Dilemma 1

Is it ethical to help a patient against his will or when he doesn't know or understand his situation?

A young man with schizophrenia and a history of non-compliance with treatment was admitted to my outpatient practice in a severely psychotic condition. He was completely lacking insight into his condition, and all approaches to gain compliance—most importantly, taking medications that could reduce his psychotic state—failed. His mother convinced me to prescribe medication, which she secretly placed in the patient’s food for nearly two years. I saw the patient for medication checks regularly, but he was unaware of his “compliance” throughout this time. This strategy resulted in slow, steady and quite remarkable improvement in all areas of functioning. The only untoward event, if you will, was the patient’s return to a pattern of partial compliance and eventual return of some symptoms several weeks after I chose to tell him the entire story. I had simply grown too uncomfortable with the situation, realized that this could not go on forever, and hoped that his clinical improvement just might allow him to embrace a proven, efficacious treatment (which was the ultimate plan discussed with his mother prior to embarking on treatment). Despite some decline in his condition and only partial compliance, the patient continues today improved from admission and much more amenable to inducements to adhere to his regimen. I believe I have given this individual a fighting chance where there was none—yet I have been acutely aware of the ethical dilemmas in his treatment along the way. Was I right to pursue this course?

“A person with schizophrenia, such as this patient during psychotic exacerbations, may not be capable of making a variety of decisions and may require guardians to look after their interests. Guardians, however, may not force medications on outpatients in Connecticut,” says Howard V. Zonana, M.D., professor of psychiatry and head of that department’s forensic psychiatry residency program. “Patients frequently don’t like to take medications. They have some unpleasant side effects. As part of their illness, some patients don’t believe they’re sick.” Zonana chaired the YNHH Bioethics Committee from its inception in 1985 until 1999.

He notes that psychiatrists are not alone among health care providers in receiving requests from one family member that they deceive another about care being given. For instance, physicians in family practice may encounter patients with sexually transmitted diseases who request that the doctor treat their spouses surreptitiously because they are afraid of threatening their marital situation. To hide information from one patient for the sake of another, he says, “is putting the needs and beliefs of the person who wants to keep the secret first and is conspiring in a deception. The doctor who does so is making complicated value judgments and is being co-opted. Sometimes, as in a case like this, it may work out, but there are many more times when it won’t, and the price for a betrayal of trust is very high, threatening both the present and future physician-patient relationships.”

Zonana, medical director for the American Academy of Psychiatry and the Law, helped to write the state of Connecticut’s civil commitment statutes. Psychiatrists, he points out, operate under extensive legal regulation because they have powers akin to those of the police to detain a mentally ill person involuntarily. He says, “There are many chronic schizophrenics on the street, and we don’t go around surreptitiously injecting them with syringes of medications. There’s always a balance between individual autonomy and social needs and health. If somebody becomes gravely disabled or dangerous, the person loses some autonomy. There is always a dilemma about what values the individual and a community hold more primary. In this case, I don’t see the clinical situation compelling enough to justify this deception.” He contends that there are other ways to help someone gain insight into his or her condition. “The doctor’s intent was clearly humane, but I think in the long run honesty trumps health outcomes. I would not have been willing to do this.”