Is ECT Practice Ethical?

Electroconvulsive therapy is widely considered a controversial treatment in psychiatry. Many cite it as the most controversial treatment in medicine. It is not its efficacy that is controversial, however; as we’ve seen, it offers effective relief for severe psychiatric illnesses even when other interventions have failed. Nor is the controversy about the immediate risks of the treatment, for the risks and death rates are extremely low—almost certainly lower than the risks acknowledged for the psychoactive agents that are the core of modern pharmacotherapy. No systemic illness or medical condition limits its use. The controversy is based on the belief that inducing seizures by electricity permanently damages the brain, causing such severe losses of personal memory that the patient is no longer recognizable as the person known before. This belief is unfounded, and any effects on memory and cognition have been shown to be limited to the time during and directly before treatment. The roots of the controversial image are many, not the least of which is the unfortunate conflation of ECT with lobotomy and insulin coma. The poor portrayal of the treatments by the media inflames viewers’ perception. Conflicts between believers in the biological basis of mental illness and those with the psychological interests of psychoanalysis and clinical psychology roiled psychiatry throughout the twentieth century. As a result, governmental regulations for ECT, especially those limiting its use in children and adolescents, and requirements for written consent (in some venues for each treatment), have restricted its use. Ethical guidelines for the relationship between physician and patient have a long history, the Hippocratic Oath developed by the ancient Greeks being the most widely acknowledged guide. The shameful evidence of medical experimentation on unwilling prisoners by physicians in Germany and the Soviet Union during the Second World War incited a worldwide reassessment of the patient-doctor relationship. Until the 1970s, no limitation on experimental intervention with psychiatric patients was envisioned. Treatments without a scientific basis were lauded and then discredited when the adverse consequences were shown to be greater than the benefits. Treatments were applied in institutions where the patients had an utterly dependent role, and assigned treatments were mandated at the discretion of the institution director.