Covert Drug Administration: `Win Battle, But Lose War'

Spiking a child's food or drink with medication may be an acceptable necessity when there's no other way to give a drug. Adults are another matter, even for those with severe mental illness who cannot or will not take their medicine.

The practice of covertly administering drugs may seem like a minor matter, but it touches on legal and ethical issues of the patient's competence, autonomy, and insight, wrote Peter Whitty, M.B., M.R.C. Psych., and Pat Devitt, M.B., M.R.C. Psych., of the department of adult psychiatry at the Adelaide and Meath Hospital in Dublin, Ireland, in the April issue of Psychiatric Services.

“The paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent,” they wrote in the journal's “Open Forum.”

Research on the extent of the practice is spotty but suggestive. Drugs were given covertly at some time in 24 of 34 residential, nursing, or inpatient units in southeast England, according to a study in the August 2000 issue of the Journal of the Royal Society of Medicine. A recent survey of caregivers for 1,362 dementia patients in Norwegian nursing homes found that between 11 percent and 17 percent of the patients received drugs mixed in food or beverages at least once a week. Patients who were administered drugs covertly more often received antiepileptics, antipsychotics, and anxiolytics than those given their drugs openly, wrote Kirkevold and Engedal in the January 1 BMJ.

Little information is available on the extent of the practice in the United States, said former APA President Paul Appelbaum, M.D., now chair of APA's Council on Psychiatry and Law, but he thinks it is rare in inpatient settings, given professional sensitization to informed consent and knowledge of how to obtain consent or what to do if the patient is not competent.

“If anything, it is probably more a phenomenon of families or nursing homes,” he said in an interview. “But how many families would do it and how many prescribers would know about it is unknown.”

Medication without consent of a responsible, competent person is unethical and illegal in the United States, said APA Ethics Committee Chair Spencer Eth, M.D., of New York's St. Vincent Hospital in an interview: “Can you treat someone without his or her consent? Not without violating the patient's autonomy and the core ethical principle of consent. It is a paternalistic attitude that is an anachronism in psychiatric practice. You can't justify it in the name of `the patient's best interests.'”

On one hand, suggested Whitty and Devitt, physicians and caregivers might consider covert administration of drugs to avoid delays in treatment. Such delays could increase morbidity or self-destructive behavior, worsen outcomes, or prolong the patient's suffering.

“Surreptitious prescribing can also prevent the need to repeatedly restrain and forcibly administer injections to patients,” they said.

On the other hand, covertly medicated patients may lose insight into the relationship between nonadherence and relapse, they said. Ethically, surreptitious administration can be seen as a breach of trust by the doctor or by family members who administer the drugs. Patients may become angry and refuse treatment after learning that their trust was betrayed. The practice may feed patients' sense of unreality or paranoia. They may reject further treatment if they feel that the diagnoses are unfounded or that they have gotten better on their own. Given its secrecy, covert administration of medication is frequently undocumented, which could lead to serious interactions with other, openly prescribed drugs. Side effects may be more upsetting and harder to manage.

“It's hard to slip a patient an antipsychotic without the patient's becoming aware of it,” said Appelbaum, chair of the department of psychiatry at the University of Massachusetts Memorial Medical Center in Worcester.

Administering drugs without a patient's consent also crosses legal boundaries, said Whitty and Devitt. They suggest recourse to mental health laws covering guardianship and involuntary hospital or outpatient commitment. Clinicians must continually weigh the patient's competence to understand and consent. Even if medication is given surreptitiously in an emergency, patients should be involved in future treatment decisions once they are capable of doing so.

“Before proceeding, the clinician should have a documented history of recurrent relapses secondary to medication nonadherence,” wrote Whitty and Devitt. “All factors associated with nonadherence should also be examined, and every intervention as a means to improving adherence should be exhausted.”

Medicating patients without their knowledge, they said, is not justifiable solely as a shortcut for institutions or families wishing to calm a troublesome patient and thus alleviate some of the burdens of caregiving.

Covert administration of drugs is at odds with practice in the United States and Canada and may represent differences between mental health laws in Ireland, compared with this side of the Atlantic.

“The practice of covert administration of medication is not specifically covered in the mental health legislation of Ireland,” said Whitty in an e-mail interview. “Therefore, in terms of the ethics this rests with individual clinicians. We are not advocates of this form of practice. What we did was critically examine potential advantages and disadvantages of this form of practice from the published literature and informal discussion with colleagues.”

Others believe there is no excuse for violating norms of patient autonomy and professional ethics.

“The practice of surreptitious prescribing to so-called noncompliant patients is coercive and forced treatment at its most sinister,” wrote Laurie Ahern, associate director of Mental and Disability Rights International, and Laura Van Tosh, director of consumer affairs at Western State Hospital in Tacoma, Wash., in an accompanying commentary.“ Surreptitious prescribing violates every tenet of the doctor-patient relationship and is the antithesis of recovery.”

Force and trickery only reinforce the sense of loss of control that mental patients often feel, said Ahern in an interview. Patients' prior experience with a drug's side effects or its interference with daily living may give them good reason to avoid medication, she said.

“Even for incompetent patients,” said Appelbaum, “I would have strong reservations about covertly administering medications because it may encourage a loss of respect for that individual patient and for all patients, so that deception becomes easier.”

He recommends other actions like a guardianship hearing in the courts for an incompetent patient, where evidence is weighed and a substitute decision maker can be appointed if needed.

“Patients can then be confronted with the reality that they have been judged incompetent and offered the choice of injected or oral medications,” he said. “They will usually choose oral medication and may feel coerced, but not deceived.”

Covert administration is inappropriate even if the person were judged incompetent, Ahern said. “You win the battle but lose the war, if the goal is to help the person get better. There are many ways to heal.”

The really tough cases, said Appelbaum, arise with patients who are competent but refuse treatment, especially those with a history of nonadherence.

“In the history of psychiatry we get into trouble when we take extraordinary measures out of desperation—as with psychosurgery,” he said. “Rather than resorting to deception, we must recognize that accepting limits is the greater part of wisdom. We must not abandon these patients, but continue to work with them.”

The study, “Surreptitious Prescribing in Psychiatric Practice,” is posted online at<http://ps.psychiatryonline.org/cgi/content/full/56/4/481>. The accompanying commentary, “The Irreversible Damage Caused by Surreptitious Prescribing,” is posted at<http://ps.psychiatryonline.org/cgi/content/full/56/4/383?>.▪