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Book Forum: LAW AND ETHICS   |    
Ethics in Electroconvulsive Therapy
WILLIAM H. SLEDGE, M.D.
Am J Psychiatry 2005;162:2203-2204. doi:10.1176/appi.ajp.162.11.2203
View Author and Article Information
New Haven, Conn.

By Jan-Otto Ottosson and Max Fink. New York, Brunner-Routledge, 2004, 157 pp., $34.95.

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This review of ECT and the ethics of ECT enjoys the authorship of well-known, established scholars and practitioners of ECT, with the added advantage of a European as well as an American perspective. This is an overview treatment, encyclopedic in some ways, of the issues of ECT. The authors do a credible job of pulling together a disparate set of fields and perspectives on the use (or lack of use) of ECT in the modern Western world. The tone is even and objective, but what comes through in the content are the voices of advocates, two men who have devoted much of their careers to the robust use of ECT.

The premise of the book is to examine ECT through the lens of modern biomedical ethics. The authors begin with a chapter on the stigmatization of ECT, citing different theories of the origin and maintenance of this stigmatization. The next chapter, an overview of the principles of medical ethics (based on the work of Beauchamp and Childress), identifies the four principles of medical ethics of the "Georgetown" group, namely, beneficence, nonmaleficence, autonomy, and justice. This is a competent overview of these issues; however, in presenting their synthesis on bioethics, the authors manage to give very positive views of ECT, which seems a little bit like editorializing in the news, or giving an opinion before all the facts are presented. Chapter 3 is a history of previous ethical approaches to ECT, and chapters 4 through 7 address the topics of beneficence, nonmaleficence, autonomy, and justice in terms of the specifics of the practice of ECT. These chapters could be called "Efficacy" for beneficence, "Side Effects" for nonmaleficence, "Consent" for autonomy, and "Access" for justice. The authors make the point strongly that the existing literature supports these four principles of biomedical ethics.

The chapter on beneficence addresses the evidence for the efficacy and/or effectiveness of ECT in a variety of disorders, including depressive mood disorders, psychotic depression, mania, postpartum psychosis, schizophrenia, malignant catatonia, and parkinsonian disorder. Also described are the salient features of the effectiveness of ECT, namely, the provocation of convulsive activity and the continuation of treatment. This chapter, in many ways the center of the book, might be expected to be the most important, but it has some weaknesses. It tends to be encyclopedic, and there is no critical differentiation among the studies reported. Furthermore, there are several personal attestations, and these are, to my mind, a bit too much oriented toward celebrities and, for that matter, too celebratory of ECT. However, the basic content is important, namely, that the existing literature supports ECT as an effective treatment for many illnesses, particularly for severe depression when other treatment approaches fail and as a frontline treatment given at the beginning of an episode.

Chapter 5, "Nonmaleficence," basically deals with the side effects of ECT and rightly emphasizes the cognitive effects. The authors give a very nice account of retrograde and antegrade amnesia as well as other memory dysfunctions. They appropriately note that, in many instances, it is very difficult to disentangle the cognitive distortions brought on by the illness itself as opposed to side effects from ECT. One disappointing aspect of this discussion is that the issue of the memory defect is dealt with more anecdotally than through systematic studies. Perhaps the systematic studies do not exist.

The chapter on autonomy thoroughly addresses the idea of consent. The authors do a particularly good job of discussing the subtle ethics of getting consent from someone who is mentally ill and who may have thought disorder as a result. Their views are practical, humane, and well considered ethically.

The chapter on justice addresses the issue of availability of ECT. The authors argue that ECT is an effective treatment with a low incidence of serious side effects that is also cost- effective; however, ECT is not widely available. They discuss the availability of ECT in several Western countries and point out that refusing to give, abstaining from, or being prejudiced against ECT are, perhaps, unethical in themselves. This chapter is passionately written; the authors make their case quite well.

The strength of this small offering is its encyclopedic account of efficacy and outcome studies. It has the advantage of a multicultural perspective, and it strives to give an adequate overview of ethical practice in psychiatry. There are elements that are particularly strong, such as the chapters on autonomy (consent) and justice (access).

The weakness is the authors’ unabashed advocacy for ECT. It is not so much that they say anything that seems to be erroneous or misleading, but their enthusiasm raises the prospect that they might be overly zealous. The vignettes are always positive and always show how ECT saved the person’s life or the absence of ECT may have contributed to someone’s demise. The authors do not deal with some of the knotty realities of ECT, such as the substantial cost, particularly given the necessity to have an anesthesiologist present. They also do not deal with the issue of whether ECT may be associated with higher costs because patients may be hospitalized at the beginning of a course of ECT, when they would otherwise not need to be admitted to a hospital. Also, the writing itself at times is verbose, uncritical, and repetitive. All of these factors conspire to make reading the book a little tedious.

Despite these inelegant features, however, I can strongly recommend this book. The content is worthy and informative and will serve us well as we contemplate a future that is likely to contain increasing use of brain stimulation in the treatment of mental illness.

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