Organic Psychosis: The ethics and legal implications of treating
Mental Illness with a Physical cause
By Roxanne Keynejad
I embarked upon my elective in Cape Town with a specific project. To explore the limits,
ethics and legal implications of mental health act legislation. In practice, I gained a richer and more
complex practical exposure to ethics in action than I could have anticipated. In addition to fulfilling
my original objectives, I learned the pervasive nature of ethics in psychiatry and medicine alike and
the need for flexibility in ethical judgement, always tailoring it to the patient. In this context, more
than any other, a deontological ‘one size fits all’ approach was far too simplistic.
Groote Schuur and Valkenberg Hospitals had a wealth of organic psychiatry. Widespread tik
(methamphetamine) abuse caused an enormous burden of disease in Cape Town, triggering
aggression, hypersexuality and psychosis. Widespread alcohol abuse was exacerbated by the
historical practice of dop, whereby vineyard workers were paid partially in wine. Cape Town has one
of the world’s highest foetal alcohol syndrome rates, resulting in learning disability, congenital
defects and antisocial behaviour. With high HIV prevalence (17.8%), doctors had to differentiate
psychosis, depression and dementia caused by the virus or side-effects of anti-retrovirals from
psychiatric causes.
From long-stay wards and forensic services to community outreach clinics, the ethical
parameters of HIV psychiatry were everywhere. The neuropsychiatry ward, with just five beds, let
me examine my original question. In the UK, the Mental Health Act (1983) enables patients who
pose a danger to themselves or others to be treated for their mental illness without their consent,
while the Mental Capacity Act (2005) enables treatment for those who lack capacity. British
legislation allows treatment for mental (and not physical) disorder only, under the Mental Health
Act. Is it ethical to treat HIV against a patient’s will, to improve their psychiatric symptoms?
The first lesson I learned was that there is no single answer to this question. It fundamentally
depends on the patient, the situation and the risks involved. On the one hand, the South African
Mental Healthcare Act (2002), widely applauded for its liberal approach to psychiatric rights in
Africa, is less specific than ours. It is perfectly legal to treat a patient with HIV psychosis with antiretroviral medication (ARVs) against their will, to treat their psychosis. On the other hand, discussion
with practising psychiatrists revealed many reasons why this might not be the best course of action.
Clinicians were well aware of the risks of poor adherence to ARVs. Due to the devastating
outcomes of resistant HIV strains, none would wish to commence a lifelong course of treatment
requiring so much patient understanding and self-direction, without consent. This would be neither
ethical nor practically sensible, for the patient’s psychiatric or physical wellbeing. However, patients
frequently presented to A&E with undiagnosed HIV and CD4 counts of five or less. They usually had
florid psychiatric as well as immunodeficiency symptoms, the only possible treatment being ARVs.
Often, these patients lacked capacity, and medication would be prescribed in their best interests,
but if they had capacity and refused treatment, intensive efforts were made to explain the benefits
of treatment and likely outcomes of refusal. Thus, while the ethics of psychiatric treatment in HIV
are multifaceted, I learned that with flexibility, tailoring the approach to and involving the patient,
ethical decision-making could be achieved. I saw how practising psychiatry in a more holistic way,
embracing medical and psychiatric skills, made this strategy much more practicable. I was struck by
the artificiality of the dualism in Britain between the medicine of the mind and that of the body and
was inspired in my own career never to consider any aspect of a patient’s health irrelevant to my
care.
The challenge in Cape Town was to reassess the ethics for each and every complex patient,
under great time pressure and with so few resources to meet a great burden of disease. For the first
time, I understood that ethics is not a feature of medicine that appears occasionally with a
problematic case. The only way to practise ethically is to assess ethical implications routinely. I now
realise how transferrable these lessons are to the NHS. I was struck during my geriatrics placement
by widespread ethical concerns, from capacity in dementia to assessment of delirium. This
consolidated my appreciation of a rigorous ethical grounding for all clinicians, regardless of their
specialty. I was inspired to write up the case of a challenging patient, whose COPD-induced anxiety
and Alzheimer’s disease made assessing her capacity to demand discharge to her own home, despite
not coping, extremely difficult. I submitted this essay to the RCPsych faculty of Old Age Psychiatry
medical student essay prize.
Furthermore, I am motivated to expand my knowledge and training in ethics. I was recently
awarded an IME Institutional Grant to attend the BMA conference: ‘Morals and Medicine: A
changing landscape’. The event explores challenging cases in modern medicine, invaluable as I enter
the time-pressured world of Foundation Doctor jobs in August. Afterwards, I will present to the KCL
student Clinical Ethics Committee, to share lessons from the conference and encourage further
debate among my peers.
I was invited by the Royal College of Psychiatrists to write a blog about my elective. It was
very rewarding to undertake regular reflection on my experiences, a key feature of ethical medical
practice. It shared my learning with other students and explored the complexity of the cases I
encountered; I believe mutual education is integral to progressing in medicine. I referenced my IME
bursary on the blog and hope it inspires other students to apply.
My elective was the most stimulating, frustrating and inspiring experience of my medical
education. Every lesson learned was transferrable to ethical questions I will face as a new doctor in
2012. I explored a complex ethical question, learned the pervasive nature of ethics and identified my
dedication to a career that fosters lifelong learning. The insights, experiences and realisations I
acquired in Cape Town will stay with me for life, will make me a better doctor and as such, are
absolutely priceless.
Words: 1000
My Blog for the Royal College of Psychiatrists can be read at:
http://www.rcpsych.ac.uk/members/overseasblogs/capetown.aspx
Images (L to R, top to bottom):
Groote Schuur Hospital; Valkenberg Hospital, Cape Town
Valkenberg Hospital Shield, symbolising the valk (the raven) and the berg (Table Mountain) behind it; Apartheid-era sign
displayed at the District Six Museum.
Athlone community clinic, where psychiatrists undertake community psychiatric clinics in the heart of the township;
Selection of a traditional herbalist’s remedies, on sale outside the clinic pictured.
19th Century French saying, adopted as Valkenberg Psychiatric Hospital’s motto.