Sohail Nasir ( Aga Khan University School of Nursing and Midwifery, Karachi, Pakistan. )
January 2023, Volume 73, Issue 0
Sohail Nasir ( Aga Khan University School of Nursing and Midwifery, Karachi, Pakistan. )
Schizophrenic patients deny health care due to lack of insight in many cases. In such situations most of the psychiatrists opt for covert medication in consultation with the families. Covert medication has legal and ethical implications. Moreover, it has certain clinical implications for the patient. In addition, how long the covert medication can be continued and when should it be revealed to the patient are questions that cannot be answered in black and white. This article is a commentary on a real scenario of covert medication in ethical perspective.
Keywords: Schizophrenia; Covert medication; Insight; Psychiatrists; Ethical.
Submission completion date: 04-12-2021 Acceptance date: 21-07-2022
Schizophrenia is a chronic brain disorder that causes hallucination, delusion, problems with thinking, perception and concentration, and lack of motivation.1 It approximately affects 21 million people globally.1 Most of the times, lack of insight incapacitates the patients and they deny health care. Generally, in cases where there is active refusal and the patients lack insight, psychiatrists are left with no choice but to covertly medicate the patient. Covert medication is the administration of medicines in disguised form like in food and drinks.2 Although the practice of covert medication is predominant, it is done in sly. One third of the patients with severe mental illnesses received covert administration of medication during their life time.2 Moreover, there is no defined procedure for covert medication.3 This practice of covert medication in psychiatry raises many ethical concerns, and has clinical implications for the patient as well. The case is presented to highlight the use of covert medication and ethics involved. It will bring awareness to the medical fraternity for providing an amicable solution.
Patients/Methods and Results
The case was seen in October 2014. A 26-year-old young man, who was a nurse, visited a private psychiatrist clinic in one of the cities in KP with his mother. During history taking the young man revealed that they came to the clinic to discuss his father's condition. He claimed that for the last two years his father had been delusional, aggressive, physically abusive and homicidal towards his mother; he suspected that his mother had illicit relationship with others. Moreover, he slept with a loaded gun under his bed. The son said that he tried to convince his father to visit a psychiatrist but he refused.
His father was a 60-year-old man and the family was from KP. He used to work in a government department as a head clerk but took early retirement due his delusions.
The psychiatrist gave a diagnosis of schizophrenia and prescribed Risperidone 2mg per day. He asked the young man to bring the patient as soon as he develops insight. Ten years have passed by and the father is still being covertly medicated and he is doing fine. It was only the mother and her elder son who knew the diagnosis. The younger son somehow came to know the facts, and he was adamant to reveal it to the father.
The son, who is a nurse, discusses general health concerns with the psychiatrist on a regular basis; however, they have not yet informed the patient that he was on medication. The patient was performing all the activities of daily life and all the negative symptoms have disappeared.
This article presents a discussion on covert medication considering the conflicting ethical principles and theories, its clinical implications, and future recommendations for practice and research.
Autonomy vs Non-maleficence and Beneficence: Autonomy gives an individual the right to decide for themselves. According to this principle, the individual must have the power to decide for one's self without the control of others; however, the individual must be in a sound mind to make decisions.4 The Universal Declaration of Bioethics and Human Rights, as cited by Wolinsky,5 states, the autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. For persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests.
Moreover, the purpose of psychotropic medicines is to restore autonomy of the patients. So schizophrenic patients may not have insight initially, but they may resume it after taking medicines and with the resumption of insight, the right to autonomy must also resume. So, respecting autonomy means restoring the person's autonomy by providing them all the information and allowing them to decide for themselves. However, it may have consequences of anger, resentment, and persecutory delusions of the family members. When exercising autonomy can cause harm to the individual or others it can be overridden by non-maleficence. The principle of non-maleficence is prima fascia.6 Thus, covert medication may be used in patients who can potentially harm themselves and others around them including their family members. Furthermore, the principle of beneficence ensures patient's best interests.6 Covert medications ensure access to treatment for the psychiatric patient who lacks insight. It is beneficial since the positive and negative symptoms are devastating for the patients. In addition, the family has to deal with the anger and suicidal and homicidal symptoms that are difficult to manage. Thus, covert medication assists the family to manage the patient.
Individual rights vs Family rights: Another facet that should be weighed against the individual rights is family rights in covert medication. Individual rights stress on the rights of a persons and does not consider the social context in which they live. Many cultures, for instance Western culture, put more stress on safeguarding individual rights of the patients. They believe in liberal individualism of the patients; however, this approach in psychiatry is counter argued by many researchers. The right to make informed decision about medical treatment is central in Western bioethics.7 Family rights proponents believe in viewing individuals in their social contexts. For instance, in Eastern culture of the subcontinent, individuals are seen in a social context. Family input in decision-making is a norm and often decisive. So, proponents of family rights may propose that covert medication can be justified in the obligation to preserve the family's interests. The disease process is such that the safety and wellbeing of the family in general are always at risk, particularly in the context of developing countries, due to lack of strong community health care systems.
Right based theory vs Paternalism: Right-based theory advocates for the rights inherent to human beings. These are the moral rights that protect individuals against oppression, unequal treatment, intolerance, and invasion of privacy regardless of gender religion, ethnicity, and economic status.8 In addition, it also protects the right to information and right to autonomy. Right-based theorists may argue that covert medication is against the inherent rights of human beings. Moreover, the rights of the individuals cannot be taken away for lifetime merely because they have mental disorder. In addition, the purpose of health care is not only to relieve the symptoms through medicines, but it is obligated to improve the quality of life of the patients to an extent that they should be able to exercise their rights. On the contrary, according to paternalism when health care professionals believe that exercising autonomy may bring harm to the patient or others related, the patient's autonomy can be overridden. It works on the principles of beneficence and non-maleficence. Thus, paternalists may argue that covert medication is justified because it is a protective measure for the patients and other people related to him.
Clinical implications of Covert Medication: The impact of covert medication in psychiatry goes beyond ethical facets. It has significant clinical implications that health care professionals cannot deny or ignore. With covert medication regular follow-ups and necessary blood tests cannot be warranted. Moreover, covert medication of paranoid people can threaten the safety of the family. For instance, if a paranoid person realises that he has been medicated he may become angry and homicidal towards that person. In addition, if concealed, dealing with the side effects of certain anti-psychotics can be difficult. The patient may not reveal the symptoms to the family members, for instance unusual body sensation, akinesia, and sedation. These symptoms require only dose adjustment, but they may get overlooked by the family members since they are not professionals.
On the contrary covert medication ensures strict following of a treatment regime. It serves the purpose of regular and accurate dose administration, thus preventing overdosing or abuse. In the context of Pakistan, mental health disorders are still considered taboo and stereotyped. The person who gets to know of their mental health disease loses hope and gives up on life. Moreover, social repercussions, for instance stereotyping of the patient and family, augments the suffering. Covert medication limits the news of psychiatric disorder to the family thus preventing from social consequences and relapses are minimised by regular administration. Moreover, ignorant of covert medication, the patients enjoy their life.
The subject of covert medication in psychiatry must be an open discourse. Practicing psychiatrists and nurses must be aware of covert medication and its utility in patients who lack insight. Psychiatrists, no matter fewer in number, must come together to share knowledge and experiences and develop contextual code of conduct for practice. Furthermore, specific health educational materials for families covertly medicating their loved ones must be developed and disseminated. Moreover, large scale longitudinal studies must be conducted to assess the impact of covert medication in psychiatric patients. Qualitative studies about the perceptions of family members and challenges faced in covert medication must be explored to have an in depth understanding.
To close the gap between urban and rural health care accessibility, digital technology and tele-psychiatry clinics must be established. The health care professionals in primary healthcare centres must be trained in mental health promotion, prevention, identification, and referral of patients and families.
In the context of Pakistan, familial decision-making must be advocated and adopted as health care policy in cases with chronic mental health disorders. Covert medication of chronic psychiatric patients lacking insight and active refusal of treatment in consultation with the family must be allowed to the psychiatrist and the practice must be protected by law and code of conduct. Lastly, it must be the family's decision whether to continue to covertly medicate the patient even after resumption of insight or not. The family must not be coerced ethically by health care professionals or legally by law to reveal the disease to the patient.
In conclusion, covert medication has been a discourse in psychiatry for the last decade. It has major ethical, legal, and clinical implications. The practices are different across different cultures based on the available resources and cultural norms. Covert medication is justified in the context of developing world because of the unavailability of community-based mental health care. This practice must be legally protected by laws in the context unless proven ineffective by a long-term large-scale longitudinal study.
Ethical Concerns: Verbal consent was taken from the family to publish this article. To ensure privacy and confidentiality some specific information has been withheld in this article.
Acknowledgement: I acknowledge Dr Rozina Karmaliani and Dr Rubyna Khan for their support and guidance.
Disclaimer: This article has not been published nor presented anywhere else and neither it was part of any thesis.
Conflict of Interest: None to declare.
Funding Disclosure: None to declare.
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