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Mental illness, choice and rights -Harsh Mander
-The Hindu

The new Bill should pitch for free care to mental health patients in public hospitals.

Persons with mental illness have long been subjected to cruelty, neglect, ridicule and stigma. In the last half-century, medical science has made significant strides in finding some cures and palliatives for afflictions of the mind – of emotion, mood, thinking and behaviour. Parallel to this is the evolution in our ethical frameworks: of human rights, and acknowledgment of the equal dignity of all human beings. But changes in the law, social attitudes, and the work of healthcare institutions and psychiatric professionals, have not kept pace with these scientific and normative advances.

The Mental Health Care Bill, 2012, recently released by the government, is an exceptional State-led attempt to correct many of the historical wrongs to which persons with mental illness have long been subject. The draft emerged after a long and engaged process of consultation with persons with mental illness, their care-givers, their organisations, and professionals.

The Bill met immediately with fierce opposition from some radical disability and mental health organisations. Many of their concerns and fears are legitimate. But I believe that this is on balance a humane and progressive Bill, bravely and compassionately navigating difficult ethical and professional terrains.

Until quite recently, it was routine to lock away people with mental illness in jails or jail-like mental hospitals, kept naked or in prison-like uniforms, bound in chains, abandoned and often forgotten for lifetimes. The number of beds in mental hospitals were, however, minuscule, and the large majority of patients were denied any kind of care, except those offered by faith healers and untrained practitioners.

The new Bill contains many protections to persons with mental illness. It bars prolonged hospitalisation, chaining, compulsory tonsuring, forced sterilisation, and electro-convulsive therapy without anaesthesia, and defends rights of patients to privacy, personal clothes and protection from abuse. It also prescribes that all persons with mental illness have the right to dignity, and to live in, be part of, and not segregated from society.

The Bill also mandates that mental health services shall be integrated into general health services at all levels – primary, secondary and tertiary, and that these services shall be available in the neighbourhood. If enforced, this will draw a curtain on the long tragic history of injustices and abuses which characterised large, segregated mental hospitals.

The opening sections of the Bill are forthright in admitting that persons with mental illness suffer discrimination, and that the current law has failed to protect their rights and promote their access to health care. It goes on to assure all persons the right to ‘affordable’ good quality public health care.

I believe this guarantee does not go far enough. In these columns last fortnight, I recounted the story of Rajesh, a young man suffering from hallucinations from full-blown psychosis, badly injured, who was repeatedly refused admission by many major public hospitals in the capital. The story underlines the general experience of growing abdication by professionals and public institutions to take care of impoverished and difficult patients. I believe that the Bill must guarantee nothing less than free care in all public hospitals for all patients who seek or need care, and prescribe deterrent punishments for hospitals and professionals who refuse to provide care.

Against their will

Despite its many progressive and humane features, the Bill is still attacked by some radical associations of persons with mental illness, mainly because it retains provisions in rare cases to admit patients for care, even against their will. This debate has an important history.

Until as recently as 1987, the colonial Indian Lunacy Act, 1912, prevailed, in which persons with mental illness (described as ‘lunatics’ and ‘idiots’), were admitted into mental hospitals through the order of Magistrates. The law treated persons with mental illness not as persons who deserve treatment and care, like any other person who falls ill, but as people who are vaguely dangerous, and therefore it in effect primarily aimed to protect other people from persons with mental illness.

The Mental Health Act of 1987 partially corrected this, by allowing for voluntary admissions, but Magistrates still retained a central role for patients who were admitted to mental hospitals against their will. Mental health activists rightly campaigned against this provision, as it was undignified and stigmatising; and it was on occasion misused to abandon and ‘tame’ assertive and non-conforming women and men.

Radical mental health activists are dismayed because the new Bill still allows involuntary admissions of patients against their will. They are uncompromising that the will of the patient should be absolute regarding whether or not she wishes to accept treatment and care.

On the other hand, many persons with mental illness, and their care-givers, recognise that there are occasions when it is in the paramount interest of some patients to be given care forcefully, even when they refuse it, if the person is in imminent danger of causing harm to herself or to other people. The Bill limits involuntary admissions to only such cases, with many checks and balances. Forced admission is only for 30 days at a time. The Magistrate is removed from the picture completely, and is replaced by mandatory reviews of all such cases by mental health panels, which comprise judges but also administrators and persons with mental illness and their care-givers.

There are moments I have observed - among loved ones, friends and the young people from the streets who are now in our care - when a person is suicidal or hallucinatory, abandons home or is suspicious of loved ones, is compulsively manic, spending or gambling life savings, violent and dangerous to himself or to neighbours. In the name of human rights, no hospital or professional offers them care. But there are deeper human rights in these moments, which cumulatively may temporarily override the right of free choice. These are the rights to empathy, protection, dignity and care. I believe that the Bill is right in the delicate balance it has found, retaining the provisions for involuntary admissions, but limiting these severely with many cautions and checks.

These debates are important, and we need to listen to each other more. But while we discuss, we must welcome a draft law which promises to reverse the cruelty, ignorance and abdication, which still characterises ways the State and professionals still treat people battling demons in their minds and souls, while guaranteeing them empathy, respect, protection and care.