Clinical ethics committee case 6: Our patient wishes to take an unlisted drug though we’re not sure of his diagnosis.

Abstract

Referral to the Clinical Ethics Committee: A 30 year-old man with suspected ADHD Case description A 30 year-old United States citizen, Mr D, who successfully studied in the USA was referred to a consultant psychiatrist in the UK two years ago. He had been given a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in the USA and tried various stimulants there before settling on Adderal (a mixed amphetamine/ methamphetamine). Upon arrival in the UK he paid for this drug out of his own pocket but when he could no longer afford it, he approached his general practitioner (GP) to ask for a prescription for it. The GP then requested a psychiatric opinion as to the drug’s suitability, and ongoing psychiatric supervision if it was felt the drug was clinically indicated. The consultant psychiatrist was not persuaded that the patient did in fact have ADHD, but agreed to continue the treatment whilst assessing him further to review the diagnosis. There was no way of obtaining third party information about Mr D from his childhood or from his treating psychiatrist in the USA. He concluded that the patient had difficulties in his personality and with forming close relationships and that the diagnosis of ADHD was obscuring the main problem. Mr D would not accept the suggested revised diagnosis of personality disorder nor would he contemplate any alternative treatment. He passed examinations for Microsoft during the next year, but remained isolated, doing maths at home and corresponding with friends in the USA. Eventually he got a job in information technology, which he had held for a month. At around the same time, the GP declined to prescribe the drug any further, questioning the psychiatric indication, and saying it was expensive, and had to be ordered from the USA. The patient went for two weeks without the drug and felt his mind was wandering, that he was distractible, that he tended to waste time, and was worried about losing his job. His medication was then recommenced. However a second opinion was sought from another psychiatrist who concluded that, although the diagnosis could not be reliably established, it could not be discounted. His apparent benefit from medication argued for its potential continuation. A further opinion was recommended from a substance misuse specialist. This consultation confirmed that Mr D evidenced no signs of dependence or misuse of the stimulants, that he understood the potential long-term consequences of stimulant use and was competent to make that treatment decision. Mr D was able to continue work and, in fact, subsequently secured a better-paid job. Although he claimed to have good relations with work colleagues, he has not formed anything like a trusting friendship and remains fairly isolated. Dilemma prompting referral to the Clinical Ethics Committee Our team has approached the CEC to discuss the case with the following dilemma in mind: The key difficulty is that the psychiatrist does not feel he has a clear diagnosis which would justify the prescription and is authorising a prescription based purely on the balance of benefit and harm as perceived by the patient. Aside from the cost-benefit calculation, the question is: who should decide what constitutes the patient’s best interests?