"First, do no harm" is the healing profession's best-known ethical precept because in the actual practice of medicine doctors may unwittingly do harm [1,2]. However, is it ethical for physicians to give harmful treatments knowingly?
Such a course of action might be considered proper if no alternative treatments are available, if the treatment is not only effective but likely to be life-saving, if no coercion is involved, and if true informed consent is obtained for the procedure. Unfortunately, electroconvulsive therapy (ECT) meets none of these conditions. In fact, to the horror of truly ethical physicians, there are several recent instances in the United States of the involuntary administration of ECT, over the expressed repeated wishes of the patient .
The issue is rather simple. The defining feature of ECT (modified or unmodified, bilateral or unilateral)—that which distinguishes it from any other treatment and is indicated in its name—consists in the electrical induction of a generalized seizure. This frequently leads to an acute organic brain syndrome characterized by amnesia, apathy, and euphoria .
Administering ECT to depressed or severely depressed patients shows an "effectiveness" (evaluated by rating scales including many items that would respond to any nonspecific sedative intervention) lasting no more than 4 to 6 weeks . Within 6 months of receiving ECT, 84 percent of patients relapse . ECT is not life saving: no decrease in suicide results from its use , and some increase in suicide may follow .
ECT is not safe: it produces varying amounts of memory loss and other adverse effects on cognition in nearly everyone who receives it, typically lasting weeks or months after the last treatment (as well as many other adverse consequences, from ocular effects to postictal psychosis).
ECT is not necessary: numerous alternative, less harmful interventions—that work with the patient's consciousness, strengths, and social network—are available . ECT is too often given as the treatment of next resort (not, as some of its supporters would insist, last resort) when drug treatment has seemingly failed, as drug treatment often does , especially for the modal ECT patient today, an elderly woman. Less harmful options are not considered for reasons having very little to do with the patient's "condition" and very much to do with psychiatrists' increasing unfamiliarity with nonbiological interventions, professionals' frustration that patients are not recovering "quickly enough," and some institutions' reliance on the procedure as a revenue source.
Needed: A Study of Consent Forms
Finally, we suggest that true informed consent is almost never obtained, because practically no one would sign a truthful consent form for ECT (if any exists) unless coerced—grossly or subtly—to do so. Defenders of ECT might claim that informed consent is scrupulously obtained, but it is at present impossible to evaluate this claim properly. Indeed, despite the importance of divulging the risks of this most controversial treatment in psychiatry, no study describing actual ECT consent forms used in different institutions (even a small sample of 2 forms) has ever been published.
Unless a harmful treatment is life-saving, unavoidable, uncoerced, and its risks are fully divulged, knowingly administering it is unethical.
Here are the words of 3 individuals who received ECT and described publicly what they view as ethical violations involved in their experience of this procedure. Leonard Roy Frank said, "I have concluded that ECT is a brutal, dehumanizing, memory-destroying, intelligence-lowering, brain-damaging, brainwashing, life-threatening technique. ECT robs people of their memories, their personality, and their lives. It crushes their spirit. Put simply, electroshock is a method for gutting the brain in order to control and punish people who fall or step out of line and intimidate others who are on the verge of doing so" .
Thomas Hsu wrote, "My ECT's were in 1998. Overall I feel violated and very emphatically wish I had never consented to the treatments and would caution others. While I was not coerced into receiving the 'treatment,' I do feel I was misled and at the very least not suitably informed about the potential negative effects and lack of efficacy in treating depression. I would never consent to receiving ECT again" .
Jackie Mishra said, "One moment that I remember clearly from my hospital stay for ECT in 1996 is the horror I felt when after one of my treatments I couldn't remember how old my children were. Not only did the ECT not work for me, but my suffering was compounded when I realized that approximately 2 years of my life prior to the ECT had been erased. My retention of new information is also severely impaired. If anyone had told me that this could happen, even a remote chance, I never would have consented to ECT. I would much rather have lost a limb or 2 than to have lost my memory—my 'self'" .
Sharpe VA, Faden AI. Medical Harm. Cambridge, England: Cambridge University Press: Cambridge, United Kingdom; 1998.
Biller J. Iatrogenic Neurology. Butterworth-Heinemann Medical: Philadelphia; 1998.
See MindFreedom Support Coalition International's Web site. Accessed September 26, 2003. See also ECT.org. Accessed September 26, 2003.
- Cohen D. Electroconvulsive treatment, neurology, and psychiatry. Ethical Human Sciences & Services. 2001;3(2):127-129.
Banken R. The use of electroconvulsive therapy in Québec. Agence d'évaluation des technologies et modes d'intervention en santé: Montreal; 2003. Accessed September 26, 2003.
- Sackeim HA, Haskett RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA. 2001;285(10):1299-1307.
Black D, Winokur G, Mohandoss E, et al. Does treatment influence mortality in depressives? A follow-up of 1076 patients with major affective disorder. Ann Clin Psychiatry. 1989;1:165-173.
- Brodarty H, Hickie J, Mason C, et al. A prospective follow-up study of ECT outcome in older depressed patients. J Affect Disord. 2000;60(2):101-111.
Kirsch I, Moore T, Scoboria A, Nicholls SS. The emperor's new drugs: an analysis of antidepressant medication data submitted to the US Food and Drug Administration. Prevention & Treatment. 2002;5. Accessed September 26, 2003.
As only one example of several sources describing practical brief approaches with "chronic," "resistant," and "difficult" patients, see: Miller SD, Hubble M, Duncan BL. Handbook of Solution-focused Brief Therapy. San Francisco: Jossey-Bass;1996.
MindFreedom Journal. Winter 2002-2003;45:51.
Hsu T. Quoted by: Support Coalition International Response to the March 1998 Electroconvulsive Therapy Background Paper by Research-able Inc, Prepared for the US Dept. of Health and Human Services. MindFreedom Support Coalition International. Eugene, Oregon;1999:6.
Mishra J. Quoted by: Support Coalition International Response to Electroconvulsive Therapy Background Paper. Research-able Inc, Prepared for the US Dept. of Health and Human Services. March 1998. MindFreedom Support Coalition International: Eugene, Oregon; 1999:8-9.