Running head: ETHICAL ISSUES ON DRUG ADMINISTRATION: COVERT

MEDICATION

Ethical Issues on Drug Administration: Covert Medication

Ronilyn A. Alvarez
Saint Louis University

Do we really respect autonomy? The practice of hiding medication in food or beverages so

that it goes undetected by the person receiving the medication, also known as covert medication,

ETHICAL ISSUES ON DRUG ADMINISTRATION: COVERT MEDICATION

is more widespread than one may expect. By this practice, is it ever ethically permissible? This
scenario raises far more questions than it answers. I have chosen this topic out of all the ethical
issues because it involves issues regarding to a patients right to refuse and how health care
professionals should abide with it. This paper aims to determine go by the practice of covert
medication and also the reasons that goes behind it.
The first research entitled Administration of medicines in food and drink: a study of older
inpatients with severe mental illness used a cross-sectional survey of nursing staff and medicine
chart review. The study aims to examine the nature, frequency, safety, reasons for and
documentation of the administration of medicines in food and drink. The researchers interviewed
with nurses concerning medicines administration to 110 older patients in a specialist psychiatric
hospital. Of the 110 patients, 31% were receiving medication mixed with food or drink. The
reasons for this practice were swallowing difficulties (62%) and medication refusal (47%). 13
out of 110 patients (12%) were receiving medication covertly, most commonly antipsychotics
and anxiolytics or hypnotics. Most had dementia but a few had chronic schizophrenia. Covert
administration was documented in the care plan of 46% of patients and 69% on the medication
chart. Administration of medication in food or drink and covert medication were common in this
group of hospitalized patients with severe mental illness. Before administering medication
covertly it is important to discuss the matter with the multidisciplinary team and, where
appropriate, with the patients relatives. It is also important to ensure that supporting
documentation has been completed in order to avoid medico-legal difficulties. The study had a
relatively small sample size, which limits the conclusions that can be drawn from it. More
standards could have been audited. It would have been of interest to ask clinicians what harm to
patients would have occurred if the covert medication had been withheld. The second research
entitled A pill in the sandwich: covert medication in food and drink 24 (71%) of units
sometimes concealed medication in food or drink and 10 (29%) did so at least daily. Covert
administration was considered acceptable to prevent mental distress (14), physical harm (4) or
risk of harm (5). Eleven (11) said the practice was only justifiable if the patient lacked capacity.
Records documented the covert administration 11/34 (32%) units. In10/34 (29%) units the
decision to disguise medication was made by the nurse on duty alone. In only 10/34 (29%) units

ETHICAL ISSUES ON DRUG ADMINISTRATION: COVERT MEDICATION

was the decision made by the doctor. Carers in both settings- institutions and the communityseemed to regard it as acceptable for both physical and mental disorders, as a last resort.
Moreover, covert medication is often based on the judgment of a single nurse, and relatives may
well be kept in ignorance. The study was more focused on a population sample on patients with
dementia, it would have been broader and more conclusions could have been brought out. The
interest I have for this topic makes me want to study and unravel more issues revolving around it
but in the other hand few related researches were done which makes me limited to the articles I
could read. It would seem that I need fair judgment and a wide knowledge on the events and
circumstances that would require the use of covert medication.
Communication among the treating team, patients, and relatives should be transparent,
avoiding secrecy in the administration of medicines, with ongoing feedback. If the team decides
to covertly administer medication, it may be appropriate to inform the patient of the
circumstances once she/he is stabilized. The patients past and present wishes should also be
taken into account. How does one reasonably balance ethics with respect to whether covert
administration of medications in psychiatric emergencies is ever appropriate? What do patients
want? How will the courts ultimately rule on this question in the future? Further studies should
be conducted to explore the acceptance of covert medication in different settings.

ETHICAL ISSUES ON DRUG ADMINISTRATION: COVERT MEDICATION

References
Treolar, A., Beats, B., & Philpot, M. (2000). A pill in the sandwich: covert medication in food
and drink. England, UK. Retrieved from
http://jrs.sagepub.com/content/93/8/408.full.pdf+html
Haw, C. & Stubbs, J. (2010). Administration of medicines in food and drink: a study of older
inpatients with severe mental illness. Northampton, UK. Retrieved from
http://www.globalaging.org/health/world/2010/severe.pdf