A psychiatric patient with severe illness refuses to give consent for electroconvulsive therapy (ECT). What should be the doctor's next appropriate step?

Appeared in: NORCET 10 Prelims-2026

Explanation

When a patient with a severe psychiatric illness lacks the capacity to make informed decisions, the standard of care is to seek consent from a legally authorized representative.
This process, known as proxy or surrogate consent, balances the need for treatment with the protection of the patient's rights.
The severity of the illness is the primary justification for assessing capacity and, if it's lacking, turning to a surrogate decision-maker.
This approach is supported by both ethical principles and legal frameworks, such as the Mental Healthcare Act, 2017 in India.

Option A: Discharging a severely ill patient who requires urgent intervention is a form of patient abandonment and medical negligence.
Option C: This is a vague action and not the specific, immediate step required. The protocol defines who to approach for consent (the surrogate) and which bodies provide oversight (like a Mental Health Review Board), not a generic 'higher authority'.
Option D: Administering a medical procedure like ECT without any form of valid consent (either from the patient or a legal surrogate) is illegal, constitutes battery, and is a severe violation of human rights.

Visual 1: Flowchart - A flowchart illustrating the decision-making pathway for ECT consent. It would start with 'Patient requires ECT', branch to 'Does patient have capacity?', and show the different paths for 'Yes' (patient consent) and 'No' (surrogate consent and/or board approval).

Clinical Relevance

Nursing practice connection: Use the key finding related to Informed Consent and Proxy Consent in Psychiatric Care to guide bedside assessment, documentation, and the next nursing action.
A nurse's primary role in this scenario is to be a patient advocate, ensuring that the correct legal and ethical procedures for consent are followed before any treatment is administered.
Nurses must be familiar with the Mental Healthcare Act, 2017, as it dictates the specific requirements for treating patients with mental illness in India, including procedures for consent for ECT.
What if? If a patient is assessed to have full decision-making capacity but still refuses ECT, their decision must be respected. The team would then need to explore alternative treatments with the patient.

How to Approach the Question

First, identify the core of the question: It's a clinical ethics scenario involving a conflict between a patient's refusal and their need for treatment.
Recognize the significance of 'severe illness'. This is a strong hint that the patient's capacity for informed consent might be impaired.
Recall the legal and ethical principle of capacity. A patient's refusal is only legally binding if they have the capacity to make that decision.
If capacity is lacking, the principle of substitute judgment applies. This means a legally authorized person must make the decision.
Evaluate the options based on this principle. Seeking consent from a legal representative (proxy consent) is the correct application of substitute judgment.
Eliminate other options: Discharging is negligent, proceeding without consent is illegal, and transferring to a 'higher authority' is not the specific procedural step.

Concept Tested & Keywords

Concept Tested: Informed Consent and Proxy Consent in Psychiatric Care
Stem keywords: psychiatric patient, severe illness, refuses consent, electroconvulsive therapy, ECT
Lead-in keywords: next appropriate step
Clinical cues: The patient's 'severe illness' is a key cue that their decision-making capacity may be compromised.
Clinical cues: The patient's 'refusal' triggers the need to assess capacity before taking further action.

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Attempt every question from this paper in a timed mock, then review the full solution for each one.