Consent to treatment in psychiatric patients

The evolution from custodial psychiatry to therapeutic and rehabilitative psychiatry, which has characterised the medical, cultural and social setting of the last 40 years, has necessarily brought out the complete homologation of the mentally ill and the somatically ill subjects.2 3 Both regard themselves as individuals who benefit from particular rights and, consequentially, have extended duties and problems regarding the consent to treatment and medical actions in general.

If on a theoretical level this homologation appears completely coherent and natural, on a more practical level there is an undoubted increase in the complexity of the factors involved.4

In general it is necessary to make two main distinctions. First, the increase of complexity is more marked in the case of consent for treatments compared with consent regarding clinical and instrumental diagnosis. Regarding treatments, the consent required for psychopharmacological therapy or for electroconvulsive therapy (ECT) is essential and must be exactly the same as that obtained for somatic treatments in all other branches of medicine. Also the position of psychotherapy with respect to that of somatic treatments is not different. In psychotherapy, in which the theory is based on practice, there cannot be any form of therapy without the participation of the patient. These ethical dilemmas, especially in psychoanalysis, are particularly complex.5 6

Second, with regard to complexity, it is important not to generalise all psychiatric patients. There is no clinical motivation to believe that patients with schizophrenia are less able than somatic patients to evaluate the information regarding consent for treatment given by his psychiatrist.7

It is in psychotic patients, particularly those whose perception of reality is altered, that problems related to consent are the most complex.8

The fundamental characteristic of delusional thought is that attributes given to situations or people cannot be verified. Furthermore, the same delusional thoughts are used in many other situations, including the process of evaluating the nature and aims of the treatment, the patients often creating unrealistic expectations regarding the treatment itself. To give or to refuse consent is the expression of the patient’s will to undergo or not to undergo treatment and it occurs subsequently to having evaluated the doctor’s suggestion of a course of therapy.9 10

It is in this ambiguous space that realistic understanding and delusional understanding are conflicting, overlapped and distanced from one another, and are either understood or confused in the psychotic patient.

A detailed or generic description of the treatment must be given but this does not influence a delusional patient’s decision-making. Consequently, the consent may be an act of ‘non refusal’ and not true consent.

As it stands, faced with the proposal of any kind of therapy, more frequently psychopharmacological, there are four possible patient responses.

1. ‘Aware refusal’ is that which must be considered before all others. However, the authors feel it is unnecessary to deal with the possible coexistence in the same individual of healthy and delusional parts in the evaluation of reality in depth. The presence, even if severe and pervasive, of delusional thoughts does not automatically exclude the possibility of a good understanding of reality, not directly connected to the delusional area of conscience. The consideration that the patient is able to evaluate reality, independently from any delusional influence, is the basis on which to evaluate to which extent the refusal of treatment by a patient can be substantially free from the influence of the delusion and, therefore, conserves all those prerogatives of autonomy that characterise the act of informed consent in its most general formulation. This is the case of many patients affected by forms, even severe, of depression, whose life of anguish does not necessarily exclude the faculty to request or refuse different types of treatment. This is what happens in some patients with schizophrenia, who have adapted to the invasiveness of their paranoid symptoms enough to, at least partially, possess an insight into their illness, and are able, up to a certain degree, to evaluate and decide on their own treatment.

2. The ability, at least partially, to objectively judge aspects of reality and one’s own relationship with it, is the condition in which the subject can express his own adherence to therapeutic treatment in a congruent and aware manner or make a suitable request for treatment. The condition of extreme suffering experienced by a patient or a condition of perplexity regarding his delusional state and the fact that the patient is aware of this suffering, means that he is able to understand and accept a proposal for treatment. The same problem frequently occurs in the case of patients with depression who express complete willingness to undergo treatment, even if affected by delusional thoughts. In some cases, however, a patient may request a specific therapy, but the reasons for his wish to undergo this therapy may differ from those of the therapist.

3. The possibility that medical intervention is refused by a subject in a psychotic state due to motivations directly influenced by delusional thoughts is the most frequent event. This is obviously the case that creates less problems of ethical or medicolegal nature. It is only the evaluation of the clinical severity and of the therapeutic necessity that deems the treatment to be mandatory. The patient in this state does not appear to have the mental capacity to understand the nature and aims of the proposed therapy or even the state of the illness itself, and therefore to give valid consent or refusal. Due to the psychotic nature of their disorder and to their altered ability to provide an adequate judgement of reality, many patients with schizophrenia are in this condition for lengthy periods of their illness.

4. The most intrinsically contradictory situation, and the most ethically problematic, is when the psychotic patient expresses his consent based on motivations that appear directly influenced by his delusional thoughts. This situation, in which delusional thoughts influence the patient’s decision-making, is frequently given inadequate consideration by the therapist. In this case the patient may accept the proposed therapy for reasons intrinsic to his delusional thoughts, not for those stated by the doctor.

In real practice, it is a condition which often allows the treatment of patients who would otherwise not give their consent or who would be directed towards compulsory treatment. This condition is often accepted, or even sought by the therapist himself, so that the treatment can in fact be carried out. A complete evaluation of the patient’s decision-making capabilities may not be investigated further. Unfortunately, however, it is necessary to recognise that this situation may sometimes occur, primarily for patients with schizophrenia, where tacit acceptance of the equivocality of the situation is often the doctor’s only means to carry out therapeutic interventions.

However, ‘delusional’ consent to a somatic treatment, as a consequence of a profound and recognisable alteration of understanding, creates problems that are not easily resolved from an ethical and medicolegal point of view. The most common clinical situation is that related to the proposal of a psychopharmacological treatment. However, the situation becomes even more complex in the events of ECT being proposed, with a greater number of practical and ethical factors becoming involved.

Electroconvulsive therapy

The use of ECT, formerly known as electroshock, is well known. It was widely used from its introduction at the end of the 1930s to around the end of the 1960s, when psychopharmacological treatments began to assert themselves.11 For many years this was the only effective method of treatment for psychotic patients, such that its use became the almost exclusive method of treatment in psychiatric hospitals in that period, becoming the symbol of treatment in psychiatric institutions. However, with the evolution of social attitudes and scientific knowledge of mental illnesses, together with developments in pharmacological therapies, there was a drastic reduction in the use of ECT.

This association of ECT with psychiatric institutions does not consider the fact that alternative therapies, apart from psychoanalysis, did not exist. Furthermore, the great efficiency of psychopharmacological therapies in the era after the closure of psychiatric institutions played a role in the decline of ECT. The antipsychiatric movement, on a worldwide level, quite often saw the negative identification of psychiatric institutions with ECT, linked with the predominant ideologies of the period, so becoming a symbol of ‘repressive’ psychiatry.

At the same time, however, the use of ECT continued, although in a reduced manner in comparison with the past. More recently, a renewed interest in the nature and efficiency of ECT and a significant evolution of the technologies of its application and knowledge of its mechanisms, have been significant factors in its resurgence in the Western world.12–16

Although there was a renewed interest in ECT by researchers and clinicians, the prejudice of the public opinion against this form of treatment became accentuated.17 The 1970s were the period of the greatest prejudice of mass media against ECT, often based on distorted information or medically unfounded arguments. Newspapers, television, cinema, debates and press campaigns supported the arguments of the antipsychiatric culture, often based on invalid information. ECT became a symbol of repression, social deviancy or, in the best case, an old-fashioned and damaging technique, practised essentially for profit.18 19

On the other hand, the re-evaluation of the clinical use of ECT was codified by a series of Consensus Conferences in several Western countries (USA, Canada, UK). This re-evaluation recognised its efficiency and often its irreplaceability in a series of specific clinical situations, particularly severe depression, catatonic schizophrenia and postpartum psychosis.20–24 As a matter of fact, with a certain variability in different countries, the evaluation of the possible use of ECT today oscillates between objectivity and prejudice. This objectivity derives from clinical considerations which give indications and contraindications and the benefits and risks of the therapy. The prejudice is essentially at an emotional level, and derives from ideological paradigms, often fed by fictitious arguments fuelled by mass media.25

Three intrinsic elements of ECT, which make it a vigorous medical procedure, augment the prejudice surrounding this form of treatment: electric current, anaesthesia and seizure. It is conceivable that the prejudice for the electric current, more correctly defined in this case as fear, is the expression of an unconscious aversive conditioning, linked to a previous phylogenetic memory: the fear of the flashes of primitive men, inscribed in the amygdala. This ancestral memory underlies the fear of electricity and the risks associated with the increase in voltage. If, on the one hand, the current can be a life saver, as in the case of the defibrillator, on the other hand, high voltages can produce accidental or intentional death, as in the case of the death penalty. Anaesthesia is associated with ‘death’ because the patient is completely unconscious and the idea of ‘going under’ or being ‘put to sleep’ is linked to ‘death’. Seizure, instead, may be linked with the image of ‘violence’. The symbolic meaning of these three elements are a part of the collective consciousness and became vivid and lifelike in patients with several psychiatric illnesses, particularly psychotic patients, and in patients with delirium or severe somatic diseases.

Consent to ECT

Informed consent to ECT must also comply with the existing norms and regulations, which are often unclear and contradictory, and which vary from country to country, reflecting various jurisdictions, sociocultural traditions and the development of psychiatric services.26 Consent is frequently requested in writing, ideally after an opportune explanation of the expected benefits, possible risks and side effects, also for anaesthesia. The procedures to be followed regarding the therapy must be clearly explained to the patients, although, depending on the gravity of the case, this may prove difficult.27–33

By and large, a psychotic patient’s way of responding to a proposal of ECT does not deviate greatly from that for somatic treatments in general, as explained previously. Consent to ECT, therefore, can be consciously denied, on the basis of reasons which the doctor recognises as being indirectly or not substantially connected to delusional experiences; in this case alternative treatments must be proposed.

On the other hand, the refusal of ECT can be closely related to delusional elaborations of the patient’s experiences, including the relationship with the doctor and the information given to him. From a deontological point of view the recognition of a clinical necessity for ECT, which the patient refuses because of delusional thoughts, should lead to treatment being imposed on a mandatory basis.

The aim of this paper is to stimulate a clinically based reflection on the critical issue of the consent to ECT in psychotic patients. Obviously, no conclusive indication can be given, but just going through the problem in-depth represents a step forward towards an ethically inspired conduct in such a complex clinical situation.

A few brief comments to conclude the ideas expressed in this paper

In the first instance, as mentioned above, the problem of the validity of consent in a psychiatric patient exists for all types of interventions, somatic in particular, with the pharmacological therapy in the first position. However ECT, due to a complex series of reasons, concentrates and amplifies those problems inherent to other treatments. The complex factors which accompany consent create a new paradigm, which influences the use of ECT.

On an ethical and medicolegal level, the most critical point is that concerning consent to the treatment by a psychotic subject with a severely compromised ability to comprehend the nature and objective of the proposed therapy, but who nonetheless expresses his consent, for reasons derived from delusional thoughts.

In fact, this situation necessarily brings to light the contradiction between an explicit expression of consent, a necessary formality for the commencement of therapy and the validity of this consent, which may be severely compromised due to the patient’s inability to comprehend reality, and therefore the proposal of treatment which is intrinsic to this reality.

However, a more common situation is when the patient’s inability to understand the reasons for proposing this form of therapy leads him to a blank refusal of the proposal.

In the first case, the use of ECT on a mandatory basis, due to the severity of the patient’s condition, is a relatively simple medicolegal decision. On the other hand, in the second case, the decision is much more difficult due to the complexity of the evaluation required. In fact, the manifest inability to express a mindful opinion should automatically negate the patient’s decision, putting it in the hands of the doctor. However, in the first case, the inability to comprehend leads to accepting the treatment that the doctor has proposed, a treatment, which is very trying in its execution and incisive in its results. As a result, this treatment is used only for the most severe patients who, one may speculate, if they weren’t driven by delusional elaborations of the received proposal, would probably deny consent and thus deprive themselves of the possibility of being cured.

In pragmatic terms, the ethical question posed, in this case even before the medicolegal issues, is whether to use the patient’s formal acceptance and go ahead with the treatment. However, a coherent scrutiny of the patient’s acceptance, considering his clinical condition, could lead to it being deemed invalid.

The formal conditions for acceptance of the patient’s consent may have been fulfilled. However, the real patient’s underlying psychic condition poses contradictions. It seems correct to assume that the legal licence to perform the medical act may in some cases, such as those described, be still considered guaranteed by the explicit manifestation of the patients’ consent. Anyway, deontological coherence would encourage taking into consideration the delusional nature of the patient’s judgement. It follows, therefore, that the consent given by a psychotic patient, due to delusional convictions, cannot be considered valid.

To avoid the doctor’s deontological coherence prevailing over medicolegal issues and possibly affecting the curability of the patient by not permitting the necessary treatment, the legal act regarding the mandatory application of ECT should be taken into consideration. In other words, the patient has given ‘delusional’ consent. However, the treatment is deemed to be necessary and since the medicolegal conditions have been fulfilled, it is carried out. This is particularly relevant in cases in which consensus is given by delusional psychotic patients.

It is desirable that in person-centred treatments, the first task of the psychiatrist should be to empathise with the psychotic patient, trying to convince him to accept the proposed treatment. The use of a mandatory ECT should be the last possibility practicable to treat patients. It is in fact possible that the hospitalisation with frequent clinical interviews and pharmacological therapy in place are factors that can facilitate informed consent in subsequent ECT sessions. The use of hospital ethics committees and the intervention, if necessary, of legal figures must be taken into consideration only in the most complex cases. In practice, however, a serious in-depth reflection of this issue seems unlikely in the foreseeable future.