Local ritualistic healing practices need policy change, legal reform: Academics

  • Highlight necessity to safeguard patients’ rights and cultural values/relativism
  • Informed consent, action against medical negligence, essential

By Ruwan Laknath Jayakody

There is need for a policy change that would in turn pave the way for legislative reforms with regard to the functioning of local ritualistic healing practices and processes, local academics noted, so as to both safeguard patients’ rights, and cultural values and relativism by allowing and providing for multiple systems of healing to work in collaboration in the best interest of the patients.

This recommendation was made by G.S.S.R. Dias (attached to the Peradeniya University’s Medical Faculty’s Psychiatry Department) and I. Gooneratne (attached to the same Faculty’s Forensic Medicine Department) in a research article on “Do rituals violate the rights of the mentally ill patient/s?” which was published in the Sri Lanka Journal of Forensic Medicine, Science, and Law 2 (1) in November 2011.

Ritualistic practices

The health seeking behaviour of local psychiatric patients is also influenced by, Dias and Gooneratne noted, both traditional practices and cultural beliefs, with family members, in numerous cases, subjecting their sick family members to the ritualistic management of their conditions. Dias found in “Pathways to psychiatric care” that 45-55% of patients had sought ritualistic management prior to embarking on allopathic (science-based, modern medicine) treatment.

There are also instances where the ritualistic healers, Dias noted, have referred the patient to clinics for allopathic medication. The types of ritualistic treatments range from the tying of a cord around the wrist or neck, a “dehi kapeema” (cutting limes) ceremony, to charms, and ceremonies carried out in temples, kovils (Hindu shrines), mosques, or churches, and thovil (an exorcism involving ritual chanting, dance, and drumming) ceremonies. Dias and Gooneratne also observed that many caregivers involved in providing such ritualistic treatment also read the charts of their patients as a guide to the management of the mental illness.

However, the issue is that some of these rituals involve rigorous, physically demanding, and exhaustive procedures (such as walking on live charcoal, hitting the body with objects, introducing foreign bodies, etc.) that could be abusive, in turn leading to the violation of the individual’s rights, including both as a human and as a patient.

Medical negligence is, Dias and Gooneratne explained, an active process, where the medical team that is treating the patient commits acts of omission or commission contrary to the recovery of the illness, which in turn cause complications or detrimental effects to the patient. As C.J. Ryan and S. Callaghan’s “Protecting Our Patients’ Rights” elaborated, in issues of medical negligence, there are direct legal processes that are involved where the allopathic doctor in question may have to stand trial, thus this process seeks to ensure at all times that the patient’s rights in terms of explicitly and implicitly benefitting from the treatment process, are safeguarded.

This same aspect of medical negligence and the connected issues apply to ritualistic practices, with a basic related issue being the question of the consent of the patient to be subjected to the ritual. There are, Dias and Gooneratne explained, no regulatory bodies within the country’s criminal justice system to control ritualistic activities involving rigorous, physically demanding, and exhaustive procedures which are performed in good faith.

Therefore, Dias and Gooneratne conducted a study based on the findings from the assessment of four cases referred to the Peradeniya Teaching Hospital’s Psychiatric Unit and a case published in local newspapers, to identify and analyse any violations of rights, ethical issues, and the medico-legal implications stemming from the ritualistic management of psychiatric patients.

First case

A 35-year-old patient presented with a history suggestive of depression (characterised by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). She was subsequently hospitalised and treated accordingly. The physical examination showed several five to six centimetres long, linear abrasions over the shoulder blade on both sides. On questioning, it was revealed that she was forced to undergo a ritual against her will, during the process of which, she was physically assaulted by the ritualistic healer with the inflorescence (complete flower head of a plant including stems, stalks, bracts [a modified or specialised leaf], and flowers, and which has a main branch or a complicated arrangement of branches) of an areca nut tree.

Second case

A 35-year-old patient presented with severe depression, after being subjected to a severely abusive ritual during which she was physically restrained by six men, who had, neglecting her cry for help, forced her to hold burning camphor until it was completely burnt off. This treatment was performed against her will, with the proxy consent of her family.

Third case

A diagnosed schizophrenic (affects, distorts, and interferes with the way a person thinks, perceives reality, feels, expresses, and manages emotions, and acts and behaves, and makes decisions, and relates to others while also impacting their sense of self and use of language) patient who was stable on medication had been requested by a healer to stop all medications and to consume only a vegetarian diet, primarily fruit-based. Owing to the lack of continuity of the medication, the patient had relapsed and attempted deliberate self harm.

Certain ritualistic healers, as Dias and Gooneratne pointed out, give contradictory messages, as in this case, which amounts to an omission rather than a commission of malpractice. It is further noted that it is a serious situation if a patient who is stable on medication is advised or reprimanded contrary to the factors which maintain remission. Dias and Gooneratne added that the pragmatic way to deal with such a scenario is to mutually respect each treatment system and to function therefore in a complementary manner.

Fourth case

A 24-year-old patient presented with acute symptoms of mania (a sustained period of abnormally elevated or irritable moods that cause a person to experience unreasonable euphoria, very intense moods, hyperactivity, and delusions) and burn marks on her soles and in between her toes, owing to the burning of camphor tablets by a ritualistic healer.

Fifth case

A middle-aged patient was reported dead due to an assault by a ritualistic healer who was performing a charm in a state of trance. The post-mortem confirmed that there had been intracranial haemorrhages (acute bleeding inside the skull or brain) due to blunt trauma.

Implementing proper procedure

Healing is a process that involves, as per “Physical restraint of patients: Historical notes relating to the 19th and 20th Centuries”, A. Alem’s “Human rights and psychiatric care in Africa with particular reference to the Ethiopian situation”, and the Oxford Textbook of Psychiatry, multifarious stakeholders, with allopathic medication being just one such stakeholder. In Sri Lanka, Dias and Gooneratne mentioned that it is a common practice to seek alternative treatment options such as Ayurvedic medication and to even consult astrological charts of the patient, when a loved one is ill.

Hence, the duo pointed out that there cannot be any disagreement regarding the different modes of remedial approaches; including ritualistic healing, alternative methods, and allopathic treatment practices for a person who is diagnosed as ill, even those who are mentally ill. Especially disagreements stemming from issues pertaining to seeking and obtaining consent for the procedures and the physical abuse carried out in certain treatment systems and their resultant medico-legal implications.

Informed consent is understood to be having a clear and full understanding of the nature of the condition to be treated, the procedures available for the treatment, and their probable side-effects. Based on such understanding, agreement or consent can be given to undergo a certain procedure, covering the entire process of the procedure, and to then receive the treatment. Parallel to the understanding, the patient should have the legal capacity and competency to take decisions regarding such. Furthermore, the patient should have the right to and be able to withdraw at any stage of the remedial procedure, the Oxford Textbook of Psychiatry noted.

The ritualistic mode of treatment, Dias and Gooneratne described, has a very blurred view of consent. This is partly because owing to the extreme faith placed on the ritualistic healer by the family, especially when they are in a very desperate state for a cure for a mental illness, the family often disregards the consent of the patient. The fact that patients in the first, second, and fourth cases had to be held by force indicates that the patient did not give consent or could not reverse the consent, which they may have granted due to not knowing the gravity of the procedures of the ritual to be performed on them. Also, the grievous nature of these rituals are justified in such instances by a promise of miraculous healing.

All of the five cases demonstrate the traumatic nature of the physical abuse, including emotionally.

Thus, ritualistic remedial seekers in the community could be a group of silent sufferers who, as “A review of basic patient rights in psychiatric care” by R.F. Cady and “Forensic psychiatry: Opportunities and future challenges” by R.W. Brendel and A. Glezer noted, have no voice to inform that their rights as humans and patients have been and are being impinged upon, for the sake of and in the name of healing. Further, P. Menzel pointed out in “The cultural moral right to a basic minimum of accessible healthcare” that the treating psychiatrist who is responsible for the patient’s wellbeing may in certain instances, be summoned by a court to explain injuries concerning which the psychiatrist may not be aware of, nor responsible for.

As to why a person approaches a ritualistic healer as opposed to attending a psychiatric service, Dias and Gooneratne observed, is because the stigma is less, and as there is only minimal awareness regarding the availability of psychiatric services, and the relative scarcity of allopathic service provision compared to ritualistic healing.

Moreover, the criminal justice system provides no legal safeguard to address issues that arise out of ritualistic healing and only deals with the extreme cases, which Dias and Gooneratne opined, is only the tip of the iceberg as the great majority of such occurrences are not recognised nor adequately addressed in terms of the country’s judicial system.