Hostname: page-component-78c5997874-g7gxr Total loading time: 0 Render date: 2024-11-19T05:57:45.319Z Has data issue: false hasContentIssue false
  • English
  • Français

Deception in Caregiving: Unpacking Several Ethical Considerations in Covert Medication

Published online by Cambridge University Press:  01 January 2021

Rosalind (Roz) Abdool
Get access Rights & Permissions [Opens in a new window]

Abstract

From a clinical ethics perspective, I explore several traditional arguments that deem deception as morally unacceptable. For example, it is often argued that deception robs people of their autonomy (Frankfurt 2005). Deception also unfairly manipulates others and is a breach of important trust-relations (Williams 2009, Scanlon 1998). In these kinds of cases, I argue that the same reasons commonly used against deception can provide strong reasons why deception can be extremely beneficial for patients who lack mental capacity. For example, deception can enhance, rather than impair, autonomy in certain cases. I argue that deception ought to only be used after considering several key morally relevant factors and provide a practical and morally justifiable framework for exploring these issues.

Type
Symposium Articles
Information
Journal of Law, Medicine & Ethics , Volume 45 , Issue 2: Symposium – Covert Medication: Legal, Professional, and Ethical Considerations , Summer 2017 , pp. 193 - 203
Copyright
Copyright © American Society of Law, Medicine and Ethics 2017

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Kirkevold, Ø. and Engedal, K., “Concealment of Drugs in Food and Beverages in Nursing Homes: Cross Sectional Study,” BMJ (Clinical Research Ed.) 330, no. 7481 (2005): 1-4.Google Scholar
Anton, V. and Rutherford, J., “Suspension of Nurse Who Gave Drug on Consultant's Instructions: Over a Third of Psychiatrists Had Given a Drug Surreptitiously or Lied About a Drug,” BMJ 315 (1997): 300-314.Google Scholar
Covert medication is not merely an act of not getting consent directly from the patient, but also involves an act of misleading another without their knowledge and presenting the beverage/food as if it were a regular beverage or food item. An act for which consent is not obtained and no deception is occurring may occur if a patient is being physically restrained, for example.Google Scholar
Health Care Consent Act, 1996, 2010, C.1, available at <http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm#BK12> (last visited May 3, 2017).+(last+visited+May+3,+2017).>Google Scholar
Id.Google Scholar
Id.Google Scholar
College of Registered Nurses of Manitoba, “Covert Medication Administration: Code of Ethics Application,” last modified July 2006, available at <https://www.crnm.mb.ca/uploads/document/document_file_39.pdf?t=1442260453> (last visited May 3, 2017).+(last+visited+May+3,+2017).>Google Scholar
College of Registered Psychiatric Nurses of British Columbia, “Dose Form Modification of Medication: Evidence Based Guidelines,” last modified September 2011, available at <http://www.crpnbc.ca/wp-content/uploads/2011/07/Dose-Form-Modification-of-Medication_2011October.pdf> (last visited May 3, 2017).+(last+visited+May+3,+2017).>Google Scholar
National Institute for Health and Care Excellence, “Managing Medicines in Care Homes, ” last modified March 2014, available at <https://www.nice.org.uk/guidance/sc1> (last visited May 3, 2017); Northamptonshire Healthcare (NHS Foundation Trust), “Covert Administration of Medicines Policy and Guidelines,” last modified July 2013, available at <http://www.humber.nhs.uk/Downloads/Services/Pharmacy/Guidelines/Covert%20medication%20guidance%20in%20HFT.pdf> (last visited May 3, 2017); The College, “College Statement on Covert Administration of Medicines: Royal College of Psychiatrists,” The Psychiatrist: Formerly the Psychiatric Bulletin 28 (2004): 385-386.+(last+visited+May+3,+2017);+Northamptonshire+Healthcare+(NHS+Foundation+Trust),+“Covert+Administration+of+Medicines+Policy+and+Guidelines,”+last+modified+July+2013,+available+at++(last+visited+May+3,+2017);+The+College,+“College+Statement+on+Covert+Administration+of+Medicines:+Royal+College+of+Psychiatrists,”+The+Psychiatrist:+Formerly+the+Psychiatric+Bulletin+28+(2004):+385-386.>Google Scholar
Breen, R. and Thornhill, J. T., “Noncompliance with Medication for Psychiatric Disorders: Reasons and Remedies,” CNS Drugs 9, no. 6 (1998): 457-471.Google Scholar
Sørensen, L., Foldspang, A., Gulmann, N. C., and Munk-Jorgensen, P., “Determinants for the Use of Psychotropics among Nursing Home Residents,” International Journal of Geriatric Psychiatry 16, no. 2 (February 2001): 147-152.Google Scholar
See Kirkevold and Engedal, supra note 1.Google Scholar
Sonntag, A., Matschinger, H., Angermeyer, M. C., and Riedel-Heller, S. G., “Does the Context Matter? Utilization of Sedative Drugs in Nursing Homes—a Multilevel Analysis,” Pharmaco-psychiatry 39, no. 4 (July 2006): 142-149.no. 4 (July 2006CrossRefGoogle Scholar
See Kirkevold and Engedal, supra note 1.Google Scholar
See, for example, Hung, E. K., Binder, R. L., and McN-iel, D. E., “Covert Medication in Psychiatric Emergencies: Is It Ever Ethically Permissible?” Journal of the American Academy of Psychiatry and the Law 40, no. 2 (2012): 239-245.Google Scholar
Mccullough, L. B., Coverdale, J. H., and Chervenak, F. A., “Constructing a Systematic Review for Argument-Based Clinical Ethics Literature: The Example of Concealed Medications,” Journal of Medicine and Philosophy 32, no. 1 (2007): 65-76; M. Schermer, “Nothing but the Truth? On Truth and Deception in Dementia Care,” Bioethics 21, no. 1 (January 2007): 13-22.CrossRefGoogle Scholar
See Health Care Consent Act 1996 (section 21), supra note 4.Google Scholar
DeGrazia, D., “Value Theory and the Best Interests Standard,” Bioethics 9, no. 1 (1995): 50-61.CrossRefGoogle Scholar
See DeGrazia, , supra note 18.Google Scholar
Kopelman, L. M., “The Best Interests Standard for Incompetent or Incapacitated Persons of All Ages,” Journal of Law, Medicine & Ethics 35, no. 1 (2007): 187-196.Google Scholar
Beauchamp, T. L. and Childress, J. F., Principles of Biomedical Ethics, 6th ed. (New York: Oxford University Press, 2009): at 197.Google Scholar
Pellegrino and Thomasma argue that acting in the patient's good reflects the patient's desires and values, and they argue that in doing so, one is respecting the patient's authentic autonomy; hence, beneficence is merely an extension of respect for autonomy. They remark: “the best interests of the patients are intimately linked with their preferences” from which “are derived our primary duties toward them.” This view reduces beneficence to autonomy and fails to recognize that a patient's good can extend beyond the capacity to make one's own choices. Pellegrino, E. and Thomasma, D., For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1988): at 29.Google Scholar
Bok, S., Lying: Moral Choice in Public and Private Life (New York: Pantheon Books, 1978): at xvii.Google Scholar
Griffith, R., “Managing Medical Compliance,” British Journal of Healthcare Management 16, no. 8 (2010): 402-408.Google Scholar
One ought to also be careful when taking prior expressed capable wishes at face value. Wishes should be interpreted and adapted to new circumstances given the context of a patient's values and life, as there are often multiple unexpected variables involved in medical decision-making given a new context in the medical setting. Taking the time to probe and explore what the previous capable wish meant for the patient given her experiences can help enlighten what one ought to do.Google Scholar
Mccullough, L. B., Coverdale, J. A., and Chervenak, F. H., “Constructing a Systematic Review for Argument-Based Clinical Ethics Literature,” Journal of Medicine and Philosophy 32, no.1 (2007): 73-74.Google Scholar
See Schermer, supra note 16, at 13-22.Google Scholar
Framingham, J., “Schizophrenia: The Challenges of Taking Medication,” Psych Central, last modified May 2016, available at <http://psychcentral.com/lib/schizophrenia-the-challenges-of-taking-medication/> (last visited May 3, 2017).+(last+visited+May+3,+2017).>Google Scholar
Gilson, L., “Trust and the Development of Health Care as a Social Institution,” Social Science and Medicine 56, no. 7 (April 2003): 1454-1468.Google Scholar
See Gilson, , supra note 28.Google Scholar
Id.Google Scholar
Ahern, L. and Van Tosh, L., “Taking Issue: The Irreversible Damage Caused by Surreptitious Prescribing,” Psychiatric Services 56, no. 4 (April 2005): 383.Google Scholar
Armstrong, K., Rose, A., Peters, N., Long, J. A., McMurphy, S., and Shea, J. A., “Distrust of the Health Care System and Self-Reported Health in the United States,” Journal of General Internal Medicine 21, no. 4 (April 2006): 716-721.CrossRefGoogle Scholar
See Armstrong, et al., supra note 32, at 41.Google Scholar
See Mccullough, et al., supra note 26, at 73.Google Scholar
Id.Google Scholar
Baier, A., “Trust and Antitrust,” Ethics 96, no. 2 (1986): 251-260, available at <http://www.jstor.org/stable/2381376> (last visited May 4, 2017).Google Scholar
Williams, C. L. and Tappen, R. M., “Can We Create a Therapeutic Relationship with Nursing Home Residents in the Later Stages of Alzheimer's Disease?” Journal of Psychosocial Nursing and Mental Health Services 37, no. 3 (March 1999): 28-35.Google Scholar
See Williams, and Tappen, , supra note 37, at 2.Google Scholar
Id., at 3-4.Google Scholar
Schermer further raises an interesting point that requires addressing; patients who suffer from advanced Alzheimer's disease (and this can be extended to other patient populations who lack mental capacity) are unable to appreciate the truth. Schermer remarks: I will argue that what can be called deception, or a lie, changes over the course of dementia because dementia slowly diminishes the capacities one needs to distinguish between truths and falsehoods. Once these capacities are lost, the ability to be lied to is also gone. Schermer, M., “Nothing but the Truth? On Truth and Deception in Demetia Care,” Bioethics 21, no. 1 (January 2007): 13-22.Google Scholar
Manson, N. C. and O'Neill, O., Rethinking Informed Consent in Bioethics (Cambridge: Cambridge University Press, 2007): 160.CrossRefGoogle Scholar
Baier provides the example of a plumber who is providing service for a client who must trust that the plumber is working appropriately, given her lack in understanding of how plumbing actually works. This can be extrapolated to other social contracts, like hiring a mechanic and some aspects of health-care, like undergoing surgery.Google Scholar
Thom, D. H., “Physician Behaviors That Predict Patient Trust,” Journal of Family Practice 50, no. 4 (April 2001): 323-328.Google Scholar
See Thom, , supra note 43.Google Scholar
Mechanic, D. and Meyer, S., “Concepts of Trust among Patients with Serious Illness,” Social Science and Medicine 51, no. 5 (September 2000): 657-668.Google Scholar
See Mechanic, and Meyer, , supra note 45, at 665.Google Scholar
Dworkin, G., The Theory and Practice of Autonomy (Cambridge: Cambridge University Press, 1997).Google Scholar
Johns, R., “Critical Commentary: Who Decides Now? Protecting and Empowering Vulnerable Adults Who Lose the Capacity to Make Decisions for Themselves,” British Journal of Social Work 37, no. 3 (April 2007): 557-564.Google Scholar
See Beauchamp, and Childress, , supra note 21; Richardson, H. S., “Specifying, Balancing and Interpreting Bioethical Principles,” Journal of Medicine and Philosophy 25, no. 3 (2000): 285-307.Google Scholar
See Beauchamp, and Childress, , supra note 21, at 17.Google Scholar
Id., at 381-387.Google Scholar
Hence, there could be a mix of utilitarian and deontological or other impacts from the act of deception, which is why I think the inclusivity of principlist account is most feasible.Google Scholar