Munchausen syndrome by proxy, now known as Factitious Disorder Imposed by Another (FDIA), is a recognized mental health condition. Individuals with this disorder, often dominant and assertive, present themselves as saviours of a vulnerable, supposedly ill person. They impose their perception of the illness on the patient, typically a relative or close associate, and publicly claim that even top medical professionals cannot diagnose or treat the condition properly. These individuals often exaggerate the patients' symptoms and acquire extensive medical knowledge to support their claims.

To achieve his goals, he exaggerates the patient's symptoms, distorts facts, and even fabricates conditions to discredit the treating doctors. He moves the patient from one doctor to another, none of whom find any specific pathology to explain the alleged complaints. He claims that the doctors are unable to diagnose the cause of the patient's suffering. He demands sophisticated tests such as endoscopy, CT scans, MRI, and PET scans. When these tests return negative results, he accuses the doctors of conducting unnecessary tests just to make money.

He frequently disputes with the doctors, files complaints, and makes public statements to the press, emphasizing the supposed plight of the 'poor' patient. Although he portrays himself as a selfless saviour and martyr for a good cause, his actions are driven by personal gain, public image, and, where possible, financial benefits. The Consumer Protection Act (CP Act) in the country is often exploited for these purposes.

Law enforcement authorities, often unaware of this medical condition, tend to take such cases at face value. It is usually with great difficulty that a doctor can diagnose the condition in the caregiver, providing sufficient evidence to satisfy the authorities. Numerous cases have been reported in global literature where the individual has been prosecuted and penalized.

The characteristics of the syndrome
The characteristics of the syndrome, as described by researchers, (Munchausen Syndrome by Adult Proxy: A Review of the Literature. Authors: M. Caroline Burton, Mark B. Warren, Maria I. Lapid, J. Michael Bostwick, Journal: J Hosp Med, January 2015, 10(1):32-5), are as follows:

The study defines Munchausen syndrome by proxy (MSBP), more formally known as factitious disorder imposed on another, as a form of abuse where a caregiver deliberately produces or feigns illness in a person under their care to ensure the proxy receives medical attention that gratifies the caregiver. While well-documented in paediatric literature, few cases involving adult proxies (MSB-AP) have been reported. This study reviews existing literature on MSB-AP to provide a framework for clinicians to recognize this disorder.

Diagnostic Criteria
According to Bursch B. in "Munchausen by Proxy: Five Core Principles" (Annals of Paediatrics and Child Health, 2020), the following signs are important to identify in a caregiver:

• Refusal to leave the victim's side during assessments
• Spotty, vague, or inconsistent medical history of the victim
• Possession of medical knowledge and possibly working in a medical setting
• Discrepancies between the caregiver's reports and those of medical personnel
• A strong desire to be perceived as proficient in caring for the victim
• Frequent seeking of approval and attention from medical staff
• Unquestioning acceptance of recommendations for invasive diagnostic and surgical procedures
• Switching doctors when confronted with doubts or resistance from medical staff
• Additionally, caregivers often seek second opinions, further interventions, and additional procedures.

Real-Time Case Study in Local Context
As narrated by the treating surgeons and published in "Perverse Medical Negligence Judgments are the Bane of Medical Profession" by Dr. S.G. Kabra:

A man brought his 50-year-old wife to a gynaecologist, insisting on personally informing the doctor of her complaints. Despite her regular periods having stopped, he claimed she experienced heavy bleeding and severe pain every few months. He mentioned that she had been examined at a government hospital and diagnosed with a fibroid in her uterus, but the treatment she received was ineffective. He was advised she needed a hysterectomy. Continuing he said, although he could have had the surgery done for free at the government hospital, he chose to bring her to a private hospital, seeking the best facilities and complication-free treatment. He emphasized that, despite his limited means, he wanted the best care for his wife.

Upon examination and investigation by the gynaecologist, it was found that she had adenomyosis and a fibroid in her uterus.

After obtaining informed consent for surgery and anaesthesia, a Laparoscopic Assisted Vaginal Hysterectomy with Bilateral Salpingo-Oophorectomy was performed, as desired and insisted. This procedure involved removing the entire uterus, along with both fallopian tubes and ovaries, through a combination of laparoscopic mobilization from above and vaginal removal. The patient's husband specifically chose this technically challenging operation due for its benefits: no large abdominal incision, minimal scarring, and quick postoperative recovery.

During the surgery, while separating the uterus from the urinary bladder, some bladder fibers were torn due to the uterus being adhered to the bladder because of adenomyosis. The surgeon repaired the tear with a stitch. The rest of the operation proceeded without incident. At the end of the surgery, the surgeon tested the bladder's integrity by filling it with a coloured dye, confirming there was no leakage. A catheter was left in the bladder to prevent distension during the postoperative period.

Complaints Start
The next day, when the surgeon visited the patient, the patient's husband confronted her, saying, "You have injured her urinary passage. I have read your operation notes."

The surgeon explained that due to adenomyosis, the uterus was adhered to the urinary bladder, necessitating separation and resulting in some bladder fibres being damaged. The damage was repaired without opening the bladder.

The husband questioned why a catheter was left in her bladder, implying it was to cover up the damage. When the surgeon began to explain, he interrupted, asking why a bottle of blood was requested. He complained that his son had to donate blood, became weak, took leave from work, and they had to pay for it, yet the blood was not used. He accused the surgeon of a cover-up.

Despite the catheter draining properly, there was slight leakage, soiling the bed sheet.The husband to create a commotion in the ward, insisting that the urinary passage was cut during surgery and demanding a urology specialist to come. He filed a written complaint with the medical superintendent.

As expected after a vaginal hysterectomy, the patient recovered well, resumed a normal diet, had regular bowel movements, and was able to walk. The catheter, which was to remain for two weeks, was still in place. She was advised to be discharged with the catheter, to be removed on the follow-up visit. Although the patient was willing to go home, her husband was reluctant due to the catheter. He lodged a written protest with the medical superintendent but eventually took her home after receiving assurance of proper follow-up care.

The patient was brought to the hospital on the scheduled date. The gynaecologist clamped the urinary catheter to allow the bladder to fill and tested for any leakage. After confirming there was no leakage, the catheter was removed. However, the next day, the patient was brought back to the hospital by her husband, who complained that she was leaking urine and wetting her undergarments.

Upon questioning, the patient mentioned that she experienced urine leakage whenever she sneezed, coughed, or strained. The surgeon diagnosed her as stress incontinence and explained that prolonged catheter use can weaken the urethral sphincter. With time and appropriate pelvic exercises, the sphincter's tone would return, and the incontinence would stop. She was advised to visit the hospital's physiotherapy department to learn these exercises.

The husband refused this suggestion, insisting that she be admitted and treated by a competent urologist to repair the supposed damage to her urinary bladder. He caused a commotion in the outpatient department, demanding that the Medical Superintendent's assurance of proper care be honoured, and insisted on her admission and treatment.

She was admitted and referred to the hospital's urologist, who recommended descending pyelography to assess the urinary passage's function and integrity. The test showed that both kidneys were functioning normally, with the radio-opaque dye making the urine visible in sequential radiographs as it passed through the urinary tracts. The ureter from one kidney to the bladder was fully visualized with no leakage. The other ureter was partially visualized, showing slight dilation in the upper part and some obstruction in the lower part, but no leakage.

The urinary bladder was well-filled with opaque urine and showed no signs of leakage. The urologist then performed a cystoscopy, finding one ureter opening normal and the other stretched due to a visible stitch on the bladder wall. After filling the bladder with coloured dye and confirming no leakage into the vagina, the urologist concluded that the vaginal hysterectomy had not caused any breach in the urinary passage. No surgical intervention was needed. The urologist advised discharge with continued pelvic floor exercises and a follow-up review in a month or six weeks.

The patient's husband interpreted the findings to suit his narrative. He extracted details from the reports and filed a written complaint, alleging negligent injury to her urinary passage. He claimed that the urologist was trying to cover up for the gynaecologist and demanded immediate surgical intervention to correct the supposed operative injury, threatening to file a criminal complaint and go to the media if his demands were not met.

The urologist explained that no surgical intervention was indicated or advisable at this stage, as the patient was still recovering from the operation. A reassessment would be done after six weeks, once the tissues had stabilized, to make an informed decision.

The husband made a significant issue of her wetting her clothes. The patient had been prescribed diapers and physiotherapy. He demanded to know who would bear the cost. The medical superintendent ordered the hospital to supply the diapers and directed the physiotherapist to provide home care. The husband lodged a written protest before taking the patient home.

Before leaving, he made a scene in the ward, shouting, "See, they are providing diapers worth thousands for free. If they were not at fault, would they do so? I have forced them."

He brought the patient back after the stipulated weeks, alleging that the injury persisted, the leakage continued, and she was still wetting her clothes. He claimed that her condition had made both their lives miserable, as he had to take leave from work to care for her.

She was readmitted and, at the husband's written insistence, examined by another senior urologist. Descending pyelography was repeated, and this time, the previously unvisualized lower part of the ureter was fully visible from the kidney to the bladder, showing no breach in the urinary passage. The surgeon also examined the bladder cystoscopically, filled it with coloured dye, and tested for leakage, finding none.

However, the pyelography report noted a small collection of radio-opaque urine in the vaginal vault, despite no evidence of a breach in the urinary passage. The husband extracted this finding from the report and used it as evidence of injury and leakage, filing a written complaint with the superintendent. He demanded that the urologist perform surgery to correct the leakage, threatening to lodge a police complaint, expose the situation in the media, and write to the Prime Minister and the state Chief Minister if his demands were not met. He refused to take her home unless the urologist operated on her, making his complaint now against the urologist.

After obtaining informed consent, the senior urologist performed surgery. He detached the lower end of the ureter, which showed slight obstruction in the pyelography and was stretched in the cystoscopy, and transplanted it to a different location in the bladder. This was a major and technically challenging operation. He also separated the bladder from the vagina, where they were in close contact, and repaired the intervening area to prevent any potential seepage from the bladder to the vagina.

The patient recovered uneventfully. Descending pyelography confirmed that the transplanted ureter was functioning well, draining urine into the bladder, which filled normally without leakage. The bladder was filled with coloured dye, and no leakage into the vagina was observed. The patient was then discharged.

Two days later, the husband returned with the patient, alleging continuous leakage and constant wetting of clothes. The patient, however, mentioned that she could not fully hold her urine, with occasional dribbling, especially when straining. The surgeon verified this by asking her to hold her urine and then cough, which resulted in some leakage, confirming stress incontinence. The surgeon explained that unless she does regular and proper pelvic exercises to strengthen her ability to hold urine, there was nothing more he could do surgically.

The husband demanded a written statement from the surgeon, claiming that the operation to repair the damage caused by the gynaecologist had failed. He caused a disturbance in the surgeon's chamber and the superintendent's office, parading his wife before taking her home.

He claimed, "She has urine leakage and wets her clothes. They injured her urinary passage during the operation and tried to hide it, postponing action until I forced them. By then, it was too late and didn't help. They've made her life hell, and I've lost my job. They don't realize whom they're dealing with. I'll make them pay dearly."

Complaint under CPA
He served a legal notice and, later, filed a complaint in the Consumer Forum, claiming over 90 lakh in compensation (Smt. Chandravati Rai and Ramkrishna Rai vs. Santokba Durlabhji Hospital and Dr. Preeti Sharma: Complaint No. 30/2010, State Consumer Disputes Redressal Commission, Rajasthan, Bench No.2, Jaipur). He created scenes in court, lamenting the poor condition of his 'incontinent' wife and himself. He obtained a report from a urologist suggesting an 'occult vesico-vaginal fistula' (VVF). Though, on test with radiopaque dye, no fistulous tract had been identified, he diagnosed VVF on the basis of some opaque dye present in the vagina. He over looked the fact that a trickle of urine from urethra in females would collect in the vagina. The urologist was not examined. He won a compensation of 20 lakhs.

In the Indian context, this is a typical case where an over-dominant husband exploits the real and enforced medical conditions of his submissive wife, acting as a martyr for personal gain and monetary benefits—a case of Munchausen Syndrome by Proxy. This situation presents a significant medico-legal dilemma for honest senior specialists.

Written By: Dr. Shri Gopal Kabra, MMBS, LLB, MSc, MS(Anatomy), MS(Surgery)
15, Vijay Nagar, D-block, Malviya Nagar, Jaipur-302017
Ph no: 8003516198 email: [email protected]