Although electroconvulsive therapy is widely considered a controversial therapy, it has survived for 70 years and usage has even increased. In Scandinavian countries, ECT is given on an equal footing with drugs and psychotherapy to psychiatric patients, while in the United States and some other European countries, there are social impediments to its use. As a consequence, patient suffering is prolonged, the cost of psychiatric care is increased and avoidable tragic deaths occur.
Reasons for Controversy
Three reasons are given for the aversion: 1) ECT is considered old-fashioned and politically incorrect; 2) it is forced on the patient; and 3) the memory disturbances are so severe and persistent that no rational human being would undergo this procedure, no matter how well-intended.
Electroconvulsive therapy is the oldest psychiatric treatment now in use, but modern practice is very different from that of early years. The technique of stimulation has been refined, and superficial anesthesia with muscular relaxation and oxygenation are in wide use. These changes contribute to a more lenient procedure.
The popular perception of ECT as forced upon an unwilling patient as pictured in the film One Flew Over the Cuckoo's Nest is no longer a feature of modern treatment. Treatments are now given with patients' individual consent. Only when patients are incompetent by reason of a severe psychiatric disturbance is ECT proposed without patients' individual consent. At such times, the laws of the state for the application of life-saving procedures may be invoked and the patient treated.
Immediate confusion accompanies ECT, but it is not persistent. Loss of personal memories is often described but is persistent in only a few patients. In the overall picture of the thousands of patients treated with ECT each year, the memory effects are a nuisance rather than an unassailable obstacle to its use.
An ethical analysis of our practice may lead us out of the present impasse. An upsurge in interest in the application of ethical principles to medical care followed World War II, leading to the declarations and codes of the United Nations and scientific and professional communities. Four principles of health care--beneficence (doing good), non-maleficence (not doing harm), respect for personal autonomy and justice (equality of opportunity)--are widely accepted since their proposal by the philosophers at Georgetown University (Beauchamp and Childress, 2001). In practice, all principles are to be respected in all instances. When such is not possible, an analysis of the alternatives and their consequences in both the short and long term is made, and the least harmful alternative is accepted.
The Principles of Ethics
Many randomized clinical trials crystallize the indications for ECT where its efficacy is unsurpassed by other treatments. The effective indications are major depression, especially its psychotic form (Petrides et al., 2001; UK ECT Review Group, 2003), and catatonia, especially its malignant form (Fink and Taylor, 2003). Electroconvulsive therapy also relieves severe mania (Mukherjee et al., 1994) and some forms of schizophrenia (Fink and Sackeim, 1996). The risk of suicide decreases after ECT (Prudic and Sackeim, 1999). In these conditions, ECT complies with the principle of beneficence.
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