| Abstract|| |
The prevalence of suicides has been increasing in recent years. The number of persons who attempt to die by suicide is 25 times that of the number of those who die by suicide every year. Indian Government passed the Mental Healthcare Act (MHCA), 2017 in the middle of 2018. Section 115 of the act decriminalized the attempt to die by suicide, thereby reducing further stress on the victim. This has legal implications with regard to abetment laws of Sections 109, 116, 306, and 309 of Indian Penal Code. Regarding mental healthcare delivery, this act enables the person who attempted to die by suicide, to access free healthcare, treatment, and rehabilitation. The cost implications for the government are enormous. Medical professionals, mental health professionals, and general and mental health establishments involved in the care of persons who attempted to die by suicide need to update their knowledge to enhance their assessment and management skills to align with the provisions of the act. Massive public awareness programs need to be conducted to enable persons who attempted to die by suicide, to access mental healthcare as per the provisions of the MHCA 2017.
Keywords: Attempted suicide, Mental Healthcare Act 2017, suicide
|How to cite this article:|
Vadlamani LN, Gowda M. Practical implications of Mental Healthcare Act 2017: Suicide and suicide attempt. Indian J Psychiatry 2019;61, Suppl S4:750-5
| Introduction|| |
Suicide is defined as an act in which a person intentionally causes his/her own death. In India, the number of people who ended their lives by committing suicide was 131,666 in 2014; 133,623 in 2015; and 230,314 in 2016. Attempt to die by suicide is defined as a nonfatal and self-injurious behavior with an intent to die. For every death by suicide, on an average, 25 people attempt to die by suicide.,, As per the ratio, in 2016 alone, approximately 5.75 million people attempted to die by suicide in India. Attempts to die by suicide can be classified into: (i) severe, leading to incapacity and (ii) nonsevere, with full recovery in the short term. As per WHO, in 2016, 17% of the persons who attempted to die by suicide belonged to the severe category, i.e., 977,500 persons, and the remaining 83%, i.e., 4.77 million persons belonged to the nonsevere category.
In a study by Kumar et al., the most common methods of suicide attempt were ingestion of pesticides (50%), drug overdose (35%), hanging (10%), and use of sharp objects, drowning, self-immolation, and falling from a height (5%). In the same study, 48% had a diagnosable psychiatric disorder. Adjustment disorder was the most common diagnosis (23.5%) followed by major depressive disorder (14.5%). Low intentionality (58%), low lethality (68%), and impulsive attempt (80%) were some of the significant observations. Marital conflicts, family stress, low socioeconomic status, financial issues, and alcoholism  contributed to the majority of the risk factors in those who attempted to die by suicide.
In India, the Mental Healthcare Act (MHCA) 2017 was passed on April 7, 2017 and enforced on May 29, 2018. This is “an Act to provide for mental healthcare and services for persons with mental illness (who have substantial disorder and whose functioning is grossly impaired) and to protect, promote and fulfill the rights of such mentally ill persons (who have substantial disorder and grossly impaired functioning), during delivery of mental healthcare services and for matters connected therewith or incidental thereto.”
Until now, an attempt to die by suicide was a criminal offense as per Section 309 of Indian Penal Code (IPC), 1860. It is worth remembering here that the words “mental illness,” which were used in a previous draft of the MHCA in 2013, were replaced by “severe stress,” in 2016, by the Indian Parliament in MHCA 2017 after a lot of deliberations. The main crux of these deliberations  was:
- Stigma associated with the word “mental illness” for every person who dies by suicide or attempts to die by suicide and
- The existence of various sections of IPC such as Section 306 (abetment of death by suicide) which states “If any person dies by suicide, whoever abets the commission of such suicide shall be punished with imprisonment of either description for a term which may extend to 10 years, and shall also be liable to fine”, Section 109 (abetment of a crime if the crime is not committed), and Section 116 (abetment of an offence punishable with imprisonment if the offense is not committed).
Hence, considering the stigma and abetment laws associated with attempted suicide, the words “mental illness” were changed to “severe stress.” However, it is still important to recognize the need for mental health interventions in persons who attempt to die by suicide.
| Legal Scenarios|| |
Let us consider some legal scenarios from the past.
Type 1: Accidental or unintentional
Mr. A throws himself into a well with an intention to die by suicide. He is guilty of an attempt to die by suicide, and this is punishable under the above section if he fails in the attempt to die by suicide.
In Emperor versus Dwaaraka Poonja, Mr. Poonja had jumped into a well to evade arrest by the police and not with an intention to die. Hence, he was not charged under Section 309. Thus, if a person takes an overdose of poison by mistake or in a state of intoxication, or jumps into a well to evade capture by the pursuers, he/she would not be guilty under this section.
Likewise, if a person unintentionally and impulsively decides to take his life, because of family discord, distraction, loss of a near and dear relative, or other cause, he should not be held guilty for an attempt to commit suicide. In Queen Emperor versus Ramakka, again the Honorable Court ruled Ramakka not guilty. The Court observed that, in such cases, the person deserves sympathy and necessary support instead of punishment.
Type 2: Protest or hunger strike
In Ram Sunder v. State, the accused was employed at a psychiatric hospital in Bareilly, India. He was suspended for dereliction of duty. Hence, he went on a hunger strike. He was charged under Section 309, IPC for an attempt to commit suicide by resorting to a hunger strike. Setting aside the conviction, the Honorable High Court of Allahabad said that the evidence in the case fell short of an attempt to commit suicide. On the other hand, if a person openly declares that he will fast unto death and then proceeds to refuse all nourishment until a stage is reached when he may collapse at any moment, then there is an imminent danger of death ensuing, and he would be guilty of an attempted suicide under Section 309, IPC.
Type 3: Mental illness
In 1981, a police constable suffered a head injury. Later, he developed schizophrenia. He then attempted to die by suicide on account of his mental illness and was charged under Section 309. In 1987, the Honorable High Court of Bombay, in Maruti Shripati Dubal v. State of Maharashtra  declared him not guilty, and Justice Sawant observed that those who attempt suicide on account of mental disorders require psychiatric treatment and not confinement in the prison cells where their condition is bound to worsen. Thus, in such cases, a punishment would serve no purpose, and in some cases, it may even prove self-defeating and counterproductive.
Type 4: Euthanasia
In March 2011, in a path-breaking judgment (Aruna Ramchandra Shanbaugh v. Union of India ), the Honorable Supreme Court of India allowed “passive euthanasia” of withdrawing life support to patients in a permanently vegetative state but rejected out rightly active euthanasia of ending life through the administration of lethal substances.
Considering the scenarios described above, the modifications introduced in MHCA 2017 regarding suicide and attempt to die by suicide have legal, clinical, and cost implications.
| Legal Implications|| |
Attempt to die by suicide is discussed in Section 115 of MHCA 2017. Part 1 of the section states that “Notwithstanding anything contained in Section 309 of the IPC, any person who attempts to die by suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said Code.”
Section 309 of IPC, which deals with those who attempt to die by suicide, was not only unsatisfactory but also discriminatory. In fact, it was a monstrous act that inflicted further suffering on the person who had already found the life so painful and unbearable and the chances of happiness so slender that the person decided to embrace death to end the life. If such a person failed in the attempt to die, inflicting torture and degradation by punishment would be unreasonable and unjust. In fact, such persons deserve compassionate and sympathetic treatment.
In State v. Sanjay Kumar Bhatia, the Division Bench of the Honorable High Court of Delhi observed “The continuance of Section 309 IPC is an anachronism unworthy of a human society like ours. The provision like Section 309 IPC which has no justification has no right to continue to remain on the statute book.”
The suicide attempt is decriminalized by Section 115 of MHCA 2017, superseding Section 309 of IPC. However, that does not absolve anyone from abetting an attempt to die by suicide. From the legal perspective, does overruling of Section 115 of MHCA over Section 309 leave no legal trail and address only the mental health care issues? The following questions need to be answered before coming to any conclusion:
- Is it a crime to abet to death by suicide?
- Is it a crime to abet an attempt to die by suicide? and
- Is it a crime to abet an abetment of an attempt to die by suicide?
Abetting is an offense punishable by the law. Hence, there must be an offense defined in terms of the law, i.e., Section-40 IPC. Unless there is a defined offense, there cannot be abetment.
Is it a crime to abet to death by suicide?
In the IPC, there is no mention of death by suicide as an offense. Observing this lapse in the law code, the Indian Legislature created one specific offense by a direct provision and enacted Section 306, IPC which reads as:
“If any person dies by suicide, whoever abets the commission of such suicide, shall be punished with imprisonment of either description for a term which may extend to 10 years, and shall also be liable to fine.”
Is it a crime to abet an attempt to die by suicide?
Abetment of an abetment is a well-recognized legal proposition. Section-108 IPC says “The abetment of an offense being an offense, the abetment of such an abetment is also an offence.” This can be illustrated as follows:
- A instigates B to instigate C to die by suicide.
Now, if C actually dies by suicide, there will be clarity in all legal sense. In such a case, B will be liable to be punished under Section 306 IPC. Clearly, B has committed an offense, but since B himself was instigated by A to commit that offense, A too will be liable as an abettor and will be tried under Sections 108, 109, and 116 of the IPC. Hence, there would be two culprits: A as the abettor for abetting an offense and B as prime accused of committing an offense of abetment to commit suicide.
Section 109 IPC states that “Whoever abets any offense shall, if the act abetted is committed in consequence of the abetment, and no express provision is made by this Code for the punishment of such abetment, be punished with the punishment provided for the offence.” Moreover, according to Section 116 IPC, “Whoever abets an offence punishable with imprisonment shall, if that offense be not committed in consequence of the abetment, be punished with imprisonment of any description provided for that offence for a term which may extend to one-fourth part of the longest term provided for that offence; or with such fine as is provided for the offence, or with both.”
But if C does not die by suicide, the instigation by B will not materialize, and as such, B would not be liable under Section 306 IPC in terms of the aforesaid judgment. However, B would still be liable for punishment under Sections 109 and 116 of IPC.
Hon'ble Supreme Court, in Satvir Singh v. State of Punjab, (2001) 8 SCC 633, where Mrs. Tej Kaur failed in her attempt to die by suicide, convicted her husband and in-laws for abetment under Sections 306 and 116.
Hon'ble High Court of Karnataka, in Mrs. K. Kamala versus State of Karnataka, convicted Mr. V. G. Maiya for abetment of an attempt to die by suicide under Sections 309 and 109.
Is it a crime to abet an abetment of an attempt to die by suicide?
A had primarily instigated B to abet the commission of suicide. Now, abetment to commit suicide is punishable and therefore is an offense. As such, A abetted an offense and became an abettor. Section-108 will come into the picture as an offense has been abetted. Therefore, even if the abetted offence, i.e., punishable under Section-306 does not stand committed, A will be liable under Section-309/109/116 too.
| Advance Directives|| |
Advance directives (AD) pertain to treatment options for mental illness (substantial disorder and grossly impaired functioning) only and not for medical illnesses. For instance, if a person legally drafts an AD not to treat him if he has survived an attempt to die by suicide, it is not tenable, as such treatment involves medical management and not just treatment for his mental illness. However, treatment of his mental illness can be initiated only if the Mental Health Review Board decides to revoke the AD.
In the rarest of the rare scenario, with legally valid ADs on both medical illnesses as well as under MHCA 2017, if someone attempts to die by suicide and requires assisted mechanical supports for survival or is in a permanently vegetative state, then withdrawal of the life support may be allowed as per the Supreme Court Judgment as in the Aruna Shanbaugh vs. Union of India.
| Clinical Implications|| |
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:
- Step 1: Assessment and triaging in the emergency room
- Step 2: Stabilize the patient medically and/or surgically by providing necessary treatment
- Step 3: Medicolegal case registration, and depending on the severity, admission if required
- Step 4: Mandatory psychiatric referral for required assessment (making a diagnosis and assessing the severity of stress and suicidal intent) and treatment
- Step 5: Inform the patient regarding Section 115 of MHCA 2017
- Step 6: Inquiry by the health team and police regarding Sections 108, 109, and 116 IPC
- Step 7: Discharge planning and follow-up care with medical, surgical, and psychiatric teams as per guidelines.
Care and treatment
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 stabilize the person wherever required. Regardless of whether the self-injury incident is minor or major, medico-legal procedures and necessary paperwork have to be completed as early as possible after stabilizing the person. Detailed collateral information from caregivers, relatives, and concerned people has to be documented. A referral to the psychiatric team should be sent as early as possible. A comprehensive and clear history of the incident should be taken by the attending health professionals.
Role of psychiatric team
The psychiatric team as a part of its assessment has to ascertain whether the event is a deliberate self-harm or injury or an attempt to die by suicide. The key difference  between deliberate self-harm or injury and attempt to die by suicide is in the intent to end one's life. For example, a person takes a small overdose of some tablets intending to kill oneself but does not die (nonfatal suicide attempt). Another person takes plenty of tablets because of being upset and impulsive; the person did not want to kill himself but wanted to de-escalate a stressful situation (nonsuicidal self-injury). Further, some nonsuicidal self-injurious behavior may actually result in death – either by ignorance, accident, delay in treatment, or just miscalculation (e.g., the latter person is not aware of the toxic effects of the tablets and actually dies as a result). Again, one has to keep in mind that both forms of self-harm can occur in the same individual, i.e., those with nonfatal suicide attempts can also exhibit nonsuicidal self-injurious acts and vice versa.
Assessment of stress and suicide intent
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 person who has attempted to die by suicide or done nonsuicidal self-harm, irrespective of the lethality of the incident.
Risk assessment for high-risk suicidal behavior has to be done at hourly basis, two hourly basis, and in increased durations as per the decreasing risk, with necessary staff support at the general hospital till the person is stabilized medically or surgically.
MHCA 2017 and attempt to die by suicide
The psychiatric team has to inform the person and the caregivers about Section 115 of MHCA 2017. Police need to be involved in ascertaining the application of abetment laws and for further legal procedures wherever required.
Once the person who has attempted to die by suicide is undergoing treatment medically or surgically at the general hospital (not a licensed mental health establishment) but continues to suffer from severe stress or mental illness (substantial disorder and grossly impaired functioning), emergency psychiatric treatment can be started at the general hospital under Section 94 of the MHCA 2017 limited to 72 h or till the person is assessed at a mental health establishment. Once the same person has been medically or surgically stabilized, the same Section 94 of MHCA 2017 enables transfer and transport of the person to a licensed mental health establishment. All such persons with nonfatal suicidal attempts or nonsuicidal self-injuries, who have a mental illness, and hence, admitted in a mental health establishment have to be informed to the respective mental health review board under Section 89 of MHCA 2017. A registry of all persons who attempted to die by suicide admitted to the mental health establishment is desirable for future management and policy decision purposes.
In the scenario of a person attempting to die by suicide, doing nonsuicidal self-injury, or committing suicide in the premises of any general hospital or mental health establishment during the treatment of the current incident or during the admission or treatment of any medical illness or mental Illness, apart from the natural legal processes, we recommend the establishment to inform the mental health review board which may then conduct a detailed psychological and procedural autopsy. In such cases, after detailed inquiry, the mental health review board's role could be to recommend necessary measures to prevent recurrence of similar incidents.
Discharge planning  should be initiated once the risk of nonfatal suicide attempts or nonsuicidal self-injurious behavior is low. Discharge protocol should include detailed psychiatric assessment, including risk assessment of nonfatal suicidal behavior and nonsuicidal self-injury, management of comorbid medical and psychiatric issues in consultation with the liaison team, contingency supports for the precipitating stress factors, psychoeducation to the person as well as caregivers regarding the use of drugs or alcohol and about securing lethal substances, need for a supportive person at the destination place of discharge, community psychiatric team wherever available, and scheduled follow-up visit with the medical and psychiatric team wherever indicated. A 24-hour contact number for support has to be included along with commitments by the person to adhere to the treatment and contingency plans. The recurrence rate  is around 10%, and subsequent management plans should be aimed at preventing this.
As per the recommendations of MHCA 2017, apart from the regular follow-up care in the community, the person can be provided rehabilitation that could include medical, surgical, and brief psychological interventions  or even cosmetic treatments. There should be a focus on the subsequent integration of the patients into applicable occupational, family, and social rehabilitation.
| Economic Implications|| |
The costs of suicide and attempt to die by suicide can be categorized into production disturbance costs, human capital costs, medical costs, administrative costs, transfer costs, and miscellaneous costs. In the same study, the medical costs of each severe attempt to die by suicide was 12515 Australian dollars and the medical costs of each nonsevere attempt to die by suicide was 821 Australian dollars. In another study, the medical costs alone of each nonfatal suicidal attempt was 5252 US dollars.
Extrapolating  the same to Indian scenario, the total medical costs of severe attempt to die by suicide would be on an average Rs. 9775 crores (Rs. 1 lakh per person) and the total medical costs of nonsevere attempt to die by suicide would be Rs. 4770 crores (Rs. 10,000 per person). Hence, going by the 2016 statistics, the overall medical costs of treating an attempt to die by suicide would be around Rs. 14,545 crores. This is just the medical costs. Other costs such as production disruption costs, human capital costs, administrative costs, transfer and transport costs, and other costs have not been calculated.
As per the MHCA 2017, even rehabilitation has to be provided by the government. This would further increase the cost of care of persons who attempted to die by suicide. It is worth remembering here that the total funds allocated to health for the year 2018–2019 by the Government of India was Rs. 52,000 crores.
| Conclusion|| |
There are numerous practical implications of implementing the MHCA 2017 in persons who attempt to die by suicide. The law enforcement authorities, the judiciary, and the police need to be sensitized about the legal nuances of Sections 108, 109, 116, 306, and 309 in the background of Section 115 of the MHCA. The lawmakers, policymakers, bureaucrats, and administrators of various organizations have to go on a war footing to ensure implementation of the provisions of the MHCA 2017.
In addition, the medical and mental healthcare professionals, healthcare establishments, and other health professionals in contact with persons who have attempted to die by suicide need to update their knowledge regarding the procedures, protocols, guidelines, and management of persons who attempt to die by suicide within the framework of the MHCA 2017.
The cost implications of the MHCA 2017, hence, are enormous. The intentions of the government to create a welfare state by taking care of its mentally ill persons are magnanimous. Cost implications and limited resources would be the practical constraints in implementing the provisions of MHCA 2017 in toto.
Above all, the governments, nongovernmental organizations, health care establishments, professionals, and other related and concerned people need to educate and create awareness among the public at large to fulfill the aims, objectives, and the purpose of enactment of the MHCA 2017 with reference to suicide and attempt to die by suicide.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Laxmi Naresh Vadlamani
Department of Psychiatry, Columbus Hospital - Institute of Psychiatry and Deaddiction, 1-10-63/4/1, Chikoti Gardens, Begumpet, Hyderabad - 500 016, Telangana
Source of Support: None, Conflict of Interest: None