Is Involuntary Electroconvulsive Therapy Ever Appropriate?

For many, electroconvulsive therapy (ECT) –- more colloquially, “shock therapy” –- conjures up negative images of science-fiction quackery. But ECT is currently more common than you might think, including its use on patients who can’t or won’t provide consent.

The Irish parliament and the United States’ Food and Drug Administration (FDA) are both in the process of reevaluating existing regulations regarding ECT. They join other countries that have in recent years taken a hard look at the practice. Nonetheless, standards for the administration of involuntary ECT vary significantly. Setting aside all of the cultural baggage, ECT posits several difficult questions regarding human rights and psychiatry.

Many psychiatrists consider ECT a safe, effective treatment for serious mental illness, particularly depression. They consider it even more appropriate where other treatment methods have failed (a recent Newsweek cover story highlighted growing doubts over the effectiveness of existing antidepressant medication). Proponents of ECT also argue that its risks ought to be measured against the harsh side-effects of many drugs.

But even amongst those mental health professionals that consider ECT a legitimate treatment (and there are some that don’t), there is much uncertainty. It’s not clear how ECT actually works and there is controversy over the procedure’s long-term side-effects.

The debate ultimately comes down to whether we ought to defer to individuals’ rights or medical practitioners. Unfortunately, psychiatry and human rights have a checkered past. This is not entirely psychiatry’s fault; many political actors have been more than eager to use the field as a tool to discredit rivals or justify oppression. Of course, other times psychiatrists have been simply overzealous and wrong.

Even if one defers to supporters’ assessment of ECT, forcible treatment jeopardizes a broad array of rights ranging from civil protections to personal autonomy and freedom from restraint. A 1991 UN General Assembly Resolution outlines recommended procedural safeguards for involuntary commitment. The rights implications of involuntary ECT are even more problematic if one doubts its therapeutic value. Accordingly, a 1994 recommendation from the Council of Europe states that ECT should occur only with informed consent. The World Health Organization (WHO) endorsed the same position in 2005.

However, a rights-based vision grounded in patient autonomy is problematic in the domain of serious mental illness. How can a doctor obtain meaningful informed consent from patients that might be catatonic, severely depressed, or manic? A consent form? The Council of Europe and WHO recommendations go much further by calling for independent review of informed consent prior to the administration of ECT.

Finally, it is important to remember the medical dimensions of the problem. Candidates for ECT often have serious psychiatric problems. Brendan Kelly, a psychiatrist at University College Dublin, has argued that the complete denial of involuntary ECT for mentally incapacitated patients would constitute “simple discrimination on the basis of capacity” and a possible deprivation of their rights to life and medical care. There is a point where focusing on individual autonomy undermines the well-being of a patient. However, there are too many uncertainties surrounding ECT to conclusively determine that restricting or prohibiting its involuntary use falls within that category. A profound respect for individual integrity and dignity demands the utmost reluctance before forcibly administering treatment on patients.

Photo credit: dierk schaefer