The Ethics of Electroconvulsive Therapy (ECT)

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OP-ED

The Ethics of Electroconvulsive Therapy (ECT)

by Loren R. Mosher MD and David Cohen, PhD

 

" First, do no harm " is the healing profession's best-known ethical precept

because in the actual practice of medicine doctors may unwittingly do harm [1,

2]. However, is it ethical for physicians to give harmful treatments knowingly?

 

Such a course of action might be considered proper if no alternative treatments

are available, if the treatment is not only effective but likely to be

life-saving, if no coercion is involved, and if true informed consent is

obtained for the procedure. Unfortunately, ECT meets none of these conditions.

In fact, to the horror of truly ethical physicians, there are several recent

instances in the United States of the involuntary administration of ECT, over

the expressed repeated wishes of the patient [3].

 

The issue is rather simple. The defining feature of ECT (modified or unmodified,

bilateral or unilateral)—that which distinguishes it from any other treatment

and is indicated in its name—consists in the electrical induction of a

generalized seizure. This frequently leads to an acute organic brain syndrome

characterized by amnesia, apathy, and euphoria [4].

 

Administering ECT to depressed or severely depressed patients shows an

" effectiveness " (evaluated by rating scales including many items that would

respond to any nonspecific sedative intervention) lasting no more than 4 to 6

weeks [5]. Within 6 months of receiving ECT, 84 percent of patients relapse [6].

ECT is not life saving: no decrease in suicide results from its use [7], and

some increase in suicide may follow [8].

 

ECT is not safe: it produces varying amounts of memory loss and other adverse

effects on cognition in nearly everyone who receives it, typically lasting weeks

or months after the last treatment (as well as many other adverse consequences,

from ocular effects to postictal psychosis).

 

ECT is not necessary: numerous alternative, less harmful interventions—that work

with the patient’s consciousness, strengths, and social network—are available

[9]. ECT is too often given as the treatment of next resort (not, as some of its

supporters would insist, last resort) when drug treatment has seemingly failed,

as drug treatment often does [10], especially for the modal ECT patient today,

an elderly woman. Less harmful options are not considered for reasons having

very little to do with the patient’s " condition " and very much to do with

psychiatrists’ increasing unfamiliarity with nonbiological interventions,

professionals’ frustration that patients are not recovering " quickly enough, "

and some institutions’ reliance on the procedure as a revenue source.

 

Needed: A Study of Consent Forms

Finally, we suggest that true informed consent is almost never obtained, because

practically no one would sign a truthful consent form for ECT (if any exists)

unless coerced—grossly or subtly—to do so. Defenders of ECT might claim that

informed consent is scrupulously obtained, but it is at present impossible to

evaluate this claim properly. Indeed, despite the importance of divulging the

risks of this most controversial treatment in psychiatry, no study describing

actual ECT consent forms used in different institutions (even a small sample of

2 forms) has ever been published.

 

Unless a harmful treatment is life-saving, unavoidable, uncoerced, and its risks

are fully divulged, knowingly administering it is unethical.

 

Here are the words of 3 individuals who received ECT and described publicly what

they view as ethical violations involved in their experience of this procedure.

Leonard Roy Frank said, " I have concluded that ECT is a brutal, dehumanizing,

memory-destroying, intelligence-lowering, brain-damaging, brainwashing,

life-threatening technique. ECT robs people of their memories, their

personality, and their lives. It crushes their spirit. Put simply, electroshock

is a method for gutting the brain in order to control and punish people who fall

or step out of line and intimidate others who are on the verge of doing so "

[11].

 

Thomas Hsu wrote, " My ECT’s were in 1998. Overall I feel violated and very

emphatically wish I had never consented to the treatments and would caution

others. While I was not coerced into receiving the ‘treatment,’ I do feel I was

misled and at the very least not suitably informed about the potential negative

effects and lack of efficacy in treating depression. I would never consent to

receiving ECT again " [12].

 

Jackie Mishra said, " One moment that I remember clearly from my hospital stay

for ECT in 1996 is the horror I felt when after one of my treatments I couldn’t

remember how old my children were. Not only did the ECT not work for me, but my

suffering was compounded when I realized that approximately 2 years of my life

prior to the ECT had been erased. My retention of new information is also

severely impaired. If anyone had told me that this could happen, even a remote

chance, I never would have consented to ECT. I would much rather have lost a

limb or 2 than to have lost my memory—my ‘self’ " [13].

 

References

1. Sharpe VA, Faden AI. Medical Harm. Cambridge, England: Cambridge University

Press: Cambridge, United Kingdom; 1998.

2. Biller J. Iatrogenic Neurology. Butterworth-Heinemann Medical: Philadelphia;

1998.

3. See MindFreedom Support Coalition International’s Web site. Available at:

http://www.mindfreedom.org/mindfreedom/ paul.shtml. Accessed September 26, 2003.

See also ECT.org. Available at: http://www.ect.org. Accessed September 26, 2003.

4. Cohen D. Electroconvulsive treatment, neurology, and psychiatry. Ethical

Human Sciences & Services. 2001;3:127-129.

5. Banken R. The use of electroconvulsive therapy in Québec. Agence d’évaluation

des technologies et modes d’intervention en santé: Montreal; 2003. Available at:

http://www.aetmis.gouv.qc.ca/fr/publications/scientifiques/aetmis_x/2002_05_en.p\

df. Accessed September 26, 2003.

6. Sackeim HA, Haskett RF, Mulsant BH, et al. Continuation pharmacotherapy in

the prevention of relapse following electroconvulsive therapy: a randomized

controlled trial. JAMA. 2001;285:1299-1307.

7. Black D, Winokur G, Mohandoss E, et al. Does treatment influence mortality in

depressives? A follow-up of 1076 patients with major affective disorder. Ann

Clin Psychiatry. 1989;1:165-173.

8. Brodarty H, Hickie J, Mason C, et al. A prospective follow-up study of ECT

outcome in older depressed patients. J Affect Disord. 2000;60:101-111.

9. Kirsch I, Moore T, Scoboria A, Nicholls SS. The emperor’s new drugs: an

analysis of antidepressant medication data submitted to the US Food and Drug

Administration. Prevention & Treatment. 2002;5. Available at:

http://www.journals.apa.org/prevention/volume5/pre0050023a.html. Accessed

September 26, 2003.

10. As only one example of several sources describing practical brief approaches

with " chronic, " " resistant, " and " difficult " patients, see: Miller SD, Hubble M,

Duncan BL. Handbook of Solution-focused Brief Therapy. San Francisco:

Jossey-Bass;1996.

11. MindFreedom Journal. Winter 2002-2003;45:51.

12. Hsu T. Quoted by: Support Coalition International Response to the March 1998

Electroconvulsive Therapy Background Paper by Research-able Inc, Prepared for

the US Dept. of Health and Human Services. MindFreedom Support Coalition

International. Eugene, Oregon;1999:6.

http://www.mindfreedom.org/mindfreedom/shock/shock_response.shtml

13. Mishra J. Quoted by: Support Coalition International Response to

Electroconvulsive Therapy Background Paper. Research-able Inc, Prepared for the

US Dept. of Health and Human Services. March 1998. MindFreedom Support Coalition

International: Eugene, Oregon; 1999:8-9.

http://www.mindfreedom.org/mindfreedom/shock/shock_response.shtml

 

Loren Mosher, MD, is a psychiatrist and director of a mental health alternative

consulting firm, Soteria Associates. He is clinical professor of psychiatry at

the University of California in San Diego. He was formerly chief of the Center

for Studies of Schizophrenia at the National Institute of Mental Health and

served as first editor-in-chief of Schizophrenia Bulletin.

 

David Cohen, PhD, is a professor of social work at Florida International

University in Miami and editor-in-chief of Ethical Human Sciences and Services.

He has published widely on socio-cultural uses and iatrogenic effects of

psychiatric drugs. He received the 2003 Eliot Freidson Award from the American

Sociological Association for outstanding publication in medical sociology.

 

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