Abstract
The debate about ECT in Ireland in recent times has been vibrant and often polarised. The uniqueness of the Irish situation is that the psychiatric profession is protected by legislation whereby ECT treatment can be authorized by two consultant psychiatrists without the consent of the patient. This paper will consider if ECT is ever ethically justified, and if so, under what circumstances. The proposal is to investigate ECT from an ethical perspective with reference to the UNESCO Universal Declaration on Bioethics and Human Rights. The enquiry will begin with an historical context to the origin and development of ECT as a treatment for severe mental illness. The application of various ethical principles will be considered in conjunction with the relevant literature before arriving at a conclusion.
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Notes
Where sections of the Declaration are referred to throughout this paper, reference will be given by the relevant Article number.
The current edition is the DSM IV published in 1994 by the American Psychiatric Association. The fifth edition is due for publication in May 2013.
Although beyond the scope of this paper some analysis of the economic implications of providing ECT might be relevant to this debate. The most recent textbooks emphasize cost as a principle of treatment. In Ireland one-third of the national ECT treatment figures are carried out in one private institution. See footnote 7 for further figures.
Many of these structures around the country are different in appearance to general hospitals and are instantly recognizable as such. While the buildings themselves are of merit architecturally; in Gothic or Tudor style of cut stone, their nineteenth century history as lunatic asylums casts an unhelpful shadow and perpetuates the stigma and fear that still accompanies mental illness.
It should be noted that both these papers were received for publication on 22. 12. 09 and 26. 2. 2010 respectively so it appears likely that the authors of both papers would not have had access to the others conclusion at the time of submission. However, the latter paper bases its thesis that ECT is “the most acutely effective treatment for depression” on the UK ECT Review Group study (2003) which concluded that ECT is an effective short-term treatment for depression. That study acknowledged the lack of evidence on the possible long-term cognitive effects of ECT. The former paper—the Read and Bentall review—concluded that “Given the strong evidence of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified”.
The first data published by the Mental Health Commission on the administration of ECT in Ireland was in 2008 and collected under the Rules Governing the use of ECT for involuntary patients (November 2006) and Code of Practice Governing the use of ECT for voluntary patients (2008). Prior to these rules and code of practice there was no uniform way in which ECT was recorded in approved centres. In 2008 it appeared that there was underreporting regarding programmes of ECT administered to patients (voluntary or involuntary) that were referred from one approved centre to another for the administration of ECT. Data is processed manually and the Commission considers this as a limiting fact in what they can reasonably request. Therefore it is difficult to compare the administration of ECT in Ireland to other jurisdictions because of the lack of data.
St. Patrick's University Hospital is Ireland's largest independent mental health service provider and one of the eight independent private institutions which are approved by the Mental Health Commission in Ireland. St Patricks Hospital reported the highest number of programmes of ECT in 2009 accounting for a third (33.8 %) of the national figure. A programme can be up to 12 treatments of ECT, see Mental Health Commission (2011). As there are sixty registered approved centres for adults in Ireland the survey could not reasonably be considered a representative study, notwithstanding that this one location administered one-third of the total ECT treatments administered in the same period, see Mental Health Act (2001a, b).
A multi-disciplinary approach to informed consent tends to favour the following elements as the components of informed consent; competence, disclosure, understanding, voluntariness and consent. See Beauchamp and Childress (1983, p. 120).
The Mental Capacity and Guardianship Bill (2008) which addressed these difficulties has lapsed but the recommendations therein provide useful guidelines such as: no intervention is to take place unless it is necessary having regard to the needs and individual circumstances of the person including whether the person is likely to increase or regain capacity; any intervention must be the method of achieving the purpose of the intervention which is least restrictive of the person’s freedom. In reference to a person who does not have the capacity, account must be taken of the person’s past and present wishes where they are ascertainable. See Irish Senate debates online (2) (2011).
The Administration of Electro-convulsive Therapy in Approved Centres: Activity Report 2009, p. 2, notes that under the requirements of S59 of the Mental Health Act (2001a, b), where two psychiatrists must approve a programme of ECT without consent, there was a 9.2 % difference of opinion on the authorizing form 16s returned in 2008, treatment proceeded based on 4.5 % of these forms.
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Acknowledgments
This article owes particular thanks to the late John McCarthy of Mad Pride Ireland for his commitment in lobbing for legislative change regarding ECT in Ireland and to Senator Dan Boyle for taking up the issue and initiating the debate in the Senate. I am grateful to John and Dan for their help in clarifying the myriad of systemic difficulties surrounding this issue after the Senate debate on 23rd March 2011. Finally, to Dr. David L. Magee M.B., MRC. Psych; Psychiatrist and Psychotherapist, for his willingness to debate the issues and recommend useful source materials with exceptional hospitality.
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Stefanazzi, M. Is Electroconvulsive Therapy (ECT) Ever Ethically Justified? If so, Under What Circumstances. HEC Forum 25, 79–94 (2013). https://doi.org/10.1007/s10730-012-9182-0
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DOI: https://doi.org/10.1007/s10730-012-9182-0