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Saturday, October 21, 2023

Should Trackable Pill Technologies Be Used to Facilitate Adherence Among Patients Without Insight?

Tahir Rahman
AMA J Ethics. 2019;21(4):E332-336.
doi: 10.1001/amajethics.2019.332.


Aripiprazole tablets with sensor offer a new wireless trackable form of aripiprazole that represents a clear departure from existing drug delivery systems, routes, or formulations. This tracking technology raises concerns about the ethical treatment of patients with psychosis when it could introduce unintended treatment challenges. The use of “trackable” pills and other “smart” drugs or nanodrugs assumes renewed importance given that physicians are responsible for determining patients’ decision-making capacity. Psychiatrists are uniquely positioned in society to advocate on behalf of vulnerable patients with mental health disorders. The case presented here focuses on guidance for capacity determination and informed consent for such nanodrugs.


Ethics and Nanodrug Prescribing

Clinicians often struggle with improving treatment adherence in patients with psychosis who lack insight and decision-making capacity, so trackable nanodrugs, even though not proven to improve compliance, are worth considering. At the same time, guidelines are lacking to help clinicians determine which patients are appropriate for trackable nanodrug prescribing. The introduction of an actual tracking device in a patient who suffers from delusions of an imagined tracking device, like Mr A, raises specific ethical concerns. Clinicians have widely accepted the premise that confronting delusions is countertherapeuti The introduction of trackable pill technology could similarly introduce unintended harms. Paul Appelbaum has argued that “with paranoid patients often worried about being monitored or tracked, giving them a pill that does exactly that is an odd approach to treatment. The fear of invasion of privacy might discourage some patients from being compliant with their medical care and thus foster distrust of all psychiatric services. A good therapeutic relationship (often with family, friends, or a guardian involved) is critical to the patient’s engaging in ongoing psychiatric services.

The use of trackable pill technology to improve compliance deserves further scrutiny, as continued reliance on informal, physician determinations of decision-making capacity remain a standard practice. Most patients are not yet accustomed to the idea of ingesting a trackable pill. Therefore, explanation of the intervention must be incorporated into the informed consent process, assuming the patient has decision-making capacity. Since patients may have concerns about the collected data being stored on a device, clinicians might have to answer questions regarding potential breaches of confidentiality. They will also have to contend with clinical implications of acquiring patient treatment compliance data and justifying decisions based on such information. Below is a practical guide to aid clinicians in appropriate use of this technology.