No

A recent study of covertly medicating patients who have dementia has exposed this form of deception as a fairly widespread phenomenon in the medical community.¹ These findings may prompt an uncomfortable selfawareness in readers. A “pill in the sandwich” is not a benign gesture. It should never be undertaken without thoughtful consideration of the circumstances, the possible consequences, and the practice of good care. It is rarely ethically justifiable.

Patients have the right to autonomy, or self-determination, which demands a physician's truthful disclosure regarding their medical treatment, its benefits, and its harms. Patients can then integrate this information into their own value systems. Autonomy is predicated on capacity, which is the ability to comprehend the medical situation, to communicate, and to reason about the relevant treatment alternatives. Capacity is a flexible concept that depends on mental abilities, the medical issues, and both the complexity and gravity of the possible consequences.^2,3 Despite memory impairment, capacity can exist, as long as the decision process remains intact through consistent reasoning and understanding.³ When a patient lacks this capacity to give consent, a surrogate is designated to exercise substituted judgment.⁴ Covert medication is a breach of the physician's duty to respect patients' autonomy, represented by the patient or a surrogate.

It is the physician's duty to provide treatment that is beneficent—ensuring that benefits exceed possible harms. Treatment must also be nonmaleficent—inflicting no harm.⁴ Barring extenuating circumstances, there should always be someone, either the patient or surrogate, who is fully informed and who consents to or rejects a treatment.² Consent must be unequivocally voluntary. This process must fully embrace the cultural fibers, belief system, and condition of the patient, for dignity and respect of the person should never lose priority to the good intentions of the medical profession.

Treloar and colleagues found that medication was given covertly to patients without their surrogates' consent, a practice that is both distasteful and unethical.¹ All interventions, medications, and procedures have consequences, including side effects and adverse complications, that need to be considered in the decision to surreptitiously administer medication.⁵ If patients lack capacity to give consent, their surrogates' consent is vital in this process.

If a patient refuses important medication, capacity must be determined and a fully informed surrogate appointed, as necessary, to decide whether the benefit of the medication warrants deceptive measures. This should be congruent with the patient's practiced and expressed value system. It is neither the responsibility nor the privilege of the nurse, physician, or pharmacist to make decisions for patients. Without policies, awareness, and frank discussion of “underground” practices, surreptitious administration of medication will continue in secrecy and shame. The practice is acceptable only in limited contexts and only when all parties—medical care team and patient representatives—are forthright. Otherwise, covertly medicating patients is merely an exercise in paternalistic self-righteousness and an invitation to legal disaster.

Figure 1.

A “pill in the sandwich” is a form of deception that rarely is ethically justifiable