The most astonishing trait of the world we live in, the 21st Century World, is the connectedness, often superficial, but nonetheless connectedness. The people of the modern world are always ‘linked’ together, considering the rapid advance of globalisation, social media, multilateralism, and soft power.
One can celebrate 4th of July sitting in New Delhi, another can keep a fast on Navratri while living in Germany. On the other side, we also come together to stand up against matters like global hunger, climate change, and racism, but this connectedness, time and again, goes down the drain when it comes to mental health and peace. The life is fast paced, and people do tend to become a part of the rat-race, but the ultimate reality is, at the end of the day, decent mental health is imperative to healthy functioning in the, and of the society.
Most of the people at some point in their lives can be characterised with a form of mental illness, and it is nothing to be ashamed of, but to be sought professional help about, or at the least be talked about.
Speaking of India, a country where mental illness is widely considered to be a taboo, unrealistic, or just a first-world problem, it comes with no surprise when we see that a substantial number of suicide gets committed in the same country.
Not acknowledging the problem neither helps in the present, nor gives solutions for the future; in contrast, it makes the situation even worse.
Anybody can get diagnosed with mental illness, it is not a first-world problem, but it is prevalent worldwide. Suicide is the highest stage of mental illness where an individual thinks he/she has no alternative left, except to succumb to death.
Released last year, World Health Organisation's Global Health Observatory report suggests that India’s suicide rate (number of suicides per 1,00,000 people) was 16.3 in 2016, ringing alarm bells in the ears of concerned authorities and law-making bodies.
At 16.3 per 1,00,000 people, India's total suicide number more than that of the South-East Asia region, and the world. Female suicide rate at 14.7 is almost double than the world average at 7.7, and male suicide rate at 17.8 is more than that of South East Asia and the world. These are some unfortunate numbers.
In the 21st century, Southeast Asia is regarded to be at the frontline for delivering on the aspirational Sustainable Development Goal of a one-third reduction in the number of suicide deaths by 2030. With around 18 percent of the world's population living in India, addressing suicides in India is imperative to make a global difference in the burden of suicides.
In India, suicide is defined as an act of an unnatural death, the idea of which is originated in the concerned person itself, and the reason for taking one’s own life may or may not be specified. Global Burden of Disease study estimated that there were 2,30,314 death because of suicide in India, and according to the National Crimes Record Bureau (NCRB), suicide accounted for 133,623 deaths in India in 2015.
Attempt to die by suicide is defined as a nonfatal and self-injurious behavior with an intent to die. Attempts to die by suicide can be classified into: (i) severe, leading to incapacity, and (ii) non-severe, with full recovery in the short term.
According to Article 21 of the Indian Constitution, “No person shall be deprived of his life or personal liberty except according to procedure established by the law.” While the Constitution covers the right to life or liberty, it does not include the ‘right to die’. The attempts at taking one's own life are not considered to fall under the purview of constitutional right to life.
Section 309 of the Indian Penal Code (IPC) clearly states, “Whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for a term which may extend to one year or with fine or both.”
Historically, the religious institutions asserted great deal of influence over the matters of the State, especially in the cases of life and death. This led St. Augustine in fourth century BCE to frame legal declaration where suicide attempts were criminalised, considering the suicide being a sin and an act against the will of God.
The modern world - post enlightenment and renaissance - brought major socio-cultural changes in the society, especially after French revolution, which established the modern democratic nation based on liberty, equality, and fraternity. These qualities diversified and modernised the attitude towards suicide and attempted suicide. Nineteenth and twentieth century saw developed countries to repeal criminalisation of attempted suicide, but some countries continue to treat suicide attempt as a criminal offense, or at least as a social offence.
Two major kinds of arguments are generally put forth for criminalisation of suicide attempts, though in the contemporary political and socio-cultural times, these have been challenged.
First is rooted in the religious belief that only God has the right to dictate the end of life of a person, and it is perceived to be a sinful activity, punishment worthy, if a person attempts otherwise. Traditionally, suicide has been deplored by every major religion around the globe, and in Hinduism, the most practiced religion in India, death by suicide does not lead to achievement of salvation (Moksha).
The second argument for criminalisation is the belief that law can act as a deterrent against other such attempts in the society.
The criminal prosecution, and the imposition of custodial & financial penalties on those convicted of suicidal behaviour constitute an insult to human dignity. In a large majority, suicidal behaviour is typically a symptom of psychiatric illness, or is an act of psychological distress, indicating that the person requires assistance in his personal and psychological life, and not punishment by fine and/or imprisonment.
India is carrying the legacy of Indian Penal Code from the times of British Raj Regime, which ironically, Britain itself got rid way back in 1961 after decriminalisation of attempted suicide, but it seems that India is still hooked on to British Raj's archaic laws which were meant to be bounded on natives treated like slaves.
Delhi High court in a landmark judgment of 1985 had commented that “the continuance of Section 309 IPC (criminalising suicide) is an anachronism unworthy of a human society like ours.”
Mentally ill people are incapable to take decisions rationally or on their own, and mental illness lasts for a protracted period leading to a poor quality of life, and in the worst case, suicide.
Taking a progressive step, the Indian Parliament had passed the legislation called the Mental Healthcare Act in 2017 which defines “mental illness” as a substantial disorder of thinking, mood, perception, orientation, or memory that grossly impairs judgment or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs."
This is “an Act to provide for mental healthcare, and services for persons with mental illness and to protect, promote, and fulfill the rights of such mentally ill persons during delivery of mental healthcare services and for matters connected therewith or incidental thereto.”
This act rescinds/revoked the existing Mental Healthcare Act, 1987, which had been widely criticised for not recognising the rights of a mentally ill person, and paving the way for isolating such dangerous patients.
This act gives right to every person to access good quality, convenient, affordable, and accessible healthcare services. It protects mentally ill people from inhumane treatment along with access to free legal services. The act also empowers every mentally ill person to make an advance directive towards the way she/he wants to be treated for the requisite illness, and have a right to nominate her/his representative which has to be vetted by a medical practitioner.
Section 115(1) of The MHCA says, “Notwithstanding anything contained in section 309 of the Indian Penal Code any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said Code.”
The act also constitutes the directives for law enforcement agencies; police officer in-charge shall report to the magistrate, if the officer has reason to believe that a mentally ill person is being ill-treated or neglected. It also imposes a duty on a police officer to take under protection any wandering person, who will further get examined by medical authorities. Based on the authority’s report, the person either gets admitted in a mental health establishment, or be taken to her/his residence or to an establishment for homeless persons.
Under the act, a person with mental illness shall not be subjected to electroconvulsive therapy (ECT) therapy without the use of muscle relaxants and anesthesia. Furthermore, ECT therapy will not be performed for minors.
Part 2 of Section 115(2) of MHCA 2017 states that “The appropriate Government shall have a duty to provide care, treatment, and rehabilitation to a person, having severe stress and who attempted to die by suicide, to reduce the risk of recurrence of an attempt to die by suicide.”
Healthcare professionals in any hospital can use the following steps to manage a person who has attempted to die by suicide:-
- Assessment and triaging in the emergency room
- Stabilise the patient medically and/or surgically by providing necessary treatment
- Medico-legal case registration, and depending on the severity, admission if required
- Mandatory psychiatric referral for required assessment (making a diagnosis and assessing the severity of stress and suicidal intent), and treatment
- Inform the patient regarding Section 115 of MHCA 2017
- Inquiry by the health team and police regarding Sections 108, 109, and 116 IPC
- Discharge planning and follow-up care with medical, surgical, and psychiatric teams as per guidelines.
Once a patient is admitted in a general hospital following an attempt to die by suicide, emergency triaging and necessary medical or surgical management are mandatory to stabilise the person wherever required. The psychiatric team have to ascertain whether the event is a deliberate self-harm, or injury, or an attempt to die by suicide. To ascertain the severity of stress and the intent objectively, the psychiatric team may administer the perceived stress scale and the suicide intent scale on a patient, irrespective of the lethality of the incident. The psychiatric team has to inform the person and the caregivers about Section 115 of MHCA 2017. The police will get involved to ascertain the application of abetment laws.
The Section 94 of the MHCA 2017 allow the person who has attempted suicide to be treated at a general hospital for emergency purposes, but the person has to shift to mental health establishment within 72 hours.
The steps towards the decriminalisation of suicide in India are commendable, but were long overdue. Decriminalisation will reduce the trauma and potential prosecution in the aftermath of a suicide attempt. The new Mental Healthcare Act, 2017 is supposed to change the fundamental approach on mental health issues. It will provide for a sensible patient-centric health care, instead of a criminal-centric one. It cost us the death of a famous actor to start a conversation regarding mental illness, but it is never too late to talk about the things that matter.