This issue of The Journal of ECT has 4 articles on the topic of the intersection of electroconvulsive therapy (ECT) and forensic psychiatry. This topic area has not only been neglected, but I suspect it also has been actively avoided because it raises uncomfortable questions—questions that often do not have easy solutions. And yet the questions posed in the accompanying articles are real-life concerns of the ECT provider and must be met head on.
Every provider is eventually faced with concerns regarding an ECT patient’s ability to consent to ECT. The pre-ECT evaluation should include a comment regarding the patient’s ability to comprehend risks and benefits of choosing or not choosing ECT and ability to make to come to a decision. In those instances that the ECT provider elects to pursue ECT on the basis of substituted consent (ie, guardianship or health care power of attorney), then Dr Rasmussen’s article will be reassuring in describing the generally favorable impression of ECT in those patients who have received it under the condition of substituted consent.1
Of course, the patient’s capacity to make medical decisions may fluctuate across a course of ECT, in directions that are difficult to predict. For example, a patient who lacked capacity at the beginning of a course of ECT (say, for example, the patient was referred for ECT because of catatonic stupor), may regain capacity midway through the treatment course. Should we now ask the patient to sign the consent document, or can we still go forward on the basis of substituted consent that was obtained when the patient lacked capacity? The opposite situation may also arise—that is, that a patient with full decision-making capacity at the beginning of ECT might temporarily lose that capacity if cognitive adverse effects are more than expected. These dilemmas are addressed in Dr Mankad’s article.2
The American prison system has become the de facto surrogate system for treating the overflow of patients with severe and persistent mental disorders who cannot be handled in state hospitals. Access to ECT can be viewed as a basic right to treatment in settings that care for patients with severe and persistent mental disorders. Yet, Dr Surya and colleagues’3 article shows us that ECT is generally not available for prisoner-patients within the US prison system.
Civil lawsuits are inherent risk in the practice of medicine. Of course, the mere occurrence of a lawsuit does not imply actual malpractice, as lawsuits can be misguided in their intent or can actually be intended for a toxic effect.4 This issue provides a case study of an ECT malpractice case, based on an unsubstantiated complaint of devastating memory loss and describes how it was successfully defended.5
This issue is not a comprehensive review of the topic of ECT in forensic psychiatry. For example, we did not consider the role of ECT in restoring capacity to a mentally ill person who is accused of a crime and has been determined to be unable to assist in his/her own defense. Nor do we consider the example of an ECT patient who makes an error of judgment during ECT (signing a will, buying/selling property, etc). The Journal would be glad to receive more contributions on the topic of the forensic aspects of ECT.
1. Dare FY, Rasmussen KG. Court-approved electroconvulsive therapy in patients unable to provide their own consent: a case series. J ECT
. 2015; 31: 147–149.
2. Mankad M. Continual evaluation of capacity to consent during ECT. J ECT
3. Surya S, McCall W, Iltis A, et al. The practice of electroconvulsive therapy in US correctional facilities: a nationwide survey. J ECT
. 2015; 31: 150–154.
4. McCall WV. Psychiatry and psychology in the writings of L Ron Hubbard. J Religion Health
. 2007; 46: 437–447.
5. Goodman T, McCall W. Electroconvulsive therapy malpractice: verdict for the defense. J ECT
. 2015; 31: 155–158.