Opinion: The invisible pill

As patients, doctors have earned our trust and attention. We choose them based on experience, recommendation, or prestige, but ultimately, we put our care in their hands. Despite this trust, we expect to maintain free will when deciding to continue or decline treatment. For those with exacerbated neurodegenerative diseases and various mental disorders, would you and your loved ones let a doctor be the final decider?

“Even though doctors have the right to treat, patients also have the right to be treated.”

Though patient autonomy means the right to be in control, doctors have the responsibility to act as they see fit for the health of the patient, which may contradict the patient’s wishes. In most cases, losing patient autonomy equates to the loss of decision making capabilities. In the case of mental hospitals and elderly care facilities, doctors often employ “covert medication” to ensure consistent treatment. Covertly medicating a patient involves sneaking pills into their food or drink. It is by no means the default method of administration, however, it is used in special cases when a patient constantly refuses care or is deemed incapable of decision making. In these cases there are three options: covertly medicate (with family consent), not treat at all after patient refusal, or inject medications intravenously by using physical force and restraint.

Thus, an ethical dilemma is presented. One side of this debate argues to stop covert medication, believing the physician and patient bond should not be jeopardized. If a patient were to find out they were receiving treatment even after declining, it could taint their view on both the medical field and its professionals no matter the status of their health. The opposing side believes that, under the Hippocratic Oath pledged before receiving one’s medical degree, a physician reserves the right to decide if a patient is unable to decline treatment. So if a nonautonomous patient refuses and they relapse or their condition deteriorates, the doctor could be liable for malpractice as a result of doing nothing to treat them. Even though doctors have the right to treat, patients also have the right to be treated.

Noted in a 2010 study, “covert medication occurs in 43% to 71% of nursing homes in the United Kingdom,” especially for those with either dementia or schizophrenia. Such a large range suggests that, while present, this is happening at an unpredictable and untrackable level. In a controlled study performed by the Indian Journal of Psychiatry, 67 “non-compliant” patients with schizophrenia were medicated surreptitiously; after becoming aware, 26% opted to continue treatment while only 18% became resentful. Overall, 91% showed clinical improvement as a result of treatment. The alternatives to this deception lead to burnt out nurses, physically restrained patients, and an increased likelihood of condition deterioration.

“If a patient were to find out they were receiving treatment even after declining, it could taint their view on both the medical field and its professionals no matter the status of their health.”

When it comes to covert medication, a moral aspect comes into discussion. Though the issue concerns medical professionals, the ethical considerations can be reviewed through the lens of philosophy. Simplifying this ethical dilemma can lead to two schools of thought, represented by philosophers like Immanuel Kant and Peter Singer and summarized by Northeastern Professor Jung Lee. Kant’s philosophy is rooted in categorical imperatives, which assert that a morally right decision is always correct, regardless of the consequences. The categorical, or “moral,” choice is often ignored, as nursing homes and mental hospitals around the world abide by their secretive method. On the other hand, Singer’s consequentialism posits that the ends justify the means. In the context of covert medication, Singer’s perspective may seem more appealing due to its focus on the overall result. At first glance, abiding by patient wishes could seem like the obvious choice. However, in situations where a patient lacks the capacity to make clear decisions, medical professionals hold the responsibility of making choices that align with the patient’s best interests. The chance for long term condition stability or improvement outweighs the “right” choice in many cases.

When considering the alternative that patients may suffer more due to their choices, covert medication can, surprisingly, be the more humane option. In this context only, Singer’s approach safeguards patients from the dehumanizing process of restraint and the painful, protracted process of intravenous administration that strains medical staff. Non-autonomous patients can and should rely on their families and healthcare providers to act in their best interest, even during moments of non-compliance. Ultimately, this ensures that patients continue to receive treatment for their afflictions.