Covert medication in India—Revisiting practice in the light of Mental Healthcare Act (MHCA) 2017

Dear Editor, We read with great interest the article titled “Attitudes of psychiatrists and caregivers towards covert medication (CM) administration in India: A cross-sectional study.”[1] The authors explored a sensitive, understudied area and provided valuable empirical findings regarding the widespread use of CM by psychiatrists in India. They also reported the divergence in attitudes between psychiatrists and caregivers concerning CM. However, we wish to draw attention to a crucial gap in the paper—namely, the absence of a critical evaluation of these findings considering the provisions of the Mental Healthcare Act (MHCA), 2017.[2] Discussing controversial mental healthcare practices in India, such as CM, requires balancing legal mandates of a human rights-based framework with the realities of resource-constrained psychiatric care. This study also highlighted this ethical tension: psychiatrists acknowledged CM as a violation of patient integrity compared to caregivers, yet most used it in their clinical practice, primarily due to non-adherence and safety concerns. This paradox cannot be adequately understood without situating it within the MHCA 2017 that marks a decisive shift from a paternalistic medical model to one grounded in autonomy, dignity, and legal accountability.[3] Under the MHCA 2017, CM raises significant concerns because it violates many provisions of the Act, such as informed consent, capacity-based decision-making, advance directives, and the patient’s right to treatment-related information.[4] It is evident that CM bypasses informed consent and undermines therapeutic transparency. The reported anger among patients upon discovering CM underscores this loss of trust and highlights the ethical and relational costs of such practices. While the Act permits limited coercive interventions under stringent conditions, it also mandates the use of the least restrictive alternative—leaving unresolved the question of whether CM can ever be justified within this framework, or whether it represents a form of “informal coercion” operating outside legal safeguards. However, given India’s collectivistic society and the crucial role that families play in supporting individuals with mental illness, the Act’s predominantly individualistic view of autonomy might not sufficiently guide clinical decision-making.[5] We therefore propose the incorporation of “relational autonomy” as a more contextually relevant ethical framework for Indian settings. Relational autonomy acknowledges that clinical decision-making often involves multiple people within care networks and that family involvement usually supports the patient’s perceived best interests.[6] Within the framework of the MHCA, 2017, this relational understanding of autonomy finds formal expression through provisions such as advance directives, nominated representatives, and supported decision-making.[2] However, this does not legitimize CM as routine practice; rather, it calls for a shift from unilateral decision-making to ethically grounded, family-engaged deliberation, with the ultimate aim of restoring the patient’s own autonomy. In light of the above discussion, we propose the following safeguards to align the practice of CM with the spirit of the MHCA 2017, while acknowledging clinical realities: (1) CM should be considered strictly as a last resort after documented attempts at engagement, psychoeducation, and adherence-enhancing strategies; (2) a formal assessment of capacity and involvement of the nominated representative, where applicable, should precede any such decision; (3) CM, if used, must be time-limited, with mandatory documentation of the rationale, alternatives attempted, and periodic review; (4) its continuation should be contingent on demonstrable clinical benefit and clear safety thresholds; and (5) a structured plan for eventual disclosure should be integral to care, enabling restoration of trust and the therapeutic alliance. Another important finding of the study is the ethical dilemma underlying CM practice, wherein psychiatrists recognize its problematic nature yet continue to use it, reflecting potential moral distress and the strain of working within constrained systems where ideal care is often unattainable. Addressing this requires not only legal clarity, but also ethical frameworks that can guide practice in such gray zones. We suggest that the “deliberative model of clinician–patient communication” offers one such pathway.[7] In this model, the psychiatrist functions neither as a passive informant nor as an authority figure, but as a moral collaborator who engages both patient (where possible) and caregivers in shared reflection. This involves open discussion of risks, values, and constraints—including the ethical costs of deception versus the harms of untreated illness—thereby reducing the need for covert practices and fostering trust. In conclusion, while the study makes an important contribution by documenting prevailing attitudes and practices, the lack of engagement with MHCA 2017 limits its normative relevance. Any meaningful discourse on CM in India must move beyond descriptive accounts to a legally and ethically grounded analysis. We hope this perspective contributes to an ongoing dialogue toward developing context-sensitive yet rights-consistent guidelines for psychiatric practice. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.