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 anti-retroviral 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:

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.