Ethical and professional challenges in mental health care in low- and middle-income countries

Abstract

Mental health practitioners in low- and middle-income countries (LAMICs) face particular ethical and professional challenges in their day-to-day clinical practice. A systematic review of the published literature from all LAMICs identified 42 relevant articles. The majority of papers dealt with violations of individual autonomy, particularly in the context of involuntary admission, use of electro-convulsive therapy and the lack of information given to patients about prescribed psychotropic medications. However, the appropriateness of this focus on individual autonomy was challenged in settings where values emphasizing the interconnectedness of communities prevail and the family shoulder the burden for most mental health care. When access to the least restrictive, culturally relevant, evidence-based care is limited to the privileged few, caregivers may be forced to over-ride the individual autonomy of the patient in order to ensure receipt of effective treatment or protection of others. Enactment of modern mental health legislation in all LAMICs remains an essential goal to protect the rights of the mentally ill. In parallel with this, supporting calls for the scaling up of mental health care will do more to ensure the right to mental health care and ensure actual implementation of international ethical frameworks.

“I cry every day and night, I have my son tied in chains”: physical restraint of people with schizophrenia in community settings in Ethiopia

“…Although the potential psychological and physical harm related to restraint was discussed, participants did not frame restraint explicitly as a human rights concern. In the study setting, the priorities and prevailing beliefs focused on the safety and needs of the community or family [6, 22], whilst individuals’ needs were considered chiefly in terms of ensuring they access care irrespective of their wishes [51]. Read et al have previously noted the contrast between international outrage at the issue of restraint and the mundane way it is sometimes discussed in the communities where it occurs [6].…”

Unpacking the psychiatric advance directive in low-resource settings: an exploratory qualitative study in Tamil Nadu, India

“…However, autonomy is not necessarily the most dominant principle in many low and middle-income countries (LMICs), where cultural emphasis centres more on reciprocity, family, community, and joint decision-making [10]. In many LMICs, for example, the family often assumes the role of decision-maker, instead of the individual, responsible for ongoing mental health care [11]. …”

“…This is also the case in India, where mental health care often aims to do what is best for the family [11,12]. This is also embedded in India’s Mental Health Act of 1987, which recognises the importance of family as the primary decision-makers; however this system has been criticised as it leaves the potential for family members to abuse these decision-making powers [11].…”

Global challenges and ethics in protecting and promoting the interests of psychiatrically ill patients

“…Furthermore, many patients do not feel that they had freely consented to electroconvulsive therapy even when they had signed a consent form (Rose, Wykes, Bindman, & Fleischmann, 2005). Thus, in the case of electroconvulsive therapy, Hanlon et al (2010) correctly emphasize the importance of providing reliable information to patients and their families and to being alert to the possibility that patients will feel coerced to accept electroconvulsive therapy.…”

“…A second theme Hanlon et al (2010) identify is that patients become open to abuse during processes of admission to psychiatric institutions when they lose the capacity to consent or decline admission and are unable to advocate for themselves. The ethical issues of substituted judgement (Buchanan & Brook, 1989) and beneficence (Engelhardt & Coverdale, 1993) are considerations in decision making.…”