Practices of the mental health profession are among the least debated in health care. Like other specialities, the mental health field is influenced by various interests, including those of the pharmace- utical industry. Horror stories, like the chaining of mentally ill patients in Erawadi, appear in the media periodically but are soon forgotten. Despite the existence of legislation, there is no evidence of regulation of mental health practices, and little discussion within the profession. Patients are rarely in a position to complain, given the nature of their problem, and their relatives sometimes have interests different from those of the patient.One such practice is the use of electroconvulsive therapy (ECT) without anaesthesia, euphemistically termed ‘unmodified’ or ‘direct’ ECT. A writ petition by a Delhi-based voluntary organisation, Saarthak, calling for various changes in mental health practice, has triggered off a heated debate within the profession. The demands included a ban on unmodified ECT, guidelines for its use, and a procedure for taking informed consent for ECT with anaesthesia. Some professionals feel strongly that while ECT may be of great benefit, it should never be used without anaesthesia. Others believe that its benefits outweigh the risks, and the absence of facilities for giving anaesthesia should not rule out its use as a life-saving procedure. At least one mental health advocacy group maintains that the procedure is barbaric and should be banned.ECT itself has a controversial history and has been discontinued in many countries. Some of the concerns by the opponents of ECT involve its safety— fractures and memory loss are just some of the complications reported— and its scope for misuse because it is relatively simple to perform. There is the worry that ECT machines are a source of profit and could be misused. The practice of sedating frightened patients who refuse the procedure is also worrisome. Should the patients’ fears be dismissed? Shouldn’t their consent be sought? Then there are questions concerning ECT, with or without anaesthesia. Every psychiatrist will accept that the procedure should ideally be performed with anaesthesia. Now, should it be done if anaesthesia facilities are not available, for whatever reason? Some feel that ECT is the only option for patients suffering from severe and suicidal depression and who are not responding to drugs. Refusing ECT in such cases would amount to being inhuman, they argue. The counter-view is that since ECT is a serious medical procedure, it should be used with caution, and given either with anaesthesia or not at all.Clearly then, ECT is just one of many practices in mental health treatment that desperately needs to be debated within the profession. What about the prescription of drugs with known and irreversible side-effects? Are those prescribed these drugs informed of these side-effects before the drugs are started? Not likely, because it is felt that the patient is not in a position to give informed consent. If it is felt that the patient is not in a position to give informed consent, should a relative’s consent suffice? What do mental health professionals do to prevent ‘psychiatric abuse’ by relatives—and ensure that they are not party to such abuse? How should the psychiatrist respond when a man reports that his wife is hallucinating and asks for medication? Are there circumstances in which they can prescribe a psychotropic drug to be administered to the wife, without her knowledge and without the doctor ever meeting her? Does the situation change if the complainant is a woman whose husband has delusions and won’t see a doctor?Clearly, what is needed is a wide-ranging discussion on issues of this kind, to ensure that all their aspects are discussed adequately. There is also a need to evolve guidelines for ethical mental health practice with the full involvement of professional organisations and the general public.(The writer is executive editor, ‘Issues in Medical Ethics’)
