Challenging lesser evil justifications for non-clinically indicated uses of antipsychotics in aged care facilities

By Hojjat Soofi.

The administration of antipsychotic medications to residents with dementia in aged care facilities remains a subject of considerable controversy. A major focus of the controversy has been on the (questionable) influence that non-clinical considerations have on the rate of antipsychotic prescriptions in aged care facilities. Often, the primary beneficiaries of antipsychotic uses in aged care facilities are not the residents who take them. Instead, the medications are (primarily) used, more often than not, for the benefit of care staff: they may be used, for their sedative effects, in under-staffed and under-resourced aged care facilities to make the staffs’ workload more manageable.

Given the potential harm of antipsychotics including increased risk of death and increased risk of stroke, non-clinically indicated uses of the medications are clearly ethically undesirable. The practice involves putting vulnerable residents at significant risk of harm for third-party benefits. The practice may leave residents in zombie-like state for extended periods of time, exacerbating their social marginalisation and inhibiting them from engaging in social interactions.

Does this mean that the practice cannot be, all things considered, ethically justifiable?

While thinking about this question, I came across some interesting empirical research revealing that care staff in aged care facilities perceive the non-clinically indicated uses of antipsychotics as ‘a lesser of two evils’. Here is an illustrative quote captured from an interview with a community psychiatric nurse working in a care home:

“So in some people’s cases it, it’s the lesser of two evils. You don’t want to give them medication but you don’t want them to, the whole home situation to fall apart yeah so it’s weighing it up …”

This quote explicitly acknowledges that the practice of using antipsychotics on non-clinical grounds is ethically undesirable (or evil). However, it further claims that the alternative may be even more ethically undesirable (or more evil). Not using antipsychotics, in the ways described above, may have adverse consequences for the whole care environment: a larger number of residents overall will be deprived of adequate care if staff allocate their energy and time to more ‘demanding’ residents.

I realised that this is, basically, a (perhaps, less articulate) form of standard lesser evil justifications that are widely discussed in ethics literature. The idea is simple: when an agent is in a situation where they have no option other than taking action A or action B, and both A and B are otherwise ethically undesirable, they have a justification for doing the course of action that is a lesser evil.

In my recent contribution to the Journal of Medical Ethics, I investigate whether this form of lesser evil reasoning can be used to justify the use of antipsychotics on non-clinical grounds in aged care facilities. My conclusion is, for the most part, negative. I contend that the lesser evil reasoning cannot be applied to the practice under discussion straightforwardly and without major conceptual complications.

This is because much of the discussion on lesser evil justification in the philosophical ethics literature assumes that lesser evil situations are rare. But, non-clinically indicated uses of antipsychotics are not rare occurrences. What’s more, the standard lesser evil justification in philosophical ethics literature is predicated on the idea that the agent in lesser evil situations does not have any connection to those affected by a (supposed) lesser evil course of action. This idea has very little relevance to the practice under consideration: the care staff have a connection to residents by virtue of their duty of care to residents.

Even if we could apply the philosophical discussion on lesser evil justification, there would have remained further challenges. First, in many cases, the choice between using the medications and not using them is just a false dichotomy. Second, weighing the ethical undesirability of using the medications against not using them will be feasible only if there is some common denominator for comparing evils under consideration. I suspect that finding such a common denominator is highly challenging, if not impossible.

The upshot then is this: lesser evil reasoning can be and, as I argue, should be, challenged in aged care facilities insofar as such reasoning is used to justify non-clinical uses of antipsychotics as a strategy to cope with limited resources.


Paper title: Non-clinical uses of antipsychotics in resource-constrained long-term care facilities: ethically justifiable as lesser of two evils?

Author: Hojjat Soofi

Affiliations: Macquarie University Research Centre for Agency, Values, and Ethics (CAVE), Department of Philosophy, Macquarie University

Competing interests:  None declared.

Social media accounts of post author: @hojjatsoofi

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