The underlying problem for Mr. T’s doctors and his wife is that Mr. T seems unable for much of the time to realise that he is ill. This gives his doctors and other mental health workers, and indeed his wife, very little room for manoeuvre with him. His illness apparently makes him dangerous, because of his beliefs that others are involved in conspiracies against him, which seem to arise from his condition, and this danger particularly affects his wife who has been subject to threats by Mr. T. The initial question is whether Mr. T’s doctors should support or collude in Mrs. T’s proposal to medicate her husband surreptitiously — and if not, what is the alternative? A no less important question is how Mrs. T’s safety might be assured. Underlying these issues is a wider question about the relation between the mentally ill and their doctors, relations (partners and other family members) and society. Mr. T’s behaviours threaten to isolate him from his loved ones and from society.
Presumably, Mrs. T’s hope is that giving Mr. T medication will keep his symptoms under control, ensuring her safety and enabling him to retain his relationship with her and perhaps with others; in short, maintaining his place in society. There is also strong evidence that a delay in psychiatric treatment is related to poorer outcomes in terms of, for example, increased morbidity.1 Moreover, some form of long-term medication does seem to be the main hope of achieving a desirable outcome in Mr. T’s case. It seems from the case description that some control of Mr. T’s symptoms results from his taking his medication, and his return to delusions comes only when he gives up on it. It is not made clear, however, why he does give up on it. [End Page 212]
From the description of Mr. T, one gets the strong impression of behaviours dominated by the command hallucinations and the paranoid delusions that seem to gather around them. However, there are also, perhaps, periods where other motivations and beliefs have some grip on his life. We are told he has a job, and of course he has the relationship with his wife. What seems to happen is that, at least as far as the latter goes, when his illness reasserts itself, the meaning of his wife’s relationship to him becomes changed in his mind, and Mrs. T becomes part of the conspiracy he believes aims to kill him.
Nonetheless, it is unacceptable for Mr. T’s doctors to support Mrs. T’s plan or to collude in it. The primary reason for this is not that it will be a potential disaster — though it stands a good chance of failing and going terribly wrong. There may be dangers to those who administer covert medication if discovered by a paranoid patient in addition to dangers for Mr. T who may misinterpret the side effects of the drugs he is unaware he is taking, or take other drugs that may interact with the drug he is receiving covertly.2 The primary objection to psychiatrists’ colluding in this is that using a third person to surreptitiously deliver medication to Mr. T is to betray his trust in the medical profession, and that this is unacceptable.
Mr. T seems to have at best an ambivalent relationship with the medical profession. He seems unable to develop any long-term trust in them, and after a short time off his medication, any trust he may have developed disappears and he turns to his own judgement as to whether he is ill or not, ignoring the advice of his psychiatrist. The trust that the medical profession enjoys from patients is partly responsible for giving it its authority over their actions; and is partly why doctors and other health workers are offered great access to details about a person’s private life. Since this is so basic to the success of the doctor-patient relationship, but is also rather fragile, it is incumbent upon doctors to seek to retain their patients’ trust.
So, in the usual situation, the patient and doctor...