Ethics of antipsychotic treatment for people with behavioural and psychological symptoms of dementia in long-term care facilities

Antipsychotic (AP) treatment is a common pharmacological intervention in long-term care facilities (LTCFs) to manage behavioural and psychological symptoms of dementia (BPSD). The current evidence, however, indicates that AP treatment may have at best modest efficacy for managing BPSD and may have severe adverse effects. Moreover, AP treatment varies across LTCFs independent of residents’ clinical characteristics, suggesting that the medications may at times be used to sedate residents rather than as needed to manage their symptoms. These observations raise ethical concerns about the justifiability of AP treatment in LTCFs. In the existing academic literature, however, the ethical concerns are often poorly articulated. This is partly because potentially relevant philosophical concepts such as informed consent, dignity or personhood do not straightforwardly apply to people with dementia. In this thesis, I provide an original and detailed investigation into the ethical justifiability of using APs for managing residents with BPSD in LTCFs. I interrogate different potential interpretations of concepts and ethical considerations relevant to the practice in question. Along with that, I discuss what work, if any, these ethical considerations can, and should, do in assessing the justifiability of the practice under discussion. In Chapter 1, I argue that there are relevant autonomy considerations to AP treatment in LTCFs, but that Beauchamp and Childress’ widely used account of autonomous decision-making needs some modifications to improve its relevance and usefulness in this context. In Chapter 2, I argue that the relevance of personhood considerations, in the form defined by Kitwood, is unclear. Chapter 3 discusses dignity considerations. I defend the relevance and value of invoking dignity as a normative notion regarding the use of APs in LTCFs. In so doing, I develop a modified version of Nussbaum’s account of dignity. In Chapter 4, I argue that despite the gaps and inconsistencies in the current body of evidence about benefits and harms of APs, the considerations of beneficence and non-maleficence do provide moral guidance for AP treatment in LTCFs. Chapter 5 investigates whether there are any relevant institutional considerations in LTCFs that sanction AP treatment for people with BPSD absent any clinical indication for the use of the medications. I argue that there are institutional considerations in LTCFs that, in a limited range of cases, can provide prima facie justification for the use of APs to protect the welfare of caregivers/co-residents. I contend, however, that, in many cases, the lesser evil defence of using APs by caregivers to cope with limited resources in LTCFs is not a robust ethical justification. In Chapter 6, I focus on situations in which the ethical considerations discussed one by one in the first five chapters conflict with one another. I argue for a dignity-prioritising framework to guide ethically justifiable decisions about the administration of APs in LTCFs and resolve conflicts between the ethical considerations. In Chapter 7, I advance the claim that, whether or not the practice in question involves conflict between the ethical considerations, using APs should always be part of a dignity-promoting plan of care in LTCFs.