Patient's right to consent or refuse treatment has to be balanced with a professional duty of care writes
TONY BATES
THERE ARE few topics in the field of mental health as emotive and as divisive as electroconvulsive therapy (ECT). This is a procedure that has been used since 1930 in the treatment of severe depression, mania and, occasionally, schizophrenia.
During ECT, electrodes are put onto the patient’s head and an electric current is passed briefly through the electrodes to the brain, which causes a seizure. ECT is given under a general anaesthetic and a muscle relaxant is also given to prevent body spasms.
Research has established that ECT can work to lift some people out of a severe and disabling state of depression. Its effectiveness is attributed to its apparent ability to modulate key neurotransmitters in the brain that malfunction in states of depression and psychosis. It has been demonstrated to be a life-saving intervention for some service users with whom more conventional treatments have been tried without success.
I am thinking of a lady, aged 72 years, who had lost her husband and two years later was still lost in her grief. Her will to live had completely disappeared and every day she woke feeling that she was utterly unworthy of her life, that she did not deserve to be fed or cared for, and that she should be simply allowed to die.
An experienced bereavement counsellor had worked with her for more than a year without any success; medications had also been tried, but to no effect.
When a programme of six ECTs was recommended after a review of her condition, I admit I was slightly appalled. She was incredibly frail and this intervention seemed so “extreme”.
But when I saw her literally “awaken” after the six ECT procedures and regain her natural exuberance, I had to acknowledge the benefit of this intervention to her. She graduated from our service and remained well.
However, the administration of ECT is not always this successful or straightforward. Research studies on the cognitive effects of ECT have concluded that the memory difficulties it can produce are “limited and tolerable”.
But there is a very weak correlation between objective tests of memory and subjective reports. A systematic review of articles containing service user reports after receiving ECT found that at least one-third of them reported persistent memory loss (Rose et al, 2003).
Guidelines for the use of ECT are inconsistent across the world. The National Institute for Clinical Excellence (Nice) in the UK recommends that ECT be used as a last resort “to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening”.
However, the American Psychiatric Association (APA) states that ECT “should not be reserved for use only as a last resort . . . as this may deprive patients of an effective treatment . . . and prolong suffering”.
The Mental Health Commission (MHC) has produced, for the first time in this State, some clear procedural safeguards for the administration of ECT, and committed itself to monitoring and reporting its use.
The MHC’s Rules Governing the Use of ECT (2009) do not deal specifically with what mental conditions are considered appropriate for ECT, but they do specify that the decision to use ECT should be considered only when “alternative therapies have been considered or proven ineffective”. This guideline leaves some room for ambiguity.
A lack of clarity regarding the selection criteria for ECT may be contributing to the marked variations across Ireland in its use. In successive reports from the Mental Health Inspectorate, attention has been drawn to the fact that while the practice of ECT is waning considerably in some parts of the State, it remains very high in certain regions. For example, the Inspector for Mental Health Services noted in her 2004 report that use of ECT in the southeast was five times greater than in the south.
The MHC rules have also been challenged for their position on “patient consent”. On the one hand, they insist that if the patient is admitted voluntarily to a psychiatric hospital, ECT cannot be administered without their consent; but they do not address the issue of what happens if during the course of hospitalisation a patient deteriorates to a degree where they become incapable of giving consent.
On the other hand, the rules say that in the case of someone who is detained in hospital involuntarily, ECT can be administered without their consent (provided two consultants agree it is appropriate). This latter ruling assumes that if someone is detained involuntarily, they are de factoincapable of consenting to or validly refusing ECT.
The Nice guidelines on ECT are very clear about the issue of consent: “Valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent.
“Furthermore, consent should be enabled by the provision of full and appropriate information about the general risks and potential benefits specific to that individual . . . without pressure or coercion.”
This issue is tabled for discussion before Government in the coming months. It is vital that these discussions move beyond a polarised debate as to whether it should be condoned or condemned.
Any meaningful debate needs to involve service users and carers. Risks and benefits have to be acknowledged and balanced in any consideration of this procedure. Clarification is needed as to when and for whom ECT may potentially be appropriate in order to rectify the current situation where rates of usage vary dramatically.
While this discussion may sound clinical and the issues raised somewhat academic, it is important to keep in mind the core reason so many people feel uneasy about this procedure.
Concern about ECT is widespread because it impacts directly on the functioning of the brain and causes temporary and sometimes long-term loss of memories that are a fundamental part of our identity.
It also brings into focus an ethical conundrum where a patient’s right to consent or refuse treatment has to be balanced with a professional duty of care to save that person’s life.
Tony Bates is founder director of Headstrong – The National Centre for Youth Mental Health (www.headstrong.ie)