Continuing my series of responses to the New York Timesâ€™, The Ethicist, without imposing values, here is my take on todayâ€™s post, â€œWhen a Patientâ€™s Mom Is Slipping Her Daughter Prozac.”
I am a pediatrician with an adolescent female patient who has had some mental health issues over the last couple of years. She reported being molested and subsequently suffered a depression and engaged in self-injurious behavior requiring commitment to a psychiatric hospital. After her discharge, she was treated by both a psychologist and a psychiatrist. Some months ago, she refused to continue seeing either. Recently, her mother called me to ask if I would write her prescriptions for Prozac. The mother reports that she is doing well and that she has not been cutting herself. She then told me that she has been slipping her daughterâ€™s medication into her orange juice every morning. I thought she meant that her daughter didnâ€™t like to swallow the pill, but she confessed that her daughter is unaware she is taking the medication. She had refused to take it some time ago because she did not feel that she needed it anymore.
I told the mother that this did not feel right to me, but I am conflicted. If the daughter were thinking objectively, she might recognize that she feels better because of the medication. But if she found out her mother was slipping it to her, sheâ€™d be so angry that itâ€™s unlikely she would continue to take it. I can understand the motherâ€™s actions: She saw her daughter suffering for quite a while and feels that her stabilization and improvement are because of the medication. She wants her to stay well.
If I refuse to write the prescription, the medication has a long enough half-life that the daughter could self-wean without a taper, but if she got into trouble as she came off, she would need to know why she was feeling worse. I donâ€™t think I can keep from discussing this with her. It seems wrong to medicate her without her knowledge; she is not yet 18 but she does not have diminished capacity. There are other factors (passage of time, talk therapy) that may account for her improvement. No matter how I look at it, I cannot come up with a scenario that ends well. Name Withheld
My response: Thank you for sharing this vignette and your perspective. It looks interesting. I can think of many relevant questions. I’m surprised you didn’t ask any, but you didn’t. I hope you’ll share with us what happens next.
The New York Times response:
One symptom of a mental health problem may be an inability to think rationally about your treatment. But the standard for overruling someoneâ€™s judgment is, rightly, high: The person would have to be a threat to herself or others. That doesnâ€™t appear to be the case here. Your patient is, you say, capable of making decisions about her therapy for herself. Given that your first duties are to her, you must not knowingly participate in this ruse â€” you canâ€™t continue to prescribe a drug that you know will be administered stealthily.
I understand that the mother is concerned that her daughter will harm herself if she ceases to take the drug. And as your patientâ€™s parent, she has a duty to look out for her interests. But she shouldnâ€™t do it in a way that denies her daughter any measure of autonomy. (Also, given the possibility of drug interactions, it can be dangerous to put people on medications they donâ€™t know about.)
The serious issue is whether you have a duty to tell her what her mother has done. There are conflicting demands here, as you recognize. On the one hand, her mother spoke to you in confidence. And your patient will presumably be badly affected, as you say, by learning the truth. On the other, the young woman should not be medicated against her will, and she needs to be prepared for whatever changes may come as the drug and its effects clear her system. On balance, the right thing to do is to discuss it with her. (You might also tell her that managing her situation isnâ€™t best left to a nonspecialist like yourself.) But you owe it to her mother to tell her what you plan to do so that she may inform her daughter first if she chooses to do so.
My supervisor at the nonprofit where I work is planning to apply to become its director. For years I have been subjected to sexist and racist treatment and comments from him. I have been told â€˜â€˜Boys will be boysâ€™â€™ when reporting other harassing behavior, heard countless stories about â€˜â€˜dangerousâ€™â€™ (i.e. â€˜â€˜blackâ€™â€™) neighborhoods and been called â€˜â€˜princess.â€™â€™ The lack of human resources channels, along with a fear of retaliation, has left most of these incidents unreported. The institution recently hired an H.R. person and installed an interim director with a sterling reputation. If my supervisor is being seriously considered for the position, do I have an obligation to report these behaviors? Name Withheld
My response: You have the option.
What is it with people writing this column asking about obligations? A few moments’ thought reveals that the question doesn’t make sense, at least on the face of it. If there were an obligation, who would enforce it? If you have to ask, doesn’t that imply people will disagree or at least not form a consensus? Isn’t it clear that the question must afford multiple answers, then? If there were an absolute right answer, why would anyone have to ask?
I think the point is not to look at the face of the question. It obviously has no absolute answer, but posing it that way leads the responder to support the perspective that there is. I conclude that the asker wants an absolute answer. Why? The best answer I can come up with is to absolve him or herself of responsibility, to be able to report these behaviors and then, if there’s blowback, say, “I had no choice, I was obligated.”
Instead of confusing the issue with opinions disguised as abstract obligations, if the asker looked at the situation in problem-solving mode, he or she could dispassionately find a solution based on how his or her actions would affect others. I find creating options and then choosing among them based on likely outcomes evaluated based on empathy and compassion for those affected works well.
This method yields no more universal or absolute answers, but enables and empowers the asker to resolve such issues in the future. It enables the asker to develop and refine his or her response to “What feels right to me?, also known as a moral compass, without which you are piloting a rudderless ship, if you’ll indulge me confusing the metaphor.
The New York Times response:
You are certainly entitled to file complaints about inappropriate behavior with your H.R. person. Any retaliation you suffered would be wrong; and, in response to allegations of sexist and racist behavior, it would most likely be illegal as well. Iâ€™m not sure you are obliged to report these past incidents, though. Your account leaves it unclear if you think this person has created a hostile work environment or if you think heâ€™s just a jerk; but to dismiss reports of harassment, in the way you describe, is certainly a moral and managerial failure. Putting the question of obligation aside, it would be a good thing to report your experiences; your organization shouldnâ€™t be led by someone with these habits. (Iâ€™m assuming that your characterizations of his speech and conduct are fair-minded.) Whether or not heâ€™s appointed to the top job, he should be told to stop doing what heâ€™s doing.
If the search for the new director is properly conducted, the board of your organization will get reports from subordinates and co-workers about any internal candidates, and you should be assured of confidentiality in this context. At that point candor would be required in the interests of the organization, whose aims I presume you share. You might want to encourage others to pass on what they know as well.
I volunteer at a thrift store in a large retirement community. Residents donate goods that volunteers, also retirees, take in, sort, process, price and put on the sales floor. All the money we make, which is substantial, goes to the wider community â€” to schools, animal rescues, local scholarships. I have seen several volunteers put donated items in their pockets when they thought no one was looking. They, like me, work for hours every week without pay. We are welcome to buy donated items, but it takes several days for them to be processed, and they canâ€™t be held for anyone. We are a close, fun-loving team. What, if anything, should I do? Name Withheld
My response: Talk to them.
The New York Times response:
I am glad youâ€™re a friendly, fun-loving lot. But â€” though it wouldnâ€™t be very fun-loving or friendly of you to point this out â€” some of you are thieves. You could object when you see theft going on: These goods werenâ€™t donated for the benefit of the thrift-store volunteers. Or you could leave well enough alone: Youâ€™re all volunteers; the objects presumably are of no great value; the sin is venial. I understand that you value your collective esprit; you donâ€™t want to be a monkey on anyoneâ€™s back. One possible intermediate step, then, would be to ask the store managers to remind people that pocketing donations is against policy. Some of your co-workers, who may have been excusing their pilferage to themselves, will be encouraged to straighten out and fly right.
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