5.8 Consent, information and explanations.

1. The rights of patients to give or withhold consent to E.C.T. are essentially the same as that for other patients. Patient do not have an absolute legal right to refuse E.C.T.

2. Particular care is required in regard to consent to treatment for patients under 16 years or adults with a learning disability.

3. Initial consent does not imply agreement to a course of E.C.T. and should be verified before each treatment.

4. There are particular considerations needed for consent in regard to patients detained under the Mental Health Act 1983, both generally for any treatment and specifically for E.C.T., as detailed in the Mental Health Act Code of Practice.

5. Depressive illness can influence a person's perception of events and their ability to think, ask questions and concentrate.

6. There is anecdotal evidence that some patients consent to E.C.T. because of coercion or threat by clinical staff.

7. The validity of consent by many patients is questionable in terms of the quality and sufficiency of the information and explanations given, and their perception (real or otherwise) of whether they have a choice to accept or refuse E.C.T. or alternative treatments.

8. Sufficient information and explanations, including about any significant risks and alternative treatments, must be given to a patient (using languages and formats appropriate to their individual needs) before they can make an informed decision about whether or not to give consent.

9. The quality and depth of information and explanations for patients is often poor and sometimes non-existent. Nearly all information for patients about E.C.T. is that written by professionals and does not incorporate survivors' views and experiences.

10. Many survivors report that they were never advised about any significant risks or alternative treatments before consenting to E.C.T.

11. Older people and women are less aware of their rights than younger people and men. This may be even worse for people with sensory impairments, people from black and ethnic minorities and people whose first language is not English.

12. Patients (whether or not detained under the Mental Health Act) have no legal right to be offered or to be given an independent second opinion where E.C.T. is considered as a treatment of choice.

13. Independent advocacy is rarely available or offered to patients before they are asked to consent to E.C.T. or indeed at any other time. This is especially so for older people.

14. Memory loss due to E.C.T. may affect the patient's recollection of information given beforehand. It is advised that this should be repeated at an appropriate time soon after the treatment has been given, at the end of a course of treatment and when they are symptomatically improved.

15. About 2 000 people per year in England and Wales are given E.C.T. without or against their consent. Many are considered not able to give or withhold their consent. These are people who are seriously ill and treated under the Mental Health Act following an opinion given by a second opinion appointed doctor. More than half are women over 50 years old. Compulsory treatment is twice as common for people diagnosed with schizophrenia than for those diagnosed with depression.

5.9 The monitoring of E.C.T. and its administration.

1. The Royal College of Psychiatrists has a role to inspect the facilities available for the administration of E.C.T. and ask searching questions about the training of junior doctors administering the treatment. If serious shortcomings are detected and are not rectified, the Royal College can withdraw educational approval from the N.H.S. trust or other provider in question.

2. The Royal College of Psychiatrists stated in 1997 that failure to provide E.C.T. in accordance with its guidelines may result in the withdrawal of approved training status of the N.H.S. trust or other provider concerned.

3. The Mental Health Act Commission has a responsibility to ensure that patients detained under the Mental Health Act 1983 meets the standards within the Act and the Mental Health Act Code of Practice. The Commission is considering ways in which to ensure that the recommendations in The E.C.T. Handbook of the Royal College of Psychiatrists are adopted.

4. While there has been considerable work done in Scotland to audit the use and administration of E.C.T. in Scotland (by the Clinical Resource and Audit Group for the Scottish Office 26 27), there is no comparable work in England, Wales or Northern Ireland.