Ethical Issues in Surreptitious Prescribing

To the Editor: I was pleased to see the topic of surreptitious prescribing addressed in the April issue of Psychiatric Services (1). In the course of my work in state hospitals in Massachusetts, I have had to make decisions about whether to prescribe medications concealed in food or fluids. In most of these cases, guardians and other nonclinicians were the main advocates of this type of prescribing. I agree with the authors that there may be a role for this type of prescribing in work with patients with dementia and severe retardation, when the patient is not aware of the medications prescribed and a guardian has given consent for them. However, it is less clear whether any role exists for this type of prescribing for patients with psychotic illness, who are aware of the medications that they take.

One ethical issue in this population is whether an adult with the capacity to understand the implications of having a medication prescribed has the right to know what is being given. The finding of incompetence does not preclude an individual's having the capacity to recognize that he or she is being given a medication that has the potential to cause adverse effects—which creates a dilemma if the patient develops side effects. Does the patient have a right to know about these side effects and the fact that they are caused by a medication? A physician has an ethical obligation to explain side effects to patients, even to patients deemed incompetent. A patient's discovery of the fact that medication is being given surreptitiously could have devastating effects on the treatment relationship and the patient's ability to trust the psychiatrist and the treatment team, an issue raised by Ahern and Van Tosh in their Taking Issue commentary in the April issue (2). I would also be concerned that a psychotic patient who learns accidentally that he or she is being medicated surreptitiously might stop accepting all treatments and potentially all food and nourishment. For inpatients deemed incompetent who have a high level of awareness, it could be quite difficult to shield this information, given the number of staff on different shifts who might accidentally disclose information about the concealed medication. For these reasons, the practicality of this practice is far from certain. Further reports on the application of this practice would be welcome.