The Ethicist: Can I Trick My Brain-Damaged Brother Into Taking His Meds?

October 21, 2018 by Joshua
in Ethicist

My series answering the New York Times’ Ethicist column with an active, leadership approach instead of an analytical, philosophical perspective continues with “Can I Trick My Brain-Damaged Brother Into Taking His Meds?”.

My older brother suffered a serious brain injury about 10 years ago. His communication skills were hard-hit. He understands some of what people say as long as they speak slowly, but even then concepts are hard and reasoning with him can be difficult.

He was quite brilliant before the injury, and he understands that his brain can no longer do what it once did. To make matters even sadder, he has psychological problems that have never been properly addressed. Both my dad and I learned we had bipolar disorder late in life. We each had successful careers up until our diagnoses. My brother has never been able to hold a job for more than a short time and has never really understood how to deal with people. The doctor who works on his cognitive recovery believes that psychiatric medication is most likely needed to facilitate his healing.

My brother seems to believe that his only problem is with comprehension and communication. He will not consider taking psychiatric meds because he sees himself as emotionally more evolved than everyone else in his sphere. He often talks about being the “oldest soul in the family.” But he no longer understands boundaries and, given his size, he can be intimidating. Though his round-the-clock caregivers go above and beyond the call of duty, he insists that they are there to serve him. They don’t stick around for long.

I do not know what his diagnosis would be, although I believe he might have more than one personality disorder. Being bipolar myself, I know how much medication can help. I am convinced that medication would vastly improve my brother’s life, and his adult children agree. But he simply will not comply. If we were able to get a psychiatrist to diagnose him and prescribe the proper medicine, would it be ethical to tell him that the meds were for one of his physical issues rather than for his psychological and emotional issues?

I try not to lie in my life, with the exception of unnecessarily hurting someone’s feelings or telling a white lie for the benefit of a child. My brother is no child, but his reasoning and understanding can be comparable. (He has a financial conservator as he is not capable of taking care of his finances.) What should I do? Name Withheld

My response: You ask what’s ethical. Since everyone has different values, you’ll just get a label that not everyone agrees on. I suggest you want not a label but a practical plan to resolve your situation as best you can by your values and the values of others affected as best you can tell using empathy and projecting possible outcomes.

Labeling something doesn’t change your situation. You probably want to resolve it more than label it. I suggest that more than a New York Times columnist labeling something for you, you’d benefit from developing the social and emotional skills to resolve the situation and improve your emotional well-being. You’ll lose the excuse to say, “But the New York Times told me to” but gain the ability to resolve these inevitable parts of life without needing others’ help. You’ll make mistakes, but you’ll learn from them. Experience is the best way to learn these things, I’ve found, as have millions of others. I recommend accepting the missteps you’ll make, looking at them as learning experiences, and using them to learn and grow.

“What should I do?” … Asking what you should do makes sense for children asking their parents. For an adult, it looks like asking someone else to take responsibility, which I call juvenile. Asking for options or views you might have missed makes sense, but you didn’t ask that.

I recommend a different perspective than asking what others think you should do. There are many choices you can make where you don’t know all the possible outcomes, who will like the results, who might get hurt, and so on. I think of it like looking down a ski slope that splits, the paths diverge so you can’t either past the first part, and you have to choose. Or choosing which wave to surf.

When you can never know all the information you wish you could but still have to choose or risk standing in the cold while others pass you by, in life or on the slopes, the best I can think to do is to know that whichever you choose, you’ll enjoy it or live it the best you can, and that you’ll take responsibility for making it work. Also not to judge your choice based on information or experience that came after you chose but couldn’t have known at the time.

The New York Times response:

Your brother’s situation raises one of the great ethical challenges of modern life. There are more and more people, many of them toward the end of their lives, who have suffered cognitive deterioration that leads them to make bad decisions about their own best interests. If people have some basic measure of rational capacity — this is not a terrifically demanding criterion — they are normally entitled to make decisions for themselves, even ill-advised ones. Here, where beneficence clashes with autonomy, beneficence must stand down. With children and the severely cognitively disabled, by contrast, beneficence prevails: We may impose a treatment on people who have a clearly expressed wish that we not do so.

Your brother, you believe, has overlapping conditions that have robbed him of the capacity for reasonable self-management. Assuming a professional assessment confirms your view, it would be ethically permissible to try to find ways to improve his mental functioning, even though he doesn’t believe this is necessary. In the absence of a court order or a true medical emergency, however, it’s unlawful to treat someone against his or her will, including through deception. Most states have provisions for involuntary outpatient commitment, but typically this requires a judicial determination that your brother is a danger to himself or others.

Although I wish I could tell you to try to proceed with your plan anyway — you care deeply for your brother, and his sense of reality is an attenuated one — there’s an ethical rationale for these extraordinary hurdles. One consideration among many is to avoid “Suddenly, Last Summer” scenarios, where a troublesome family member might be subjected to treatment by kin with complicated motives. Out of justified caution, we now err on the side of putative autonomy, and the heartbreaking story of your damaged brother is a result; when we erred on the side of putative beneficence, other heartbreaking stories resulted. I don’t say that we’ve got the balance right. But the perennial clash between these two ideals can never be perfectly resolved.

I went back to school a few years ago and lived in a nearby building, where I was paired with a roommate. When I moved in, my roommate told me that he was schizophrenic but was taking his medication and everything was fine. I try not to judge; I have severe A.D.H.D. and I spent 20 years flooding myself with meds to get over social phobia, so I was in no position to cast stones.

On the whole, he wasn’t a bad roommate. But in the last year we lived together, it was obvious he was skipping his medication more and more. There were times I felt on the border of being “in danger.” He told me that he’d been married once but was thrown in jail after he went off his meds and beat up his wife.

In the spring, I paid my rent until the end of my lease and set out on a long-distance hike. While I was away, he went off his medication, attacked the building maintenance staff, attacked the police who responded, was thrown in jail, got us both kicked out of the building, lost his job and joined a fringe Hindu cult.

He still calls me. This I don’t mind. But I’m worried that he might want to move in until he “gets back on his feet.” A few days would be O.K., but he would probably try to stay for months.

Recently, he called to tell me he is collecting cans on the street to make money. I’ve considered lending him a few thousand dollars to help him get set up. But I’m in school, and money is tight. My parents want me to change my phone number. He doesn’t have other friends — according to him, they’ve all betrayed him. Not really sure what I should do. Name Withheld

My response: We’ve all experienced trying to help someone only to find what we meant to help got the other person angry, frustrated, or the like. We’ve also all experienced someone trying to help us who only made things worse.

I usually respond to letters with no questions by saying something like, “Thank you for sharing your story,” and not giving advice or commenting much more. Not commenting may sound like an easy way out of more thoughtful and helpful writing, but I’ve learned many times in coaching, teaching, and friendships that helping people who haven’t asked for it is a recipe for disaster.

My starting point for why is that what different people consider “helping” depends on their values, views, goals, and other factors that you, giving unasked advice, don’t know. For example, offering potential solutions to someone who just wants to be heard often leads to exasperation, frustration, and feeling devalued. But just listening to someone who wants advice can lead to impatience, frustration, and other emotions neither party wants.

However obvious you consider your interpretation of what the letter-writer wants, dozens of other interpretations exist, any of which the writer may have meant, or not. Acting on unchecked assumptions risks imposing your values on others, which usually provokes responses you wish you hadn’t from others.

I’ve found the best policy to keep neutral until the person clarifies what they want so I know what “help” means to them in that situation.

The New York Times response:

If he were a member of your family, you’d have continuing obligations to help him, of the sort I just touched on. If he were truly a friend, the same would apply, though the obligations are almost certainly less demanding and can diminish as your paths diverge. But your former roommate, it seems, isn’t either. Although most schizophrenics aren’t violent, this one beat up his wife and sometimes left you feeling threatened. The potential costs of offering him a place to stay are too high for you to have to bear them.

There are other ways to help, but I wonder whether giving him a relatively large sum of money all at once is a good idea. (You say “lending”; it’s probably better to think of any money you provide him as a gift.) My guess is that regular smaller gifts, which would entail periodic meetings with you, might do him more good, and — in light of your limited means — be less burdensome to you. In addition, you might see if you can help get him back on his medications by offering to go see a doctor with him regularly. To help him in these ways would be generous, kind and loyal — and a larger commitment than you are required to undertake.

People with untreated schizophrenia present society with a serious quandary; it’s another arena where beneficence and autonomy clash. We are no longer inclined to institutionalize schizophrenics, except when they commit crimes or pose a serious danger to themselves or others. It’s difficult, as a result, to provide most schizophrenics who are living on the street with the kind of care that would ensure they are taking their medications (and there are reasons they often don’t do so, not least that the meds can produce dysphoria). But your having once shared a home with someone who has this problem doesn’t impose on you the obligation of solving it for him. And there is a risk in involving yourself more deeply in his life; the more you offer, the more you will be enmeshed in further obligations of dependency. It would be wise to get clear about the limits of the commitments you’re willing to enter into at the start.

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