On covert medication: The issues involved.

A response to Kala's article on covert medication. This discusses the issue of covert medication from points of view of autonomy, insight, legality, liability and good practice.

INTRODUCTION

Many thanks are due to Kala[1] for bringing to academic discussion the hitherto “taboo” subject of covert medication. This is a subject that so far has been the topic of hushed whispers or confidential discussion in the professional chamber. Academia, despite a handful of papers, has so far pretended either that it does not exist, or that, since silence actually covers a multitude of virtues, it does not need to be addressed (why fix something that is not broken?). In fact, semi-formal fora like professional internet groups have, interestingly, been a space where the nuances and complexities of the practice have been explored, and again, thanks are due to Kala for highlighting this.

Psychiatry, as one of the youngest specialities in medicine, essentially serves to bridge spaces between the more “core” clinical disciplines and the “softer” ones that intersect with the social sciences, where both the role of and influence upon psycho-social factors are much more. It is in psychiatry where social norms of defining what constitutes “normalcy” and acceptable interventions become more important than in any other branch of medicine. So as we move away from the scientific medical processes which remain an integral part of psychiatry to the more socially influenced mores of what is acceptable and desirable in the practice of psychiatry, this debate, among others, gains relevance.

Given the review, we understand that what is called covert medication is actually not uncommon in India, and that this takes place in a multitude of settings. We also accept that usually, hopefully, it happens with good intentions, and, at least in some cases, results in benefit. There, however, remains an equal amount of anecdotal material where the outcome of such a practice has been less than desirable. What we also need to understand is that it raises some rather tricky questions.

THESE QUESTIONS ARE IN MANY DOMAINS

The first is the question of personal autonomy. While the practice of covert medication is doubtlessly a convenient answer to a difficult clinical situation, we should not lose sight of the fact that it is clearly an infringement of the personal right of the individual. Coupled to the fact that it is often practiced in situations where a proper examination has not happened, it can often be a problematic issue. We understand that Eastern and Western societies lay different emphasis upon individual rights as opposed to societal rights, but the determination of that in societies in transition, like ours, is a complex and nuanced path. So, for the mental health professional to be a spectator, an analyst, a chronicler, or an influencer of that change would be fair, but going further would raise uncomfortable questions. As societies negotiate these winding journeys of change, it may be wise for professionals or professional bodies to not take on themselves the role of arbiters of what is right or wrong.

The second is the issue of the development of insight. If a person who is being treated without his knowledge gets better, in what form is the development of insight likely to happen? In the setting where clinical improvement happens in the absence of knowledge of treatment, is the individual likely to link “cause” and “effect”? Given the fact that many medications are long term, the question remains as to whether the practice would actually help or hinder the process of insight.

The third is the question of legality. While, as Kala points out, this can be considered to be “acting in good faith” the strength of that defence is yet to be tested in court, and it is equally likely that the judicial system would construe this as assault or battery, providing grounds for criminal liability. The consequences of that would be certainly anything but pleasant.

The fourth is the question of professional and civil liability, and clearly no professional indemnity can or would cover the practice of covert medication. So any professional who may be charged with the practice of covert medication would obviously be vulnerable to allegations of malpractice.

The fifth is what may be called “good” practice. The prescription of covert medication reduces psychiatric intervention to purely pharmacological prescription, and while it may be argued that in very difficult and rare situations this may be better than nothing, the danger of the exception defining the norm remains. It also means that everything else that needs to be done in the form of monitoring for both the therapeutic and adverse effect of medication becomes redundant.

In many of the narratives of covert medication what seems to emerge is the fact that when the individual is on medication, and, hopefully, better, the question of continuity raises pertinent questions. So families are then in the position of being unable to stop, while finding it difficult to continue. The example given is that if a person has “unsoundness of mind,” and so it may be acceptable for a desperate family to treat him covertly because they have no other choice, what happens when he is better, and theoretically not “unsound” any more, but, unsurprisingly, not willing to seek treatment? So, as in many complex situations, this will need a pragmatic working ethic, as well as an overarching societal ethic, and balancing the short-term need against a larger “good” will, in all probability, need to be done.

The counter arguments in the debate in the internet group Indian_Psychiatry@yahoogroups.com actually brought to light many of these facets. So while cogent and powerful arguments for covert prescription remain, the picture is far from one-sided.

It may also be wise to remember that when it comes to the practice of medicine, while it is essentially interplay between the service provider and the intended beneficiary, care givers and larger society also have a role and a voice, which is both enabling and regulatory. So, for the professional to be either “unapologetic” or critical of it may, in a sense, be overstepping of role. This is certainly something that needs to be addressed and discussed in the professional space, but more so we must bear in mind that unless the discourse happens with all the other stake-holders in the process, as professionals for us to start formulating “rules” or “norms” for covert prescription, we may be overstepping our mandate in no small manner. Also learning from the history of such narratives in other parts of the world, such overstepping may actually result in strengthening contrarian positions, regardless of the purity of intent.