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
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
"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
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
"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
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
"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?>.▪