Electroconvulsive Therapy Background Paper - Opponents of ECT

Written by RESEARCH-ABLE, INC.

Professional organizations such as the American Psychiatric Association have proposed guidelines (37) to educate patients and their families about informed patient consent to ECT, and a substantial number of States have passed laws regulating the practice of ECT. Still, there may remain instances in which physicians and facilities comply neither with the letter nor the spirit of the laws, nor with professional guidelines. When noncompliance occurs, it increases public distress about the use of ECT.

Opponents of ECT

While some opponents of ECT seek a total prohibition of its use, others focus on situations that may involve less than fully informed, fully voluntary consent.

David Oaks, editor of Dendron News for the Support Coalition International, emphasizes the importance of informed consent, "Our position on TEC as a treatment option is pro-choice - if the patient wants it, that's his or her decision, but they must understand there is no proof of sustained efficacy." (38)

Peter Breggin, a psychiatrist in private practice, strongly opposes the use of ECT. He characterizes the effects of ECT as "brain injury." (39)

Leonard R. Frank, a writer often cited by ECT opponents, received combined insulin coma-electroshock in early 1962. He charges, "... ECT as routinely used today is as least as harmful/...[[[;overall as it was before changes in the technology of ECT administration were instituted." (40)

Linda Andre, Director of the Consumer Rights Advocacy Group, the Committee for Truth in Psychiatry, states that all ECT involevs involuntary treatment. Her organization, whose 500 members have experienced ECT, asserts that all patients receiving ECT are under some form of coercion. They maintain that ECT causes permanent head injury (brain damage). Recently, Andre stated, "Forced shock is the most profound violation of the human spirit imaginable. The use of force is a second injury superimposed upon the damage of the shock itself." (41)

The National Association for Rights Protection and Advocacy is a non-profit organization composed of mental disability program administrators, paralegals, professionals, lay advocates, and consumers of mental health services. Its director, Bill Johnson, believes most members of the organization are opposed to the use of ECT and involuntary treatment. He stated, "Our members are against forced treatment laws. People should make their own choices, they have the right to choose. We try to empower people who have been labeled." (42)

Proponents of ECT and Informed Consent

While no organizations have been established which are dedicated exclusively to retaining ECT as a treatment choice, representatives of the organizations identified below have expressed support for the position that ECT remain an option.

The National Depressive and Manic-Depressive Association (NDMDA), an organization of persons who have experienced depressive or manic-depressive illness and their families and friends, "strongly supports the appropriate use of electroconvulsive therapy." (43)

The National Alliance for the Mentally Ill (NAMI), a grassroots organization composed of families and friends of people with mental illness and people recovering from mental illness, does not endorse any particular treatment or services. However, it recognizes the efficacy of ECT and of medications such as Clozopine and Prozac, and is opposed to measures intended to limit the availability of recognized effective treatments provided by appropriately trained and licensed practitioners. (44)

The National Mental Health Association, a non-profit organization of citizens concerned about the promotion of mental health and the prevention, treatment, and care of mental illness, supports the use of ECT in life-threatening situations (suicide), and for the treatment of severe affective disorders that do not respond to other treatments. (45)

The National Association of Protection and Advocacy Systems (NAPAS), the membership organization of State protection and advocacy agencies, has Federal authority and funds to investigate abuse and neglect of persons with mental illness. While NAPAS has not adopted a formal position on ECT, it strongly supports the importance of full and informed patient consent. (46)

IV. LEGAL PERSPECTIVES AND STATE REGULATION

Forty-three States have enacted legislation that in some way regulates the use of ECT. (47) Most of the State statutes directly address the administration of ECT; others regulate psychiatric treatment generally without specific reference to ECT. The most common approach, adopted in 20 States, requires either informed patient consent before the administration of ECT, or in the absence of informed consent, court determination of patient incompetency. There is substantial variation among requirements from one State to another.

Debate continues about the need to protect patients' rights and the use of effective, albeit invasive, treatments such as ECT. (48) The argument is made that overly protective regulation can result in urgently needed treatment being substantially delayed. Most States regulate the administration of ECT, and require a judicial determination of incompetency before involuntary administration of ECT can begin. (49)

The issue of informed consent has been a significant focus of litigation, legislation, and regulation in recent years. Three key questions have been raised:

1. Does the individual have the capacity to form a reasonable judgment? (For example, to what extent is a person's capacity to give informed consent to ECT treatment compromised, or even eliminated, by the condition for which the ECT is being recommended?);
2. Was consent obtained under circumstances free of coercion or threat? (For example, did the patient consent freely or did the patient feel threatened with court proceedings or isolation? Under what circumstances does the physician's "opinion" unduly influence the informed voluntary consent of the patient?); and
3. Was sufficient information about the risk and availability of less invasive therapies provided to the patient as part of the education and consent process? (This last question is particularly complex involving, among other concerns, the uncertainty regarding the precise nature and duration of short and long term memory loss associated with ECT).