What’s in the applesauce? The ethics of covert administration of medication in food

By Megan Dean, Laura Guidry-Grimes and Elizabeth Victor.

Do you know what’s in your food? Food is a site of physical and epistemic vulnerability for us all–we rely on often invisible others to produce, store, transport, prepare, and serve our food safely, without contamination or adulteration, and to be honest and accurate when describing and labelling foods. This reliance on others is intensified in contexts where eaters have highly constrained opportunities or capacities to choose, procure, prepare, and consume food, like in care institutions.

And this is not necessarily a bad thing; as feminist scholars have emphasized, relationality, vulnerability, and dependence are essential to all eating. But our deep reliance on others to nourish ourselves raises many ethical considerations, including the possibility that these others may not live up to our expectations.

This possibility is a central issue in the ethics of covert administration of medication, which 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—often in food or drink. Covert administration of medication is used to treat the medical needs of patients who lack decisional capacity and who would otherwise refuse the medication. It is a relatively common practice in both homecare and institutional contexts globally, yet there is a general dearth of regulatory or professional guidance for it.

Most of the bioethical work on this topic focuses on patient autonomy and trust, caregivers’ responsibilities to protect incapacitated patients from medical harms, and the importance of organizational guidance and oversight. But as we argue in our paper, the use of food to covertly administer medication raises its own ethical issues. Food and eating are of rich and complex ethical importance. Eating practices can be sources of health, opportunities to exercise autonomy, ways to create valuable experiences, ways to express or reinforce identity, and ways to connect with others. Risking eaters’ trust in food through the covert administration of medication places these goods at risk.

One of the goods we discuss in detail has to do with identity. Ways of eating—such as eating red meat, prioritizing local or traditional ingredients, or being an adventurous eater—inform our identities and how we understand ourselves within a broader social context. We can “hold” ourselves in our identities by eating in “identity-congruent” ways: I am this sort of person, I eat these sorts of things. We can also hold others in their identities by encouraging and enabling them to eat in ways that reinforce and resonate with who they understand themselves to be. Caregivers can support or undermine patients’ identities through providing identity-congruent foods and enabling patients’ eating agency, as far as is feasible within clinical or 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, such as in long-term and psychiatric care facilities.

Further, we argue that the practice of administering medication covertly in food risks undermining trust between patients and caregivers, which can result in a foreseeable deception loop. Consider a scenario where a patient receives covert medication and has improved symptoms and behaviour as a result. Even though the patient recognizes the improvement, they could not know that medications likely contributed, so they may continue to refuse the treatment. At the same time, the patient’s caregivers become more convinced that the medications are beneficial. If the caregivers reveal that the patient was covertly medicated, then they risk the patient distrusting the caregivers and refusing the medication anyway. If the caregivers choose not to disclose the covert medication, then the patient remains ignorant of important health information that could inform their preferences and decision-making. Faced with this dilemma, caregivers may choose the path of least resistance or minimal conflict: continuing covert medication, perhaps for an indefinite period of time. Discussions about initiating or maintaining covert medication – whether in healthcare environments or at home – often do not include explicit plans for when and how to cease the practice. There is no clear endpoint for the deception, which turns the eater-feeder/eater-food relationship into one of conflict, struggle, uncertainty, and fear.

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. Although covert administration of medication may be ethically permissible when there are no suitable alternatives, this practice should be continually reevaluated due to building costs to the relational agent over time. We argue that at least some of these costs are because of the deep ethical importance of food and eating, and we offer preliminary recommendations for mitigating these harms.

 

Paper title: Covert Administration of Medication in Food: A Worthwhile Moral Gamble?

Authors: Laura Guidry-Grimes1, Megan Dean2, Elizabeth Kaye Victor3

Affiliations:

1 University of Arkansas for Medical Sciences, Assistant Professor of Medical Humanities and Bioethics, Secondary appointment in Psychiatry, Clinical Ethicist.

2 Hamilton College, Chauncey Truax Postdoctoral Fellow and Visiting Assistant Professor of Philosophy

3 William Paterson University, Assistant Professor of Philosophy

Competing interests: None

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