Charlotte Blease is a philosopher (“main philosophical interests lie in philosophy of mind, philosophy of science and medical ethics”) currently teaching at Queens University, Belfast, and one of BBC radio’s new generation thinkers (“Specialist subject: The placebo effect and the ethics of deception in medical practice”). She can be heard on BBC Radio 3 tomorrow night, talking about “the medicine game”.
Last month the Journal of Medical Ethics published an article by Blease entitled “Electroconvulsive therapy, the placebo effect and informed consent”. Almost all articles about electroconvulsive therapy (ECT) in academic journals are written by psychiatrists who use the treatment and it makes a refreshing change to see someone from outside psychiatry tackle the subject.
The author says that, after a sharp decline in the 1970s, ECT is undergoing “something of a (restricted) renaissance in the UK and USA…” In the UK at least, ECT use did indeed decline during the 1970s, but it continued to decline during the 1980s, 1990s and the 2000s, with – as yet – no sign of any sort of renaissance. As far as the USA is concerned, it is more difficult to be certain because so few figures are available. But, although ECT is often described in the media as making a comeback, the evidence to support this statement seems to be lacking. In Texas, one of the few states to keep track of ECT, there has been no sign of a renaissance, with annual statistics remaining fairly constant over the years.
I would also take issue with the author’s statement that, in both the UK and USA, ECT without consent is “rare”. This is true for Texas, where only about 1 per cent of ECT patients are described as undergoing ECT without consent. It may be different for other states in the USA with different regulations. But it certainly is not true for the UK, where about one in 3 or 4 courses of ECT are given to patients who are deemed to lack the capacity to make a valid decision about their treatment.
The main argument of the article is that patients should be informed that “ECT may work by inducing placebo responses”. Evidence for this comes in the form of a number of studies done in the 1970s and 1980s in which ECT was compared with sham ECT (the ECT procedure without the electric shock). The results of these studies were generally in favour of ECT, but not by dramatic amounts – the people undergoing sham treatment also improved. Blease points out that these trials had methodological constraints; she could also have noted that in those days ECT was used much more widely and many of the patients would have been people who nowadays would not be considered for ECT, for example those with milder depression.
The article concludes with recommendations for “authentic informed consent”:
“The importance of informed consent in clinical practice is stringently asserted in medical ethics codes. However, ‘fully’ informed consent would mean detailing everything that is known about particular treatment options. While this is not a realistic proposal it is incumbent on physicians to ask: ‘What is a medically relevant fact for this patient if they are to agree to this form of treatment:’ This opens up the following questions: i) ‘What do all patients need to know if they are [to] make decisions and to understand information on the effectiveness and side effects of a treatment?’ and ii) ‘What do individual patients consider to be significant with regard to treatment options?’ In the case of a therapy – such as ECT – where the mechanism of action is not known, for which there is controversy over its effectiveness, and for which there are significant and serious side effects, it seems clear that patients deserve to know this information… In the case of procedures such as ECT which carries potentially very serious side effects, the need for improvement in patient information can be regarded as timely. Given the prevailing variety of claims made about the effectiveness of ECT (from straightforward endorsement for severe depression, to qualified concerns, to outright repudiation of its use as a therapeutic tool), it seems only appropriate that patients are informed of these serious consequences.”
I don’t know what patients are told about ECT in face-to-face consent discussions with psychiatric staff, but if patient information leaflets are anything to go by, it would fall far short of the sort of information Blease suggests. I remember a training video on ECT that was produced by the Royal College of Psychiatrists some years ago (I would guess the 1990s) which showed a psychiatrist putting a form in front of a patient with a comment (if my memory serves me correctly) along the lines of getting consent out of the way. Hopefully things have improved somewhat since then.