The case of “Non-consensual Electroconvulsive Shock Therapy” is a prime example of two of Beauchamp and Childress’ principles of medical ethics opposing each other: non-maleficence and personal autonomy (Pugh). This case involves a man, Simon, who is heavily contemplating suicide and is refusing treatment that could potentially prevent him from completing suicide. When his son is asked to sign a waiver allowing his father to receive electroconvulsive shock therapy, he also declines it. This presents the dilemma of doctors overriding both Simon and his son’s wishes for the purpose of potentially saving his life, or respecting his and his son’s wishes and potentially leading to death (Wilfrid, Waluchow, Gedge 124 – 125).
As a blog from the University of Oxford states that, “…we intuitively believe that the principle of non-maleficence should trump what [Dr. Ronald Pies’] claims to be the patients autonomous choice…” (Pugh). Often times in medical ethics, it is believed that saving a life is the most important thing. However, this statement was in response to cases involving assisted suicide. Even though the case of “Non-consensual Electroconvulsive Shock Therapy” is trying to provide a treatment that could potentially save a life, the case actually poses many similarities to cases of physician assisted suicide (PAS). Most physician assisted suicide cases involve a patient who is terminally ill and in immense amounts of physical pain. While there have been numerous debates about the ethical nature of PAS, Oregon passed a law in the mid ‘90s, making it the only state to allow PAS (Dahl and Levy).
It seems like a stretch to compare the ECT to PAS, however both cases present opposing medical ethics principles of autonomy and non-maleficence, while also incorporating concepts of an informed decision or whether or not a patient is in a rational state of mind to make the decision. In Simon’s case, he was experiencing extreme depression and was mentally in excruciating pain. Even if Simon and his son, who is not experiencing depression and therefore considered to be more rational, both decide against ECT, does the doctor have the right to perform a treatment that may have other side effects even if the patient lives? Whereas in the state of Oregon, if a patient is physically very ill and in pain, a doctor legally can assist that patient in their death. How are we able to decide that mental pain is less important than physical pain and therefore a patient should have to continue to live in mental pain? As Wilfred, Waluchow, and Gedge asked, “May not quality of life be so poor, or be perceived to be so poor, that death may be rationally deemed preferable?” (Wilfred, Waluchow, and Gedge 130). In both cases of treating a patient with ECT or agreeing to PAS, one must ask themselves about the patient’s quality of life. If a patient’s quality of life is so poor, one might think that respecting autonomy is more important than practicing non-maleficence.
Dahl, E., and N. Levy. “The Case for Physician Assisted Suicide: How Can It Possibly Be Proven?” Journal of Medical Ethics 32.6 (2006): 335–338. US National Library of Medicine National Institutes of Health. BMJ Publishing Group Ltd & Institute of Medical Ethics. Web. 31 Jan. 2015. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563370/>.
Pugh, Johnny. Practical Ethics. University of Oxford, 10 Oct. 2010. Web. 31 Jan. 2015. <http://blog.practicalethics.ox.ac.uk/2012/10/physician-assisted-suicide-and-the-conflict-between-autonomy-and-non-maleficence/>.
Thomas, John, Wilfrid Waluchow, and Elisabeth Gedge. “Non-Consensual Electroconvulsive Shock Therapy.” Well and Good. 4th ed. Toronto: Broadview, 2014. 124 – 130. Print.
In this response I am just focusing on the psychiatrist’s perspective. Mr. S’s diagnosis was severe psychotic depression. He described his life in ways that were not truly reflective of his reality such as saying he was on the verge of financial ruin when in fact he was financially stable – according to his son. The psychiatrist was proceeding with that diagnosis in mind therefore he was forced to always question Mr. S’s competence. When Mr. S insisted on being allowed to commit suicide the question in the psychiatrist’s mind was is a result of delusional thinking or is this coming from a competent patient. The psychiatrist believed that ETC would bring the patient to a point where he would be competent enough to then decide if he would still like to commit suicide. If after treatment that was still Mr. S’s wishes then I believe he should have been allowed to proceed with refusing treatment. In this case maybe bringing the patient to a certain point of competence should be placed above autonomy but once the patient is deemed competent autonomy should trump non-maleficence
A doctor’s ROLE is to save lives and not to take away lives. In a hopeless and a helpless case where there are no means of cure, one can talk about the quality of life. However, when there are some options that might improve the patient’s health, then the doctor has to try his best to CONVINCE the patient to accept the treatment. No Treatment can be forced on any patient whether mental or physical patient. With every force there is resistance and here, the personality of the doctor and his power in convincing the patient to take the treatment plays a great role. Moreover, one has to endure pain and adapt to painful treatments if there is a slight hope of improvement. Nothing is guaranteed in life even a very simple surgery. There are many patients that become disabled after an accident that will change their quality of life; however, they choose to fight and endure pain to adapt to their new condition.
Then when one has to choose between saving a life and losing a life, it is ethical for the decision to be saving a life by all available means. What is also important is not only what the doctor decides to do, but also how to do it. ECT is suggested as a treatment, in cases of severe clinical depression that do not respond to other treatments and thus a prompt action is required as the depression is health and life threatening to the depressed person.Hence upon, the decision to be made of taking ECT is a lifesaving for the patient. Though the patient is not in a mental state to choose what to do, but the doctor has to inform the patient how important is this procedure to reduce his pain and suffering. A psychiatrist has to acknowledge the patient how much this treatment might reduce his pain and depression. If the patient still refuses and so does his son then the role of a doctor is to acknowledge the son on the benefits of ECT and how it might help his father to a great extent; though in treatment nothing is guaranteed. If he still refuses, the doctor has to make his son feel responsible for his father’s life in case of further suicidal attempts. Then the son will feel the burden and responsibility of his decision. If the son still doesn’t agree, then ethically the doctor tried his best to help. I believe that respecting autonomy is not more important than practicing non-maleficence. I do not believe that a doctor legally (according to the state of Oregon) can assist that patient in their death if the patient is physically very ill and in pain, especially if there are means to help him which the patient refuses to accept. Again the doctor’s role is not to help in taking away lives but rather in saving lives. It is a pity that the judicial system constrains the doctor to accept decisions from others that is not in favor for the patient’s benefits.
I don’t think that we can even begin to compare this electroconvulsive shock therapy case to a case of PAS. It’s not fair to say that the doctor’s part in each case is synonymous. In PAS, the doctor is in a hands-on way assisting in the suicide of a patient. However, in the electroconvulsive shock therapy case, he did exactly what he was supposed to do as a doctor: he educated the patient and the family on their options and possible outcomes. In the end, it’s not his fault if the patient and family chose not to go with the course of action that will possibly save his life. However, it should be pointed out that the doctor doesn’t even know if this last effort of shock therapy would even improve the patient’s quality of life to make it worth living in his eyes. He’s not helping to kill the patient by respecting the his choices. Suicide may be a possibility, but it’s not certain and could happen even after the shock therapy. Even if we want to argue that the patient isn’t competent due to his severely depressed state (even though the case does mention that he was deemed competent to make his own medical decisions), his son also supported his dad’s decision to refuse treatment. As far as we know from the case, the son doesn’t experience depression like his father, but he still believes his dad has the right to refuse treatment and make his own decisions about his life. I do not think PAS is morally right, but I also do not think the doctor in this case can force shock therapy onto a patient who doesn’t want it. The doctor doesn’t know that the therapy would even help the patient, and even if it does it would take months of continued mental agony for the patient before it would begin to work anyways. The doctor isn’t assisting in his patient’s suicide; he is simply respecting the choice of a man in agony who is tired of failed treatments. The doctor’s role is to try convince the patient to do the thing that will do the most good for the patient, but he cannot be blamed if the patient refuses and cannot force the patient into treatment.