Every day physicians deal with patients who could improve their health by engaging in some behavior change, but want instead to be prescribed a pill. A patient might say for example “Yes, I know it would be good for my cardiovascular system if I lost 10 pounds, ate more fruits and vegetables and went for a brisk walk each evening. But I don’t feel like doing those things so give me the statins and the antihypertensives I heard about on that TV ad”.
There are a range of ethical issues for the care provider here, including balancing the need to take care of people while at the same time not enabling poor health behaviour, weighing the risk of side-effects with the benefits of medication, and recognizing that sometimes medications are best but if everyone refuses to change their health behaviour it puts more strain on already strained social programmes (e.g., Medicare), and so forth.
But what doesn’t arise is the “split decision” ethical problem common in child mental health treatment. By “split decision”, I mean when someone is faced with a choice not between changing their behaviour or taking a pill, but changing their behaviour or making someone else take one. Here are some examples of such conundrums:
A 14-year old boy is brought in by his parents, who report that he has low self-esteem and cries a lot. They want him on an anti-depressant. When the doctor observes the family and does a private interview with the boy, s/he discovers that the mother constantly tells the boy that he is fat and stupid, and that it’s his fault that his parents got divorced. The father has visitation rights every weekend, but more than half the time, he doesn’t show up, repeatedly disappointing his son. When these issues are raised with the parents, they say angrily “We told you to fix him, not us!”.
A 9-year old girl is engaging in strange ritual behaviours (e.g., compulsively re-arranging her room) and has difficulty concentrating. Her parents want her on an ADHD or anxiolytic medication. Her mother is concerned while the father seems angry to even have to come in to the clinic. You smell alcohol on his breath, and it’s noon. As you watch them leave the clinic the father brushes against another patient and screams “Watch where you are going, you moron!”, leading his child to cover her ears and start sobbing. When you come out to intervene the father tells you to mind your damn business, and that if you don’t put his kid on a medication he will find another doctor who will.
Everything about these situations is terrible, most of all of course for the children concerned. But they are also rough on the treatment provider. To really help the child would require a change in someone else’s behavior, and that person refuses to do anything other than consent to have the child medicated. If you refuse to sign on to this arrangement, the child receives no help at all. If you agree to help the child adapt, you are reinforcing the destructive family myth that the only thing wrong is that the child is defective for a reason at which no one can guess.