Covert Medication & Deprivation of Liberty Safeguard - Essay Example

COVERT MEDICATION Covert Medication & Deprivation of Liberty Safeguard Covert Medication & Deprivation of Liberty Safeguard Introduction Covert medication is the practice of medicating patients without their knowledge. This is usually done by hiding the medicine in food or beverages, crushing tablets or giving liquid medicine to the patients who are not in a position to give consent. Covert medicines are usually prescribed to the patients who are not willing to take medicine by themselves. For example, covert medication is used in psychiatric emergencies. In 2000, it was found out that in the United Kingdom covert medication was being carried out in 34 residential nursing care units (Latha, 2010). Therefore family members, health care providers, physicians and nurses give these medicines to patients when it is important for the patient. There are two different settings in which covert medication is practised. In the western countries, old patients such as those suffering from dementia or other neurodegenerative diseases receive medicine in this. Also, patients who are confined to their homes, such as those suffering from psychosis and refuse to take any medication are given medicine this way. The later type is practiced on a large scale and it is these patients who receive most of the covert medication. In a study done on Indian patients, for instance, the authors found out 67 patients who had been given covert medication by the family because they were non-compliant. The medication, however, was given on the advice of the psychiatrist (Kala, 2012). Considering the different ways of medicating the patient, there are also rights of liberty and security needed to be provided to the patients. All of us have the right to liberty and safeguard. Ethics is a branch of knowledge that is concerned with the moral principles. There are tensions in the ethics related circles regarding the practice of covert medication. These concerns revolve around the autonomy of patients, beneficence, liberty, safeguard and nonmaleficence. Therefore this paper will critically analyze the use of covert medication and that whether it is ethically allowed to use or not. Ethics It is considered unethical to covertly medicate an autonomous person because it is considered a basic form of deception that is considered unethical in medicine (Heinonline.org, 2015).. This is due to the fact that it violates the autonomy of the patient. Every patient has the right to decide for himself what he wants and hence is autonomous. Therefore, has a right to know about the medical treatment that is being administered upon him. However, sometimes the patient is wrong in assuming that their condition is stable and they don’t need medicine and so shows resistance to it.In such a case it is justified for family members for example to help out the patient for their own betterment even if the patient is not aware of it.The term ‘better’ is used to support the principle of beneficence and nonmaleficence – the fact that the patient is being deceived on the basis of moral justification for deceiving him.In medical sciences, the process of deceiving a patient has been debated as unethical, due to the reason that even if it is intended for improved outcomes for the patient, it cannot justify the act of deception (Bollig et al., 2015). There are also conditions when the patient and their families consider the outcome to be more ethically allowable than deception. Consider a psychiatry patient in the emergency room who refuses to take medicine orally. The patient is also getting violent to the doctors and the support staff. There is definitely an option to covertly medicate the patient but the clinical staff realizes that covert medication is prohibited. Therefore the patient is sedated and medicated forcefully through intramuscular injections every time he is agitated. In this situation, are the other ways of medicating the patient more ethical or not and what are the moral and legal grounds on the basis of which the patient is being medicated forecully (Rennie v. Klein, 1979). If the patient is medicated here with an intravenous line without him knowing or if the nursing staff carefully injects the medicine into a sealed apple juice container the outcome might be advantageous for the patient and it can be thought of as a least resistive action to the patient’s autonomy and liberty (Irvine, 2015, pp. 198-201). However, consent of the patient has still not been sought and so ethical guidelines have not been fully followed. Covert medication is ethically more justifiable to patients who are confined to nursing homes and require medicine on a day to day basis as compared to those patients who are in emergency settings and require medicine on a one-day basis. This is due to the fact that these people are under the care of a specific setting and there is a routine that is being followed for their treatment that will eventually lead to their recovery. In the case of an emergency setting it is more of a risk when covert medication has to be done because the patient is in a dangerous situation and he needs to be informed about what is going to be done to him so that consent can be taken. However, even in this case the patient might not be able to make an informed decision about what is best for him or might not even be in the state to do so for himself and so requires the assistance of the care or his family to help him out. Laws There are laws of the state ranging from reporting injurious diseases to carefully putting on seatbelts, to use of cell phones during driving etc. These laws range from those that are a part of the constitution and the rest are made by the concerned institutions. For example, law enforcement agencies make laws that guide people how to drive, what age group is allowed to drive and the traffic rules that need to be observed. On the other hand, the constitution defines the rights of the citizens of a country like the right to life, the right to safety and well being etc. The government has set up laws to ensure the safety and health of its citizens. It is these laws that rate the public health and safety higher than their autonomy to make decisions. HSE in the UK enforces health and safety for the working class. When it was found out that the employees with exposure to stoving paints were being diagnosed with dermatitis actions were taken and the employers were made to take steps to improve the working conditions of the employees (Hse.gov.uk, 2015). This is only one instance on how the government and its institutions are working towards protecting the health and safety of its people. Although it is legally permissible to allow covert medication if the law allows it, any adult patient who is mentally competent is allowed to either accept or reject a particular treatment or nursing intervention (Washington v. Harper, 1990). It will therefore be the duty of the nurse to respect the decision of the patient as it will illegal and unethical to medicate the patient without his permission. But if the patient lacks a certain mental capacity under the Mental Capacity Act (MCA) (2005) then it can be considered legal and ethically to covertly medicate the patient in order to improve the health outcome of the patient.This is included in the preliminary clauses of the act. If the use of covert medication is required as part of a research project, it is not permissible. There are cases of patients where the use of covert medication might not be allowed and might even be dangerous. Due to such cases, therefore, the staff should attain legal advice and consent of health professionals before such a practice can be done(Latha, 2010). According to the Mental Capacity Act of 2005, the use of covert medication should be the very last option. It should not be a routine practice or a contingency measure taken when a person refuses to take proper medication. There are certain conditions where the use of covert medication is both legally and ethically permitted as long as certain rules are met. The healthcare providers should establish informed consent of the patient (Blumoff, 2015). This can be done by carefully telling the person regarding their medication. Thus, if the person agrees than covert medication should not be used. But, if the person partially agrees then the principles of MCA (2005) are to be followed and the use of covert medication will be allowed in such condition. An important thing to note here is that family members on anyone else cannot consent on the behalf of the patients in this case then. Non treatment is an option that violates the ethical principals of beneficence that is to work for the greater benefit of the patients. Health care providers should also establish reasons that why a patient is refusing to take medicine properly. There should be proper considerations made that whether this decision of patient reflects some long term belief regarding medication, existence of some future directive related to refusal of taking medicine, any belief related to religion or culture or some illogical decision. The health providers should respect each and every reason as they all are valid. They should also maintain a proper clinical record of the reasons put up by the patient. Apart from ensuring that all the alternatives have been explored and the patient has been offered with leniency and flexibility, there should also be proper evidence that the medication to be given is necessary. Medication process becomes more convenient if the patient is involved in his or her decision making process because then the ethical guidelines do not have to be broken. For example, if drug addicts realise that they need help and join rehab with their consent the process of medication becomes easier (Matsimbi, 2012) Thus, it must be properly documented that the medicine that the person is refusing to take is deemed to be necessary for his or health and safety (Tsulukidze et al., 2015). These rules apply to patients who are considered mentally sound. For patients who lack a certain mental capacity to decide for their health there are different rules according to the law mentioned in the act of 2005. These laws ask the health care providers to properly conduct a capacity assessment. This should be done by engaging the patient in a conversation regarding their medication. The assessments should be related to the ability of the patient to understand the situation, properly communicate his or her decisions and consider the risks associated with not taking medication just like in the case of addicts. According to the 4th preliminary clause of the MCA (2005) all possible efforts should first be made in order to make the patient understand. There are times during the day when the mental capability of the people changes, therefore a suitable time should be chosen by the health care providers. No matter if efforts are to be made more than once or if an interpreter has to be called upon. Record should be maintained at all times. Hence, if the patient passes the assessments described in the previous paragraph then the nurses should consider him mentally sound to decide for himself, no matter if the decision appears to be irrational (Vacco v. Quill, 1997). According to the MCA, in these circumstances patients decision should be respected the use of covert medication is prohibited The Nursing & Midwifery Council (NMC) (2010) states that by disguising medicine in patient’s food or drink, he or she is made to believe that they will not be medicated, whereas they are. The attendant has to make sure that whatever they are doing will be for the benefit of no one but the patient. By establishing whether a patient is mentally stable and has the capacity to provide consent or not, a decision can be made about covert medication on that patient. This should be done by ensuring that all the rational and holistic factors were considered. All the health providers who are involved in the decision making process for the patient should be aware of the fact that it is not always appropriate to covertly medicate the patient because mostly it is done against the consent of the patient.A decision made for one person may not be suitable for the other, thus proper examinations should be conducted depending on the situation of patients (Blumoff, 2015). The views of people who are concerned with the well being of the patient should be sought. This will ensure that the decision to covertly medicate the patient is not confined to one person only. Multi disciplinary team members, patient’s family members, their general practitioners, home care providers or Independent Mental Capacity Advocates (IMCAs) can be called to share their views. Also, it is important that the decision to deliver medicine covertly is made after proper discussions with the above mentioned personnel. This will help ensure that the decision is made on the basis of what the person wants and not necessarily on what will be best for their health outcomes. However, if an advanced directive exists, then the patients wishes mentioned in it must be respected as they are legally bound. If there is a concern about the liberty of Deprivation of Liberty Safeguard application (DoLS) and a proper consent cannot be reached then a second opinion will be used. For example, the study that was conducted in India on schizrophenic patients sought the consent of the family members and covert medication was only done after proper advice of the health professionals had been taken (Kala, AK). Having established proper evidences that medication is bound to be delivered to the patients, a pharmacist’s advice should now be taken on mixing the medicine in food or drink. This will further ensure that the medicine is given safely to the patient and any correction or alteration in the process is done as suggested by the pharmacist. If any change in the way of covertly medicating the patient has to be made, pharmacist should again be contacted. For, patients living in some community, their dispensing community pharmacy should be sought for advice. Record should then be maintained to ensure proper documentation backs up every act just like explained in the example above. Documentation not only ensures transparency in administering medication covertly but it will also provide a complete plan containing details about why the person did not agree with their medication. This is a very important necessity for covert medication as it will improve the decision making process. If the patient is to be discharged from the hospital and there is still a need to covertly medicate the patient, then in this situation proper guideline should be communicated to their family members or home carers and strong follow up should be kept. This is usually the case when patients are released from rehab or medical care centers. NMC (2010) recognises that there can be some exceptional circumstances where the use of covert medication may ensure that the patient is not deprived from proper healthcare treatments- “The NMC would not consider this to be good practice.” It is allowed to use covert medication on people who lacks a certain mental capacity and that their behaviour might be dangerous for the people around them. In such conditions the nurse may conduct discussions with their immediate reporting authorities and provide an initial dose accordingly where the patient is not able to consent (Boumil, 2015). This condition will be reviewed within the next day and then decision will be made in order to continue the medication or not. If no decision can be made then assessments mentioned in the previous paragraphs should be conducted. The patients who are detained according to the Mental Health Act of 2005, protocols of consent continue to be applicable for any medication that is not related to the mental condition for which they were detained mentioned in the preliminary section of the Act. Tsulukidze et al., 2015). According to the law they have the right to accept or refuse any such medication. However, if the patient is given medication for the condition they were detained, then the law permits the health care providers to administer covert medication without the patients consent. However, this does not apply to all detention orders. Autonomy, Beneficiary or Non Beneficiary Autonomy is the state of exisiting separetly from othe people Autonomy of all the patients who refuse to take medicine should be respected and recognized.This cannot be followed for the patients who are mentally unfit and refuse to take medication. For these people there is a tendency to administer medication covertly. This results in health care professionals raising concerns that they are not adherent to proper code of conduct and thoughts such as ‘Are we doing right’ arises in their minds like in the case of patients suffering from schizophrenia or other psychological disorders. Therefore, they must look into the professional ethical guidelines to get clear answers regarding such situations. The practice of covertly medicating the patient, such that the person is unaware of the situation is never justified according to the principles of beneficence and non-maleficience for mentally sound patients (Bollig et al., 2015). Beneficence refers to the benefit caused by something to a person and non-malificience also means not causing harm to anyone intentionally. The most important principles related to the use of covert medication are autonomy, beneficence and justice. Patients who are autonomous should be allowed to make decisions for themselves. Though every patient has a right to autonomy in health care, principles of beneficence and provision of quality care are also very important even though the patient might not agree to for example medication.Such situations create a lack of trust between the physician and patient. Patients, who develop neurodegenerative diseases such as the Alzheimer’s disease or dementia, lack a certain mental capacity to decide for their medication. This is because the symptoms of the disease include confusion and a lack of orientation. Thus, they may not be able to understand the situation, concentrate, absorb, focus and recall certain information, and in fact even question their treatment and that they may just say “no” to their health care providers. Another concern that is to be considered here is the issue of validity (Irvine, 2015, pp. 198-201). Validity refers to how strongly does a concept correspond with reality. This is because patients who lack a certain mental capacity are not always treated justly and that they are sometimes deprived of fairness in their treatment. Thus, beneficence relates to the pursuit of a person’s best medical treatment, which is the rationale for administering covert medication for a person who does not permit its application by will. In all situations, respect for every patient requires that their dignity is respected even when his or her ability to make decision is subordinated to some other concerns. Therefore, the principle of beneficence demands that the physicians care about their patients and also respect respect the autonomy of their patient (Brodtkorb et al., 2014). Informed Consent In western countries, these ethical principles are practised through the principle of informed consent. There are certain rules that are to be followed when administering covert medications. The basic requirement of the doctrine of informed consent is to inform the patient regarding the treatment he or she will be provided. They should be given adequate information that will help in deciding about their medication. Healthcare providers should make sure that no information is altered and that the patient is provided with only the correct and relevant information related to their condition. Usually, people who are given covert medication are not informed properly. Exceptions are only given in emergency situations and where the physician has the complete authority to decide for the better health outcome of the patient. Patients are also provided with a liberty to appoint someone else as their decision makers. Like in some cases, family members are given the responsibility by patients to take care of them. If the physician deceives the patient then an elementary principle of truth telling will be violated. Physicians can also consult substitute decision makers appointed by the patient. These include the family members and home carers of the patient. If proper interest of the patient is not known or it is unclear, then the health care providers have the liberty to decide on what the patient would have expected. However, at all phases it should be made sure that whatever decision is taken, it is for the benefit of no one but the patient. Clinicians should provide proper interventions such as ensuring that only that medication will be provided which will not cause any harm to the patient. The only alternative to covert medication is to abandon the treatment or forcefully treat the patient. The first option is ruled out as it violates the principle of beneficence. Forceful treatments can never be a long term solution as it may lead to any injury to the patient (Brodtkorb et al., 2014). Like for example, in the case of covert medications in psychiatric emergencies can never be a long term solution (Estades-Negroni v. CPC HOSP. SAN JUAN, 2005). Conclusion The above discussion leads to a decision that the use of covert medication depends on a number of variables. Patients who have a certain mental capacity and are not detained under the Mental Health Act should not be given medication covertly as the law of autonomy gives them the freedom to decide for themselves. However, those patients who lack a certain mental capacity and are refusing medications can be given medicine covertly. Patients have the ability to make a decision only if the reason for their medication is not the one for which they are detained. Non treatment is an option that violates the ethical principals of beneficence. Thus, the option to forcefully medicate patients should only be used in cases of emergency and not day to day treatment as discussed in the paper. The use of this strategy is not valid for patients who have developed long term diseases and requires medication on a daily basis. The practice of covertly medicating patients is controversial. Ethical as well as legal concerns get more complex with the deterioration of the mental capacity of patients. Concept Map References Law & Statutes Blumoff, T. Y. (2015). 0n Executing Treatment-Resistant Schizophrenics: Identity and the Construction of “Synthetic” Competency. Boumil, M. (2015). FDA Approval of Drugs and Devices: Preemption of State Laws for Parallel Tort Claims. J. Health Care L. &Poly, 18, 1. Latha, K. S. (2010). The noncompliant patient in psychiatry: The case for and against covert/surreptitious medication. Menssana monographs, 8(1), 96. 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