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 covert administration of psychotropic medications
ETHICS CASE QUIZ - FOLLOW-UP
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.
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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. When reviewing the case summary the attending has prepared, the opinion of the psychologist seems most consistent with which major ethical theory?
Clinicians, including myself when I am not wearing my ethics hat, often think ethicists spend way too much energy on ethical theories that often seem the secular equivalent of analyzing how many angels can dance on the head of a pin. We should instead just get about the business of doing what is best for the patient. Yet determining what is best is often surprisingly difficult: ethical theory, like changing the lens in your glasses, can often help us see aspects of the ethical concern previously not appreciated, such as the view of the psychologist. The answers offer a mini-tour of ethical theory.5
Option A: For the consequentialist theories of which utilitarianism is the most well-recognized branch in health care, the outcome of an act or rule is determinative of what is best. In each situation, what is right or good is the action or decision bringing about the most happiness or health for the most people. Covert administration of valproic acid will quell the agitation that is keeping Mr. B from being discharged to his care facility, which is after all what his daughter and the treatment team both want to happen. This theory best characterizes the view of the psychiatric pharmacist.
Option B: Deontologists often take positions diametrically opposed to utilitarianism, and that is the situation here. Deontology comes as close to endorsing absolute values as any theory. The psychologist, although he would likely not use the word, is a deontologist. The theory supports the psychologist in his moral claim that the duty to tell the truth outweighs any other ethical principle.
There is another layer though to the psychologist’s argument, and it is a bit of word play on “categorical.” Immanuel Kant, the founder of deontology, formulated the categorical imperative, one version of which is a philosophical restatement of the golden rule.6 Since no human being wishes to be lied to, the psychologist is arguing that Mr. B does not lose his human dignity when he receives a diagnosis of dementia.
Option C: Aristotle’s virtue theory finds the good and right in the character and conduct of exemplary human beings. This is a favored theory among clinicians because we all can easily recognize a “good doctor or nurse.” Yet there are in our scenario no real obstinate villains but only uncertain heroes searching for the cleanest way to promote Mr. B’s welfare.
Option D: Principlism would consider the big 4 ethical principles of autonomy, nonmaleficence, beneficence, and justice and through a process of weighing and specifying arrive at the optimal resolution of the dilemma. But such a process requires prioritization, and the nurses see not doing harm as most important, the pharmacist as doing good through managing the behavioral disturbances, and the psychologist as respecting the patient’s autonomy. So, while we have succeeded in identifying the salient values, we are no closer to knowing which one prevails in the case.
2. This question underscores the need to involve the daughter in the discussion and to clarify her authority to make the decision.
Those who commented on this question on the website hit the target when they asked, “Where is the daughter in all this, and what can she do?” To which the various answers explicated below offered answers.
Option A: Before losing capacity, Mr. B named his daughter as what is technically called the health care agent (HCA) in his durable power of attorney for health care. This gives the daughter the legal right and responsibility to make the decisions about covert administration on behalf of her father in some states.
Option B: This answer speaks deontological language: the daughter, even if she has the legal authority, does not have the moral authority to consent for a human being to be intentionally deceived.
Option C: In many but not all jurisdictions, the daughter as in option A would have the authority to provide informed consent on her father’s behalf to the administration of covert medications. However, in some states, consent for psychotropic medications is reserved to a court-appointed conservator of treatment guardian or even the court itself. Dementia bedevils practitioners and courts alike as there is no judicial or clinical consensus on whether it is a psychiatric or a neurological, or a medical disorder.
Option D: This is a variation on option C and would be true in a state where an HCA does not have the legal sanction to provide consent for psychotropic medication and conversely the court-appointed treatment guardian may not always be able to make medical decisions.7 The warrant for the judicial bifurcation is that psychiatric treatment requires a higher level of protection because of the vulnerability of the patient and the risks of the intervention, which is analogous to the more rigorous standard often required in psychiatric research.8
3. Those experts who contend that surreptitious administration can be an ethical option specify conditions that must be met for the practice to be justified.
Question 3 assumes the daughter is empowered to provide informed consent for surreptitious medication and asks what ethical qualifications the consultant should stipulate. The answers were phrased in the negative, so readers were asked to pick which of the 4 listed choices should not be included.
Option A: As with any treatment, the decision to administer the medication covertly should not be open-ended or unsupervised. The rights and welfare of the patient require that effectiveness of valproic acid in reducing the behavioral disturbances as well as any serious adverse effects such as thrombocytopenia or distressing symptoms such as gastrointestinal distress be monitored. Both the adverse and the positive effects may well alter the risk to benefit balance that underlies the ethical acceptability of the practice.
Option B: While-depending on hospital policy-signature informed consent may or may not be required, a written treatment agreement protects all involved by ensuring the entire team has reached consensus about this unusual means of medicating Mr. B and that the daughter as HCA is informed of and concurs with the treatment plan.
Option C: A formal treatment plan also is a safeguard against covert administration being a treatment of convenience. The staff should continue to try to persuade Mr. B to take the mood stabilizer and continue to find any other non-pharmacological interventions that can help manage his behavior.
Option D: This answer describes what ethicists call a “right of conscience” or “conscience clause.” Staff who from a virtue or deontological perspective truly believe it is wrong to deceive any patient, even an incapable one, should probably be excused from the care of Mr. B out of respect for their moral beliefs. However, this recusal depends on hospital policy, ethical codes, and the pragmatic consideration of staffing.
4. This question comes back to the ethics consultant who having heard the ethical concerns of all the stakeholders must now make a recommendation. As a prelude to this, he considers the arguments and counter-arguments. Question 4 asks readers to identify the strongest of the latter.
Option A: There is a consensus in law and ethics that in a true emergency that endangers a patient, other patients, or staff, psychotropic medication can be administered over the objections of a patient.9 The risk of course is that staff out of fear, burnout, or convenience will “find” or worse “provoke” the emergency. For this reason, many states require the permission of the court to administer antipsychotic medication on any regular basis against the will of the patient or his or her ethically appropriate decision maker. The nurses also have a humanistic point that holding Mr. B down and jabbing a needle in his arm is more painful and degrading than is sprinkling medication on his pudding.
Option B: While beleaguered staff in taxing situations acting out of soft paternalism often question the motives of family members, there is no evidence in the case scenario that the daughter wants anything other than her father’s well-being. She refuses to consent to antipsychotics. As one astute reader pointed out, divalproex is not a benign drug and for real informed consent this would need to be stressed.10
Option C: Argument C is one of the strongest arguments in favor of covert administration of medication, as it has a track record of getting Mr. B back to the neuropsychiatric baseline where he can return to live in his nursing facility. The caveat being, as readers stated, that he may be given even more psychotropics in that setting without any of the due process protections the ward is utilizing.
Option D: This option takes the long and most deontological and virtue theory view of the decision. Despite his dementia, Mr. B may well grasp that he is being “fooled” and become even more resistant to treatment and, more importantly, distrustful of not just the staff, but of his daughter when a nursing assistant, as frequently happens, tells him that his daughter consented to the deception.
When I was in training, one of my teachers told me, “We will all end up being geriatric psychiatrists,” and he was prescient. As the population, including us clinicians, ages-and sans the miracle cure or preventive for dementia we all hope to see-dilemmas like this one will increasingly be encountered, which is one reason ethical theory will always have a place in ethical deliberations.
Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM.
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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.