Zoheb Rafique

INTRODUCTION:

Asia is the most diverse continent in the world in terms of culture, religion, population size, finance, education, health care, academic research, general population skills, and governmental drug regulations. Each Asian country has its own unique qualities when it comes to attracting industry sponsored clinical trials. Factors that influence selecting location of a study site for a sponsored trial are mainly population size, infrastructure, education levels, quality of health care, cost and drug regulatory platform. Some Asian countries such as Japan, Hong Kong and Singapore have among the longest life-expectancy, lowest infant mortality and highest per capita income worldwide, while others are in the lower end of such rankings. Several, notably China and India, are amid rapid economic development, as the Asian economy is more-or-less becoming the global axis, with the economies of US and Europe slowing. Asia has a population of 3.8 billion, at least ten times more than North America or Europe. As the world’s most populous continent, Asia has by no means reached full capacity in contributing with subjects in testing new medical products in collaboration with the international pharmaceutical industry. This trend will certainly direct more sponsored clinical trials to Asia, but not necessarily benefit all Asian countries. Engaged in 18.1 % of all protocols globally Asia is involved in more sponsored trials than any other region. India, Korea and Taiwan standout as the most active locations for multi-national trials in Asia. When ranking is for cities Seoul is the most active Asia city, followed by Taipei, Hong Kong, Singapore and New Delhi. The globalization process of sponsored clinical trials has provided an opportunity for Asia to attract international companies to the region and also seemingly encourages development of local life-science industries (1). In this paper, I will discuss the responsibilities of researcher/funder when the research trial is conducted in developing countries and especially in our country Pakistan and I will also talk on ethical justifications of doing research trials in Pakistan and other poor and developing countries.

DISCUSSION:

Resource poor countries require a lot of attention from the medical research establishment in order to sustain the quest for treatments and remedies for diseases and other health-threatening conditions. However, the collaboration between rich countries and well-endowed agencies, on one-hand, and economically constrained research communities, on the other, requires a careful assessment of responsibilities and options for researchers and research subjects alike. Major players in international research also include big pharmaceutical companies who seek people living in developing countries as subjects. Safety and standard of care for human volunteers are also major issues. “I had not been exploring Big Pharma of third world ‘volunteers’ as cheap guinea pigs, observes writer John le Carre (2001). “Their role, though they may not ever know this, is to test drugs, not yet approved for testing in the US, which they themselves will never be able to afford even if the tests turn out reasonably safe” (le Carre, 2001). In the US, it costs on average $ 10,000 per patient to conduct a clinical trial, in Russia $ 3,000, and in the poorest parts of the world, much less. This is one of the strong reasons why clinical trials are now a Third World growth industry. In the end, the drugs under trial are for western markets. In its May 2000 edition, Center Watch, a newsletter for the burgeoning clinical trials business, published an exuberant article under the title Latin American Fever in which it said the continent ‘may offer a unique opportunity to reach much larger numbers of study subjects’. Eli Lilly tested 590 patients, in 1994, across Africa, the Middle East and Central and Eastern Europe. In 2001, the company expected to run tests in those regions on 7,309 patients. It is not only the human subjects who are at risk. In the rush to market, poorly constructed, weakly monitored trials are releasing untried and untested drugs for consumption (le Carre, 2001). The Contemporary practice of biomedical research on a global scale has given rise to evolving forms of exploitation. Standards of justice and equality tend to be put in question in the face of research practices that often put heavy burdens on poor people and poor communities in poor countries. There is a need to remain vigilant in the prior review of these activities and the monitoring of their implementation in order to ensure that biomedical research is conducted in accordance with universally acceptable standards. One of the most important requirements for the conduct of research in developing countries is emphasized in the WHO-Council for International Organizations of Medical Sciences’ Guidelines for Biomedical Research Involving Human Subjects: to guarantee that those communities where these new drugs have been tested will be given affordable access to the newly developed and approved drugs. Otherwise, one might rightly argue that people in developing countries have yet again been exploited by Western researchers without benefiting from the positive results their risk-taking has yielded (Del Rio, Kamarulzaman, and Schuklenk, n.d.). Ruth Macklin observes that it is not just individuals who can lose out when big drug companies carry out their tests. When industrialized countries do research in a developing country, the developing country can’t afford the products of that research. The researcher’s pullout and the successful products then become available in the Western industrialized countries and the population in the countries where the research was done get nothing. So that’s truly a question of justice, and we’re beginning to see a movement to rectify that injustice (2000). The wide disparities in resources that are available for biomedical research in developed and developing countries give rise to ethically relevant issues of research prioritization and collaboration. The international research community has to accelerate the shift to an environment where researchers from developing countries are recognized as full and equal partners in biomedical studies; where the technologies of developed and developing countries are integrated and made widely available; and where the benefits of biomedical research for participant communities can be ensured (2). In resource-poor countries like Pakistan and majority of developing countries, the two primary means of protecting participants-IRB review and Informed Consent may be inadequate. IRBs in developing countries may lack training, experience, and resources. IRBs in the United States are unlikely to be familiar with conditions in the host country. Informed Consent may be problematic in a country where people are poorly educated and lack health literacy, and where physicians in clinical practice usually do not tell patients their diagnosis, admit uncertainty, or obtain consent. Participants may not accept Western models of disease. Furthermore, participants might hear rumors and other misinformation about a research study. In several highly publicized cases, researchers from developed countries have been harshly criticized for allegedly conducting inappropriately risk studies in resource poor counties without adequate consent. The other problem is health priority and it would be an imprudent use of limited health care resources in a developing country to conduct human-participants research that does not address a health or public health priority in the host country. Because of scarce resources and logistical constraints, medical interventions that are standard in developed countries may not be available or feasible in resource poor countries where the trial is conducted. This creates an ethical tension between providing a benefit to research participants and obtaining generalizable scientific knowledge. According to the ethical obligation to minimize harm to participants, researchers should provide interventions that are known to be effective and feasible to prevent or treat the condition addressed in the clinical trial. Because participants in a research study help researchers, sponsors, and society at large, they should receive some benefit in return as a matter of reciprocity. Advocates contend that researchers and sponsors must avoid taking unfair advantage of participants and their communities by providing those who bear the risks of research appropriate benefits, in addition to the long-term benefit of generalizable knowledge. Researchers and Sponsors need to consider whether the study intervention will be available in the host country if it is shown to be effective and safe. Some ethics expert point out that providing reasonable access to study interventions after a trial may be an inadequate reciprocation for participation in research. First, it is too limited and weak an obligation. If the study is something other than a pivotal clinical trial (for example, an epidemiological study), no additional benefits will be required. Even if the study is a clinical trial, it might be a negative study. Second, other benefits might be more useful to participants or their communities than the trial drug. For example, they might benefit more from better primary care or better education for host country health care workers. Third, the appropriate target group for benefits may be all persons in the community where the study is carried out, not just trial participants.

Providing benefits only to trial participants will widen health disparities in the resource-poor host country and therefore raise concerns about causing injustice. Thus, providing benefits to the host country should be done in a way that ameliorates rather than worsens health disparities. For these reasons, some writers argue that researchers and sponsors from the developed world should provide fair benefits to the research participants and their communities in reciprocity for what they contribute to the research. Researchers could provide benefits to research participants in a number of ways, such as by providing health education or some basic health services; training local health care workers, researchers, and IRBs; donating equipment at the end of the study; and giving local investigators a key in analyzing data and writing papers. Such contributions ensure that the community where the research is carried out will receive benefits in reciprocity for participating in the research. By building infrastructure, researchers can help provide sustainable improvements that will help to narrow health disparities between rich and poor nations (3). Pakistan is also among the poor and one of developing country and the health care conditions here are same as any South Asian or African country. We will apply the same ethical and moral rules when we talk about research here in Pakistan. Ethical requirements for clinical research do not end when individuals either sign the consent form or are enrolled in research or refuse enrollment. Individuals must continue to be treated with respect from the time they are approached even if they refuse enrollment throughout their participation and even after their participation ends. Respecting potential and enrolled subjects entails at least 5 different activities. First, since substantial information will be collected about enrolled subjects, their privacy must be respected by managing the information in accordance with confidentiality rules. Second, respect includes permitting subjects to change their mind, to decide that the research does not match their interests, and to withdraw without penalty. Third, in the course of clinical research new information about the effect of the intervention may be gained. Respect requires that enrolled subjects be provided with this new information. Fourth, the welfare of subjects should be carefully monitored throughout their research participation. If subjects experience adverse reactions, untoward events, or changes in clinical status, they should be provided with appropriate treatment and, when necessary, removed from the study. Finally, to recognize subject’s contribution to clinical research, there should be some mechanism to inform them of what was learned from the research (4).

CONCLUSION:

The basic disclosure requirement for satisfying the informed consent provision in U.S. research regulations focus on information needed by a potential participant to decide whether or not to participate in a study. Of the eight basic disclosure requirements, one focuses on potential benefits: a description of any benefits to the subject or to others which may reasonably be expected from the research. Traditionally, such a disclosure has been required to ensure that potential participants understand whether there is any possibility that the intervention itself might benefit them while they are enrolled in the study. There is, however, no specific mention of any post-trial benefits. If any case, those who may participate in studies should be informed of the potential benefits, if any, that they might receive by doing so. Because this information is relevant to participants’ decisions to participate in the research, ethics review committees should require investigators to make these disclosures (5). In the end I will conclude by saying that research participants should know each and every thing regarding their participation in the research trial or rejecting it, and it is their right to know all risks and benefits while participating in the research trials and this should be applicable to all countries around the world including all developing countries and also our country Pakistan.

REFERENCES:

1. Johan PE Karlberg. Development of Sponsored Clinical Trials in Asia. Clinical Trial Magnifier. 2008; Vol. 1:5: 77-100.

2. Leonardo D. de Castro Et Al. Bioethics in the Asia-Pacific Region: Issues and Concerns. 2003; 1-108.

3. LO B. Clinical Research in Resource-Poor Countries. Ethical issues in Clinical Research: A practical Guide. 2008; Ch.22:194-210.

4. Ezekiel J. Emanuel Et Al. What Makes Clinical Research Ethical? JAMA. 2000; 283(20): 2701-2711.

5. Ch 3; Voluntary Informed Consent. National Bioethics Advisory Commission. 35-53.

Diabetes and obesity have been highest in the most serious threats in world’s health. Diabetes is now one of the serious chronic diseases which have affected many of the Australians as it is the sixth highest cause of the death by disease in Australia (“Type 2 Diabetes and Obesity still on the Rise” 2007). It is caused by the constant increase in the blood glucose level in the body due to the inability to either produce or properly use insulin, which lead to many complications which can be acute and long term (Greenbaum & Harrison, 2008, pg. 1). According to the recent data, it has been shown that the prevalence of diagnosed diabetes has been doubled from the last studies. This disease and it complications were found to 8% of the total burden of disease in Australia in 2003 such as person with diabetes is at twice at the risk of developing cardiovascular, eye and kidney disease (Australian Institute of Health and Welfare, 2008).

This article is mainly based on the data from 200-08 National Health Survey conducted by the Australian Bureau of Statistics. It involves type 2 diabetes related factors such as demographics, medical history, height, weight, smoking, and physical activity. In 2007-08, national health survey estimated that 818,200 people or 4% of the population have been diagnosed with diabetes which excludes gestational diabetes (Australian Government: Department of Health and Ageing, 2009). By comparing this data with data from 2004-05, it has been increased by 0.5% that is number of people reporting to have diabetes is increased from 700,000 to 818,200 (Australian Bureau of Statistics, 2010). Recent national data indicate that with every one diagnosed case, there is one undiagnosed case (Australian Institute of Health and Welfare, 2008).

Type 2 diabetes is the most common type of diabetes as people diagnosed with diabetes, 88% reported to have this type 2 diabetes where as only reported to have type 1 diabetes. The other 2% left was not being diagnosed with particular type of diabetes. Even though there is increase in number cases of developing this disease, there is also improvement in early detection of this disease and people are living longer (Australian Government: Department of Health and Ageing, 2009). There are more cases of type 2 diabetes since 2004-05 survey, it increased from 83% to 88% in total diagnosed diabetes. Type 2 diabetes increases in obesity and physically inactive lifestyles, and with the age. Diabetes is more prevalent among Aboriginal and Torres Strait Islander peoples as compared to non-Indigenous people. Demography does play a role in diabetes prevalence as it was least prevalent among people born in north-west Europe (2.7%) as compared to people born in southern and central Asia (8.7%). Being overweight and lack of physical activity can increase the risk of developing type 2 diabetes (Australian Bureau of Statistics, 2010).

The majority of diabetes is classified into two types that is type 1 which is insulin dependent diabetes and second is type 2 which is insulin independent diabetes. Type 1 diabetes can be defined as an autoimmune destruction of pancreatic beta cells which slows or stops the production of insulin in the body. Type2 diabetes can result from insulin resistance that is inability to use insulin properly or insulin deficiency that is inability to produce adequate amount of insulin in the body (Type 2 Diabetes and Obesity Research, 2007, p. 1). This type 2 diabetes is responsible for 85-90% of all diabetes (Greenbaum & Harrison, 2008, pg. 1). Due to the inadequate insulin production, body could convert sugar which is present in the blood in the energy needed for that body. After eating, body need insulin which is produced by pancreas to transport sugar from the blood into the cells and also to inhibit the production of glucose produced in liver. When inadequate insulin is produced by the body, glucose is overproduced by the liver which stays in the blood. This cause high blood sugar level which damage blood vessels and body organs (“Diabetes – Type 2” n.d.).

Type2 diabetes can be caused by both genetic and environmental factors. Some genes can cause impaired insulin production in the body and family history can also increase the risk of developing diabetes. Other lifestyle factors such as poor diet, obesity and lack exercise can also cause diabetes. Obesity is the most common factor which is found in most the people suffering from type2 diabetes (“Diabetes – Type 2” n.d.). Obesity defined as having body mass index greater than 30 kg/m2. Obesity is the major risk factor for the type2 diabetes that is more is the body mass index (BMI) greater is the risk of diabetes which is also associated with hypertension, cardiovascular disease and hyperlipidaemia (Marks, Coyne, Pang, 2001). As per the research 90% of the people suffering from diabetes are obese or overweight (World Health Organization, 2005). As per researched statistics, over 7 million Australians adults were obese in 2004-2005. Obesity is a serious health problem which is mainly influenced by various risk factors such as heredity, diet, and lack of exercise.

Type 2 diabetes cases in 2009 versus Body Mass Index

Data sourced from (“Australian National Diabetes Information Audit and Benchmarking”, 2009, pg. 139).

This graph above shows the increase in the prevalence of type 2 diabetes with an increase in Body Mass Index (BMI) that is BMI greater than 30 is at the highest risk of developing diabetes type 2.

Insulin resistance

Insulin resistance refers to metabolic abnormality state in which body cells become insensitive to insulin. Inability of cells to utilise insulin to enhance glucose uptake by muscle and adipose tissue can lead to high blood glucose level. This insulin resistance is mainly associated with abdominal obesity and high blood pressure (Dolson, 2010).

This insulin resistance can be both genetic and acquired. Impairment in insulin receptor signal transduction pathways can decrease the biological response to insulin which will ultimately affect glucose uptake and increase in blood glucose (Surampudi, Kalarickal & Fonseca, 2009, p.218). Acquired insulin resistance is associated with obesity which can result from circulating free fatty acid that disrupt insulin signal pathways and resists insulin action to transport glucose in muscles which cause type 2 diabetes. (Guilherme, Virbasius, Puri & Czech, 2008, p.367).

There are more factors which are involved such as fat distribution, genetic susceptibility and some metabolic problems.

Fat distribution

Body fat can be divided into two parts, first is subcutaneous fat which accounts 80% of the total body fat where as other 20% is visceral fat which lies within thorax, abdomen and pelvis (Langin et al, 2009). This visceral fat is the main contributor to the problems such obesity. This visceral fat increase the production of adipocytokines, which cause the inflammation and insulin resistance and also reduce the secretion if insulin sensitizing adipocytokines. Hepatic and muscle insulin resistance can be caused by the increased amount of free fatty acids in the portal and systemic circulation system (Bays et al, 2004). Study revealed that distribution of the abdominal fat is more effective in diagnosing diabetes than the total abdominal fat. Through CT scanning, they found that the diabetics had greater amount of intra-abdominal fat than non-diabetic groups with the mean difference of 14.1 cm3. Stieler and Yelland (2009) elaborates that the abdominal fat within the peritoneum layer is more common with diabetic patient that non-diabetic patients.

Free fatty acids

Lipolysis refers to breakdown of triglycerides into free fatty acids which is more frequent in visceral tissue than the subcutaneous fat. When fat mass increases, it increases the rate of lipolysis which is more common in obese people and those with type 2 diabetes. These free fatty acids stimulate gluconeogenesis and can lead to insulin resistance and also reduce the insulin secretion. The ability of β cells to secrete sufficient insulin so as to compensate insulin resistance in the individual to maintain their normal blood glucose level will help to determine that whether the person will remain insulin resistant with normal glucose level or will the person develop type2 diabetes (Whitmore, 2010, p.880-881).

Adipocytokines

Adipose tissue in the body helps for the fat storage which increases insulin sensitivity by secreting large amount of cytokines and other related hormones. Bays et al (2004) states that in type2 diabetes, due to the reduced secretion of adipocytokines and increased production of inflammatory cytokines can cause adipocyte dysfunction. To prevent this dysfunction, it is important to control cytokines in the body system. As per Dewan & Wilding (2005), these hormones can be controlled by reducing body weight/mass.

Adipose tissue plays an important role in balancing glucose level in the body in both normal and disease body state. It helps to secrete appropriate level of adipokines which influence metabolism in the whole body and neuroendocrine control of the behaviours related to feeding. It also helps to store lipids as adipose triglycerides which reduce the harmful effects of both circulating free fatty acids and ectopic triglycerides stores. In the normal body, adipocytes help to synthesise and store triglycerides during feeding whereas in fasting stage, it help to hydrolyse and release triglycerides as free fatty acids and glycerol. In most lean individuals, insulin sensitivity and glucose uptake is normal in skeleton muscles. In obese body, deposition of triglycerides increases due to high caloric intake which cause adipocytes enlargement. Due to this enlargement, adipocytes continue to store further triglycerides even in fasting stage. As the adiposity increases, it affects adequate functioning of adipocytes as endocrine cells. The development of inflammatory state in adipose tissue due to large amount cytokines secreted by adipocytes can cause insulin resistance. Accumulated triglycerides in the form of long chain in skeleton muscles disrupt normal metabolic and secretory function of these tissues. Due to prolonged high caloric intake can cause inflammatory response which ultimately leads to adipocyte dysfunction (Guilherme, Virbasius, Puri & Czech, 2008, p.368-369).

Prevention/ management of Type 2 diabetes

Poor dietary habits decreased physical activity and obesity can increase the risk of developing diabetes as it affects insulin action or secretion in the body system. Therefore it is important to control the unwanted weight gain.

To address the significant growth of type 2 diabetes and to lower its risk, Council of Australian Governments announced the Prevention of type 2 diabetes program in April 2007. To address risk for type 2 diabetes, health practitioners use Australian type 2 diabetes risk assessment tool (AUSDRISK) which help to prioritize people with high risk of developing this diseases. Some of the other program which assists in prevention of type 2 diabetes is lifestyle modification program (Australian Government: Department of Health and Ageing, 2010).

Australian type 2 diabetes risk assessment tool (AUSDRISK) which will help to get a score from the question related to one’s life. If a person scores more than 12 points in AUSDRISK, than that person may have undiagnosed type 2 diabetes or is at high risk of developing this disease (Australian Government: Department of Health and Ageing, 2010).

Lifestyle modification programs help participants to make positive lifestyle changes which include diabetes risk factors, nutrition advice and education, goal setting for weight loss, energy balance, physical activity goals and encouraging participants to self-monitor their progress (Australian Government: Department of Health and Ageing, 2011).

National health survey, 2007-08 showed that 61.4% of the Australian population are either overweight or obese in which 25.6% of males and 24% of females were classified as obese (Australian Government: Department of Health and Ageing, 2010). It is not possible to change specific risk factors like age and genetic background but it still possible to minimise the risk of developing this disease by maintaining healthy weight, healthy eating such as eating plenty of vegetable, fruits and high fibre cereal products every day, and by increasing physical activity. Type 2 diabetes is strongly linked to obesity as recent data showed that 80-90% of people diagnosed with type 2 diabetes are over-weight or obese. International studies revealed that regular physical activity of at least 30 minutes and 5-7% of weight loss can reduce the risk of developing diabetes by 60% (“Type 2 Diabetes and Obesity still on the Rise” 2007).

This weight loss can reduce the risk of related comorbidities such as cardiovascular diseases, sleep apnoea and obesity-related malignancy by improving blood glucose level and blood pressure. People with type 2 diabetes will need to work 50% more than non-diabetic people to lose weight it can be a slower process as compared to general population and will be more difficult for the obese patient suffering from type 2 diabetes (Whitmore, 2010, p.881).

Using pharmacotherapy for obesity like orlistat that works well by blocking the hydrolysis of dietary triglycerides and inhibit fat absorption. Bariatric surgery can also be one of the option for the patient with BMI more than 35 kg/m2 (Whitmore, 2010, p.884-885).

Conclusion

Obesity and type 2 diabetes are strongly linked as obese person is at the higher risk of developing type 2 diabetes than the normal person with the healthy weight. Healthy weight, healthy eating and regular physical activity will improve insulin sensitivity, blood glucose level and the other health related issues such as cardiovascular risk factors. Weight management will the best way to reduce the risk of developing this disease. By using the AUSDRISK and diabetes related programs initiated by Australian government will help to prevent type 2 diabetes.

Reporting.

Mental illness treatments have a long history of bizarre and inhumane practices being performed on mentally ill patients which has given rise to a variety of professional, social as well as ethical issues. (Evans, 2009) At first, the situation in the given article seemed quite normal to me because my thought process was based on my previous beliefs and knowledge. As soon as I have learned the purpose of mental health nursing, I came out with some crucial issues that need to be addressed. One of the issues I have identified is the ‘stigma’ related to mental illness which in the given situation has labeled the patients as ‘unfortunates’, treated them as criminals (three men having no charges against them), seizing their freedom and socially isolating them. Moreover, subjecting these mentally ill patients to an ‘involuntary treatment’ is an another issue in which paternalistic care is forcefully being imposed on them without obtaining their formal consent that has resulted in the loss of patient-centered care as well as person’s autonomy. (Rodriguez-Osorio & Dominguez-Cherit, 2008)

Responding.

I strongly believe that mental illness results predominately from various social causes including our day to day problems, someone’s death in the family, any painful event or any issues from childhood and, some risk factors such as divorce or separation from partner, loneliness, social isolation or unemployment. (Nakane et al., 2005) Also, I believe that the people suffering from mental disorder might feel emotionally as well as physically weak, remain tensed most of the time or may not share their problems with anyone. Moreover, in my viewpoint, the symptoms of depression or unwell mental state are quite noticeable especially in case of one’s own family, friends or colleagues. But there is a need of understanding that mental illness should not be stigmatized. We should not discriminate with the people suffering from mental illness nor make them feel worthless. My beliefs, experiences, and knowledge has always directed me to approach mentally disturbed people in a positive way so that any possible help could be provided to them. Because in my opinion, the mental disorders due to such social causes or risk factors can easily be prevented from getting worse by helping people on personal front. The worsened mental condition may lead to self-harm or harm to others. The prevention methods which I usually follow include interacting with the sufferers, making them feel comfortable, sharing their problems, spending some quality time with them, empathizing them, involving them in other activities, help them to come out from the distressful conditions and if required, encourage them to go for an appropriate medical treatment.

Relating.

There is a long history of stigmatization of the people suffering from mental health issues throughout the world. (Flaskerud, 2017) I come from India, where mental health issues remain unreported due to prevalence of stigma, lack of self-awareness, social bias, fear of rejection or avoidance and embarrassment. (Kishore, Jiloha, Gupta & Bantman, 2011) I have seen that people in rural as well as urban India, irrespective of their class, still believe that mental health issues are caused by some evil spirits, sins of the past, curse of God, evil eye or bad karma. Therefore, people tend to visit faith healers or tantric for the cure of mental illness rather than going to a psychiatrist. (Kermode, Bowen, Arole, Pathare & Jorm, 2009) This indicates the lack of knowledge about the treatment of mental illness. I have also observed that transgender community face increased social stigma, discernment, rejection from family along with high physical violence which results in depression and anxiety with risk of suicide. (Iyer et al., 2019) My observation about my society and culture is that people hesitate to disclose their mental status. Moreover, the fear of ignorance and being judged, discrimination, unfair denial of employment, loss of confidentiality and autonomy and societal isolation remain at top of their mind. (Sarkar et al., 2017). In addition to this, I strongly believe that news media, as well as social media, has a major effect on people’s particular attitudes and behaviors as I have experienced it by myself. I was greatly motivated when a famous Bollywood celebrity named Deepika Padukone openly and broadly expressed her struggle with depression on India’s one of the biggest news channel. This also affected people’s perception of mental health issues and, to large extent, brought a positive change in their attitude and intentions to seek appropriate medical treatment. (Jain, Pandey & Roy, 2017)

Reasoning.

My knowledge, attitude and thinking about mental health and illness have changed with time and experience. As in given case, there is a stigma of criminalizing the mentally ill patients, discrimination in giving them fair medical treatment, ignoring the chances of their recovery and isolating them which according to my existing knowledge, possess a huge risk to the mankind and such stigma should be eliminated. Furthermore, it is clear that these mentally ill patients are being subjected to paternalistic care. Their right to know about treatment, right to refuse the treatment, their autonomy and confidentiality are all ignored. Their involuntary institutionalization without prior consent will give them poor quality of treatment and severely deteriorate their mental health, making them more weak, violent and self-harmful. I have learned that the healthcare and treatment ethics should not be ignored when it comes to the mental health.

Reconstructing.

I believe that my new understanding of mental health and illness will definitely have a positive influence on my nursing practice. The issues related to mental health which I used to intentionally or unintentionally ignore in the past will be eradicated and I will tend to be more sensitive while handling the patients with mental illness. The issues like stigma/discrimination and involuntary institutionalization/treatment are very significant. (Jaeger et al., 2013 & Flaskerud, 2017) As in the given situation putting mentally ill patients in jail can be highly destructive to the patients itself, their illness, the clinician-patient relationship and to the society as whole. (Nurse, 2003) As a mental health nurse, I will work towards developing and maintaining a proper therapeutic relationship with the patient and not being judgemental or discriminatory. This will further help in providing patients with the most appropriate treatment which will improve the quality of their life. (Harrison, Hauck & Ashby, 2017) The nurse-client relationship is strongly recommended to establish human connectedness which is based on the genuine interest in understanding the patient and how they come to be in their current situation. (Jackson & O’Brien, 2009) I have now learned that mental health nursing also requires interpersonal skills along with the clinical knowledge and experience. Therefore, Self-awareness should be there as it will help me to know about the way I respond to a particular situation, make me aware of my values and beliefs and help me to understand my attitudes and biases towards people and situation. (Jackson & O’Brien, 2009) My understanding about obtaining the consent from the patient has also changed. I have realized that coercion, forceful medical treatment, involuntary hospitalization possess a high risk to patients’ safety, privacy, and confidentiality. (Salize & Dressing, 2005) As a mental health nurse, I will treat patients fairly and appropriately, maintaining their dignity and confidentiality, obtain consent before subjecting them to treatment and respect their decision of refusing the treatment.

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