ETHICS CASE QUIZ
It is interesting that some of the thorniest ethical dilemmas in psychiatry evolve around food: forced feeding in anorexia nervosa, artificial nutrition and hydration at the end of life, and the subject of the October Ethics Quiz—the covert administration of psychotropic medications.1-3
Here is a brief recap of the case to reorient us before we turn to the quiz answers and commentary. Mr. B, an 85-year-old with vascular dementia, had been transferred to an acute geropsychiatric unit. Mr. B was admitted for psychiatric stabilization after he became aggressive toward residents at the dementia care facility where he has resided since his daughter, who is also his medical power of attorney, could no longer safely manage him.
Initially, the patient responded well to valproic acid and was about to be discharged back to the facility when he began to refuse the drug. His behavioral disturbances rapidly returned and required several emergency administrations of antipsychotics. When none of the environmental and behavioral techniques the team tried could persuade Mr. B to take the mood-stabilizing medication, the pharmacist suggested covert administration in applesauce. The treatment team was sharply divided on whether such surreptitious provision of the medication was ethical and requested an ethics consult to assist them.4
Readers were asked to imagine they were the ethics consultation team leader and to work through a series of 4 questions about the case. There were some very perceptive comments online that I will try to incorporate into the commentary.
1. Thiels C, Curtice M Jr. Forced treatment of anorexic patients: part 2. Curr Opin Psychiatry. 2009;22:497-500.
2. Terman SA. Determining the decision-making capacity of a patient who refused food and water. Palliat Med. 2001;15:55-60.
3. Latha KS. The noncompliant patient in psychiatry: the case for and against covert/surreptitious medication. Mens Sana Monogr. 2010;8:96-121.
4. Macauley RC. Covert medications: act of compassion or conspiracy of silence? J Clin Ethics. 2016;27:298-307.
5. Kuhse H, Singer P, eds. A Companion to Bioethics. Oxford, UK: Blackwell; 2012.
6. Kant I. Groundwork of the metaphysics of morals. In: Gregory M, ed. Cambridge Texts in the History of Philosophy. Cambridge, UK: Cambridge University Press; 1998.
7. Consent to Treatment of Adult Clients, 43 Mental Health, §1-15, 2006.
8. Roberts LW, Roberts B. Psychiatric research ethics: an overview of evolving guidelines and current ethical dilemmas in the study of mental illness. Biol Psychiatry. 1999;46:1025-1038.
9. Appelbaum PS, Gutheil TG. Legal issues in emergency psychiatry. In: Appelbaum PS, Gutheil TG, eds. Clinical Handbook of Psychiatry & the Law. 4th ed. Philadelphia, PA: Lippincott, Williams & WIlkins; 2007.
10. Tariot PN, Schneider LS, Cummings J, et al. Chronic divalproex sodium to attenuate agitation and clinical progression of Alzheimer disease. Arch Gen Psychiatry. 2011;68:853-861.