1. Olsen, Douglas P. PhD, RN


Is hiding medicine in food ever ethically justified?


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A patient's irrational refusal to take medication can be frustrating for the nurse. Crushing the pill into applesauce or ice cream saves time and effort, and spares the patient the aggravation of quarreling. But while hiding medication is sometimes ethically justified, often it is not.


The concealment of medication in food appears to be widespread, especially in long-term care facilities and nursing homes. Although data on the frequency of the practice are sparse, a recent analysis of nine studies, most of them conducted in the United Kingdom, concluded that in 43% to 71% of nursing homes medication is hidden in patients' food, and that 1.5% to 17% of institutionalized patients receive medication without their knowledge or consent.1 (This month's Ethical Issues concerns the nursing care of cognitively impaired medical patients, not the care of patients with psychiatric illnesses who may be endangering themselves or others by refusing medication, or those whose refusal poses a public health risk; there are specific laws that govern forcible medication in such cases.)



According to the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements, provision 6.1, "Virtues such as wisdom, honesty, and courage are habits or attributes of the morally good person[horizontal ellipsis]. For the nurse, virtues and excellences are those habits that affirm and promote the values of human dignity, well-being, respect, health, independence, and other values central to nursing."2 In addition, provision 1.4 suggests that respecting a patient's dignity requires the nurse to recognize the patient's right of self-determination.2


Swedish-born philosopher and ethicist Sissela Bok defined deception in her seminal 1978 book, Lying: Moral Choice in Public and Private Life, as an action "meant to make [someone] believe what we ourselves do not believe."3 Hiding medication in food is deceptive, yet in some instances it may be the most ethical way to deliver medication.


Two factors must be considered in determining whether hiding medication is justified or not: the nurse-patient relationship and the patient's rights.



Nurses recognize patients' dignity by involving them in the decision-making process as much as possible. They counsel patients about the benefits and adverse effects of a medication, while patients describe their treatment goals. Nurses then attempt to reconcile patients' wishes with the reality of their condition. For example, a nurse may explain, "This pill should help alleviate your pain, but you might be sleepy when your son gets here."


Deception affects both parties in a relationship. Deceived patients, no longer treated as people with legitimate thoughts and goals, lose their voice. Nurses who deceive become more like custodians than compassionate caregivers; they must also absorb the act of deception into their sense of self. Brain-imaging research confirms the folk wisdom that an initial deception makes lying easier in the future.4 Bok states, "Bias skews all judgment, but never more so than in the search for good reasons to deceive."3 For example, a nurse might choose deception by reasoning that not spending time trying to convince a patient to take a medication will free up more time for other duties.


Trust is essential to the nurse-patient relationship, and nurses' deception of their patients, however well intentioned, may cause mistrust. According to one study, nurses who admitted to having used deception in order to alleviate patients' worries (10 out of 251 nurses) indicated that occasionally their actions had shattered the trust between themselves and their patients.5 Some of the nurses who had used deception also said they were distressed by their decision, feeling as though they had been "playing a part." Patients who discover that their nurse has deceived them may lose trust not only in that particular nurse but in other nurses as well.6 Furthermore, other patients who become aware of the deception may become distrustful of their own nurses and the entire health care team.


The social meaning and function of food magnify this potential harm. Food symbolizes "interpersonal acceptance and friendliness," and being fed conjures up the warmth of maternal care.7 Beyond being necessary for survival, food, especially when shared, defines and reinforces social relationships.8 A patient who discovers that medication has been hidden in food offered by his nurse-a person in whom he has placed trust-might feel betrayed and socially isolated.



In order to ethically choose deception, a nurse must be able to justify bypassing the patient in the decision-making process. Patients have the right to decline treatment unless they are unable to appreciate the meaning and consequences of their decisions. In that case, the nurse may have an ethical obligation to protect the patient from the repercussions of impaired thinking and to ensure that the patient receives the medication-even through deception. If deception is deemed justified, the nurse should make sure that the particular medication, after being crushed and mixed with food, will remain safe and effective.


Patient's decision-making capacity. Determining whether the patient can understand and appreciate the decision to take or decline medication is critical. This decision-making ability should be assessed for each decision, because a patient may have the capacity to understand the consequences of one decision and not another.9


The most testable parameter of a patient's decision-making capacity is intellectual understanding. Can the patient discuss the effects of the medication-both positive and negative-along with potential alternative treatments and the consequences of declining the medication?10, 11 If the nurse has a sense that the discovery of deception would upset the patient, this is a strong indicator that the patient may be mentally capable of taking part in the decision.12 Surmising that patients won't notice the effect of the medication and recognize deception presupposes a fairly high level of impairment. If the nurse is uncertain whether or not the patient has the capacity to refuse consent, consultation with a mental health professional may be warranted.


If it is determined that a patient is incapable of appreciating the decision, then the nurse should consult with an appropriate surrogate decision maker about treatment options, including hiding the medication in food. If the patient has completed a durable power of attorney form (designating a health care agent), the designated person should be consulted. In the absence of a durable power of attorney, someone close to the patient, such as a spouse or a child, can be asked to serve as surrogate. (Nurses should check their institutional policy to see if there is a designated hierarchy when determining surrogates.) Together the health care team and the surrogate may decide that hiding the medication in food is the most humane action to protect the patient from the consequences of refusing medication. It may also be prudent to discuss the case with colleagues or, in difficult cases, to ask the institution's ethics committee to become involved. Institutions may benefit from developing policies and procedures regarding the deceptive administration of medication. No one should unilaterally decide to deceive a patient.



Sissela Bok provides a two-pronged test to determine whether deception is justified. First, would the deceived patient have agreed-prior to her or his mental impairment-that such a deception is warranted? This requires the nurse and surrogate decision maker to imagine how the patient might have reasoned: would the earlier, cognitively intact patient have agreed that, given the present impairment, the providers shouldn't be morally bound to accept the patient's decision to decline medication?


Second, could the deception survive public scrutiny, including that of professional peers? An ethics committee could help bring a nurse's justifications for deception into public discourse, thereby avoiding situations where deception may be more the result of frustration than of careful ethical consideration.




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6. Sellman D. The importance of being trustworthy Nurs Ethics. 2006;13(2):105-15 [Context Link]


7. Moore HB. The meaning of food Am J Clin Nutr. 1957;5(1):77-82 [Context Link]


8. Counihan C, Van Esterik P Food and culture: a reader. 1997 New York Routledge [Context Link]


9. Grisso T, Appelbaum PS Assessing competence to consent to treatment: a guide for physicians and other health professionals. 1998 Oxford; New York Oxford University Press [Context Link]


10. Beauchamp TL, Childress JF Principles of biomedical ethics. 20096th ed. New York Oxford University Press [Context Link]


11. Raymont V, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study Lancet. 2004;364(9443):1421-7 [Context Link]


12. Johnstone M Bioethics: a nursing perspective. 20095th ed. Sydney, Australia; New York Churchill Livingstone/Elsevier [Context Link]