P-K4 Project Editorial
In a twist to Hougang resident Mdm Vellama Marie Muthu’s bid for the high court to declare that the Prime Minister does not have unfettered discretion in deciding whether and when to call a by-election, the spotlight eventually fell on Human rights lawyer M. Ravi. In the run up to the hearing, he was under a lot of stress and had seen Senior Consultant psychiatrist Dr Calvin Fones. The latter had deemed that Ravi had a manic relapse of his bipolar disorder for the past 2 weeks in a review on 14th July 2012. In a subsequent development, he sent a letter dated on the 16th July 2012 to the Law Society, explaining his review on the 14th including Ravi’s lack of insight on his condition, and a determination that Ravi was unfit to practise law. A representative from the Law Society, Wong Siew Hong asked to address the court. Justice Philip Pillai summoned all parties to the Chambers where Wong argued why Ravi should not continue with the case, using Fones’ letter as a justification. However, Wong was rebuffed by Pillai, who was only interested in the fact that Ravi had a practising certificate, which he had.
A primer on Bipolar disorder
In a nutshell, bipolar disorder is a mood disorder in which the patient may fluctuate between two extreme ends of the mood spectrum, the low end of the mood that we call depression, and the high end which is mania. Both spectrums of mood are a concern for doctors. Depressed people are at risk of suicide, while those in their manic states are prone to be involved in goal-directed activities that result in severe negative consequences, like spending unnecessarily on expensive items, e.g. buying 10 Louis Vuitton bags at one go when there is absolutely no need for them, or hypersexuality, where the patient gets involved in sexual relationships which he would not have if he was not manic, which puts him at risk of contracting sexually transmitted infections. Other symptoms that indicate a person is in a manic state are flight of ideas, where the person jumps from one idea to another, and usually the ideas are unrelated, and pressured or rapid speech. The manic patient will also exhibit signs of irritability and agitation, and tends to sleep less.
Mental Health and other ethical-legal issues
Having seen some of the arguments by commentators on the issue involving M. Ravi, it is apparent that the depth of ethical issues discussed appeared superficial but in actual fact, the depth of ethical issues involved that pertain to patients with psychiatric disorders go deeper than what most lay-people think.
In grappling with the topic of mental disorders, one of the pressing ethical issues is the principle of autonomy, which is broadly defined as the capacity of a competent individual to make decisions on issues pertaining to himself and his future. What is a competent individual? The term competence is too short, so let’s lengthen it to “decision-making competence”. According to a published paper on the topic, there are four broad components to “decision-making competence” – decision structuring, comprehension, information integration and insight.
Decision structuring is the ability to not only think about the possible actions that one may take, but also assessing the likelihood and desirability of the possible actions and their consequences. In short, it is the ability to generate options, and determine which consequences to consider and identify the relevant probabilities and importance of events. Comprehension is the ability to understand the information given before it can be used to make a decision. More technical measures of comprehension ability include the ability to recall or recognise the form, main ideas, or inferences in a text. The third component, information integration, is the ability to integrate the given information properly, and this involves combining elements of a decision coherently according to their relevance. In integrating and combining the information, the person may adopt a cost-benefit approach, where he considers the summation of costs pertaining to each option presented to him and the net benefits reaped. The last component, insight, is complex, because it goes further than comprehension where patients need to be able understand what they are told in the sense that it requires the person to understand the implications of the information given on their future. Insight focuses on the personal relevance and usefulness of the information, i.e. the value the person places on the information. There is another definition of “insight” especially to the psychiatrist. In this case, it is the degree to which a person recognises that he or she is unwell.
Thus, in a sense, a competent individual making a decision should be capable of the four components as discussed earlier. A person’s competence is however called into question when he has a psychiatric illness, say bipolar disorder, psychotic disorder, schizophrenia, etc. A bipolar patient in his manic state is incapable of exercising all 4 components of competent decision making, as do a psychotic patient who is suffering from schizophrenia. The situation is that as far as the medical field is concerned, under normal circumstances when the patient is autonomous, i.e. is able to exercise all components of competent decision making, the patient should have a say on how his treatment should proceed, which is especially so during this era of consumerism where going to a doctor is similar to consuming other services where the customer has more power.
However, the situation is completely different when the patient is incapable of competent decision making. For simplicity’s sake, let’s assume that the patient has not made any Advanced Medical Directive which will direct his treatment should he loses his competent decision making ability. In this situation, the treating doctor should treat the patient in a way that he will benefit in terms of his health outcome, and this should be motivated by the principle of Beneficence as enshrined in the Hippocratic Oath. In the past where doctors used to have most of the say over their patients’ healthcare, this type of doctor-patient relationship was derisively labelled as “medical paternalism”.
Going back to the principle of patient’s autonomy, how does psychiatry fit into the context of a patient with a psychiatric illness which affects his capacity to make decisions competently? Ideally, the goal of psychiatry is to treat the patient, which hopefully leads to the regaining of his mental health to the extent that he recovers his mental faculties and his ability to make decisions competently, becoming an autonomous individual again.
Mental Health Laws, Institutions and Confidentiality
One of the talking points that emerged from the controversy involving Ravi was the issue of patient confidentiality. At least, a number of individuals thought that Fones was wrong in breaching Ravi’s confidentiality when he sent the letter to the Law Society, highlighting that the patient’s confidentiality should not be breached under all circumstances.
Ideologically, most will agree, as much as possible the patient’s confidentiality should be preserved. However, there are certain situations in which the patient’s interests are considered against that of the community’s. Consider this example. If say the Severe Acute Respiratory Syndrome (SARS) was to re-emerge again, and if a doctor diagnoses a patient with SARS, should the former just keep quiet about it and send the patient home or notify the authorities? In the sake of protecting public interests, the doctor should notify the authorities, so that they will be able to do contact tracing and determine who are risk of exposure to the virus and take appropriate measures to prevent an outbreak. In the case of infectious diseases, the community’s interest take higher priority, and even if the patient is totally autonomous. Notifying the authority in this case is already breaking the patient’s confidentiality, but it is a justifiable reason.
For psychiatric illnesses, letting patients who have relapse of their illnesses move scot-free into the community could compromise the interest of the public. Many will be surprised to know of this, but in the United Kingdom, a patient who has been diagnosed with bipolar disorder has to inform the Driving and Vehicle Licensing Agency about his condition, which in effect requires one to divulge his medical condition to the authorities, which breaks his confidentiality, albeit for a good reason. A second example is the fact that psychotic patients are capable of violence, and if exposed to the public, there could be risk of injury to members of the public. And if we allow a patient with manic relapse back into the community, it could result in public disturbance of some sort, as alleged on what had happened to Ravi who was believed to have caused a disturbance at Sri Maniamman temple when he was believed to have his manic relapse. The other issue of major concern is the patient’s health, for example his hypersexuality could result in him contracting sexually transmitted infections and even spreading it to others if he already has one. Unfortunately, the case is that if public interests are involved, patient confidentiality has to be broken for the greater good.
This is why countries have enacted Mental Health Acts that can be used on patients that have a psychiatric illness which necessitates their detention at a Mental Health Institution for assessment and treatment. Singapore’s Mental Health (Care and Treatment) Act 2008 share its similarities to those adopted in the United Kingdom and Australia. Similarities lie in the fact that the person can be detained in a Mental Health Institution for finite period of time – 72 hours to be exact, and within the time frame, the patient must be examined by a doctor from the institution, to determine if he needs to be further assessed or treated.
However, it must also be acknowledged that detention at a Mental Health Institution, or for the use of a dirtier word, asylum, has been used for more sinister reasons. In the old Soviet Union, it was used as a method of repression to discredit and lock away political dissidents. This is why certain Mental Health Acts enacted elsewhere in the world have certain provisions that are built into them. Such provisions are, the ‘patient’ cannot be detained if what he expresses are due to political, philosophical, religious, etc, beliefs. This is an inbuilt safeguard against unjustified detention of ‘patients’ for dissenting political or religious opinions. The other important safeguards are the fact that the patient requires assessment and treatment. There are a few important criteria that must be fulfilled to determine that the patient fulfils the requirement for assessment and treatment, such as the patient is indeed suffering from a psychiatric disorder and his health will deteriorate if he was not assessed or treated, there is no less restrictive way in managing him and there is a chance of patient harming himself or the public if he has not been assessed or treated at the institution.
Handling a bipolar patient and a look at the M. Ravi case
In the initial encounter, the psychiatrist will take a history from the patient. It is similar to any other medical interview, where the patient volunteers information about himself and his health. A full psychiatric history, if we are talking about a new patient whom the psychiatrist has not seen before, will usually take 1 hour plus just to interview him and extract the relevant information. Even that may not be enough, and some psychiatrists schedule a second appointment. However, in some cases, some patients are not able to furnish a proper history, and the psychiatrist will take what is known as a collateral history. A collateral history is basically just extracting the information from another party who is familiar with the patient’s health, behaviour and habits. That would be usually a relative or close friend who accompanies the patient to the clinic. Ravi said that Fones only saw him for 10 minutes and Fones described the concerns expressed by Ravi’s ‘friends’ about his recent moods and behaviour, which suggested that he might have taken a collateral history. An examination known as the mental state examination follows the psychiatric history, and this is where the psychiatrist observes the patient’s appearance, response, behaviour, speech, evaluate his thoughts, etc.
In the letter, Fones further wrote that Ravi lacked any insight into his condition, which means he thinks Ravi does not understand that he is unwell. The big question mark at this point is whether Fones had assessed Ravi for his competency, which is as mentioned earlier, i.e. his ability to function as a competent decision-maker; if he has a manic relapse when with Fones, he is no longer competent. Fones’ letter to the Law Society was dated on 16th July 2012, in which he deemed Ravi unfit to practise law which would affect his professional capacity. The second big question mark is whether Fones had also assessed Ravi’s competency on 16th July 2012 before penning the letter.
Managing a bipolar patient at risk of relapse can be a tricky one. If the patient is competent during the time of medical appointment but still has a risk of manic relapse, detaining him although will benefit him medically will raise ethical concerns about detaining a competent person. For a bipolar patient, there are certain major health issues which take higher priority than how would he function in his professional capacity as a lawyer, teacher, etc. Bipolar patients are at risk of suicide, as fans of the band Nirvana will recall – Kurt Cobain, its lead singer and guitarist committed suicide, and he had bipolar disorder. The other issues are as mentioned earlier, hypersexuality which puts him at risk of contracting sexually transmitted infections or the risk of financial ruin when he spends excessively, which is why some medical schools (surprisingly from more democratic countries than Singapore) teach more draconian methods of managing bipolar patients – detain them at Mental Health Institutions, and appointing someone to manage their finances when they are manic.
If the patient is competent but runs the risk of relapse, probably one way is to ensure that there is a guardian or someone to keep an eye on the patient, make sure he takes his medicines, and instruct him to bring the patient to a mental health institution should there be a relapse. A referral letter can be written so that it can be produced to the psychiatrists at the institution.
If the concern was with Ravi’s relapse, having him at a designated mental health institution would address some of the top concerns with a bipolar patients such as suicide and goal directed activities with negative outcomes, etc. Fones did highlight in his letter that he would impose the Mental Health (Care and Treatment) Act on Ravi, and that should be rightly be done if Ravi has a relapse.
If Ravi has a relapse, using the Mental Health Act, appointing a financial manager and advising that he could not practise in his professional capacity as a lawyer is not out of normal. In fact if Ravi is involuntary detained, he cannot be in the courts.
However, if he has a relapse, advising that he could not practise as a professional lawyer ONLY WITHOUT using the Mental Health Act will raise eyebrows. Bipolar patients are at risk of more serious health consequences highlighted earlier, that they should be addressed through an involuntary detention.
Scrutinising Wong Siew Hong’s actions
It is claimed that Wong acted with the best intention. While not questioning Wong’s intentions, it is better to discuss on how appropriate they are. It was subsequently revealed that he heads a sub-committee on member care within the Law Society and they work to support those who have well-being issues.
As was discussed previously regarding Fones, the same question could be asked of Wong – did he cross-check with Fones on whether Ravi was competent, even on the 16th July. If Ravi was not competent, he obviously could not practise law.
However, granted that we can be generous, and want to give Wong the benefit of doubt for not being familiar with the medico-ethical issue of managing psychiatric patients, let’s do this thought experiment, and determine which of the two scenarios will better reflect a genuine concern over a fellow lawyer’s welfare.
- Ravi went into a manic relapse and started shouting at Judge Pillai. Pillai rebuked Ravi and Wong appeared and produced the letter explaining the reason for Ravi’s behaviour.
- This was what happened as reported. Ravi was representing Vellama and doing his usual thing in the courts without showing signs of manic relapse, and Wong appeared, producing Fones’ letter and telling the court that Ravi was unfit to practise law due to his manic relapse.
The first scenario definitely reflects a genuine concern over a fellow lawyer’s welfare. Ravi did suffer relapse, and with good intentions, Wong pointed out that Ravi was not well.
Whilst refraining from commenting on Wong’s intention for the second scenario, which was what happened, other than the fact that it raised more questions – why produce a letter when Ravi had no manic relapse? Is Wong aware of the proceedings which did not show any changes in Ravi’s behaviour? To borrow a quote from a certain minister, what do you think (of Wong’s actions)? Well, fortunately, Pillai thought none of it, and duly rebuffed Wong.
This article has been written with input from a practising doctor, a lawyer and a postgraduate student in ethics. They have chosen to remain anonymous out of professional courtesy towards those who are involved in the M. Ravi case