Medical maleficence in ophthalmic care of schizophrenia: Errors of commission

INTRODUCTION

The Mental Health Care Act (MHCA) 2017 emphasizes the rights of persons with mental illness (PWMI).¹ The basic tenets of ethical standard of care, including beneficence, non-maleficence, respect for autonomy, and justice, are applicable equally to psychiatric patients.² Ethics in clinical practice obligates physicians to benefit patients, avoid or minimize harm, and respect patient values and preferences.²

The Code of Ethics in Psychiatry further stresses that clinicians must not exploit a patient’s vulnerability while providing the best available care after discussing all the treatment options with patients and their caregivers. Clinicians should also obtain valid informed consent from the patients undergoing procedures, and avoid misuse of professional skills for personal or financial gain.³ Given the emotional vulnerabilities and potential exploitation of psychiatric patients, clinicians must remain vigilant and sensitive in their approach.³

Maleficence encompasses both intentional acts that may cause harm and unintentional acts that result in harm due to negligence or lack of adequate care.⁴ The concept of non-maleficence extends beyond direct physical harm and encompasses psychological, emotional, and social well-being. Healthcare providers must consider the potential risks and benefits of any intervention or treatment, ensuring that the benefits outweigh the potential harms.⁴ This principle also recognizes the importance of informed consent, allowing patients to make autonomous decisions about their care while being fully aware of the associated risks and benefits.⁵ We report a case of untreated schizophrenia, who underwent an ocular surgical procedure, secondary to his persecutory delusions, with a violation of the ethical principles of non-maleficence.

CASE REPORT

A 33-year-old male, a married graduate, typist by profession, hailing from an urban background, who was brought by his family members for psychiatric evaluation. The patient had a 7-year history of untreated psychotic illness with significant socio-occupational impairment. The patient reported experiencing persistent second-person auditory hallucinations, described as a clear, male voice of unknown identity, heard in the absence of any external stimuli. The content of these voices was consistently derogatory, often commenting negatively on his character and marital relationship.

Concurrently, he developed systematized paranoid delusions with somatic and persecutory themes. He harbored an unshakable belief that cameras had been surgically implanted into his body, specifically within his abdomen, eyes, and ears, by unknown individuals. He believed that these devices enabled constant surveillance of his personal life, including his thoughts and actions, and that this surveillance posed a threat to his safety and privacy. This belief significantly impaired his interpersonal relationships. He separated from his wife, convinced that her presence would increase the risk of surveillance and intrusion. He eventually lost his job, owing to increasing preoccupation with these beliefs. He would also be suspicious of his neighbors and accuse them of collaborating in this conspiracy. During this period, he sought medical help from several ophthalmologists and requested that they operate on him to remove surveillance devices from his eyes.

Two years prior to the hospitalization, the patient approached a private ophthalmologist, insisting that cameras were inserted in his eyes by an external unknown agency, and pleaded for their removal. However, rather than referring the patient for psychiatric assessment, the ophthalmologist allegedly agreed to perform an intervention without documenting or explaining any clear clinical indication. The patient reportedly underwent an operating room procedure, which lasted 30 minutes, for which he was charged ₹40,000. The amount was paid by the patient himself, despite disagreement from the family members. Importantly, the patient was told the procedure would remove “cameras” from his eyes, directly reflecting his delusion, which was corroborated by family members. Thus, this intervention appears to have been carried out solely in response to the delusion, rather than for any legitimate ocular condition. However, the details of the ocular procedure performed were not documented, but briefed to the patient as a laser procedure. Subsequently, after this intervention, his mental health further deteriorated as the delusional conviction persisted unabated. He continued consulting multiple ophthalmologists, claiming that the cameras still remained within his eyes, with further impairment in his insight towards psychiatric illness, and consequently impacting the medication adherence.

On physical examination, his body mass index was 27.4 kg/m², and his vitals were stable. Systemic examination was normal, and neuroimaging revealed no abnormality. His complete blood count, liver, kidney, and thyroid function tests were within normal limits. A comprehensive ophthalmological evaluation was conducted during the patient’s admission, in liaison with the ophthalmology department. This revealed no ocular pathology or treatment scars. The patient had not presented with any ocular symptoms such as refractive errors, visual disturbances, other clinical indications, or ophthalmologic conditions that would warrant a laser procedure.

The clinical presentation and diagnostic work-up led to a diagnosis of schizophrenia, continuous course (ICD-11). After the evaluation, he was started on Risperidone 3 mg and gradually titrated up to 8 mg. At the 3-month follow-up, he reported significant improvement in functioning with alleviation of the auditory hallucinations, and the delusional beliefs subsided. During admission, he was monitored for symptom severity using rating scales such as the Positive and Negative Symptoms Scale (PANSS), total score reduced from 96 to 36, specifically the persecutory delusions component improved from 7 (extreme severity) to 2 (minimal severity). Psychosocial interventions were provided in the form of psychoeducation regarding the nature and course of illness, need for psychotropic medications, with a focus on treatment adherence, along with vocational rehabilitation. The patient has been maintaining well with optimal socio-occupational functioning, with adequate compliance to the antipsychotic medications, and adhering to regular follow-ups in the last 2 years.

DISCUSSION

This case exemplifies the ethical challenges surrounding the principle of non-maleficence in clinical practice, particularly when psychiatric symptoms manifest in somatic complaints. Non-maleficence, one of the core principles of biomedical ethics, obligates clinicians to “do no harm” and to avoid interventions where the potential for harm outweighs the potential for benefit.²

The ophthalmologist’s decision to perform a procedure, presumably with no identifiable medical indication, represents a serious breach of ethical and clinical standards. Even if performed with the intention to reduce the patient’s distress or gain his trust, the procedure violated the principle of non-maleficence by subjecting him to a minimally invasive intervention with no clinical benefit, along with potential physical, psychological, and financial harm. This highlights the risk of iatrogenic harm when mental health conditions are not appropriately recognized or managed.²

Furthermore, informed consent, a key aspect of both non-maleficence and respect for patient autonomy, appears to have been inadequately addressed. Consent is only ethically valid when the patient has decision-making capacity, which includes understanding the nature and purpose of the proposed treatment, appreciating the consequences of the decision, and reasoning through the options. In this case, the patient’s persistent and fixed delusions strongly suggest a compromised capacity for informed consent, and proceeding with surgery under these circumstances would be ethically indefensible.⁵

Schmid-Siegel et al. described a 45-year-old female who, following laparoscopic tubal ligation, developed a persistent somatic delusion that “gas” had been surgically inserted into her abdomen, leading to chronic sensory complaints and functional impairment.⁶ Sodi et al. reported a case in which a psychotic patient, under the influence of persecutory delusions, attempted genital self-mutilation to prevent imagined theft of his testicles, highlighting the potential for severe self-inflicted harm in untreated psychosis.⁷ Huws and Shubsachs presented a 59-year-old female who developed acute psychosis following a cholecystectomy and endoscopic retrograde cholangiopancreatography, illustrating how medically necessary procedures may precipitate psychiatric syndromes in vulnerable individuals.⁸ Similarly, Bhatia et al. documented a case of secondary Cotard’s syndrome after breast surgery in a patient with no prior psychiatric history, where surgical stress acted as a trigger for profound nihilistic delusions.⁹

In contrast, our case is distinctive because the delusional system was not postoperative or incidental but long-standing, highly systematized around persecutory-somatic beliefs of surveillance devices implanted in the body, particularly the eyes. To the best of our knowledge, no previously published case report describes medical maleficence of this nature in a vulnerable psychiatric patient. Most importantly, while prior cases either involved delusions emerging after surgery or self-harm attempts, in our case study, a clinician proceeded with an unwarranted minimally invasive ocular procedure, thereby perpetuating the psychotic beliefs and causing financial exploitation. This highlights an unusual form of iatrogenic harm where the harm was not accidental or secondary, but a direct consequence of breaching ethical standards and failing to recognize psychiatric pathology.

The case also targets the importance of appropriate psychoeducation, integrated care, and interdisciplinary collaboration. The lack of psychiatric referral in this case reflects a gap in the recognition and management of mental illness across medical disciplines, emphasizing the need for better training in consultation-liaison psychiatry.¹⁰

CONCLUSION

This case illustrates the critical concerns regarding the possible risk of iatrogenic harm to PWMI, especially in the interface between psychiatry and other specialties. It underscores the urgent need for greater awareness of mental disorders among specialists and general practitioners with robust referral systems in consultation liaison approaches. Emphasis should be placed on safeguarding vulnerable patients from iatrogenic harm through proper psychoeducation, interdisciplinary care, and strict adherence to ethical standards.