Image Source: http://www.psych.med.umich.edu/ect/how-does-ect-work.asp
Dilemma:
Simon, a 53-year-old widower and father is admitted to the psychiatric ward after overdosing on antidepressant medication. Simon is agitated and reluctant to interact with others and according to his son, he is in a state of financial instability. Simon feels much sadness over the loss of his wife and also blames himself for his mother’s death 32 years ago. He threatens to commit suicide because he has nothing to live for. His psychiatrist proposes of electroconvulsive shock therapy (ECT). Simon refuses and his son also has worries about the risks of ECT and refused to go against his father’s wishes. ECT offers great benefits if successful; however, there are risks. The dilemma is whether the psychiatrist should go against the will of the father and his son and administer the treatment or if the father should be allowed to make his own decision about his life (Thomas, et al. 124-31).
Discussion:
The potential risks and benefits of ECT must be considered. ECT is a controversial treatment that involves administering anesthesia and running an electric current through the brain to cause a seizure. This is repeated from 6-12 times. Memory loss and confusion follow the procedure and it could provide relief from severe depression (“Electroconvulsive Therapy (ECT)”). There are risks of brain damage post-treatment, however the prognosis has improved over the years and it offers a quick solution when compared to prescribed drugs.
It is important to consider patient autonomy and the moral status of the patient. In medicine, patient autonomy is essentially the patient’s right to make intentional and well informed decisions about the course of treatment without pressure from the physician (Beauchamp and Childress). It is a basic human right to have autonomy; however, the level of autonomy a person may have can be determined by their competency. In this case, although Simon is severely depressed, he is not mentally incompetent. So shouldn’t he be able to make his own decision? Often in psychiatry, patients may refuse to take medications and sometimes, covert medication may occur where medicine is hidden in foods and beverages without the patient’s knowledge which is unethical but may be ethically justifiable. For example, for an Alzheimer’s patient who is losing cognitive function, forcibly giving medication may seem justifiable because they are not able to fully realize that the medication will help them (Latha). However, does this reasoning apply to Simon who is severely depressed but fully competent?
There are differences between the case of the Alzheimer’s patient presented previously and Simon. The Alzheimer’s patient is not competent while Simon is competent and giving prescription drugs covertly does not compare to applying electric current through a patient’s brain forcibly. One can argue that Simon’s unstable emotional state may inhibit his judgement to the point where he would rather die than to try any more treatment. However, this would be operating under assumption which is not the duty of the physician. Because this treatment is so severe and risky, I believe that Simon should be able to make his own decision about his life. This argument does require accepting that Simon may commit suicide; however, from the psychiatrist’s standpoint, I do not believe that is his or her choice to make. If the psychiatrist has done all that they can in terms of informing the patient of their options and allowing the patient to make an informed decision, they have done their job.
Works Cited
Beauchamp, Tom L, and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics, Oxford UP, 2001, p. 101.
“Electroconvulsive Therapy (ECT).” Mental Health America, www.mentalhealthamerica.net/ect.
Latha, K. S. “The Noncompliant Patient in Psychiatry: The Case For and Against Covert/Surreptitious Medication.” PubMed Central (PMC), www.ncbi.nlm.nih.gov/pmc/articles/PMC3031933/.
Thomas, John E, et al. “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.
Great analysis, Kianna! While I agree that ECT has its risks, it also offers important benefits that have the potential to transform Simon’s life. Regarding major depressive disorder specifically, it has been found to be highly effective in “treatment-resistant patients” (J ECT, 2008). In my opinion, I believe the chance of giving Simon a life free from depression and suicidal tendencies is worth the risk of possible side effects such as temporary memory loss.
Another point I would like to comment on is Simon’s competence. While I acknowledge the importance of patient autonomy, I do not believe that Simon is mentally able to make this decision for himself. His altered view of life (i.e. misconceptions about the cause of his mother’s death and his financial situation) are evidence that he is not “all there.” (Thomas, et al. 124-31).
As such, I think the physician should override their decisions and perform the therapy. Because Simon has exhibited clear intentions to commit suicide, I believe this holds the physician accountable for Simon’s actions. While you say that it is not the physician’s choice to make, protecting Simon from further harm would fall under a physician’s duty to uphold the principle of beneficence, or the norm of preventing harm, as defined by Beauchamp and Childress. For example, if a patient expressed the wish to commit suicide to a psychiatrist, it is the psychiatrist’s duty to try to protect them from harm. In fact, they could even be charged for medical malpractice or negligence if the patient’s intentions are ignored. To quote Colleen Tarpey, JD, and Eve Koopersmith, JD: “Physicians have been held liable for…failure to administer medications that led to a patient’s suicide, and for their failure to commit or confine a patient when necessary to prevent the suicide attempt” (Tarpey and Koopersmith). Shouldn’t it be this physician’s duty, too?
References
Beauchamp, Tom L, and James F. Childress. (2001). “A Framework of Moral Norms.” Principles of Biomedical Ethics, Oxford University Press, pp. 13.
Khalid, N.; et. al. (2008). “The effectiveness of electroconvulsive therapy in treatment-resistant depression: a naturalistic study.” Journal of ECT, 24 (2), pp. 141-5. doi: 10.1097/YCT.0b013e318157ac58
Tarpey, C.; Koopersmith, E. (2014). “Understanding physcians’ duties toward suicidal patients. Medical Economics. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/centers-disease-control-and-prevention/understanding-physicians-dutie?page=full
Thomas, John E, et al. (1987). “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview Press.
You say Simon is competent, and I agree. But, have you considered that his mental state is biased and his perspective may not be “stable” or “normal”? If so, should he still be allowed autonomy and final say in the decision to receive treatment or not? Since Simon is already suicidal, would you say that he has “nothing to lose” in trying the ECT treatment?
On the note of autonomy, I also think it is important to uphold a patient’s choices and his or her actions that result. However, a patient should be competent in his or her decision. In this case, the patient seems that he is not fully competent. He lacks sleep which impairs judgement, and he has severe depression. He is also still recovering from his traumatic event of attempting suicide. His son, who does have a say in whether he should receive treatment, may not be fully aware of the procedure of ECT. It is easy to be caught up by media’s misrepresentation of the procedure.
According to Owens in the British Journal of Psychiatry, “nine out of ten people who attempt suicide and survive will not go on to die by suicide at a later date”. I believe that there is still more to discover as far as types of treatments and more time to allow Simon to become fully competent.
Citations
Harvard T.H. Chan. “Attempters’ Longterm Survival.” Means Matter. The President and Fellows of Harvard College, 09 Jan. 2013. Web. 30 Jan. 2017.
Thomas, John E, et al. “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.