Ethics in Electroconvulsive Therapy

Jan-Otto Ottosson, Max Fink

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135940041
• Edition: 1
• Topic: Derecho
• Subtopic: Ética y responsabilidad profesional en el derecho

Few mental illness treatments are more reviled in the public mind than Electroconvulsive Shock Therapy. However, in reality, ECT is a safe and effective treatment for cases of clinical depression and catatonia that are unresponsive to drug therapy. Also, unlike drugs, ECT has relatively few side effects. The authors argue that it is time for this historically stigmatized procedure to be reevaluated. The authors make a strong case for greater professional and public attention to the procedure's benefits, offering historical coverage of ECT-related movements, legislation, public and practitioner sentiment and the introduction of competing treatments. This volume will not only garner the interest of mental health professionals, but will call on policy makers and ethicists to examine its arguments.

CHAPTER 1

The Stigmatization of Electroconvulsive Therapy

The stigmatization of ECT has many roots—in fears of electricity and of epileptic seizures, in competing ideologies within psychiatric practice, in the association with old-fashioned health care, and well-meant but misdirected desires of medical personnel to abide by public opinion. Many complain that ECT is overused and misused. When a physician discusses ECT with a patient and the family, the recommendation elicits many concerns and is often rejected. To avoid conflict, physicians delay the recommendation for ECT until all other means, even many with lesser efficacy and unproven safety, have been tried and failed and the illness has become severe and persistent.

Claims of misuse, concerns about the properties of the treatment, ideological conflicts within psychiatry, and economic factors dominate its stigmatization.

Claims of Misuse

Convulsive therapy, in the form of chemically induced seizures, was first tested in the 1930s in patients with dementia praecox, a disorder that is now widely labeled as schizophrenia. While the benefits were immediately obvious in patients with acute forms of the illness, and especially with the catatonic variety, the trials in patients with chronic schizophrenia failed. In other disorders, such as alcoholism, drug abuse, hysteria (conversion reaction), and anxiety states, ECT did not benefit the patients. In patients with obsessive compulsive disorders, the benefits were transient. These illnesses did not become indications for its use (Sargant & Slater, 1962; Kalinowsky & Hippius, 1969; APA, 1978; Fink, 1979). By contrast, in patients with involutional melancholia, an often fatal disorder, the results were gratifying and ECT immediately became the accepted treatment (Ziskind et al., 1945; Bond, 1954a; Bond & Morris, 1954b). The benefits in patients with malignant catatonia, psychotic depression, and manic delirium were later defined and were so great as to encourage the frequent and primary use of ECT for these conditions (Fink, 1999; APA, 2001; Abrams, 2002; Fink & Taylor, 2003).

Experimentation in diverse conditions to define the indications for any new treatment is by no means unique for ECT. It is a feature of all new medical discoveries. After the hormone insulin was identified as effective in diabetes, it was tried in many other conditions including the relief of withdrawal of opiate dependence and in schizophrenia. As schizophrenia did not respond to sub-coma doses, higher doses, sufficient to induce states of coma were tested and found to be sometimes effective. Insulin coma therapy was an accepted treatment for psychosis for two decades until it was replaced by antipsychotic drugs (Fink, 2003). Another example is seen in trials of penicillin for infections associated with war wounds. Trials in patients with syphilis led to the discovery that the spirochaete was uniquely sensitive to penicillin and to the remarkable eradication of both the acute and chronic forms of the illness. These trials were considered a remarkable success despite the occurrence of fatal complications (Quétel, 1990).

Overuse of Treatment

Before penicillin, the treatments of syphilis included poisonous arsenicals and the periodic fevers of malaria. The success of malaria therapy, with its fevers occurring in 48 to 96 hour intervals, was hailed as a major advance in medical care, for which the 1927 Nobel Prize in Medicine was awarded. The frequency of malarial fevers and their apparent success became the model for the first attempts at convulsive therapy (Meduna, 1937). As more experience was gained, other treatment frequencies for ECT were examined. If two and three seizures a week were effective, perhaps daily treatments would be more so? Regressive ECT, in which patients were treated daily or twice daily, was tested. The benefits, however, did not occur earlier than with conventional treatment frequencies. The appearance of severe confusional syndromes, occasionally persistent, discouraged this form of ECT and it was abandoned (Fink, 1979; Kalinowsky et al., 1982; APA, 1978, 1990).

In multiple monitored ECT, from four to eight seizures were induced in one morning under one anesthesia, in the hope that the benefits would be superior to the two to three week schedules then in use (Blachly & Gowing, 1976). Only a few patients benefited from this intensive procedure but more patients developed a delirium that was severe and persistent (Abrams & Fink, 1972). This method of ECT was also abandoned (APA, 1978, 1990).

Experiments using varying dosages are a feature of all medical treatments. In the assessment of neuroleptic drugs, high doses, even mega-doses, have been tested and while some benefits were noted, they are only occasionally used today (DiMascio & Shader, 1972; Riker et al., 1994; Hurford, 1999). Radiation and toxic chemical treatments for malignant tumors are another example of the achievement of a reasonable balance between benefits and side effects (Vaeth, 1979; van Houtte et al., 1999). Despite occasional severe side effects, high dose neuroleptic dosing for the severe psychiatrically ill, and radiation and toxic chemical treatments of cancer are accepted by physicians and their patients. Neither course of treatment is stigmatized.

Association with Forced Incarceration

By the first half of the 20th century, most treatments of the psychiatrically ill were carried out in large psychiatric hospitals. According to accepted medical practice, physicians were authorized to compel hospital care for patients considered dangerous to themselves or to others. Such legal commitment was usually in state supported institutions, many of which were overcrowded, inadequately staffed, underfunded, and poorly managed (Deutsch, 1937; Hunter & Macalpine, 1982; Grob, 1994; Shorter, 1997; Ottosson, 2003). The power to commit patients to hospitals and to forcefully treat them was a derived power of the state to protect its citizens. The rules were lax and claims of abuse common. The introduction of such complex treatments as fever therapy, prolonged sleep, insulin coma, convulsive therapy, and lobotomy put overwhelming burdens on the nurses, aides, and physicians in the state facilities. Patients frequently attacked each other and the professional staff, damaged furnishings, smeared walls and floors, and set fires. One of the first evidences of the usefulness of chlorpromazine and other antipsychotic drugs was in the reduction in attacks on personnel and other patients, windows broken, and fires set (Kalinowsky & Hippius, 1969; Sargant & Slater, 1964).

Overuse of isolation rooms, physical restraints, and hot and cold baths to manage unruly patients were frequently reported in the public press. Such management techniques and the intrusive treatments could be administered at the order of the medical staff and without individual consent (Deutsch, 1937, 1946; Grob, 1994; Braslow, 1997). Indeed, the justification for admission to a psychiatric hospital was that the necessary treatments would be applied. Despite widespread complaints of abuse, forced hospitalization and forced treatments were tolerated when physicians were viewed as healers committed to serving the better interests of their patients and justified by the principles of the Hippocratic Oath as it was then interpreted.

In the latter half of the 20th century, however, after two world wars and the controversial conflict for Americans in Vietnam, the public openly questioned the authority of the state to force its will on its citizens. One nidus for this conflict was the forced conscription of men for military service in an undeclared and illegal war. The challenge to authority broadened to include questions whether the state had power to incarcerate individuals for behavior that it deemed dangerous. Reports of the use of commitment procedures to imprison dissidents and force psychiatric medications in the Soviet Union and China raised questions whether these same powers were being abused in the United States. Writers questioned the concepts of psychiatric illness and argued that in forcibly hospitalizing patients, physicians were acting as agents of the state in a fashion that was no different than the behavior of physicians in totalitarian societies (Szasz, 1961, 1963, 1965, 1977). Such arguments led to demands on state governments to limit the power of physicians to hospitalize individuals. By the beginning of the 21st century, regulations in many countries severely restricted the incarceration of the psychiatrically ill.

Then, because some critics considered ECT, lobotomy, and psychiatric drugs intrusive and brain-damaging, state governments were called upon to limit and proscribe these treatments. As lobotomy (psychosurgery) had already been widely replaced by antipsychotic drugs, the regulations limited lobotomy research but had little direct impact on a practice that had already waned (Valenstein, 1980, 1986). Insulin coma therapy was abandoned when it was shown that the new medications were easier to use, safer, and of almost equal efficacy (Fink et al., 1958; Fink, 2003). Despite studies that showed ECT was more effective than medicines in treating depression, the enthusiasm for medicines quickly replaced ECT in many hospitals and academic centers.

At best, medication reduced the symptoms of severe psychiatric disorders, often leaving enervated and persistently debilitated conditions. By the 1970s, faced with increasing numbers of symptomatic ill, clinicians recalled the use of ECT. In the interim, however, as a by-product of the public challenges to the authority of the state, many legislatures had imposed strict restrictions on ECT practice, limiting the age criteria and the indications (to last resort treatment), and introducing restraining consent requirements. (APA, 1978; Fink, 1991; Shorter, 1997). The image of ECT as an intrusive treatment associated with forced incarceration severely tainted its image.

Disrespect for Privacy

The primitive conditions of many mental hospitals did not encourage respect when treatments were administered. Patients were often poorly clothed. Those who had soiled themselves remained in unpleasant states for hours. All activities took place in large open wards. Restraints, screaming, and assaultive behaviors were commonplace. In this scene of bedlam, treatments were given in the same open wards and with little respect for privacy.

It was under these conditions that ECT was initially given with a mobile ECT device. Overactive and loud-voiced patients who were difficult to control were treated in their beds, barely hidden behind screens. Other patients could not avoid hearing what was going on. These unpleasant experiences were related to friends and relatives, giving ECT the image of a brutal treatment. They were described in the public press, and soon became standard fare in film and television portrayals of psychiatric care (Gabbard & Gabbard, 1987).

Not that ECT was selectively abused. Limb and wet sheet restraints and isolation chambers allowed patients and even visitors to see patients under adverse and unpleasant conditions. Following lobotomies, patients returned to the wards in a stupefied state, with fresh bleeding around their eyes (Freeman et al., 1942; Valenstein, 1980, 1986; Briska, 1997). In insulin coma, secondary episodes of hypoglycemia, seizures, and coma occurred among patients herded together in their ward units (Fink, 2003). These other treatments were abandoned, leaving ECT as the main residual to which the memories of abuse were attached.

Libertarian movements, encouraged by an optimism that the new medications would allow patients to live outside psychiatric hospitals, spawned the drive to de-institutionalization and the emptying of state supported psychiatric hospitals (Isaac & Armat, 1990; Johnson, 1990). Thousands of patients were released to live in the streets and slums of the cities, to fill the prisons, and to become mainstays of the revolving door actions of psychiatric treatment centers rather than being cared for in institutions. Public disgust encouraged a widespread pessimism for all psychiatric treatments including ECT.

ECT as Restraint

Following each seizure, patients are sedated, stuporous, and confused, encouraging its use not as a treatment of an illness but as a means of sedation of unruly patients. Such use was never condoned and often condemned. It was abandoned and was replaced by the intramuscular or intravenous administration of highly potent antipsychotic drugs, especially haloperidol (Okasha & Tewfik, 1964; Rees & Davies, 1965). Although useful as a low dose preparation in the relief of psychosis, haloperidol has often been given in very high doses. Such dosing entailed severe extrapyramidal motor effects, irreversible tardive dyskinesia, and a febrile malignant syndrome. It took another decade for such use to be abandoned, although reports of its use and toxicity persist (Riker et al., 1994; Seneff & Mathews, 1995). Failure to assure informed voluntary consent and coercion at the time of injections are features of this use of antipsychotic drugs. From an ethical point of view, it can be called in question whether ECT and high doses of neuroleptic drugs differ as methods of restraint.

While this image of forced administration of ECT is widely held, in actual practice today, ECT is almost always given to voluntary patients who consent to the treatment.

Confusion among Biological Treatments

Convulsive therapy has been in continuous use for more than 70 years. It was introduced in 1934 and is considered old-fashioned. It is sometimes confused with two other treatments that were introduced concurrently, insulin coma in 1933 and lobotomy in 1935. Since these treatments are now abandoned, it is often a surprise to physicians and families that ECT is still in use. In their testimony about their illnesses and treatment with ECT, Endler (1982), Manning (1994), Rosenberg (2002), and Nuland (2003), among many other observers, each remarks on their surprise when their physicians broached its use (chapter 4).

The treatments have superficial similarities. They were applied in the same populations of patients labeled as suffering from schizophrenia. With increasing experience, they were also applied to patients with manic depressive illness in its depressed and manic forms.

A second commonality is the incidence of grand mal seizures for each of the treatments. Seizures are the therapeutic agent in convulsive therapy, both the pharmaco-convulsive and electroconvulsive forms. Numerous attempts to replace seizures with anesthesia alone or sham seizures failed (Fink, 1979; Palmer, 1980; Abrams, 2002). Seizures occurred in about 10% of insulin coma treatments. When the benefits of the comas alone were not sufficient, electrical-induced seizures were superimposed (Fink, 2003). After frontal lobe surgery, more than half the patients developed spontaneous seizures (National Commission, 1977; Shutts, 1982; Valenstein, 1980, 1986). In retrospect, seizures could be seen as the common element in these interventions, contributing to the efficacy of insulin coma and frontal lobe surgery, as well as being central to convulsive therapy (Fink, 1979, 1993, 2003).

The criteria for selecting one treatment over another were poorly defined, confusing professional and public minds. The blurred distinctions are exemplified by the presentation of ECT and lobotomy in the popular novel and film One Flew over the Cuckoo's Nest in which the protagonist undergoes both treatments (Kesey, 1972). In the recent film A Beautiful Mind the patient receiving insulin coma is depicted as undergoing a dramatic grand mal seizure (Fink, 2003).

Insulin coma and frontal lobe surgery were poorly effective with high rates of morbidity and mortality. Both were replaced by antipsychotic drugs, but the memory of those experiences still confuses the image of ECT. The psychiatric profession has not been successful in educating the population about the differences among the treatments.

Treatment Properties

Discomfort with Seizures

Both seizures and electricity are repellant features of ECT that encourage unfavorable attitude to its use.

Spontaneous epileptic seizures are frightening and may be associated with injury and death. They have been perceived as blows from the gods, reflecting something evil or sinful. In some cultures epileptic subjects were favored and their statements deemed to be holy, but more often they were considered tainted and badly treated. Many epileptics were ostracized from the community.

Professional attitudes to seizures vary profoundly. At one time, neurologists and psychiatrists were part of a single discipline, comfortable in treating the spontaneous seizures of epilepsy and also in inducing seizures in ECT. With progress in diagnostic methods and increased emphasis on psychoanalysis and psychotherapy, especially in the United States, the disciplines separated. Those who practiced psychoanalysis and psychotherapy became the mainstays of departments of psychiatry and treated the mentally ill in psychiatric and general medical hospitals and offices. Those who focused their interest on structural brain disorders, cerebrospinal fluid examinations, electroencephalography, and brain imaging techniques became the mainstays of departments of neurology and treated their patients in general medical hospitals. The eradication of epilepsy has become their principal focus and their attitude to seizures is uncompromising. Some find it difficult to accept that seizures may be safely induced for therapeutic purposes. Denying such uses, they are unacquainted with the benefits of ECT, exaggerate the risks, and ignore the unique experimental opportunity to study seizures induced in man. Such an attitude does their patients no service.

Fear of Electricity

The widespread fear of electricity strengthens the image of a dangerous and painful procedure. Not that electricity is essential to the benefits of convulsive therapy; it is not, for effectiv...