Balancing Medical Ethics to Consider Involuntary Administration of Electroconvulsive Therapy.

Abstract

E lectroconvulsive therapy (ECT) has been used as a treatment modality for psychotic disorders from the times before the advent of pharmacological agents. However, introduction of antipsychotic medications in the 1950s and thereafter has led to a decline in the use of ECT. This decline can be attributed to the convenience of administration and better acceptance of pharmacotherapy. Despite the availability of a basket of pharmacological agents, a large proportion of individuals with psychotic disorders do not achieve significant treatment response. Electroconvulsive therapy is especially beneficial for suicidality and catatonic syndromes, where the need for acute intervention and rapid improvement in symptoms is crucial to prevent dismal outcomes. Despite the robust evidence for the efficacy and safety of ECT in serious mental illnesses like schizophrenia, bipolar disorder, and psychotic depression, some parts of the general public continue to harbor a strong negative perception of ECT. These negative views have been reinforced by the depiction of ECT in films andmedia accounts from self-selected subjects. On the other hand, most patients who have undergone ECT found treatment effective and viewed this modality positively. Partly due to societal stigma, informed consent is an important subject of debate in ECT practice. This is specifically relevant to individuals with serious mental illnesses, where the ability to consent is limited due to poor insight or impaired cognitive functions. In these cases, where principle of autonomy cannot solely guide the treatment, psychiatrists are expected to consider principles of beneficence and nonmaleficence by offering safe and effective treatments. The consent process in individuals who lack capacity or refuse consent is guided by state laws in the United States, ranging from allowing family members to consent to court-ordered treatment. How do individuals receiving ECTwithout or against their consent react once they can acknowledge improvement in their symptoms with ECT? Do they reject their prescribed treatment, or do they agree with the generally favorable view of ECT reported by individuals who receive consensual ECT? Is the risk-benefit ratio of involuntary (without individual consent) treatments similar to that of voluntary treatments (with individual consent). In this context, surveys by Takamiya et al and Besse et al, published in this issue of the journal, make important contribution to the field of ECT. Takamiya et al compared the attitudes toward ECT among participants who received treatments involuntarily and those who