This is a response to Dr Charlotte Rosalind Blease's paper ‘Electroconvulsive Therapy (ECT), the Placebo Effect and Informed Consent’, written by Julie K. Hersh who has had ECT. Hersh argues that placebo effect is impossible to prove without endangering the lives of participants in the study. In addition, informing potential ECT patients of unproven placebo effect could discourage patients from using a procedure that from experience has proven highly effective.

The debate about ECT in Ireland in recent times has been vibrant and often polarised. The uniqueness of the Irish situation is that the psychiatric profession is protected by legislation whereby ECT treatment can be authorized by two consultant psychiatrists without the consent of the patient. This paper will consider if ECT is ever ethically justified, and if so, under what circumstances. The proposal is to investigate ECT from an ethical perspective with reference to the UNESCO Universal Declaration on Bioethics (...) and Human Rights. The enquiry will begin with an historical context to the origin and development of ECT as a treatment for severe mental illness. The application of various ethical principles will be considered in conjunction with the relevant literature before arriving at a conclusion. (shrink)

Long-standing psychiatric practice confirms the pervasive use of pharmacological therapies for treating severe mental disorders. In many circumstances, drugs constitute the best allies of psychotherapeutic interventions. A robust scientific literature is oriented on finding the best strategies to improve therapeutic efficacy through different modes and timing of combined interventions. Nevertheless, we are far from triumphal therapeutic success. Despite the advances made by neuropsychiatry, this medical discipline remains lacking in terms of diagnostic and prognostic capabilities when compared to other branches of (...) medicine. An ethical principle remains as the guidance of therapeutic interventions: improving the quality of life for patients. Unfortunately, psychotropic drugs and psychotherapies do not always result in an efficient remission of symptoms. In this paper I corroborate the idea that therapists should provide drug-resistant patients with every effective and available treatment, even if some of such interventions could be invasive, like Electroconvulsive Therapy (ECT). ECT carries upon its shoulders a long and dramatic history that should be better investigated to provide new insights. In fact, ECT has attracted renewed interest in recent years. This is due to the fact that antidepressant drugs in younger patients show often scarce effectiveness and unpleasant side-effects. Moreover, I show that, thanks to modern advances, ECT may work as a successful form of treatment for specific and rare cases, such as severe depression (with suicide attempts) and catatonia. (shrink)

Major depressive disorder is not only the most widespread mental disorder in the world, it is a disorder on the rise. In cases of particularly severe forms of depression, when all other treatment options have failed, the use of electroconvulsive therapy (ECT) is a recommended treatment option for patients. ECT has been in use in psychiatric practice for over 70 years and is now undergoing something of a restricted renaissance following a sharp decline in its use in the (...) 1970s. Despite its success in treating severe depression there is continued debate as to the effectiveness of ECT: in some studies, it is argued that ECT is marginally more effective than sham ECT. In addition, there is still no clear explanation of how ECT works; among the range of hypotheses proposed it is claimed that ECT may work by harnessing placebo effects. In light of the uncertainties over the mechanism of action of ECT and given the risk of serious side effects that ECT may produce, I contend that the process of informed consent must include comprehensive accounts of these uncertainties. I examine the possible consequences of providing adequate information to potential ECT patients, including the consideration that ECT may still prove to be effective even if physicians are open about the possibility of it working as a placebo. I conclude that if we value patient autonomy as well as the professional reputation of medical practitioners, a fuller description of ECT must be provided to patients and their carers. (shrink)

The administration of electroconvulsive therapy (ECT) to children and adolescents remains an unresolved area of clinical debate for nurses. Thus, some nurses have refused to participate in the treatment of minors with ECT, invoking codes of conduct to justify their actions. Other nurses have supported the use of ECT with children and adolescents, via provision of technical assistance to medical colleagues. A cross-national comparison of ethical codes of conduct has confirmed that nurses should take decisive action in the (...) clinical arena when the needs or rights of vulnerable minors are compromised. The provision of clinical guidelines is suggested as one method to enshrine the rights of at-risk children and adolescents. (shrink)

After reaching the verge of obsolescence, electroconvulsive therapy (ECT) is once again on the increase. There remains, however, no sound theoretical basis for its use. By 1948 at least 50 different theories had been proposed to account for the workings of ECT. Today there are numerous more. Further, there is no good evidence for its therapeutic effectiveness. Although some studies show what are claimed to be positive results, others show significant amount of relapse, even with severe depression (the (...) disorder against which ECT is supposed to be most effective), while even other studies show ECT to have little more effect than a placebo. Finally, there is much evidence for ECTs damaging effects, particularly to cognitive functioning like memory, general intelligence level, and perceptual abilities, and quite possibly to brain functioning. Some studies even suggest that the alleged therapeutic effects of ECT are essentially the effects of organic brain damage. The question, then, is why, despite these problems, does ECT continue to be used? ECTs salient features suggest an answer here. These are the features of dehumanization, power, control, punishment, and others, all of which can be traced back to the fear of deviant psychotic behavior. (shrink)

Electroacupuncture (EA) and electroconvulsive therapy (ECT) are often used in the management of schizophrenia. This study sought to determine whether additional EA and ECT could augment antipsychotic response and reduce related side effects. In this retrospective controlled study, 287 hospitalized schizophrenic patients who received antipsychotics (controls, n = 50) alone or combined with EA (n = 101), ECT (n = 55) or both (EA+ECT, n = 81) were identified. EA and ECT were conducted for 5 and 3 sessions (...) per week, respectively, with a maximum of 12 sessions for ECT during hospitalization. The Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) were used to assess the severity of psychotic symptoms. Clinical response on SAPS and SANS, weight gain, and adverse events were compared. Survival analysis revealed that the ECT and EA+ECT groups had markedly greater clinical response rate than controls on SAPS [72.7% and 90.1% vs. 64.0%; relative risk (RR), 1.974 and 2.628, respectively, P ≤ 0.004] and on SANS (67.3% and 70.4% vs. 42.0%; RR, 1.951 and 2.009, respectively, P ≤ 0.015). A significantly greater response rate on SANS than controls was also observed in the EA group (64.4% versus 42.0%; RR = 1.938, P = 0.008). EA-containing regimens remarkably reduced weight gain and incidences of headache, insomnia, dry mouth, and electrocardiographic abnormalities. These results suggest that EA and ECT can serve as additional treatment for enhancing antipsychotic response and reduce the side effects in hospitalized patients with schizophrenia. (shrink)

Although the use of ECT has declined dramatically from its inception, this decrease has recently shown signs of leveling out because of ECT's powerful therapeutic effect in severely ill depressed individuals who either do not respond to pharmacologic alternatives or are too ill to tolerate a relatively lengthy drug trial. Notwithstanding its therapeutic benefits, ECT has also remained a controversial treatment modality, particularly in the eye of the public. Given the unsavory qualities associated with the word “electroconvulsive,” claims of (...) possible, probable, or even certain brain damage with ECT have easily found listeners. A careful, nonselective assessment of data covering the areas of pathology, radiology, electrophysiology, biochemistry, and neuropsychology leads both to certain conclusions and to certain unanswered questions. ECT is not the devastating purveyor of wholesale brain damage that some of its detractors claim. For the typical individual receiving ECT, no detectable correlates of irreversible brain damage appear to occur. Still, there remains the possibility that either subtle, objectively undetectable persistent deficits, particularly in the area of autobiographic memory function, occur, or that a rarely occurring syndrome of more pervasive persistent deficits related to ECT use may be present. Clearly, more research directed toward answering these questions needs to be carried out so that the role of ECT can be more rigorously defined. While such research is pending, however, we cannot expect that the conditions that predispose to clinical referrals for ECT will disappear. Given the misery, anguish, and risk of death by suicide, starvation, or debilitation associated with severe depressive illness, for example, it still appears that ECT, at least for the present, must continue to be available. (shrink)

I thank Julie Hersh for her thoughtful and valuable comments on the use of electroconvulsive therapy .1 Discussions with those who have experience of treatments is of the utmost importance when debating issues such as informed consent. I am therefore very pleased to be given this opportunity to respond. Hersh offers three main criticisms of my paper but I hope to show that the tenets of the paper are not undermined by her commentary.Hersh's first criticism stems from her (...) personal experience: she claims that, ‘The results of ECT for me were miraculous’. She argues that ECT ‘works’ and we have ‘70 years of remarkably positive experience’ to support this fact. In response, I agree that there are certainly patients who believe that ECT has been a highly effective intervention: but equally, there are others who have experienced intolerable side effects as a result.2 ECT is a controversial treatment precisely because of the serious long-term risk of memory loss.3 ,4 If we are to strive for the best healthcare possible, we cannot base our conclusions merely on positive cases: we need to consider all cases . Thus, I reject her conclusion that ECT is ‘remarkably positive’ for all patients: studies do not unequivocally support Hersh's fortunate experiences. In addition, I must also challenge the assumption that ECT ‘works’. Counterintuitive as …. (shrink)

Sufficient doubt surrounds electroconvulsive therapy (ECT) to warrant nurses opting out of its administration and/or advising patients that it may be only one of a range of treatments open to them. In the latter respect, this discussion touches on aspects of the concept of advocacy. Relationships with the medical profession are also considered, as is the indefatigable attention given to issues of 'professional status' by nurses; this preoccupation facilitates an avoidance of therapeutic/advocacy issues.

As neuroethics continues to grow as an established discipline, it has been charged with not being sufficiently sensitive to the way in which the identification, conceptualization, and management of the ethical issues raised by neuroscience and its applications are shaped by local systems of knowledge and structures. Recently there have been calls for explicit recognition of the role played by local cultural contexts and for the development of cross‐cultural methodologies that can facilitate meaningful cultural engagement. In this article, we attempt (...) to fill this perceived gap by providing a culturally situated analysis of the practice of electroconvulsive therapy (ECT) in Argentina. ECT was introduced as a psychiatric treatment in Argentina in the 1930s but it is largely underutilized. While the use of ECT remains low in several countries, what makes the Argentinian case interesting is that the executive branch of government has taken a stance regarding both the scientific and moral appropriateness of ECT, recommending its prohibition. Here, we begin with a recent controversy over the use of ECT in Argentina and explain the legal recommendation to ban its application. Next, we offer an overview of some of the salient aspect of the international and local discussions on ECT. We argue that the governmental recommendation to ban the procedure should be rethought. While acknowledging the role that contexts and local conditions play in shaping the identification and assessment of the relevant ethical issues, we caution against using contextual and cultural considerations to avoid a necessary ethical debate on controversial issues. (shrink)

Introduction: Electroconvulsive therapy is a commonly used brain stimulation treatment for treatment-resistant or severe depression. This study was planned to find the effects of ECT on brain connectivity by conducting a systematic review and coordinate-based meta-analysis of the studies performing resting state fMRI in patients with depression receiving ECT.Methods: We systematically searched the databases published up to July 31, 2020, for studies in patients having depression that compared resting-state functional connectivity before and after a course of pulse wave (...) ECT. Meta-analysis was performed using the activation likelihood estimation method after extracting details about coordinates, voxel size, and method for correction of multiple comparisons corresponding to the significant clusters and the respective rsFC analysis measure with its method of extraction.Results: Among 41 articles selected for full-text review, 31 articles were included in the systematic review. Among them, 13 articles were included in the meta-analysis, and a total of 73 foci of 21 experiments were examined using activation likelihood estimation in 10 sets. Using the cluster-level interference method, one voxel-wise analysis with the measure of amplitude of low frequency fluctuations and one seed-voxel analysis with the right hippocampus showed a significant reduction in the left cingulate gyrus and a significant increase in the right hippocampus with the right parahippocampal gyrus, respectively. Another analysis with the studies implementing network-wise resting state functional connectivity showed a significant increase in bilateral posterior cingulate cortex. There was considerable variability as well as a few key deficits in the preprocessing and analysis of the neuroimages and the reporting of results in the included studies. Due to lesser studies, we could not do further analysis to address the neuroimaging variability and subject-related differences.Conclusion: The brain regions noted in this meta-analysis are reasonably specific and distinguished, and they had significant changes in resting state functional connectivity after a course of ECT for depression. More studies with better neuroimaging standards should be conducted in the future to confirm these results in different subgroups of depression and with varied aspects of ECT. (shrink)

Background: Electroconvulsive therapy is one of the most effective treatments for major depressive disorder. Recently, there has been increasing attention to evaluate the effect of ECT on resting-state functional magnetic resonance imaging. This study aims to compare rs-fMRI of depressive disorder patients with healthy participants, investigate whether pre-ECT dynamic functional network connectivity network estimated from patients rs-fMRI is associated with an eventual ECT outcome, and explore the effect of ECT on brain network states.Method: Resting-state functional magnetic resonance imaging (...) data were collected from 119 patients with depression or depressive disorder, and 61 healthy participants, with an age mean of 52.25 years old. The pre-ECT and post-ECT Hamilton Depression Rating Scale were 25.59 ± 6.14 and 11.48 ± 9.07, respectively. Twenty-four independent components from default mode and cognitive control network were extracted, using group-independent component analysis from pre-ECT and post-ECT rs-fMRI. Then, the sliding window approach was used to estimate the pre-and post-ECT dFNC of each subject. Next, k-means clustering was separately applied to pre-ECT dFNC and post-ECT dFNC to assess three distinct states from each participant. We calculated the amount of time each subject spends in each state, which is called “occupancy rate” or OCR. Next, we compared OCR values between HC and DEP participants. We also calculated the partial correlation between pre-ECT OCRs and HDRS change while controlling for age, gender, and site. Finally, we evaluated the effectiveness of ECT by comparing pre- and post-ECT OCR of DEP and HC participants.Results: The main findings include depressive disorder patients had significantly lower OCR values than the HC group in state 2, where connectivity between cognitive control network and default mode network was relatively higher than other states, Pre-ECT OCR of state, with more negative connectivity between CCN and DMN components, is linked with the HDRS changes. This means that those DEP patients who spent less time in this state showed more HDRS change, and The post-ECT OCR analysis suggested that ECT increased the amount of time DEP patients spent in state 2.Conclusion: Our finding suggests that dynamic functional network connectivity features, estimated from CCN and DMN, show promise as a predictive biomarker of the ECT outcome of DEP patients. Also, this study identifies a possible underlying mechanism associated with the ECT effect on DEP patients. (shrink)

Even more than for other treatments, great importance must be given to informed consent in the case of electroconvulsive therapy. In a percentage of cases, the symbolic connotation of the treatment, even if mostly and intrinsically negative, may actually be a determining factor in the patient’s motives for giving consent. On an ethical and medicolegal level, the most critical point is that concerning consent to the treatment by a psychotic subject with a severely compromised ability to comprehend the (...) nature and objective of the proposed therapy, but who nonetheless expresses his consent, for reasons derived from delusional thoughts. In fact, this situation necessarily brings to light the contradiction between an explicit expression of consent, a necessary formality for the commencement of therapy, and the validity of this consent, which may be severely compromised due to the patient’s inability to comprehend reality and therefore to accept the proposal of treatment, which is intrinsic to this reality. With the use of an electric current, the symbolic experience associated with anaesthesia, and the connection to convulsions, ECT enters the collective consciousness. In relation to this, ECT is symbolic of these three factors and hooks on to the thoughts, fears, feelings and expectations of delusional patients. These are often exemplified in the violent intervention of the persecutor in the patient with schizophrenia, the expected punishment for the ’error’ committed for which the depressed patient blames himself and the social repression of the maniacal patient’s affirmation of his inflated self-esteem. (shrink)

Despite extensive evidence for its effectiveness, ECT remains the subject of fierce opposition from those contesting its benefits and claiming extreme harms. Alongside some reflections on my experiences of this treatment, I examine the case against ECT, and find that it appears to rest primarily on unsubstantiated claims about major ethical violations, rather than clinical factors such as effectiveness and risk.

Obtaining informed consent before providing treatment is a routine part of modern clinical practice. For some treatments, however, there may be disagreement over the requirements for ‘informed’ consent. Electroconvulsive therapy (ECT) is one such example. Blease argues that patients ‘should surely be privy to the matters of fact that: (1) there is continued controversy over the effectiveness of ECT; (2) there is orthodox scientific consensus that there is currently _no_ acknowledged explanation for ECT and (3) there is a (...) serious (mainstream) debate over whether the response to ECT may be a placebo response.’ Before embracing these suggestions, two key questions must be asked. Are these claims a reasonable representation of current ECT research? And if so, will this information be of benefit to patients? The evidence-based support for ECT from both National Institute for Health and Care Excellence and the Royal College of Psychiatrists appears to undermine the validity of claims (1) and (3), and therefore the rationale for providing this information. Concerning assertion (2), it is true that the mechanism by which ECT has its therapeutic effect is not yet established, although the importance of conveying this fact to the patient is questionable. Of greater certainty is that the same irresolution surrounds the mechanism of action of pharmaceutical antidepressants, and so a double standard in patient care should be mindfully avoided if provision of this information is deemed a prerequisite for proper ‘informed’ consent. (shrink)

De Marco and colleagues claim that the standard account of invasiveness as commonly encountered ‘…does not capture all uses of the term in relation to medical interventions1 ’. This is open to challenge. Their first example is ‘non-invasive prenatal testing’. Because it involves puncturing the skin to obtain blood, De Marco et al take this as an example of how an incision or insertion is not sufficient to make an intervention invasive; here is a procedure that involves an incision, but (...) it is regarded as non-invasive. However, this ignores the context, and the term should really be understood in reference to the fetus. It is hard to believe healthcare professionals regard taking blood to measure, for example, ferritin levels as invasive but taking blood to look for fragments of fetal DNA as not. If anyone uses the term thinking it is not invasive to the mother, the solution would be to call it invasive, not redefine what is invasive. De Marco and colleagues’ second example is describing electroconvulsive therapy (ECT) as invasive. However, this is not borne out by their referenced papers. The first cited source is about non-invasive brain stimulation2 and only contains a single sentence about ECT. This sentence may suggest that their view is that ECT …. (shrink)

Background Psychiatric electroceutical interventions (PEIs) use electrical or magnetic stimulation to treat mental disorders and may raise different ethical concerns than other therapies such as medications or talk therapy. Yet little is known about stakeholders’ perceptions of, and ethical concerns related to, these interventions. We aimed to better understand the ethical concerns of a variety of stakeholder groups (patients with depression, caregivers of patients, members of the public, and psychiatrists) regarding four PEIs: electroconvulsive therapy (ECT), repetitive transcranial (...) magnetic stimulation (rTMS), deep brain stimulation (DBS), and adaptive brain implants (ABI).Methods We conducted a national survey of these four stakeholder groups, using an embedded video vignette experiment depicting a patient with treatment-resistant depression and her psychiatrist discussing the possibility of treatment with one of the four PEIs.Results Participants’ ethical concerns varied by stakeholder group, by PEI, and by the interaction of the two. The three non-clinician groups tended to have similar ethical concerns, but to differ from psychiatrists. Similar concerns were raised with regard to the two implantable technologies, DBS and ABI. Overall, there was relatively little concern about the involuntary use of PEIs, though some expressed concern about the adequacy of information provided during the consent process. There was also significant concern that patients may not receive helpful therapies.Conclusions To our knowledge, this is the first national survey that includes multiple stakeholder groups and multiple PEI modalities. A better understanding of the ethical concerns of stakeholders can help to shape clinical practice and health care policy regarding PEIs. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Threat to Selfhood: Moral Distress and the Psychiatric Training CultureEsther NathansonWhile many medical specialties offer to heal, or even cure, psychiatry—uniquely—places the doctor–patient relationship at the center of the therapeutic effort. Psychiatrists must possess a complex and challenging combination of broad medical knowledge, finely honed interpersonal and analytic skills and confidence in their abilities, despite limited understanding of the workings of the brain. Inpatient psychiatry in particular demands (...) a degree of strength to withstand emotional, and sometimes physical, assault from patients who may be suicidal, desperate, paranoid, aggressive or delusional. Beyond these abilities, a good psychiatrist must have robust but ‘therapeutically porous’ emotional boundaries that allow genuine empathy for the patient but, at the same time, limit internalization of the patient’s anguish as the practitioner’s own: the exquisite balance of ‘self–versus–other’ in the therapeutic encounter.Unfortunately, during my psychiatry residency in the UK, development of these intangible but essential boundaries was entirely absent from the curriculum. Early in training I struggled with my tendency to become an emotional chameleon with feelings and energies buffeted around by the prevailing emotions of each patient that walked through the door. I felt that patients expected me to offer tidy explanations for their suffering and provide answers to profound questions of meaning; to make the world a safe and understandable place. Given the complexity of mental illness and its interplay with social circumstances this was naïve and, I now realize, often unnecessary, but the weight of responsibility was unbearable. I was also completely unprepared for the intensity of human suffering I saw, and wholly unready to provide the level of interpersonal engagement required for genuine healing. My own emotional integrity felt threatened by the depth of patients’ needs, and my response—both physical and emotional—was intense and frightening.Much of my distress resulted from the profound and inevitable tension between the empathy necessary to comprehend patients’ experiences, which were often extreme and bewildering, and the need for resilience and self–protection at a time when my grasp of psychological theories and treatment practices was still rudimentary. I felt guilty that patients bore the brunt of my inexperience, and duplicitous purporting to help while burdening them with intolerable drug side–effects and stigmatizing, albeit effective, treatments such as electroconvulsive therapy (ECT). Time constraints and guidance from senior faculty encouraged expediency over treatment efficacy or durability; psychopharmacology was prioritized over the psychotherapeutic techniques and psychosocial interventions I found more effective for many patients. During the phase of our training that took place in a rambling, now defunct, asylum in the U.K, visits to the locked ward, which was reserved for patients considered a danger to others, were usually prompted by nurses’ requests for chemical restraint, the ‘pharmaceutical strait–jacket’. I was deeply uncomfortable with the role of ‘restrainer’ but had insufficient experience or seniority to propose other methods. It was only when, years later, I investigated re–training in the U.S that the senior psychiatry resident at a well–known program told me gently, ‘Oh, we assume that students will have a breakdown in their first year, so we have systems in place to help’. I’ll never forget those words; they are, to this day, the only validation of the emotional toll of my early training years.Adding to my discomfort were various ethically dubious administrative practices, the most troubling being the clinic’s unwillingness to disclose to patients that we were trainees, with little clinical experience. Senior faculty were dismissive when I asked whether my first psychotherapy patient had been told I was a trainee, indeed that I had never conducted psychotherapy before. My question was greeted with amusement and an assurance that, although she had not been told, I (not the patient, interestingly) would do fine.Due to the large number of no–shows in psychiatric outpatient clinics it was also standard practice to triple–book appointment times on the [End Page 115] assumption that one or more patients would fail to attend. Not uncommonly, more than one patient would arrive for the same appointment, leaving others to suffer agonizing waits that were often intensified by the deep discomfort... (shrink)

A patient with a history of bipolar II disorder and endstage renal disease who required hemodialysis for five years abruptly wished to withdraw from dialysis on day seven of her hospital admission for a urinary tract infection. She had never discussed wishing to withdraw from dialysis prior to this hospital admission. She had experienced several symptoms of depression during her stay. Her desire to withdraw from dialysis treatment was discordant with her previously expressed desires, and the psychiatry team determined that (...) her judgment was likely altered by her depressive episode. Given her previous positive response to electroconvulsive therapy (ECT), the psychiatry team recommended that she receive ECT before she choose to withdraw from dialysis. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Legal CommentarySumy Menon, Senior Associate in ResearchThe principle of autonomy must be balanced against the need to protect the person from harm. The question is how to strike that balance and what tips it over to either side. In this case, the right for Mdm. W to make her own decision whether to undergo electroconvulsive therapy (ECT) must be balanced against the concern of the doctors and (...) her relatives regarding the possible consequences of not receiving the treatment. However, this question does not even arise if Mdm. W has capacity to make that decision. Mdm. W is the decision-maker for ECT treatment if she has capacity to make that decision.1The statutory regime that underpins decision-making for persons who may lack capacity is the Singapore Mental Capacity Act (SMCA).2 It is grounded in five Statutory Principles.3 The first three are the presumption the person has capacity, has the right to make an unwise decision, and the requirement that all practicable steps be taken to help the person make a decision. The fourth principle requires decisions made on behalf of the person lacking capacity to be taken in his or her best interests, and the final one states that the less restrictive option must be selected when making decisions for persons lacking capacity.The best practice is for the doctor to conduct a formal mental capacity assessment to determine whether Mdm. W can refuse consent for ECT. A formal assessment is appropriate in these circumstances because the decision is an important one concerning serious medical treatment.4 A trained specialist should conduct this assessment. The two-stage test for mental capacity is laid out in the SMCA.5 The first stage appears to be met because it requires the person to be suffering from an impairment or disturbance that affects the function of [End Page 227] the mind or brain, and Mdm. W has bipolar disorder. The second stage requires the bipolar disorder to render Mdm. W unable to make a decision at the time the decision needs to be made. The SMCA states that a person is unable to make a decision if he or she cannot understand the information, weigh up the information, remember the information or communicate the decision.6If the formal assessment concludes that Mdm. W lacks capacity to refuse ECT treatment, then the decision should be taken in her best interests.7 Mdm. W ’s relatives have no legal right to make decisions on her behalf unless she has appointed one or more of her relatives to be her healthcare proxy under a valid Lasting Power of Attorney (LPA).8 If she made such an LPA, then the appointed proxy is the final decision-maker unless the treatment is life-sustaining or the doctor reasonably believes the treatment is necessary to prevent a serious deterioration in Mdm. W’s health.9 It is arguable that a clear and present danger of suicide may be reasonably classified by the doctor as a serious deterioration in Mdm. W’s health, although this issue has not been tested in the Singapore courts, which would mean that the appointed proxy would have to yield to the doctor as the final decision-maker. If Mdm. W did not make such an LPA, then the decision must be taken in her best interests, and is likely to be taken jointly between the healthcare team and the relatives.The best interests test involves a holistic appraisal of factors,10 balancing the benefits and burdens of the proposed ECT. The relevant factors that should be considered here include whether, when or if Mdm. W is likely to regain capacity, her beliefs and values, her past and present wishes, and the views of her relatives.11 We do not have any information about the first two factors but we do know Mdm. W rejected ECT and her relatives think she should have ECT. Another relevant factor is that Mdm. W is unlikely to cooperate with the pre-treatment fasting requirements or agree to undergo general anaesthesia. Therefore, Mdm. W will need to be restrained for eight hours before each treatment. There will be a total of six... (shrink)

Since its introduction in 1938, electroshock, or electroconvulsion therapy , has been one of psychiatry's most controversial procedures. Approximately 100,000 people in the United States undergo ECT yearly, and recent media reports indicate a resurgence of its use. Proponents claim that changes in the technology of ECT administration have greatly reduced the fears and risk formely associated with the procedure. I charge, however that ECT as routinely used today is at least as harmful overall as it was before these (...) changes were instituted. I recount my own experience with combined insulin coma - elcetroshock during the early 1960s and the story of the first electroshock "treatment." I report on who now is being electroshocked, at what cost, where, and for what reasons. I discuss ECT technique modifications and describe how ECT is currently administered. I examine assertions and evidence concerning ECT's effectivness and ECT-related deaths, brain damage, and memory loss. Finally I describe "depatterning treatment," a brainwashing technique developed in Canada during the 1950s, drawing a parallel between electroshock and brainwashing. (shrink)