cont. from

Today, the media controversy over the use of ECT is not about its safety and efficacy but rather about the public and (sometimes) professional perception that ECT is invasive and brain damaging, and that no reasonable person can give an informed consent for such an invasive treatment. Attacks on ECT continue to be featured on television, radio talk shows, and in newspaper articles. Activist antipsychiatry groups frequently launch protests and disrupt scientific proceedings in an effort to advocate against any biological psychiatric treatment. L.Ron Hubbard, founder of The Church of Scientology, has proclaimed to his international following that ECT treatments are immoral and brain damaging. In 1995, a series of four articles published in USA Today were written in conjunction with the debates in the Texas legislature to outlaw ECT. The series alleged that practitioners use ECT because of financial incentives and that death rates were much higher than were reported in the psychiatric literature. The original draft of The Surgeon General's Report7 on mental health in August, 1999 touched off an uproar among antipsychiatry groups prior to its release, with critics objecting to the Surgeon General's endorsement of the continued use of ECT and the recognition of its efficacy and safety.⁴

Unfortunately, this media sideshow has neglected the fundamental controversy, which is driven by professional-philosophical differences between the legal and medical professions over patients' health care-related rights. These differences evolved during the political upheaval of the 1960s. One of the elements of that revolution was the patients' rights movement, and ECT became one symbol of the plight of patients allegedly at the mercy of a paternalistic mental health establishment. Suits were filed against hospitals and doctors, and legislatures were urged to restrict severely the conditions under which ECT could be performed. This in turn spurred the medical and legal communities to establish standards, statutes, and regulations for the practice of ECT over the next several decades. A different perspective is presented in the recommendations from each community. The legal community, which places great value on personal autonomy, suspects medicine's paternalistic tendencies. Court decisions from several cases during the 1970s attempted to prevent ECT from ever being administered without assurance of genuine, responsible, and even independent consent. State statutes and regulations range in intent from a minimal goal of requiring appropriate consent to attempts to control nearly every aspect of treatment. In some states regulatory requirements are so stringent as to have the affect of virtually proscribing the administration of ECT to those who are most ill.8 Medicine, on the other hand, stresses caring values and often finds law insensitive to the realities of medical practice. In 1974 and then again in 1985 and 1999, the APA appointed a task force to study and to make recommendations on the practice of ECT. The task force, in its report, seeks to guarantee minimum restriction of judgment and medical management decisions and the avoidance of unnecessary delay in providing treatment.⁹

The current proposed APA Task Force Report on the Practice of Electroconvulsive Therapy (to be published in 2000) has been extensively revised to include substantially updated clinical and scientific information, enhanced training and privileging standards, and suggestions for new legal and ethical standards. Most important are the revisions pertaining to informed consent. These have been recommended in an effort to deal with consumer concerns as well as judicial and regulatory determinations dealing with the informed consent process. The current Task Force Report states that significant discussion with the ECT consentor/patient must be documented. Moreover, if the consentor/patient expresses reluctance to continue with ECT at any time he should be reminded of his right to accept or refuse treatment.¹⁰

Clearly, the psychiatric community must continue to promulgate comprehensive safeguards for ECT. At the same time, it is hoped that legislatures, the courts, and the public will recognize the benefits of a treatment which has been in use for more than 65 years and has earned its selective place in mental health therapy.

References

1. Perakos C: ECT: Beneficial or barbaric? Therapy splits expert panel. Chicago Tribune 11 October 1995.
2. Stone G: Listening to electroshock. New Yorker 14 November 1994:54-9.
3. Endler NS: The origins of electroconvulsive therapy. Convuls Ther 1988; 4:5-23.
4. Fink M: Electroshock: Restoring the mind. New York: Oxford University Press; 1999:93.
5. Calev A, Pass HL, Shapira B, et al: ECT and memory. In: Coffey CE (ed): The Clinical Science of Electroconvulsive Therapy. Washington, DC: American Psychiatric Press; 1993:125-42.
6. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. A Task Force Report of the American Psychiatric Association. Washington DC: American Psyciatric Association; 1990.
7. Mental Health: A Report of the Surgeon General. Department of Health and Human Services, U.S. Public Health Service. 13 December 1999.
8. Peterson GN: Regulation of electroconvulsive therapy: The California experience. In: Schwartz HI: Psychiatric Practice Under Fire: The Influence of Government, the Media and Special Interests on Somatic Therapies. Washington, DC: American Psychiatric Press, Inc.; 1994:29-62.
9. Winslade WJ, Liston EH, Ross JW, et al: Medical, judicial, and statutory regulation of ECT in the United States. Am J Psychiatry 1984; 141:1349-55.
10. APA Committee on ECT. Revision of 1990 APA ECT Recommendations. American Psychiatric Organization. Second Draft, 7 September 1999.

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Reviewed: 01/2006