The case study describes a patient, BB, who has a diagnosis of schizophrenia and has exhibited aggression, paranoia, and emotional dysregulation in the past. BB typically refuses medication when hospitalized for acute exacerbations. However, since BB has been judged to not have decision-making capacity (DMC), their legal guardian has permitted the medical staff to covertly administer haloperidol, a conventional antipsychotic, which needs to be hidden in BB’s food. CC, the nurse taking care of BB, has raised concerns about the ethical implications of this practice, and how it compares to the alternative: restraining BB and administering their medication via an IM injection (Lin, 2021). To some degree, both scenarios violate BB’s right to patient autonomy: they lose their ability to accept or reject the clinician’s treatments and are unable to have the final say regarding their medical care. I believe that out of the two options, administering the medication without BB’s knowledge (i.e., hiding it their food) is the more ethically sound choice.

When restraining a patient with either physical or chemical restraints, a clinician is balancing between the tenets of patient autonomy, beneficence, and non-maleficence. On one hand, patient autonomy is stripped away, and they lose the ability to be on equal footing with medical care providers when making care decisions. They are held prisoner and receive various treatments without consent. Historically, restraints have been utilized when a patient is physically combative or poses a threat to themselves or others, and after other measures have failed (Dugdale, 2019). The clinician is also striking a balance between beneficence and non-maleficence. The medical team believes that they will benefit the patient by giving treatment, but they must also consider the harms caused by restraints, which may include not only physical harm but also mental and emotional suffering. In a literature review, Tingleff et. al. found that psychiatric patients had strong negative perceptions of the use of restraints and forced injection. They wished to be treated with empathy and wanted a greater say in their own care (Tingleff et. al., 2017). The negative feelings caused by restraints and forced injections may also lead to decreased trust between provider and patient, making further interactions increasingly difficult.

Covert medication, or giving patients medicine without their knowledge, also strips autonomy away from the patient. In addition, it requires deception on behalf of the clinician, which has the potential to erode the therapeutic relationship between patient and provider. Covert medication also makes it difficult for patients to understand aspects of their illness, such as how effective certain medications are or what adverse effects each might cause (Lin, 2021).

In an effort to avoid deceiving patients, some may argue in favor of physically restraining patients and forcibly administering medications. After all, there are ways to mitigate the harms: patients have expressed that it would be better to have clinicians be present and compassionate, and for the medical team to keep communication open and debrief the patient after restraints have been implemented (Goulet et. al., 2017).

However, I believe that there are too many inherent harms to regularly use forced restraints in patients who lack DMC. While deceiving patients and using covert medication administration does remove them from direct participation in their own care, it can potentially fully circumvent the need to ever restrain a patient, avoid all the harms that it brings. This upholds our commitment to non-maleficence. There are also ways to reduce harm from covert medicine. For example, we would need to continually reevaluate the patient’s DMC. If the patient improves to a point where they once again have capacity, covert medicine is off the table. We can also refer to any documentation of the patient’s preferences prior to an acute episode. If none is available, we can refer to the patient’s surrogate, as was done for BB.

Sources:

Dugdale, D. C. (2019). Use of restraints: Medlineplus medical encyclopedia. MedlinePlus. Retrieved June 19, 2022, from https://medlineplus.gov/

Goulet, M.-H., Larue, C., & Lemieux, A. J. (2017). A pilot study of “post-seclusion and/or restraint review” intervention with patients and staff in a mental health setting. Perspectives in Psychiatric Care, 54(2), 212–220. https://doi.org/10.1111/ppc.12225

Lin, M. (2021). Who should implement force when it’s needed and how should it be done compassionately? AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.311

Tingleff, E. B., Bradley, S. K., Gildberg, F. A., Munksgaard, G., & Hounsgaard, L. (2017). “Treat me with respect”. A systematic review and thematic analysis of psychiatric patients’ reported perceptions of the situations associated with the process of coercion. Journal of Psychiatric and Mental Health Nursing, 24(9-10), 681–698. https://doi.org/10.1111/jpm.12410