Education And Debate

An Ethical Dilemma: Commentary: Treatment was not unethical

BMJ 1996; 313 doi: (Published 16 November 1996) Cite this as: BMJ 1996;313:1250
  1. David Griffith, consultanta,
  2. Alison Bell, senior registrara
  1. a Department of Healthcare for Older People, Mayday University Hospital, Thornton Heath, Surrey CR7 7YE

    Some features in this report are puzzling and disconcerting, but there are also grounds for reassurance for both patients and clinicians. The problem described is one which, in general terms, will be familiar to many doctors. Accepting that there are occasions when all measures short of drug administration may fail, is it permissible to administer such drugs against the patient's will, and if so should they be given by force or is deceit sometimes an allowable and preferable alternative?

    For mentally competent patients it is clear that in common law no treatment can be given without valid consent. However under part IV of the Mental Health Act 1983 there are provisions for certain treatments to be given without consent, as well as measures to safeguard psychiatric patients' interests in relation to treatment procedures. This applies to a patient “liable to be detained” under the act and is therefore relevant in this instance, where plans were being made to complete a section 2 for compulsory admission. “Chemical restraint,” as it is called, is defined in the code of practice as “medication for management purposes either with or without an additional therapeutic intent.” Any treatment given must not be irreversible or hazardous, must be immediately necessary, and should represent the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself or others. It seems clear that these criteria were fulfilled in this particular case.

    How may such drugs be administered? The phrase in the act “if medication has to be administered by force” makes it implicit that this is an option. It is difficult, however, to find written guidance on the question of deception. It seems sensible to us that it should be in a way which is least likely to be harmful to the patient. The phrase mentioned above that treatment should represent the minimum interference necessary should seem compatible with this view.

    We suspect that similar incidents to that described here are relatively common and are certainly aware of instances of drugs being administered without the patient's knowledge when the patient is disturbed and not mentally competent. In paediatric practice there is also a precedent for drugs being administered surreptitiously. This seems accepted both by clinicians and parents. It is reassuring that the approach taken by the consultant and the sister in this case was supported by the consent to treatment committee of the Mental Health Act Commission and also by the psychogeriatricians appointed by the region.

    We are puzzled why the case caused such a problem. It seems commendable that the staff discussed the episode with both patient and next of kin subsequently, and the response was obviously supportive. Openness about such action seems laudable, but the account implies that such frankness was viewed with concern in some quarters. Nevertheless, we feel it is reassuring for the public that clinical decisions which may be contentious are subject to scrutiny and are reviewed in various forums. However, once the reviewing bodies have pronounced, management would be well advised to heed their advice.

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