Singh Caring for Sikh patients wearing a kirpan have their autonomy respected (Kennedy & Grubb, Declaration of interest 2000). None. As Lord Donaldson Master of the Rolls (MR) stated special in Re R (1992)‘...consentbyitselfcreatesnoobligation articles to treat’. Even if there is valid consent, if the child or References parent is against this course of action this will have to be weighed in the balance. Whether, when and how to treat BRIDGE, C. (1997) Adolescents and FENNELL, P. (1996) Treatment Without mental disorder: who consents to Consent. Law, Psychiatry and the are matters of clinical judgement. The two cases Re R treatment. Medical Law International, Treatment of Mentally Disordered (19 92) and Re W (1993) shed some light on the legal 3,51-74. People since1845. London: Routledge. perception of consent. In the first of these cases, Lord DEPARTMENT OF HEALTH AND THE KENNEDY, I. & GRUBB, A. (2000) Donaldson MR likened consent to a ‘key’ that unlocked WELSH OFFICE (1999) Code of Practice: Medical Law 3rd Edition. London: Mental Health Act1983. London: Butterworths. the door to allow the doctor to treat; in the second he Stationery Office. used the analogy of consent being a ‘flak jacket’ MCCALL-SMITH, I. (1992) Consent to DEPARTMENT OF HEALTH AND THE treatment in childhood. Archives of protecting the doctor from possible litigation or prose- WELSH OFFICE (2002) Draft Mental Disease in Childhood, 67,1247-124 8. Health Bill. London: Stationery Office. cution. PEARCE, J. (1994) Consent to treatment FENNELL, P. (1992) Informal during childhood.The assessment of compulsion: the psychiatric treatment competence and the avoidance of of juveniles under common law. Journal conflict. BritishJournal of Psychiatry, Conclusion of SocialWelfare and Family Law, 4,311. 165,713-716. This small-scale survey suggests that there are basic GillickV West Norfolk and Wisbech Area Health Authority (1985) 3 All ER 402, misperceptions among child and adolescent mental health (1986) AC112 professionals regarding the legal nature of consent and Re J (a minor) (wardship: medical treatment) (1990) 6 BMLR 25 how the law in this area applies to minors. It is necessary Re R (a minor) (wardship: medical treatment) (1992) Fam11 to have a sound knowledge of the law relating to consent ReW (a minor) (medical treatment) (1993) All ER 627,(1993) 1FLR1 in children in general, before considering the treatment of Rob Potter Consultant Child and Adolescent Psychiatrist, Brynffynnon Childand mental disorder without consent. In the quiz, how well Family Service, Merthyr Road, Pontypridd, Mid Glamorgan CF37 4DD. E-mail: did you perform? [email protected] Psychiatric Bulletin (2004), 28, 93^95 SWARAN P. SINGH Caring for Sikh patients wearing a kirpan (traditional small sword): cultural sensitivity and safety issues Devout Sikh men wear the kirpan (a traditional small importance of the kirpan in the Sikh tradition and sword) as part of their religious faith. The kirpan is one of recommends policies that health authorities and mental five symbols of Sikhism (the five Ksdescribedbelow). health trusts can adopt to ensure that when caring for Many traditional Sikhs undergo the amrit ceremony, akin Sikh patients, neither cultural sensitivity nor individual to baptism, following which they are meant to wear the safety are compromised. five Ks at all times. Several legal controversies have emerged in the West, especially in the USA (Lal, 1999) and Canada (Wayland, 1997), over safety issues related to Overview of Sikhism the kirpan, such as students wearing it to school or passengers wearing it during flights (for an overview of This is a brief outline and interested readers can find more the recent cases, see www.sikhs.ca/kirpan). details in Singh (2001), McLeod (1989) or at several Some educational institutions in the UK have been websites (www.sikhnet.com; www.allaboutsikhs.com; provided guidelines to ensure that Sikh students are www.sikhs.org; www.srigurugranthsahib.org; allowed to wear the kirpan without compromising health www.sikhnation.com). There are 22 million Sikhs world- and safety standards (http://www.dfes.gov.uk/ wide, 20 million of whom live in India. The religion schoolsecurity/dwtannexf.shtml). In-patient psychiatric emerged in the state of Punjab, North India, in the 16th services looking after Sikh patients may face similar century. The founder of the faith, Guru Nanak, was born dilemmas between respecting the Sikh religious traditions in 1469 AD into a Hindu family during a turbulent period of and ensuring safety of the patient and others. This paper serious conflict between the ruling Mughals (Muslim briefly outlines the history of Sikhism, summarises the invaders from Persia) and the majority Hindu population, 93 Singh Caring for Sikh patients wearing a kirpan and also between upper and lower caste Hindus. Nanak oppression, but is not to be used as an instrument of preached the essential unity of mankind and argued violence. special against the caste system and polytheism. Combining the articles Hindu concept of karma (righteous deeds) with the Muslim concept of monotheism, Nanak rejected rituals, Safety issues related to the kirpan asceticism, monasticism and formalism in favour of egali- In the now famous ‘Quebec kirpan case’ (www.sikhs.ca/ tarianism (including complete equality of sexes), social kirpan), the public perception of the kirpan was that it order, communal harmony and charity. His followers was a potentially dangerous ‘weapon’. Sikhs do not became known as Sikhs (from the original Sanskrit perceive the kirpan as a weapon, and the translation into shishya, or disciple/pupil, with Nanak as a Guru,or ‘dagger’ is inappropriate, given the pejorative association teacher). The basic tenets of Sikhism are that there is only between a dagger and violence. However, no English one God (Akaal Purakh), who is timeless and formless term captures the true cultural meaning of the kirpan. and whose essence is power and love. Everything in the The kirpan is symbolic rather than functional, and universe occurs within the will of God (Hukam). Humanity is a reminder to Sikhs of their duty to fight injustice is the highest creation of God and human beings have and maintain independence of spirit. It is usually about been bestowed with free will. Humans should restrain the 8 inches long, is blunt and is worn sheathed and attached five passions of kaam (lust), krodh (anger), lobh (greed), to a cloth belt, called the gatra (Fig 1). Such a kirpan is no moh (undue attachment to possessions or people) and more dangerous than a dinner knife and its use in an act ahankar (false pride), with the eight virtues of gyaan of violence is practically unknown. However, there may (wisdom), sat (truthful living), niaon (justice for all), be the rare instance of a patient wearing a potentially santokh (temperance, self-restraint), djhiraj (patience, unsafe kirpan, such as one with sharp edges or a pointed tolerance), himmat (courage), namrata (humility) and tip. In even rarer instances, a patient may insist on sabar (contentment, freedom from fear). The writings of wearing a much longer kirpan, such as the 3-foot long Nanak and other Gurus are compiled in the Sikh holy ones that are worn on ceremonial occasions. In such book, Guru Granth Sahib, which for Sikhs, embodies the cases staff may have reasonable concerns about safety living spirit of the Gurus. but feel unable to discuss the issues, lest cultural sensi- Sikhism spread under the leadership of the ten tivities are compromised. Even if the Sikh patient himself Gurus at a time of increasing Mughal oppression, espe- is not deemed at risk, a kirpan may be considered a cially under the rule of the Mughal emperor Aurangzeb, ‘health hazard’ if another violent patient may somehow who levied higher taxes on non-Muslims, destroyed gain access to it. Hindu temples and suppressed popular revolts with large scale massacres. Guru Tegh Bahadur, the ninth Sikh Guru, asked Aurangzeb to stop the persecution of non- Recommendations Muslims. In November 1675, Guru Tegh Bahadur was publicly beheaded at the orders of Aurangzeb at what is A greater awareness of the cultural and religious meaning now a famous Sikh temple, Sis Ganj in Delhi. His son, the and significance of the kirpan, and knowledge of Sikhism tenth Guru Gobind Singh, created an army of soldiers in general, is a prerequisite for appropriate management known as the Khalsa (from Khalis: pure) in a ceremony of such issues within mental health. Areas such as on 30 March 1699. Khalsa were an army of ‘saint- Southall or Birmingham, which have large Sikh popula- soldiers’, created in a ceremony of amrit chhakna (the tions, are likely to have some staff from Sikh back- ritual taking of nectar) and were required to wear five grounds, or with a greater awareness of Sikh religion and Kakkars (kakkar is the letter k in Punjabi). All Sikh men, customs. However, while Sikhs have spread throughout who underwent the amrit ceremony, were thereafter to the UK, knowledge about Sikhism is unlikely to be wide- be called Singh (lion) and women as Kaur (Princess), spread, especially in areas with small ethnic minority repudiating and replacing the caste-based surnames. The populations. Mental health trusts should endeavour to five k’s are kes (unshorn hair, as a sign of a saint), kangha produce leaflets on the religious and cultural aspects of (a small comb to keep the hair tidy), kachhehara (riding different religious groups in both English and the minority breeches, a symbol of continence), kara (literally a link, a language to facilitate understanding, improve cross- steel bangle worn on the right wrist, as a reminder of the cultural communication and importantly, to allow the bond between a Sikh and the Guru, and for the need for ethnic minority patients to feel that their belief systems restraint) and the kirpan (Fig.1).