What has happened to clinical freedom?

Editor–My first reaction on reading John M Kellett's article was one of anger. The article concerned the suspension of a nurse who, on a consultant's instructions, had added haloperidol to a cup of tea given to a patient who had refused the offer of admission or a tranquilliser.1 Why should what, in my experience as a psychogeriatrician, was a not uncommon procedure be made the subject of such administrative overreaction?

But as I brooded on the matter my anger gave way to concern. I noted that the unit general manager subsequently instructed the consultant “to stop releasing information of this type [that is, an account of his clinical actions and the reasons for them] to relatives or patients.” I also noted that the consultant was “invited” to meet the unit general manager and senior community physician to “discuss” the matter; that this was in fact a disciplinary procedure is clear, the consultant being told to “avoid publicity” pending a regional inquiry.

When I was a student I was taught that the responsibility of doctors to their patients was a personal one and that their actions were subject only to the judgment of their peers (that is, the General Medical Council) or the courts–usually civil but, in extreme instances, criminal. When did it become acceptable for a manager (who presumably has no medical training at all) and a community physician (who, despite his or her own skills, is unlikely to fulfil the college's requirements for a consultant post in the psychiatry of old age) to give instructions to or discipline a consultant? What has happened to clinical freedom?

As for the unfortunate sister, it should have been sufficient defence for her to say that she had done as the consultant instructed–had done it not in slavish obedience but because, in discussion, she agreed that it was the correct approach. This would make it a joint decision but the consultant's responsibility. Then when, very properly, the patient and his family were told what had been done and accepted that it had been done in the patient's best interests, that should have been the end of the matter.

Doctor and nurse were subjected to “macho management”

Editor–The events described by John M Kellett are disturbing but not unique.1 Putting haloperidol in the patient's tea was surely preferable either to letting him go home untreated or forcibly restraining him so that he could be given an intramuscular neuroleptic. That this approach, although deceitful, was the most appropriate clinically and ethically–and valid legally–is beyond dispute. The contentious aspect of this case, I believe, is the treatment not of the patient but of the nurse.

It is disappointing that neither of the commentaries refers to the ethics of allowing one person (the senior nurse manager) to have the power of ordering immediate suspension in such circumstances. At best the decision seems to have been uninformed; at worst it could be seen as vindictive. Certainly, the rationale for the suspension was flawed. Yet, although the act inevitably resulted in great distress for the nurse and the loss to the local service of an experienced member of the team, the nurse manager has remained unaccountable. The consultant, although treated less outrageously, was still disciplined and subjected to quasilegal constraints on his clinical autonomy and freedom to communicate with colleagues. Both individuals were subjected to “macho management” that has done nothing to improve patient care and may have adversely affected the effective functioning of the multidisciplinary team.

Discussion on the ethics and legality of clinical acts is, of course, vital. I believe that this forum should also have considered the ethics of the actions of the health service managers in this case.

Ethics of giving drug treatment covertly needs further discussion

Editor–I was pleased to see John M Kellett's article about the disciplinary action taken against a sister at a day hospital who administered a drug covertly on the instructions of a consultant.1 I hope there will be further professional consideration of the ethics of giving drug treatment covertly, as well as of the disciplinary processes invoked. The paper and one of the commentaries on it, however, contain several inaccuracies.

When Kellett sought my advice as chairman of the consent to treatment committee of the Mental Health Act Commission I made it clear that the commission did not give advice on the ethics of treatment or on the application of the Mental Health Act to individual cases. I also emphasised that any indication by me that this case might represent an exception to the general rule, on the basis of the information supplied by Kellett, was entirely a personal opinion. In fact, the provisions of the Mental Health Act that concern consent to treatment do not apply in the situation described. The patient was not detained under the act and, contrary to Dave Griffith and Alison Bell's conclusion,1 he was not “liable to be detained.” This term applies only to patients who are detained–for example, patients on leave of absence under section 17. It does not apply to patients being considered for detention.

Griffith and Bell also refer to the terms of section 62(1), relating to urgent treatment. This section applies only to detained patients subject to the provisions of section 58. Neither the act nor the code of practice includes the phrase “if medication has to be administered by force.” The issues relating to the covert administration of drugs were referred to in the commission's sixth biennial report, when the commission suggested that the Royal College of Psychiatrists and the Royal College of Nursing should consider this issue.2 In the most recent edition of the Mental Health Act Manual Jones refers to this suggestion and interprets the commission's comments as “equivocal” and “regrettable” on the grounds that common law tests cannot override the clear statutory language of section 58(3)(a).

Chapter 15 of the current code of practice describes the principles that should be considered in such cases. Kellett does not make it clear whether he concludes that the patient had the capacity to consent, as is implied by his being “cognitively intact,” or whether he lacked capacity at the relevant time, in which case different legal considerations apply.

Engage staff in programmes to raise ethical awareness

Editor–John M Kellett gives details of a case in which a nurse was suspended after the surreptitious administration of haloperidol to an elderly patient.1 This shows well the damage wrought by a traditionalist management style on a multidisciplinary team faced with hard clinical choices, none of which are intuitively right but some of which may be considered less wrong than others. How much better it would be if managers helped valued employees to develop effective strategies for working through difficult decisions, thereby distributing responsibility for actions and eschewing this dysfunctional activity of apportioning blame. We contend that such pragmatism would lead to improvements in the quality of the delivery of services and give morale a much needed boost. This view is further strengthened by the recognition in common law that health providers that fail to install adequate procedural support for the actions of their employees may be vicariously or even primarily liable.2

One approach being explored by our organisation is that of a trustwide ethics initiative engaging employees across all disciplines and at all levels within the hierarchy. At a recent consensus workshop attended by a representative sample of 59 employees 55 (93%) answered a questionnaire. Forty two respondents identified at least one major ethical dilemma at work per week and 40 reported that most dilemmas involved some aspect of patient care. The most commonly encountered difficulties concerned patients' rights (48 respondents), patients' autonomy (37), and the appropriateness of treatment (34).3

In response we propose to develop an “ethical culture” with a view to enhancing employees' understanding and management of ethical problems and permitting better working relationships at all levels of the organisation. We are evaluating our existing level of skill and recognise the need to engage staff in development and audit programmes to raise ethical awareness. By encouraging explicit and transparent decision making we hope to obviate any need for draconian measures. Disciplinary procedures should be reserved for clear cases of misconduct and not misapplied when occasionally, by the nature of our work, things do not turn out as we would wish.

Over a third of psychiatrists had given a drug surreptitiously or lied about a drug

Editor–John M Kellett's article and the accompanying commentaries raise an interesting ethical debate on the surreptitious administration of drugs.1 The debate is of particular interest to us because we work in a mental health trust.

David Griffith and Alison Bell briefly mention issues concerning the Mental Health Act 1983.1 Of course, medical treatment can be given without consent in emergency or life threatening situations.2 We believe that, in the case presented, treatment under section 2 of the Mental Health Act 1983 would have been more appropriate; section 2 of the act, however, would still not have allowed the surreptitious use of drugs.

We were curious to find out doctors' experience of surreptitious prescribing and their honesty in giving patients information about drugs. We devised and used a questionnaire to survey a random sample of senior, middle grade, and junior psychiatrists working in Heathlands Mental Health NHS Trust. There was no requirement for doctors to give their name, and all 21 psychiatrists whom we approached replied. Six of the psychiatrists admitted to having ordered a drug to be given in a disguised way. Only one admitted to having given the drug personally. Five doctors said that they had lied about the type of drug prescribed. Three more admitted to having lied about the dose and the effects of the drug. Of the eight psychiatrists who admitted having taken part in any of the above practices, two said that they had always told the patients afterwards, four sometimes, and two never, but all thought that their practice was justified.

In total, therefore, over a third of doctors in our sample (38%) admitted either having participated in surreptitious prescribing or having been economical with the truth when giving information to patients. This figure, however, may be an underestimate because on direct questioning several respondents said that they felt uncomfortable about admitting to lying. We suggest that any similar such inquiries should be non-judgmental and may be better addressed either by a peer at the same professional level or by anonymous questionnaires.

Concealed administration of drug treatment may represent thin end of the wedge

Editor–The article by John M Kellett and the associated commentaries about the suspension of a nurse raise many ethical issues.1 In response, the higher trainees in psychiatry on the Charing Cross Hospital rotation recently devoted an academic session to discussing these matters.

Firstly, we were surprised to find that there is little specific guidance on the issue of deception, as noted in the commentary by David Griffith and Alison Bell.1 Certainly, the BMA's publication on ethics does not address these matters directly.2 In such circumstances doctors must seek to draw their own conclusions. The unanimous conclusion of our meeting was that the doctor and nurse involved in the case that Kellett reports acted in the patient's best interest. The alternative course of action–restraint and forced drug treatment–might well have caused more physical and psychological harm. Concern was expressed that deception cannot be differentiated ethically from lying,3 although we did not consider this to be a sufficient argument to alter our general conclusions.

Secondly, we thought that caution was necessary. Many of us had witnessed the concealed administration of drug treatment during our training–often in cases in which it was less clearly in the patient's best interest than in the case discussed by Kellett. We believe that some groups of patients are more vulnerable to such practice–for example, they have a reduced ability to detect concealed drug treatment, are more likely than other groups to be injured by physical restraint, and are often not in a position to protest. With this in mind it is well to take account of arguments against deception: that it may potentially destroy trusting relationships with patients and, particularly, may represent the thin end of the wedge and give rise to abuse.

Finally, it has been our frequent experience that nursing management can be extremely punitive. There was no clear agreement, however, over whether such knowledge should influence our practice. Whereas one could argue that doctors finding themselves in the same position as the doctor in the case discussed by Kellett should give the drug treatment themselves, an equally strong argument can be made that this constitutes medical paternalism and that other professionals should be able to make decisions for themselves.

In view of the obvious problems raised by this case, is it not time for the BMA to address the issue of deception directly, preferably in conjunction with the nursing and other professions?