Covert medication hits balance of ethics, safety

Ethics Forum. Feb. 5, 2007.

Is it ethical to medicate an agitated patient without his or her consent?

A young man comes into the emergency department saying he has bipolar disorder. He admits to not taking his medication and complains of homicidal and suicidal ideation. Hospital records show that, on a prior admission, the patient and staff were injured during application of physical restraints. When the patient becomes increasingly agitated, refusing treatment or admission, the ED physician offers him a sealed orange juice container into which antipsychotic and anxiolytic medications have been injected. Is the physician's action ethical?

Reply:

This scenario raises far more questions than it answers. No one is likely to argue that covert medication is superior to informed consent, but often the so-called consent process is really a show of force followed by physical restraint and medication. The question posed here is controversial because, given this limited information, reasonable people can disagree about the best clinical decision.

Not every emergency department is staffed or equipped to handle psychiatric emergencies, and this action would not be taken unless the physician felt there was no safe and decent alternative.

The attending emergency physician is confronted by the competing interests of the agitated patient and the safety of staff and other patients. He or she also must determine whether there is a surrogate (e.g., family member or friend) present or an advance directive from the patient or his psychiatrist that states how the patient wishes to be treated if his decision-making capacity is compromised.