Point-Counterpoint: is it ethical to give drugs to people with dementia? Yes: It is ethical if it is in their best interests.

Abstract

According to the American College of Physicians Ethics Manual, the physician's primary commitment must always be to the patient's welfare and best interests.1 This tenet gains a particular poignancy in caring for people who have dementia, because of their extreme vulnerability and dependence on others.2 The covert administration of medications is widely practiced in the care of people with dementia, occurring in 79% of a sample of long-stay care settings for the elderly.3 The question of its ethical basis arises usually in the context of a cognitively impaired patient who refuses to take medication. Ideally, before a new medication regimen is started, we obtain informed consent from the patient. However, patients with advanced dementia lack the capacity to consent to and, by the same token, refuse treatment. What should we do when a patient who lacks the capacity to refuse treatment physically rejects an important medication? The key to all interactions in the care of people with dementia is sensitivity. We need to think about what their rejection represents. Occasionally patients may harbor deeply rooted wishes to die, and instead of taking medication, they would rather “let nature take its course.” More often, refusal is due to the pill being too difficult to swallow or causing an unpleasant taste in their mouth, or to a delirium caused by an underlying illness, such as an infection. In these situations, health care professionals have usefully and effectively camouflaged medications in patients' food, which is akin to using bubble-gum or cherry-flavored antibiotics in children. Camouflaging medicines is arguably a kind way of giving them to distressed elderly patients. Because our cognitively impaired patients are incapable of making decisions, we sometimes have to make them on their behalf. Ideally, this should be done on the basis of their advanced directives or by appointed health care proxies, but many patients with dementia have neither. In these situations, we must act in the best interests of the patient. If we do not give important medication to such patients, we could cause them harm. This must be balanced against the breech of patient autonomy that covert medication entails and the medication's side effects. Our inclination to treat a patient should be proportionate to the potential seriousness of the condition and inversely related to the risks of treatment. How can we helpfully think about the autonomy of a patient with dementia? Autonomy involves the ability to direct one's own actions, and this is obviously limited by severe cognitive impairment. We should respect patients' autonomy, but we may need to breech it if they are in danger. I find it helpful to think of a “sliding scale” of risk versus benefit, analogous to that proposed by Drane for assessing patients' mental capacity.4(p155) For instance, if a cognitively impaired patient objects to being moved from a television lounge, we are likely to just let the patient be. Suppose, however, that the room is on fire. This alters the risk-benefit balance dramatically, and now we would remove the patient from that room regardless of how much he objects and would even use force if necessary. Here, it is ethically acceptable—indeed, imperative—to breech the patient's autonomy. So is it ever ethical to give drugs covertly to people with dementia? Yes it is, provided that we remain sensitive and respectful of our patients and act truly with their best interests at heart.