Consumer partnership
Services should strive to build partnerships with users and consumers. Consumer leadership can build advocacy pressure for systems reform. Patients must be involved in the workings of IECs and review boards. Decisions for aggressive interventions, especially involuntary commitment and use of ECT procedure, must come under consumer scrutiny. Complaints procedures must be established within institutions to address user grievances. There is a need to promote consumer awareness at all levels, so that their power to participate in an informed manner is increased.

Address for correspondence:
Dr Bhargavi Davar
Center for Advocacy in Mental Health
info@camhindia.org ; wamhc@dataone.in