Between law and reality: moral injury in resource-limited psychiatry

Abstract

Psychiatrists in resource-constrained Indian settings face profound ethical dilemmas when progressive mental health legislation conflicts with ground realities. The Mental Healthcare Act 2017 mandates care standards that are often unattainable given family abandonment, inadequate rehabilitation facilities and persistent stigma, particularly in rural areas. Early-career clinicians experience moral distress when choosing between legal compliance and patients’ best interests. This gap between rights-based frameworks and available resources creates systematic moral injury among providers. Addressing these challenges requires comprehensive ethics training, peer support mechanisms and coordinated community infrastructure development to protect both clinician well-being and patient outcomes.

A young man with schizophrenia had recovered from his psychotic episode and was ready for discharge. He possessed full decision-making capacity and met all legal criteria for community care under India’s Mental Healthcare Act (MHCA) 2017. ¹ Yet his family refused to take him back, citing social stigma. Despite our counselling efforts, they abandoned him completely. When I watched him leave for a rehabilitation facility, not the home he desperately wanted, I felt that we had failed not just as clinicians but as a system meant to restore dignity and hope.

This scenario illustrates a challenge facing psychiatrists working in public tertiary care hospitals across India and beyond. Systematic comparative data on discharge outcomes remain sparse in many public psychiatric settings. However, available evidence illustrates the scope of this challenge: a recent study from the National Institute of Mental Health and Neurosciences (NIMHANS), India, found that among long-stay psychiatric patients, 48.5% had untraceable families, while poverty (74.2%), family misconceptions about mental illness (76.2%) and absent community rehabilitation facilities (79.2%) created insurmountable discharge barriers despite clinical stability. ² These documented patterns of patients trapped between legal fitness for discharge and social abandonment reflect the reality facing early-career psychiatrists in resource-limited settings.

When law meets reality

Such cases experience reveals a critical gap between India’s progressive rights-based mental health legislation and psychiatric practice realities. The MHCA 2017, aligned with UN disability rights conventions, ³ emphasises patient autonomy and the least restrictive community care. While the MHCA mandates respecting capacity and promotes deinstitutionalisation, it cannot solve abandonment or create supportive families.

As early-career psychiatrists, especially those working in public hospitals and semi-urban centres, we routinely face a convergence of three forces: family stigma, inadequate infrastructure and social exclusion. When these elements combine, the outcome is not merely institutional inefficiency; it engenders moral injury. In such moments, psychiatrists become the last person expected to ‘fix’ what systems, laws and families cannot resolve. Although discharge planning should ideally involve treating teams, social workers and administrative personnel, chronic staffing shortages and the absence of dedicated social work services in many public hospitals often leave early-career psychiatrists coordinating rehabilitation, social support and follow-up arrangements tasks that extend beyond their primary clinical roles.

This structural gap generates recurring legal-ethical conflicts for clinicians working at the intersection of progressive policy and harsh realities. These challenges aren’t uniquely Indian. Kenya’s Mental Health Act 2022 faces similar infrastructure constraints, ⁴ while rural Australian communities struggle with psychiatric service gaps despite national reforms. ⁵ Wherever progressive mental health legislation outpaces infrastructure development, clinicians encounter these same impossible choices. The conflict between legal compliance and ethical duty becomes deeply personal and painful.

The hidden wound

Moral injury describes the distress of knowing what patients need while being unable to provide it due to systemic constraints. ⁶ Originally identified in military contexts, it increasingly affects healthcare workers. This is not burnout or fatigue but the distress of being compelled to act against one’s moral compass by systemic limitations.

As early-career psychiatrists in India’s public health system, we experience this injury daily. Each discharge of this kind chips away at our idealism. We entered psychiatry to heal minds but often find ourselves managing system failures instead. The legal framework increases our responsibilities without providing resources, while societal stigma makes every family conversation an uphill battle.

Training programmes often do not prepare young psychiatrists for this emotional toll. While we learn diagnostic criteria and documentation skills, we receive little guidance on navigating ethical grey areas and coping with moral burdens in fragmented systems. Daily observations of families abandoning patients, patients refusing rehabilitation and doctors navigating blame subtly erode morale and professional identity. For young psychiatrists, the cumulative effect is profound; each discharge feels like sending someone back to failure, gradually diminishing the optimism that initially drew them to psychiatry.

The effects of unresolved moral distress are multifaceted. It has been associated with adverse mental health outcomes, including anxiety, depression and symptoms resembling post-traumatic stress disorder (PTSD). ⁷ Furthermore, moral distress affects a health professional’s quality of life and has broader implications for job satisfaction and patient care. ⁸ It is also linked to higher turnover intentions, with affected healthcare workers wanting to leave their current positions or even the profession entirely. ⁹ This erosion is particularly concerning in psychiatry, where therapeutic engagement relies on empathy and hope.

A worldwide challenge

Our experience in India reflects a broader international challenge. Comparable mismatches between legislative aspirations and service capacity have been reported across sub-Saharan Africa and in rural Australia, where underfunding, workforce shortages and uneven community outreach continue to hinder the practical implementation of mental health reforms. ^5,10 These parallels suggest that when mental health laws advance faster than infrastructure and workforce readiness, clinicians across settings are likely to encounter comparable ethical and operational dilemmas

India has roughly 0.75 psychiatrists per 100 000 population, with severe regional disparities. ¹¹ This shortage translates into high out-patient loads, often requiring clinicians to review several dozen patients per day, make discharge decisions without adequate social support and bear the weight of difficult systemic choices. Many low- and middle-income countries allocate less than 1% of health budgets to mental health, ¹² making progressive laws hollow promises without parallel resource development. Community mental health services remain patchy. Rehabilitation facilities cluster in urban areas, far from patients’ homes.

These experiences raise fundamental questions. What does autonomy mean without support systems? Are we truly upholding patient rights when legal compliance leads to abandonment? How do we reconcile legal compliance with our duty to ‘do no harm’? Can we consider ourselves defenders of dignity while witnessing such neglect?

Society treats psychiatric hospitals as detention centres for ‘difficult people’ rather than healing spaces. Family abandonment is not merely a clinical challenge; it represents broader social failure. This societal attitude and inadequate community infrastructure create impossible situations for patients and clinicians attempting to implement rights-based care.

Moving forward

Recognising the problem is only the first step. We must acknowledge moral injury as a legitimate and pressing issue in psychiatric practice, especially in low- and middle-income countries. Professional organisations need to recognise moral injury as a valid form of occupational distress that necessitates an institutional response rather than relying on individual resilience. Creating forums for ethical discourse and peer support can help prevent cynicism from pushing psychiatrists away from public service.

Training reform should require moral injury awareness in residency programmes, with monthly ethical discussions that go beyond clinical management. In our experience, residents who share similar struggles feel less isolated. Institutionally, hospitals need designated psychiatric social workers instead of psychiatrists juggling discharge planning. Weekly ‘difficult discharge’ meetings with social workers and nursing staff have improved outcomes while reducing individual burdens. At the individual level, approaches that emphasise self-forgiveness, acceptance, self-compassion and making amends where possible may offer additional promise for clinicians affected by moral distress.

The Schwartz Rounds model, used in several National Health Service trusts, provides forums for healthcare professionals to discuss emotional and ethical challenges. Research shows participation in Schwartz Rounds fosters compassion, empathy and understanding among staff, positively influencing patient care and institutional culture. ¹³ Canadian medical schools are integrating moral injury awareness into curricula, showing promise in preparing students for ethical complexities. This approach may prevent psychological distress and enhance their ability to be compassionate healthcare providers. ¹⁴

Policy-level reforms are urgently needed. The MHCA’s vision must be matched with real investments in halfway homes, supported community living and trained social workers who can facilitate patient reintegration. Without this infrastructure, the MHCA risks becoming merely a legal framework enforced on a fundamentally fragmented system.

Infrastructure development must prioritise the decentralisation of rehabilitation services. Patients from remote rural areas often travel hundreds of kilometres to reach tertiary centres, making follow-up care and sustained family involvement unfeasible. Establishing halfway homes within an accessible distance of patients’ villages is essential for continuity of care and community reintegration. District hospitals should be equipped with trained family counsellors who can address psychiatric stigma and engage families over extended periods.

Finally, we need to transform public discourse on mental illness. Family abandonment signifies social failure and demands community intervention. Public education, family counselling and inclusion initiatives should complement legal reform to fight the stigma that isolates those with mental illness.

Conclusion

The young man who trusted us to help him go home deserves better than legal compliance that leads to institutional abandonment. His story reflects the daily reality for psychiatrists across resource-limited settings worldwide, caught between progressive legislation and harsh ground realities. The MHCA represents crucial progress, but implementing rights-based care without adequate infrastructure places clinicians in morally compromising positions. We need training that prepares residents for these ethical dilemmas, not just clinical protocols, and policies that match resources with rights. Until we bridge this gap between law and reality, early-career psychiatrists will continue carrying the moral burden of systemic failures. Supporting healthcare providers is integral to quality patient care, not separate from it. By addressing these systemic issues, we can only build sustainable, compassionate mental health services that serve patients and practitioners.