ECT without consent

Madam, – I have read and re-read Dr Siobhan Barry’s letter (December 14th).

In her third paragraph, she says “some mental illness requires treatment against the person’s wishes, including prescribed ECT”. She describes this as being a “human right to be given effective treatment” which right is “ethically founded” and which “all doctors are properly ethically required to protect”.

This seems to mean that psychiatrists are acting ethically in prescribing and requiring a person involuntarily to undergo ECT. It further seems to mean that not only are these psychiatrists acting ethically but that they are, in fact, ethically required to do so (ie impose ECT against the person’s wishes in relevant circumstances) in order to “protect and uphold the right to treatment”.

As a psychotherapist, I am required by professional ethics to “respect clients’ rights to self-determination and autonomy”, to “ensure that the client consents to participate at all stages of counselling and respect clients’ right to discontinue at any time”. (Code of Ethics of the Irish Association for Counselling and Psychotherapy).

If I am reading Dr Barry’s letter accurately, how could two therapeutic professions adhere to such seemingly divergent ethical positions? And what is the legal/constitutional basis for the human right referred to in her letter? – Yours, etc,

IAN WOODS,

Castle Grove,

Swords,

Co Dublin.

I typed this extract from Lars Martensonn’s book ‘Deprived of our Humanity’ in honour of Helena whose anniversary is today.  May she rest in peace?

 

 

 Neuroleptic Drugs in Homes for Mentally Handicapped and Elderly

 

It is an abomination when a doctor visits a home for “retarded” “feeble-minded”, people and prescribes neuroleptic drugs wholesale to those who are reported to be “agitated,” “restless,” “difficult” and so on.  And when he continues to the old people’s home to distribute the same neuroleptic panacea, here justified be diagnoses such as” senile confusion” and “negativism.”  As long as the neuroleptic regime lasts, these institutions deserve the inscription: “All you who enter there abandon hope.”  The Nazis killed their “useless people.”  We let the bodies live, while we kill the souls.

 

A doctor in this kind of situation should recall that medical ethics, if not his own conscience, forbid him to prescribe any medical treatment that is not in the patient’s own best interest, and demand that he respect the patient’s autonomy.  From this follows that, if neuroleptic drugs or other heavy mind medications are ever to be given to children (incompetent persons of any age), the final say and the evaluation of the effect should always rest with somebody who loves, cares for, and fully identifies with the child.

 

The neuroleptic drug phenomenon reveals a racist and fascist element in our society.  It is contrary to Christian values that emphasize love  - Be your brother’s keeper; Love thy neighbour as thyself; What you did to one of the least of these m brethren, you did to me – and the inner man as more important than his outer aspect.  It is equally contrary to humanistic and democratic values that emphasize the autonomy, integrity, responsibility, and value of the individual.

 

Who Shall Control Out Brains

 

People know with their guts and spirit – remember what Nauta said about the limbic system - that the psychiatric view of a human being is limited and incomplete.  Therefore they should demand from their law-makers laws that give them full control and final say about alterations by drugs or other somatic therapies in their own brains, of in the brains and minds of their near and dear ones.

 

Today, if we dare ask the welfare state for even temporary help, relief, asylum, for ourselves of for somebody we care about, and thus turn to a psychiatric or related medical institution, the fact is that – as a condition of help – we have to give up control of what is done to the brain in our own or our loved one’s head.  This is an intolerable condition of help.  It must be reversed by clear laws. 

 

Crimes and Tragedies in the History of Psychiatry; Past, Present, and Future(?)

 

A ban of neuroleptic drugs is the most direct and obvious conclusion from all that has been said here.  But clearly there are also other important legal conclusions and lessons to be learned from the neuroleptic tragedy.

 

The history of psychiatry is frightening.  It is easier to see the evil of past therapeutic practices than to see the evil of today’s methods.  Few would now deny that the lobotomy of large numbers of schizophrenic people 40-50 years ago was a terrible thing.  The neuroleptic drug tragedy, involving many more people, is however a disaster unequaled in the history of psychiatry.

 

The chemical lobotomy by neuroleptic drugs has a cleaner appearance than surgical lobotomy.  Other drugs and somatic therapies that look even cleaner, will be introduced in the future, for example, neuroleptic type dugs that hit the frontal-limbic brain more selectively, and therefore have “fewer side effects,” meaning less disturbance of motor coordination and of hormones – while they do as much or more, that is, catastrophic, harm to the inner man and to our essential humanity

 

The medical profession, being able to see these dangers more clearly than others, should be the first to warn and urge legal safeguards.  For example, laws of the following kinds appear necessary.

 

A legal Right to Drug- Free Care

 

The necessity of this legal right was shown above as we answered the question: who shall control our brains?  We concluded that it is intolerable coercion when people in distress are given help only on the condition that they accept mind-altering and brain-damaging drugs and other somatic brain intrusions.

 

We are talking here of a right that is a natural and self-evident consequence of the value system of our society.  Some examples have been given, and countless tragic cases could be cited, that illustrate the need for legal protection of this right.

 

When patient has invoked this right, or when somebody who rightly represents him has invoked it on his behalf, his position should be respected without questions, in a fully sincere spirit and as a matter of course.  In other words, from then on the staff of the institution is to help him according to the best of their abilities as if the drugs did not exist.  They simply have one tool less.

 

Legal Protection of Committed Persons against Brain Intrusions

 

More important and more fundamental than physical liberty is the right to protection of one’s mind and brain against unwanted chemical and physical intrusions.  To day any committed person loses this right. 

 

It is intolerable that this right can be replaced by the whim of any physician, who may order a brain or mind altering treatment that most of his colleagues would not even consider, a treatment that may have gross consequences for the future life of the patient.

 

Forced treatment must not be allowed automatically because a person is committed.  Because some people find that a person has to be locked up, this person should not at the same time lose a right that is more important and more fundamental than physical liberty.

 

A second legal step, more stringent and thorough than that required for commitment, is necessary before the brain is allowed to be touched against a person’s will.  It is an outrage that any committed person can be exposed to such measures as ECT and neuroleptic drugs, for example, in long-acting depot form, because of one doctor’s decision.  If a violation of personal in practice, more serious than imprisonment, is ever to be allowed, it must first be established that” all reasonable men can agree that the treatment is to the patient’s benefit.”

 

The medical profession-guided by the principle of informed consent, the principle of autonomy, and the principle that any medical treatment has to be in the patient’s own best interest-must insist that the court for such decisions seeks the advice of someone who loves, cares for and identifies with the patient.

 

Nobody else is better fit to represent somebody who cannot represent himself.  If this person’s verdict is a no to the treatment, the verdict of the court must also be no.

 

If patients are given this kind of legal protection and security – against for example, neuroleptic drug depot injections and electroshock treatments – then the bad reputation and the great fear of psychiatric clinics may begin to disappear.  Morals would rise.  Psychiatry and psychiatrists would also greatly benefit.

 

A Legal Ban of All Neuroleptic Drugs

 

The argument for this law is that the harm of neuroleptic drugs for out weighs any benefits, and that the present intolerable situation cannot be corrected soon enough by other means.

 

Psychiatric opinion holds that neuroleptic drugs are most clearly suitable for acute schizophrenia, and that other uses are more questionable.  For example, it is warned that these drugs are “too potent” and “too unsafe” for “trivial” uses.   In Sweden about 1.000 people get the diagnosis of schizophrenia each year, while about 100.000 persons get neuroleptic drugs on any one day.  The diagnosis of acute schizophrenia thus accounts for no more that one or a few per cent (say 0.5 – 2% depending on definitions0 of the total consumption.

 

We have seen reasons why neuroleptic drugs are particularly harmful and dangerous when given to a young person in acute schizophrenic crisis.  Psychiatrists would generally agree that if neuroleptic drugs are not good for schizophrenic people, they are not good for anybody.

 

From the three initial statements in this paper, taken together, it follows that neuroleptic drugs are indeed bad for schizophrenic people.  These statements have been supported by the evidence and arguments given in the rest of the paper.  It then also follows that the drugs are bad for other people.  Accordingly, neuroleptic drugs should be banned.

 

The residual discussion as to whether there may be some legitimate uses of neuroleptic drugs that would warrant consumption in the vicinity of zero per cent (0%) of today’s level is irrelevant in this context.  It should not be allowed to cloud the main issue and to delay the political decision.

 

 

No doubt the resistance of the psychiatric system to the needed change will be enormous.  Psychiatrists will lose the most efficient system for management and control. Those who are motivated more by desire for prestige and power than for truth and the well-being of patients and society, will resist the change.  But, deep in their minds, perhaps even they will be relieved.  An experienced psychiatrist, on the threshold of retirement, warned; “But, Lars, you have to remember: then everything they have done all their life is wrong.”  And he added:” It is a system that worked.”

The psychiatric profession is in a dilemma.  We are reminded of the truth that what is really blame-worthy is not one’s past errors, but rather one’s refusal to face them and learn from them.  We see that, when it comes to the most serious things, we are more willing to forgive others than ourselves.  We see that forgiveness, and first of all self-forgiveness, is a liberating virtue.

 

Psychiatrists as a group are not more mature in this respect than others.  They need outside help to kick the destructive drug habit.  Many of them will welcome such help, if only silently.

The Next Question

The next question is: Do we have the moral will and courage to eliminate an element in society that is contrary to our highest values.  If so, the evil of neuroleptic drugs shall be eliminated by forceful political action.

When we look at other eras and cultures, we see clearly that momentous evil were covered up or justified, considered "necessary" in the name of the reigning religion or other totalitarian ideology.  the neuroleptic drug phenomenon shows that the same is true in our own society.

We still hope that our "religion" is different, because humanism -- science--democracy is, in principle, self-critical, self- corrective, self-reflective in accordance with the structure of man's highest mind, which -- thanks to its self-reflexive structure(?) -- is,free, creative, responsible and without set limits. 

We hope, but today as always, it takes courage and action to make of hope a new reality.

The tools of psycho pharmacology are as great a threat to the inner man, as the tools of war to the outer man.  Scientists and physicians should be sobered by seeing their responsibility for this evil.

Almost forty years ago Michael Polanyi (1957) wrote an article in Science with the title "Scientific Outlook:Its Sickness and Cure," and he said

"Today...the power exercised previously by theology has passed over to science; hence science has become in its turn the greatest single source of error...I am convinced that the abuses of the scientific method must be checked, both in the interests of other human ideals which they threaten and in the interest of science itself, which is menaced by self-destruction, unless it can be attuned to the whole range of human thought."

Innumerable scientific studies show that neuroleptic drugs are effective in reducing psychotic symptoms. Such studies typically extend over two years at most.  In every respect, thus also with respect to time, such studies take only a small fraction or aspect of the patient's life into account.  We have seen, for example, that the short-term psychiatric "improvement" may be correlated with long-term personality deterioration.

The ratings and measurements of psychiatry have their uses.  But when these part truths are allowed to stand for the whole truth, the result is evil.  Truer measures of a human being are those in the eyes of another of his kind who sees him and loves him; and those of his own hopes and dreams.  Psychiatry has not understood this moral imperative.  It has become therefore a tragic and cruel measurement of man.

It seems fitting to conclude this paper, at a conference on laws and legal institutions in relation to psychiatry, with a quote by Charles Darwin that appears on the first page of a book by Stephen Jay Gould (1981) with the title you just heard, The Mismeasure of Man:

"If the misery of our poor be caused not by the laws of nature, but by our institutions, great is our sin."