One of the most unforgettable experiences of my medical school career occurred during a psychiatry clerkship. I had been on the wards for only 3 months, when I was assigned to the inpatient psychiatric unit at the university teaching hospital. On my service was a patient who had been hospitalized for severe depression. Unfortunately, the patient's depression was resistant to pharmacological therapy, prompting the attending psychiatrist to treat the patient with electroconvulsive therapy.
Electroconvulsive therapy or ECT is a medical treatment that has been around for centuries and has recently gained in popularity, but not without some controversy. Put simply, ECT involves delivering a brief electric current to the brain, which induces seizure activity and, through it, its therapeutic benefit. While the procedure may sound simple enough, witnessing it being performed on a patient was anything but simple and routine. I can still remember the patient on the gurney as he was wheeled into the ECT suite. He was in"soft" restraint. A tourniquet was applied to his left leg below the knee to prevent the skeletal muscle paralytic agent from reaching that portion of his body. As a result, only the left lower leg would be "jumping" around after seizure activity was induced. This was done so as to reduce the risk of physical harm to the patient from generalized seizure activity, while still allowing the physician to observe the desired seizure response.
For the lay person, ECT would seem downright barbaric and a throw back to a time when bleeding the sick was considered standard treatment for febrile illness. For a medical student in his fourth month on the wards, the therapeutic rationale behind ECT struck me as somewhat dubious. However, the attending psychiatrist informed me that, for a select group of severely depressed patients, ECT was the best chance they had to return to any sense of mental normalcy. While my patient was not cured of his depression, he did begin to improve slowly after the ECT treatments. Finally, the practice of "tying off" one of the legs is no longer necessary, because audible EEG tracings are used to determine the extent of seizure activity.
In this issue of Virtual Mentor, we explore the ethical and professional issues that are unique or relevant to the practice of psychiatry. The learning objectives are:
1. Understand the ethical challenges to the patient-physician relationship that are unique to psychiatry, eg, patient's competency to consent to treatment.
2. Understand the tension between psychiatrists' duty to patients and their relationship to the justice system, eg, patient confidentiality versus request to testify or inform.
3. Learn the value of psychiatry in ethics consults.
4. Understand the disparities between medical care coverage and mental health coverage, especially for the indigent.
5. Understand the principal ethical arguments concerning prescription of psychoactive drugs and use of other controversial therapies, eg, ECT.