I move: “That the Bill be now read a Second Time.” 

I also welcome the Minister of State to the House.  On behalf of the Green Party, I am very happy to move this Bill.  It is quite limited in its scope, which is deliberate.  There is a much wider debate about the appropriateness of certain psychiatric practices and the model that underpins them.  Those of us who have been involved in the mental health services are very aware that the traditional biological or medical model is increasingly being challenged in the field of mental health.  There is a very strong call for its replacement by a much more comprehensive bio-psycho-social model.   This debate is very important because of the treatments prescribed by each model of mental health disorders.  The focus of the Bill is on a couple of procedures that are currently on our statute books and which the Green Party wishes to see amended. 

The scope of our Bill relates to  involuntary procedures that are prescribed under the biological or medical model.  We specifically refer to the practices of psychosurgery and ECT.  Section 1 of the Bill seeks to amend Section 58 of the Mental Health Act 2001, which concerns use of psychosurgery.  Most of us became familiar with the treatment of psychosurgery – commonly known as lobotomies – through the famous film starring Jack Nicholson, One flew over the Cuckoo’s Nest.  Public awareness of the procedure has meant that over time, its use has almost completely died out.  It does not appear to have been used in this State over the last 20 years.  However, it is still left on our statute books and the option to use it still remains.  We are attempting to delete this section in section 1 of our Bill, and to introduce on Committee Stage a prohibition on its use. 

Section 2 of the Bill seeks to amend section 59 of the Mental Health Act 2001, which allows for the involuntary use of ECT in certain circumstances.  We are looking for this section to be deleted and replaced with the following wording.  “A programme of electroconvulsive therapy shall not be administered to a patient unless the patient gives his or her informed consent in writing to the administration of the programme of therapy.”  The issue of consent and informed consent is central to the amendment proposed  today.  The Mental Health Commission rules for 2006, governing the use of electroconvulsive therapy, are very specific on the issue of consent.  These rules state that a patient must be considered capable of giving informed consent for ECT, including anaesthesia, unless there is evidence to the contrary.  They also state that capacity to consent must ensure that the patient can understand the nature of ECT, understand why ECT is being proposed, understand the benefits, risks and alternatives to receiving ECT, understand the broad consequences of not receiving ECT, retain the information long enough to make a decision to receive or not receive ECT, make a free choice to receive ECT and communicate the decision to consent to ECT.  Consent must be received in written form. 

However, in part 2, section 4 of the guidelines entitled “Absence of consent”, it is stated that where a patient is unable to give consent or is unwilling to give consent, Section 59 (1) (b) of the Mental health Act 2001 applies.  This section states: 

Where the patient is unable or unwilling to give such consent, the programme of therapy is approved (in a form specified by the Commission) by the consultant psychiatrist responsible for the care and treatment of the patient and the programme of therapy is also authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first mentioned psychiatrist. 

A form 16, entitled “Treatment without consent Electro Convulsive Therapy Involuntary Patient (Adult)” must be completed by both consultant psychiatrists and placed in the patient’s clinical file. 

Our Bill seeks to prohibit the involuntary administration of ECT to a patient.  We will propose on Committee Stage that during a period before he or she becomes unwell, and following a full and comprehensive explanation of the procedure of ECT, a patient will be asked to sign an advanced directive, giving or refusing consent for the ECT procedure on them at any stage in the future.  We accept that the advanced directive could contain a provision where the patient is empowered to name an individual to make a decision on his or her behalf, in the event that he or she was likely to become unwell.  However, this safeguard would deal with the issue of consent and ensure that the patient was consenting in a situation where he or she understood the implications of the decision, and was not under the influence of heavy doses of anti-psychotic or anti-depression drugs while making the decision. 

Why is the issue of informed consent by patients to the use of electro convulsive therapy on them so important?  Electro convulsive therapy is a procedure that  is primarily used for patients suffering from severe depression – in some cases psychotic depression.  It is also used for patients with catatonia or mania.  It is certainly a highly controversial treatment, and while it is supported by many in the traditional psychiatric profession, it is bitterly opposed by many patients and their families as well as a growing number of mental health professionals.  

According to a recent article by Dr. Brian O’Shea in Irish Psychiatrist, October-November 2007, the use of electro convulsive therapy in Ireland was first officially reported in 2003.  He refers to a study by Daly et. al., which stated that in 2003 in Ireland, 859 had received this treatment, although the use of ECT had varied per region.  The figure was 38.7 people per 100,000 in the southern health board region compared to 8.4 per 100,000 in the south-eastern health board region.  This issue raises two important questions.  Why is it that, given the controversial nature of electro convulsive therapy, no official records have been available for those investigating and concerned about its use, until 2003?  The second issue that arises is why there is such a level of variability between the different health board regions in terms of the use of electro convulsive therapy.  This is something that must be investigated further by the Department of Health and Children.  I have no doubt that, following our debate today, this type of investigation will occur.  

Most individuals undergo a course of between four and six treatments of electro convulsive therapy, usually two per week.  The procedure is reported to work quickly, although its effect may not last longer than one month.  The literature reports that it is usual to have a memory blank for the time surrounding a course of electro convulsive therapy.  The article I referred to by Dr. Brian O’Shea makes a couple of very worrying remarks about the use of electro convulsive therapy.  It opens with a quotation which basically questions whether electro convulsive therapy should be a treatment of last resort and seems to be encouraging a much more widespread use of it.  There are other comments in the article, however, which should cause concern.  Dr. O’Shea says that dementia per se is not a contraindication to the use of electro convulsive therapy, although confusion among dementia patients after ECT can be severe and prolonged.  He says Down’s syndrome patients can also be given ECT and mentions that psychiatrists do not consider age to be a contraindication in giving electro convulsive therapy.  He refers to a study that predicts an increased use of electro convulsive therapy in elderly depressives.  Another study he refers to stated that electro convulsive therapy might actually be under-used among the intellectually disabled.  

There is a passing reference in Dr. O’Shea’s article to the possible side-effects of electro convulsive therapy.  These are side-effects such as amnesia, fractured limb  bones, dislocated jaw, broken teeth, bitten tongue, myocardial infarction and angina.  There is some reference to cognitive patients who have undergone electro convulsive therapy, and who experienced cognitive difficulties afterwards.  Again, not very much attention is given to that issue in the article.  However, I should like to read a short passage from a psychiatrist who has been a very vocal critic of the practice of electro convulsive therapy, Dr. Peter Breggin.  This highlights why there is a campaign among those who have experienced electro convulsive therapy and object strongly to its involuntary use, in particular, Dr Breggin writes as follows:  

It is impossible to find words that are sufficient to communicate the tragic personal cost to many of the patients who undergo ECT.  In my own experience, spanning more than thirty years, I have encountered dozens of individuals whose lives have been wrecked by the effects of ECT on their mental function…Many have been left with such devastating retrograde amnesia that they can no longer function as professional persons or homemakers.  Years of professional training and other key aspects of their lives have been obliterated.  Even portions of their past that they can remember may seem remote and alien as if they are watching a movie rather than recalling their own lives.  Often they have been impaired in their ongoing ability to focus or pay attention, to concentrate, to make sense out of complex situations, to remember names and places, to learn anything new, to find their way around and to read and think effectively.  Frequently they have become irritable and easily frustrated, emotionally unstable and shallow in their ability to feel.  Often they feel depressed and even suicidal over the loss of their mental function.  In short, they have shown all the typical signs of close head injury, including frontal and temporal lobe dysfunction.  Often their families have been irreparably damaged by their inability to function as wage earners, husbands or wives, mothers or fathers.  A treatment that can cause such devastation, while producing such limited and questionable results, has no place in the practice of medicine.  

Having looked at the research in the area of electro convulsive therapy in preparing for our Private Members’ Bill today, it seems to me that there is a great deal of uncertainty as to why it is that the ECT procedure is effective at all  - where it is effective in some patients.  Given the scientific uncertainty surrounding it, the point that the Green Party is making is that its use without the consent of the patient must be prevented until we have the scientific knowledge that can explain how and why it works and on what patients it can be effective. I move the motion and ask other Members of the House to support it.

Filed under:
Health and Children, Private Member's Time, Seanad Speeches by Deirdre