The open secret of covert medication

The covert administration of medication occurs when caregivers give medication without the patient’s knowledge, using some form of deliberate deception in the act of disguising or concealing the medication.1 2 ,1 The purpose is to treat the medical needs of patients who lack decisional capacity2 and who would otherwise refuse the medications. The practice is relatively common in both homecare and institutional contexts globally, though studies of its prevalence are more robust in some countries than others.1 3–9 Kala explains that in developing countries like India, the alternatives to covert medication at home can be particularly limited; family members cannot easily receive appropriate assistance from judges or police when trying to help a loved one with behavioural difficulties or at risk of harm, and psychiatric hospitals and other skilled care are often inaccessible.6 The literature attests to the prevalence of covert administration of medication in Europe as well, with 43%–71% of nursing homes in the UK acknowledging the practice.9 According to Abdool, ‘over seventy percent of healthcare staff has faced the decision to administer medication covertly, and almost all agree that deception is justified “on some occasions”’.7

Despite the commonality of the practice, there is a lacuna in legislative and professional guidance regarding this form of deception.1 8 9 In Canada, for example, laws and professional guidelines across the provinces tend to either say nothing or to caution generally against the practice, but there are no clear procedures or restrictions.7 A notable exception to the lack of guidelines is the documents and policy tools assembled by several healthcare bodies in the UK. For instance, the National Health Service (NHS) Trust outlines a broad protocol with a set of ethical considerations.10

This brief review of the literature indicates that the practice of covert administration of medication is widespread, likely to be under-reported for fear of professional censure and legal reprisal, and is in need of deeper ethical analysis. Much of the bioethics literature on the covert administration of medication focuses on concerns about undermining patient autonomy and trust,1 3 6 8 caregivers’ responsibilities to protect incapacitated patients from medical harms2 5 6 11 and the importance of organisational guidance and oversight.1 8 12 There are numerous ethical concerns worthy of further bioethical discussion and research, such as whether these patients have sufficient opportunities for shared decision-making, whether these patients have their capacity status reassessed frequently enough, the complexities of assessing capacity and insight when a patient has been routinely deceived about medication, the ethical limits of surrogate/parental authorisation and how healthcare professionals should distribute the moral burden of this practice. For many healthcare professionals, covert medication may seem to be the kind and humane way to administer medications to incapacitated and medically fragile patients who would otherwise be allowed to decompensate further or be given medication involuntarily and potentially through force.3

One element missing from these discussions is consideration of the specific ethical issues that may arise from the use of food in the covert administration of medication. In this paper, we discuss overlooked ethical issues related to the covert administration of medication, focusing on particular ethical issues that surround eating. We emphasise the variety of ways in which eating has ethical importance, highlighting what is at risk if covert administration of medication in food is discovered. Food and eating practices are sources of health, opportunities to exercise autonomy, ways to create valuable experiences (eg, pleasure, cultural connections), ways to express/reinforce identity and ways of reinforcing/building connections with others. Eating is also a relational practice, one that entails significant vulnerability to and dependency on others. In cases of covert medication, relationships between feeders—whether family members, other caregivers,4 or professionals within medical contexts—and eaters are central. We give an analysis of the ways that these relationships can be undermined and trust eroded through using food for the covert administration of medication. Highlighting the relationship between ways of eating and social identities, we argue that caregivers can support or undermine patients’ identities through providing identity-congruent foods and enabling patients’ eating agency, as far as is feasible within clinical/therapeutic constraints. Losing trust in feeders and food due to covert medication may deprive patients of important opportunities for identity maintenance in contexts where identity is already unstable, including long-term and psychiatric care facilities.

In the final section of the paper, we consider circumstances in which covert administration of medication could be ethically permissible, given these concerns. We contend that while there may be instances in which using food for covert medication is ethically justified, given a lack of suitable alternatives, in any given case this practice should be continually re-evaluated in light of the building moral costs to the relational agent over time. Our analysis spans across inpatient and outpatient settings, though the impact of covert medication will vary according to the intimacy and persistence of the caregiver relationships (eg, a hospital-based provider in an emergent situation in contrast to a family member at home). Our discussion focuses on adults who have or could come to have the ability to participate in decision-making by at least expressing preferences, even if their capacity status is diminished.13

Eating’s ethical significance

At base, food is a source of sustenance and nutrition. But eating’s ethical significance is much broader than that.5 Eating can be an opportunity to exercise autonomy: to make free choices,14 weigh competing values and express preferences. Eating can also be a means of creating valuable ‘food experiences’,15 offering comfort, pleasure, adventure or familiarity, for example.

Eating can also play an important role in shaping social identities: how people conceive of themselves and who others take them to be.16 17 Ways of eating—such as eating red meat, prioritising local or traditional ingredients, or being an adventurous eater—are narratively linked with certain identities and self-understandings. We can ‘hold’ ourselves in our identities by eating in ‘identity congruent’18 ways: I am this sort of person, I eat these sorts of things. We can also hold others in their identities by encouraging, requiring, or enabling them to eat in ways that reinforce and resonate with who they understand themselves to be.

Holding someone (or oneself) in their identity is an important moral practice. As Lindemann explains, identities ‘convey understandings of both what we are expected to do and how others may or must treat us’.19 Holding someone in their identity can be particularly important in cases where identities are unstable, unsteady, or in question, including clinical settings where memory, cognition, and other capacities may be compromised.19 In such cases, food offers an important opportunity to support and reinforce identities, but is also a site of vulnerability where identities can be further destabilised or undermined.

In addition, eating can build, reinforce or undermine connections with others. To share food and eat with others can be a way of showing respect and other important moral attitudes, strengthening important relationships and creating community.20 In a more general sense, eating has ethical importance as an inherently relational activity. It involves relationships between an eater and what is eaten, as well as relationships with those who have selected, bought and prepared the food, grown or produced the food, shipped and sold the food, and those who may feed or serve the food to the eater. This wide array of relations involves various forms of dependence and vulnerability.21 Most eaters depend on others for at least some aspect of producing, procuring or preparing food.

In situations of vulnerability and dependence like those that eating creates, a good relationship is one characterised by trust. As Whyte and Crease characterise it, trusting is ‘deferring with comfort and confidence to others, about something beyond our knowledge or power, in ways that can potentially hurt us’.22 The dependence of eaters on others creates the opportunity for the covert administration of medication in food, but it also means that trust in both food and feeders can be at risk.

As we will discuss in the next section, recognising the breadth of eating’s ethical importance highlights what is at risk if covert administration of medication is discovered. It also highlights what is lost or compromised in situations where eating is limited or constrained. In many healthcare settings, including hospitals and nursing facilities, patients or residents can have little to no opportunity to produce or prepare their own food, to observe the food being prepared or to bring in their own food from outside the institution. Their diets could be adjusted without their input and, in some cases, even without their knowledge. Their eating schedule can be completely outside of their control, which is distressing for many patients/residents and can lead to building tensions with caregivers.6

This feeling of helplessness and vulnerability can be exacerbated for individuals with diminished cognitive capacities, who may have to rely on others to set up the conditions for meaningful and valued activities. For instance, Jaworska points out that someone who once identified as a ‘good cook’ can still value preparing and eating food even while losing certain faculties due to dementia7; these are activities with deep emotional and agential connections that span across time and speak to one’s identity. Caregiving work, then, must include helping patients/residents participate in daily activities of value.23 These points can be extended to anyone who relies on others to enable or facilitate daily activities—as we discuss in detail shortly, our identities may become fragile and our agency made vulnerable when medical institutions and caregivers mediate the degree to which we can prepare and choose our own food. For patients/residents who receive nutrition through artificial means, such as through a percutaneous endoscopic gastronomy tube, the eater–feeder relationship can seem radically transformed and alienated from previously valued practices, especially if neither party knows how to enable agency and choice within such a feeding arrangement.8

Threats to trust and agency with covert medication

In their 2002 survey, Srinivasan and Thara found that a quarter of patients who had received covert medication ended up learning about the deceptive means, making loss of trust between patients and caregivers a significant risk.4 When a person refuses medication, they are trusting (or hoping) that their preference will be honoured.

The practice of covert medication involves choosing against what the person wants (not to receive medication) and then taking advantage of that person’s trust of food that is provided by caregivers. It can be especially easy to take advantage of that trust when the caregivers have been part of valued eating/feeding practices for a long time, such as with many family members. But since there can be no guarantee that the deception will succeed, covert medication threatens a person’s sense of safety with food, which can negatively impact the person’s long-term relationship with food and eating, as well as sowing distrust of caregivers and healthcare institutions. What was once a source of meaningfulness, identity and connection with others could become a source of fear, mistrust and betrayal.

These negative effects are compounded over time; one occasion of covert medication is not as impactful as continuous covert medication. Because many medications do not tend to work after a singular dose, and because a patient/resident may have diminished capacity and persist in their refusals for an extended period, covert medication is often done repeatedly, even for months or years. The practice of covert medication, then, can threaten patients’/residents’ long-term trust in both food and in caregivers. In a 2011 study, Day et al found that individuals with dementia have complex views of being lied to, though they were especially averse to blatant and habitual lies; ‘a discovered lie would impact negatively on […] relationships, and how they viewed themselves in the context of their social interactions’.24 Similarly, in studies of patients’ perceptions of coercion and involuntary treatment in psychiatric care, some of the most important factors to their overall experience were procedural fairness, validation and being treated with respect as a person.25 26 Olsen emphasises that involuntary or forced psychiatric treatment ‘can give the perception of an isolated event’, but ‘the moral weight of the act is ongoing throughout the relationship’.27 These reports underscore our ethical concerns about covert administration of medication in food; many of these patients place high value on integrity and forthrightness in their relationships, especially in contexts of increased vulnerability and decreased opportunities for agency.

Covert medication may also risk an important opportunity for identity maintenance. While we recognise that clinical staff are often overburdened and overtasked, we want to stress the importance of the work they perform with regard to identity. When others decide how and what someone eats, there is an opportunity to hold someone well in their identity, and there is also the risk of holding them poorly, of disrupting their ongoing sense of self and agential connection with food and eating. A person’s sense of self, control and responsibility can all be compromised when they reside in a care facility or hospital for any length of time. In such settings, food choices can be an important source of agency and meaning-making for individuals with otherwise limited opportunities.

Considerations for ethical permissibility

Although we have raised significant concerns with the practice of covert medication, we acknowledge that there are circumstances where it could be justified given appropriate moral safeguards and safety precautions. As mentioned earlier, covert medication can end up being an ethically appealing option if the only other options are either permitting decompensation or forcefully administering involuntary treatment. In Lindemann’s terms, covert medication could even be used as a means to hold someone in their identity. Imagine a patient with psychiatric disability who severely decompensates without medications, so much so that she cannot care for herself in the most basic sense, and she routinely ends up sleeping on the streets, where she gets infections, nearly freezes to death in the winter and goes long periods without any food. Her family and her physicians have learnt that when she receives medication, her sense of self and agency are supported; she can articulate her needs, set and achieve her ends more effectively, and maintain social supports. She can connect who she is and what she cares about over time more easily. Covert medication, in such a situation, might be a better alternative for holding her in her identity than either not medicating at all or forcefully treating her.

We will not recapitulate all of the guidance that has been suggested by the NHS Foundation Trust and others, and it is not our aim here to give a comprehensive list of ethical considerations for covert medication. Given our analysis, we want to emphasise the ethical value that food and eating can offer. If caregivers overlook the moral costs of covert medication, then they will miss ways to mitigate potential harms.

For example, if a patient is receiving medications covertly in their food, it raises the moral urgency for caregivers to create alternative ways for the patient to secure the goods they would otherwise get from eating. If their eating is compromised by distrust, having non-food-related opportunities to exercise autonomy, support identity and reinforce relationships, for example, may help patients be more resilient. Caregivers may also aim to create positive opportunities for the patient to prepare, choose or eat food. The aim would be for the patient to retain some agency in relation to food and thus to support their sense of identity. It would be a tragic result for a patient to reject all meaningful connection with food and eating on learning that covert medicating occurred, and though this consequence might be inevitable in some cases, caregivers should try to prevent that lost connection.

In general, caregivers should continually re-evaluate the reasons for the covert medication and pursue the shortest, least restrictive option. These decisions should receive input from all relevant caregivers, particularly since an outpatient physician or group home manager might know the patient better than anyone else. Advance directives, including psychiatric advance directives, might be able to minimise deceptive practices while protecting valued relationships. The details of relationships vary according to caregiving contexts (short-term or long-term stay, institutional or homecare), the patient’s capacity status (fluctuating or static, recoverable or permanently diminished) and the patient’s capabilities for interacting with others and their environment. More research should account for these differences among patient populations when analysing the impact of covert medication. In any given situation, it could turn out that providing medication in a transparently involuntary manner will have more ethical benefits than costs, though the methods used will make a difference for the overall ethical evaluation.

Finally, we want to call attention to the moral danger of having loved ones—partners, family or friends—participate directly in covert administration of medication.11 Though certain extreme cases might necessitate their involvement due to a lack of acceptable alternatives, this option should be a last resort. We have described the relationality inherent in food preparation and eating, as well as the vulnerability that is embedded in each step from food creation to consumption. If food becomes a source of distrust, then the relational harms can be significant, extending into how the person engages with others at a fundamental level. If someone cannot, from their standpoint, trust their loved ones with the most basic everyday practices surrounding food, then any aspect of daily living and bonding with others may become suspect.