Seanad debates

Wednesday, 23 March 2011

Mental Health (Involuntary Procedures) (Amendment) Bill 2008: Committee Stage (Resumed)


5:00 pm

Photo of David NorrisDavid Norris (Independent)

ECT is very much the nub of the matter and there are differing views on it. The College of Psychiatry in Ireland has made its views plain. As a matter of principle, forced medical treatment must be approached very carefully. I know there are particular cases, for example children whose parents are members of certain religious groups that do not permit blood transfusions. In those circumstances it seems to me to be absolutely clear that the courts have a right to intervene, but we are not dealing with that here. We are dealing with a situation that can be put within the broad context of the medicalisation of mental illness. That is something I feel very strongly about, as I believe do some of the people here who support this legislation which was introduced by the Green Party with my support on behalf of the Independents. I believe we understand this situation.

I have received extensive briefing documents but I shall not read them all into the record of the House. However, I would like to summarise them. With regard to the question of forcing this upon unwilling patients, I believe this is a very dangerous thing to do. As I indicated earlier, I am old enough to have dealt with people who were subjected to this treatment simply because of their sexual orientation, and it did enormous damage. I have had to cope with the wreckage of that system.

The previous amendment, about which there was some confusion, dealt with lobotomy in some way. That was a very dangerous thing and it showed the medical profession in a very poor light. Within my lifetime doctors were actually, in an uninformed way, removing sections of brain just to see what the result was. One of the classic cases of this was Rose Williams, the beloved sister of the playwright, Tennessee Williams. She was rendered into permanent infantilism by that operation. It was a tragic mistake that was consented to on her behalf by her parents because of an ignorant medical system in the United States at that point which thought that by brutal physical intervention, they could rectify the situation. Perhaps there would be a certain pacification, but they did not even address the real human problem underneath it. That is what is wrong, very often, with medicalisation. I have visited a facility in Cork and seen some of the results of this, and we need to be very careful when we introduce compulsory medication of any type, and certainly compulsory electroconvulsive therapy.

I was briefed at the introduction of the Bill by Senators Boyle and de Búrca by a man who has, sadly, since died, Dr. Michael Corr. He was passionate that this was wrong in virtually all circumstances. He produced a large body of evidence to this effect, which I read. I am not going to quote from it, as anybody who wants it can get it. To pass an electric shock through the brain tissue of a human being is a very blunt instrument, and no one actually knows how it works. They do not understand the neurochemistry or the neurophysics of it, nor can they guarantee it will be successful, and it damages memory. There is no doubt about that. It can have more serious complications, and no one who has witnessed it, as I have on video — never in person, I am glad to say — can have any view other than it has a very brutal impact on a human patient.

However, I have also been spoken to by people who have said, in effect that they did not want or welcome this, but it brought them out of a very dark place. These are the facts and I am sorry to disappoint any of those who have lobbied me, but I have to tell what I see as the truth. However, I understand that the situation can be addressed by reverting, simply, to common law. At the moment, two psychiatrists can decide that this treatment must be inflicted on a patient without his or her consent. They are protected in some reputational and legal sense from any recourse afterwards by the patient if the treatment is negative. My understanding is that this is already covered under common law. If this is the best practice or treatment, then that acts as a common law defence, so that what may be behind the briefings of my esteemed friends in the Royal College of Psychiatrists is protecting a patch. Perhaps I am wrong about this and in the event I apologise to them, as I do not mean to misconstrue the motivation. That seems to me to be the position, however, as borne out by quite a number of doctors who have said this to me. The chief psychiatrist responsible for mental health services in west Cork said that holding on to section 59(1)(b) was not really about medical practice, more about medical power. I do not believe that in 2011 this is, can or should be justifiable.

I am a layperson and if a doctor says this, I have to take that into the balance when I am speaking on this. Dr. Richard Lakeman of Dublin City University says: "Forcing or otherwise compelling people to receive an electric shock to the head is an anathema to the notion of personal recovery and an affront to all citizens who value personal autonomy and freedom." The last quote I shall give is from Dr. Agnes Higgins, partly for the sake of gender balance, because it is important we respect the different understandings that sometimes women may have, or even those of us who develop the feminine side of the brain, as I like to believe that I have. She says:

I am aware that people are making the argument that to remove 59(1)(b) is to leave some patients vulnerable if they require it as a last resort. This is not the case, as doctors can still give ECT and resort to 'duty to care' argument and common law.

Perhaps the Minister of State will be able to tell the House whether that is the case. I would be concerned if it was not, because people can be nasty. In fact, patients can be nasty. Not all patients are grateful.

I remember being profoundly shocked at hearing of a woman in Miami on a cruise who developed a sudden onset of appendicitis that was leading towards peritonitis, which could very easily have been fatal. The captain appealed for a doctor and one came and operated on her with a penknife. He saved her life and she successfully sued him because the scar reached above her bikini line. I believe it was an appalling affront to decency to sue the person who had saved her life, but it shows that it can be done. I have always believed in equal treatment in trying to reach a proper understanding of situations. I believe in equal and fair treatment for patients, but I also believe that doctors who act honourably and decently should be protected.

My understanding is that the removal of this section still leaves open the possibility in an extraordinary situation when, for example, a patient is refusing food, not communicating or refusing liquids. That is a threat to the patient's life and if in the opinion of the attending doctor there is a possibility that life may be saved by the administration of this very uncertain procedure, then, if it were someone we loved, would we not try every last resort? I believe that doctors are protected under law if they do this, but if my understanding is wrong, perhaps we shall have to look again. For that reason I strongly approve of the more radical approach to this situation.


Catherine Conway
Posted on 25 Mar 2011 9:13 pm (Report this comment)

I am a trainee psychiatrist, so you may think I am biased. I am. But please read on, and I will try to explain why.

Before I went into psychiatry, I had seen the same films, the One Flew Over the Cuckoo's Nest, and I thought ECT was barbaric. In the past, as Sen.Norris has stated, it was used as a political instrument of control. That was indeed very very wrong.

As it is used now, ECT is given, under general anaesthetic, to the most severely depressed patients. Approximately 70% of those receiving ECT are those for whom all other treatment options have failed. This is their last hope. The majority receive ECT voluntarily. A very small minority receive it involuntarily. Why? Because they are so ill, so depressed, so mentally unwell, that they have lost capacity to consent to treatment.

Severely depressed patients are among the sickest patients in the hospital. They may be mute, unable to feed or look after themselves, lacking the very will to live, actively suicidal. Psychotically depressed people may believe they are evil, or in fact even already dead inside. In a psychotically depressed patient refusing food or water, ECT is literally life-saving, as it is by far the most effective and fastest way to allieviate their distress. If you were to ban involuntary ECT, you would remove the sickest patients rights to access the best treatment available.

ECT is the most effective treatment for depression, and it can be life-saving. Response rates are 80 -90%. If you have ever seen someone with psychotic depression, and see how their life has shrunk to abject misery, and the failure of medication, of psychotherapy; and you see them regain their health with ECT, you cannot but realise the effectiveness of this treatment.

The criticism has been raised that doctors do not know how ECT works. That is not quite true. ECT stimulates neurogenesis in the hippocampus, in the dentate gyrus, which promotes nerve cell growth. It improves nerve cell signalling, and synaptic connections; precisely the opposite to the effects that untreated chronic depression has on the brain. Antidepressants have a similar effect on the brain, which correlates with their antidepressant effect.

The point has also been made that knowing something does work, but not knowing exactly how it does so, is no reason not to use it. Some folk remedies were known to be useful for years before the active chemical in the plant was extracted and the method by which it acted on the body was elucidated. For example: foxgloves were taken for heart failure before digitalis was found to be the active ingredient; yew tree bark was taken before the chemotherapeutic agents taxanes were synthesised from it. We know ECT works. We know the effects it has on the brain. Do we understand every step in the molecular intracellular signalling pathways? No. But do we know enough to know that it works? I think so.

Much research has been done into the role of ECT and memory. It is known that depression itself affects memory. In fact when people are severely depressed they can exhibit what is called "pseudo-dementia", impaired memory and concentration which resolves on treatment of depression. There are many studies on memory pre-and post-ECT. To date, a metanalysis of studies shows that ECT has no negative effect on testable aspects of memory: short term, working memory, procedural memory, etc. Autobiographical memory has been more difficult to design studies for, but a study is underway in Ireland at present, and it is hoped will provide futher data on this.

I am not aware of a circumstance where doctors can give involuntary ECT under common law. Was not the mental health act set up to safeguard the interests of patients, to ensure that patients got two formal opinions from consultant psychiatrists - which are not taken lightly by any means. If this safeguard was removed, then I believe the human rights of some of the most vulnerable people in our society would be threatened - the right to receive care, and the right to receive it promptly, in a systematic, and not on an ad-hoc basis.

On a final point, recently I attended a conference of the Irish College of Psychiatry. At this, a former patient gave a presentation. He described, in moving terms, how his life was devastated by depression. He became mute, catatonic, psychotic. He was made involuntary, and received ECT after several months of every other treatment avenue being exhausted. Within a short course of 5-6 treatments he was well. He has remained well for several years now, and credits his recovery to the ECT. This patient has written his story down, and has met with the last minister for mental health in order to advocate for ECT for the most vulnerable and ill patients. He even states that if in future he had a relapse, he would want to have ECT again. Would it not be a travesty if his wishes could not be respected?

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