Dear Minister a letter from Delete59b Campaign

Dear Minister,

Re: Section 59(B) of the Mental Health Act 2001

We hope this finds you well.

We are writing to enquire about developments in relation to the above.

When Senator Dan Boyle proposed the deletion of Section 59(B) in the Senate last year, there was an agreement that the heads of a bill to do this would be brought before the Dail by the summer session. Senator Boyle, in the company of John McCarthy, agreed to postpone debate in the Senate on the day. As we understand it, the amendment to delete 59(b) was to stand alone as a proposal in the Dail, as it was worded in the Senate amendment.

We would respectfully ask if there are plans to progress this matter.

At the hearing in Leinster House, the College of Psychiatry’s position was that there should be minimal amendments to the current regulations governing the use of ECT in Irish hospitals. Their proposal was that 1) the word ‘unwilling’ should be removed, 2) that the second opinion consultant should be nominated from a panel held by the Mental Health Commission (MHC) and that this consultant should ‘consult’ with another member of the Multi Disciplinary Team (MDT), 3) that the College itself should, in conjunction with the MHC, collect information about the use of ECT.

We believe that these changes are far from what is needed and what is being demanded by many service users in Ireland. In reality, they will lead to no significant change in the status quo. Doctors will still be able to order ECT for patients without their consent and with minimal consultation with anyone else. There will be no redress for those who feel that they were treated wrongly. The safeguards for patients will continue to be inadequate. We believe that many people working in mental health share these concerns.

We acknowledge that many patients feel that they have benefited from ECT. This is not disputed. However, a very large number do not benefit and many are significantly harmed by the procedure. When you organized the two presentations to parliamentarians earlier this year, you indicated that you thought there was merit in both sides of the debate. We hope that you will not now renege on this by putting forward the College’s proposal as your answer to the debate. To do this would be to turn away from the many service users, relatives and professionals who have grave concerns about ECT and particularly its use with patients who cannot give consent.

Our proposal to delete Section 59(B) will not affect the provision of ECT on a voluntary basis. However, we believe that the regulations governing voluntary ECT need to be amended as there is evidence that up to 50% of people who have this treatment do not feel that it was properly explained to them. It is questionable how ‘voluntary’ their consent is in these circumstances.

What is really at stake in this debate is an effort to open up the field of mental health so that different voices can be heard. For too long, the voice of the medical profession has dominated. Only service users who agreed with the medical model and who presented no real challenge to the status quo were heard. Times have changed. This culture of medical paternalism is no longer acceptable and is completely out of keeping with the values of A Vision for Change (VfC). This makes the case that: ‘service users and carers should be involved in a meaningful way with the planning and delivery of care. A partnership approach should be taken to the planning, development, delivery, evaluation and monitoring of mental health services, with the inclusion of all stakeholders. It is through partnership that trust is built for all involved’ (VfC, p 15). Many service users in Ireland and internationally do not experience the medical framing of their problems as helpful. In fact, many feel that they have been harmed by the overly forceful use of the medical approach. Some feel that they have been abused. We believe that such individuals, and the groups that represent them, have a right to be ‘stakeholders’ in the partnership approach advocated by VfC. To exclude them, to ignore them when they challenge the current power structures in the mental health field would be a travesty and an insult to those who worked to produce VfC.

However, we believe that if the voices of ‘critical’ service users are to be heard and given the same respect afforded to those who are happy with the traditional medical approach, the powers invested in mental health professionals, especially psychiatrists, will have to be lessened.

ECT is a controversial intervention. In their presentation at Leinster House, the College of Psychiatry presented a very positive version of the empirical evidence about the efficacy, safety and mode of action of this treatment. The obvious enthusiasm for ECT displayed by those who presented is out of keeping with the practice of most psychiatrists in Britain and Ireland over the past 20 years. ECT is being used less and less across these islands. Most psychiatrists seem increasingly slow to prescribe this treatment. However, the wide variation in usage of ECT across the state demonstrates that while the majority of psychiatrists are using this treatment less often, there are a minority who are ‘ECT enthusiasts’. This fact, particularly when combined with the catchment area system of mental health care (in which service users have no control over which psychiatrist will be involved in their care) is a very strong argument against the status quo.

At present, Ireland is undergoing a major cultural change. Deference to traditional sources of authority has been substantially eroded by scandals involving the clergy, politicians, bankers, financiers and the medical profession. We believe that it is time to seriously interrogate the power structures involved in the mental health system. This system, which has been dominated by the psychiatric profession since its origins in the asylums of the 19th century, has failed many of the people who were placed in its care. This debate about ECT has drawn public attention to the fact that massive powers continue to be placed in the hands of psychiatrists. Our argument is not anti-psychiatry. But we do seek a psychiatry that is more humble and more willing (and able) to engage respectfully with those who critique the medical model.

We urge you not to endorse the proposal presented by the College of Psychiatry. We urge you to consider removing Section 59(B) of the Mental Health Act, thereby placing ECT alongside all the other treatments that can be prescribed by doctors, and giving psychiatric patients the right to legal redress when they feel they have been treated badly.

Yours etc,

Pat Bracken
Harry Gijbels
John McCarthy
Paddy McGowan

School of Applied Social Studies, University College Cork

The Case of Involuntary ECT

Tuesday 27 April 2-4 pm

Boole 2, UCC

Presentations by: Dr. Pat Bracken (Consultant Psychiatrist, West Cork Mental Health Services), John McCarthy (Mental Health Campaigner, Founder MadPride Irelan……d) &
Paddy McGowan (Expert by Experience Lecturer, Dublin City University)

Followed by open debate and questions

All Welcome!

log on to www.delete59b.com and sign the petition

We live in interesting times

www.madprideireland.ie

Change is on the way.

 www. Delete 59b.com, of the mental health act 2001 of Ireland (to stop the use of involuntary ECT) is gaining significant ground, already compromise is on offer, section 59b states if the patient is “unable or unwilling” then two psychiatrists can sign a form and force you take ECT against your will.

 We have been to Lienster House over the last few weeks, debating.

 The college of psychiatry agreed yesterday that it is time to remove “unwilling”.

 There were calls for a full independent review of the whole mental health act.

 Calls, for the new capacity legislation to come into place!

 To ratify the UN Convention on the rights of the Disabled!

 Advanced directives( a type of living will)

 All necessary.

 All sounds great, but they just do not get the point, it is not enough.

 We are told we should be grateful for progress; but this is about human rights not some treatment or other.

 This is about equality, our right as members  of the mad community to stand tall as equal citizens. The common law is there to protect us, but rather then protect us we are excluded from that same common law.

 They offer crumbs we want to share the meal.

 Stigma and abuse will always exist as long as we empower one section of our community to force treatment of any kind on another.

 The recent Murphy and Ryan reports confirm this.

 The college of Psychiatry tried to divert the debate yesterday and they focused in on the benefits of ECT.

 Delete 59b will not affect anybody’s right, to choose with free and informed consent to have ECT.

 It is so important that you understand this fact.

 We believe in choice, that is your right, we do not believe that you should be forced to take ECT by force, and on the signature of two psychiatrists and that alone. No need to consult with family, or anybody else, and its legal.

 Fear again set the tone of the opposition, irrational fear of us, in the public arena, as justification for the abuse.

 It was interesting yesterday to see some facts begin to emerge in this debate. You are very un-lightly to have ECT on offer in public hospitals, yet it seems to be big business in the private sector of psychiatry.

 That factor alone surely deserves an independent investigation, the private sector of psychiatry in so much more enthusiastic in its use of ECT, as against those psychiatrists who work in the public sector. Why? You guess, I won’t speculate here.

 I will state that when I was a patient in a private hospital I was offered ECT as a last resort, as my psychiatrist explained,

“ you are going home next week John, the pills are not working and your VHI is running out, I would like to try a few doses of ECT”.

  My wife put a stop to that thank God, I had no idea at that time of what had just been proposed I was so drugged up!

 When the Neary case came before the courts, the judge reached a guilty verdict, because Dr Neary’s threshold of use of his surgical procedure was too high in comparison to his colleagues.

 This pattern is emerging now in psychiatry, across the country. We need to know the truth here, and not some peer review.

 It was both sad and upsetting to hear myself as a person who lives with the normality of madness in my life, who now recognises the great gifts that deep emotional feelings bring to my life, being referred to over and over again by those who should know better, those who purport to speak for us, as VUNERABLE members of the community.

 How can we expect to hold our heads high as equal citizens when those who “support” us believe we are not capable of walking with dignity and equality in our own communities?

 I would call for a complete ban on the use of that overwhelming, paternalistic, insulting description of my community, those gifted with deep feelings, open to insult, we who give society art, poetry, literature, beauty:

 “as those VUNERABLE people who live among us, and society has a DUTY to protect THEM”, they are insulting me to my face, when they our supporters speak thus to my position in reference to the  law. Where I am defined in article 3 of the 2001 mental health act as follows….

“3 (1) in this Act “mental disorder” means mental illness, severe dementia, or significant intellectual disability where…”

How can I as someone, a successful business man, who had a breakdown and on a temporary basis, simply lost control of my emotional feelings, expect equal treatment under the law when my capacity under that same law is accessed on the basis I exist in the same legal space as a person with intellectual disability!

It is time to talk of mental health not “mental illness”.

Those same spokespeople “supporters” will stand on another platform next week and rail on at the need to reduce stigma, in policy!!

Society has a duty to protect all its citizens equally, we ask for no more than that.

Either that or those who in their hearts do not believe we are capable of standing with pride in our own place should walk a    way from this debate.

It is most encouraging speaking on an ongoing basis to the college of psychiatry at least we both know where we stand.

There is certain honesty to their arrogance, simply put; we need to dismantle their power, granted under the law, we need to do it in cooperation with them, together, for the good and benefit of psychiatry, and all our lives.

 It is as simple, and as complicated as that.

Sometimes you can be more damaged by your supporters then those opposed in this type of debate.

There were representatives for all parties in the house in attendance; interesting questions were raised.

Finally it would be most remiss of me not tell you of the vital role being played in this debate by Senator Dan Boyle.

But more importantly Minister John Moloney, it is vital in the non political sense that this man, (not politician) stay in his position for the next two years.

 We are grateful to you minister and we thank you from our hearts.

MDAC hails compensation “milestone for global human rights”

11 March 2010, Budapest (Hungary), St. Petersburg (Russia) and Strasbourg (France). MDAC welcomes last week’s judgment of the European Court of Human Rights which ordered the Russian government to pay 25,000 EUR compensation to a man with mental health disabilities who was unlawfully deprived of legal capacity and arbitrarily detained in a psychiatric hospital for more than six months. This is the largest amount of compensation the Court has ever awarded in a disability rights case.

The Mental Disability Advocacy Center today welcomes the 4 March 2010 European Court of Human Rights judgment which ordered the Russian government to pay 25,000 EUR damages to MDAC’s client Pavel Shtukaturov. The judgment follows a judgment on the merits issued by the same court in March 2008, which found that Russia was in violation of several provisions of the European Convention on Human Rights. The client has been represented in proceedings by MDAC’s Legal Monitor in Russia, attorney Dmitri Bartenev.

Welcoming the judgment, MDAC’s Executive Director Oliver Lewis said,
“This judgment is a milestone for global human rights as 25,000 euro is the largest amount of compensation the European Court of Human Rights has ever awarded to an applicant in a disability rights case. This sum reflects the gravity of human rights violations faced by people with disabilities the world over and the seriousness with which the mainstream human rights community now views these violations. The judgment sends a clear message to governments that it will be expensive if they fail to take legislative and policy action to effectively implement international human rights law for people with disabilities.”

In its judgment last week the Court reiterated that the amount of compensation for non-pecuniary damage (meaning compensation for pain and suffering) is assessed with a view to providing “reparation for the anxiety, inconvenience and uncertainty caused by the violation” and that the respondent State is under a legal obligation to “restore as far as possible the situation existing before the breach.”

In awarding compensation the Court noted that the Russian judicial system had failed to remedy the past wrongs which had in fact persisted for Mr Shtukaturov over the previous four years. In doing so, the Russian system continued to infringe on some of his most fundamental rights. As the Court noted in its March 2008 judgment Mr Shtukaturov was deprived of his legal capacity to act independently in almost all areas of life. He was unlawfully detained in a psychiatric hospital for more than six months, not taking into account his subsequent periods of detention. Mr Shtukaturov’s suffering was, the Court held last week, “undoubtedly aggravated by the State’s failure to respect his [fair trial] rights and the authorities’ interference with his right of individual petition [to the European Court of Human Rights]“.

The Court’s scathing comments refer to the extraordinary way in which Mr Shtukaturov’s legal capacity was eventually restored in May 2009 by a St. Petersburg district court. No steps were taken by any authority following the March 2008 judgment of the European Court of Human Rights. Nor were any steps taken by any authority following the February 2009 judgment of the Russian Constitutional Court, a case concerning Mr Shtukaturov and also initiated by MDAC. In this case the constitutional court struck down as unconstitutional provisions of the Psychiatric Care Act and the Code of Civil Procedure which had been applied in his case. Despite these judgments it was an unrelated application by the State guardianship authority in light of an perceived improvement in Mr Shtukaturov’s mental health condition which eventually led to the restoration of his legal capacity. The district court’s ruling did not cast doubt upon the validity of the original decision of the court, a remarkable oversight given the damning critique of the original decision both by Europe’s human rights court and Russia’s constitutional court. Now that he is no longer under guardianship, Mr Shtukaturov is at liberty to spend his compensation as he pleases.

In its March 2008 judgment the European Court of Human rights found Russia in violation of several provisions of the European Convention Human Rights. It said that:
Deprivation of legal capacity constitutes a “very serious” interference of a person’s private life, it is applied indefinitely, and cannot be challenged by the person under guardianship (Article 8 of the Convention)
A mental illness cannot be the sole reason to justify stripping someone of legal capacity and Russian law is disproportionate in allowing this to happen without making provision for a tailor-made response (Article 8 of the Convention)
The guardianship proceedings were unfair because they wholly excluded Mr Shtukaturov (Article 6 of the Convention)
Deprivation of legal capacity is not a ground to deprive a person of their liberty (Article 5(1) of the Convention)
Every person who is detained – including those who have been deprived of their legal capacity – should have the right to pursue independently a legal review to challenge their detention (Article 5(4) of the Convention)
The Russian Government failed to comply with an “interim measure” of the European Court ordering it to allow Mr Shtukaturov’s lawyer to have access to him (Article 34 of the Convention)
For more information on this case call Oliver Lewis, MDAC Executive Director +36 1 413 2730 or Dmitri Bartenev, attorney and MDAC Legal Monitor in Russia + 7 905 222 8915. Click here to read the March 2008 judgment on merits, here to read MDAC’s related information bulletin, and here to read the March 2010 judgment on just satisfaction.

We live in interesting times

Change is on the way. The campaign www.delete 59b.com, who’s aim is to delete section 59b of the mental health act 2001 of Ireland (to stop the use of involuntary ECT) is gaining significant ground, already compromise is on offer, the section states if the patient is “unable or unwilling” then two psychiatrists can sign a form and force you take ECT against your will.

We have been to Lienster House over the last few weeks, debating.  The college of psychiatry agreed yesterday that it is time to remove “unwilling”.  There were calls for a full independent review of the whole mental health act.  Calls, for the new capacity legislation to come into place!  To ratify the UN Convention on the rights of the Disabled!  Advanced directives, a type of living will, all necessary.  All sounds great, but they just do not get the point, it is not enough.  We are told we should be grateful for progress; but this is about human rights not some treatment or other.

 This is about equality, our right as members of the mad community to stand tall as equal citizens. The common law is there to protect us, but rather then protect us we are excluded from that same common law.

They offer crumbs we want to share the meal.

 Stigma and abuse will always exist as long as we empower one section of our community to force treatment of any kind on another.  The recent Murphy and Ryan reports confirm this.  The college of Psychiatry tried to divert the debate yesterday and they focused in on the benefits of ECT.  Delete 59b will not affect anybody’s right, to choose with free and informed consent to have ECT.  It is so important that you understand this fact.

 We believe in choice, that is your right, we do not believe that you should be forced to take ECT by force, and on the signature of two psychiatrists and that alone. No need to consult with family, or anybody else, and its legal.  Fear again set the tone of the opposition, irrational fear of us, in the public arena, as justification for the abuse.  It was interesting yesterday to see some facts begin to emerge in this debate. You are very un-lightly to have ECT on offer in public hospitals, yet it seems to be big business in the private sector of psychiatry.  That fact alone surely deserves an independent investigation, the private sector of psychiatry in so much more enthusiastic in its use of ECT, as against those psychiatrists who work in the public sector.

Why? You guess, I won’t speculate here.

I will state that when I was a patient in a private hospital I was offered ECT as a last resort, as my psychiatrist explained, “You are going home next week John the tablets are not working and your VHI is running out, I would like to try a few doses of ECT”.   My wife put a stop to that thank God, I had no idea at that time of what had just been proposed I was so drugged up!

When the Neary case came before the courts, the judge reached a guilty verdict, because Dr Neary’s threshold of use of his surgical procedure was too high in comparison to his colleagues.  This pattern is emerging now in psychiatry, across the country. We need to know the truth here, and not some peer review.

 It was both sad and upsetting to hear myself as a person who lives with the normality of madness in my life, who now recognises the great gifts that deep emotional feelings bring to my life, being referred to over and over again by those who should know better, those who purport to speak for us, as VUNERABLE members of the community.

 How can we expect to hold our heads high as equal citizens when those who “support” us believe we are not capable of walking with dignity and equality in our own communities?  I would call for a complete ban on the use of that overwhelming, paternalistic, insulting description of my community, those gifted with deep feelings, open to insult, we who give society art, poetry, literature, beauty: “As those VUNERABLE people who live among us, and society has a DUTY to protect THEM”, they are insulting me to my face, when they our supporters speak thus to my position in reference to the law. Where I am defined in article 3 of the 2001 mental health act as follows….

“3 (1) in this Act “mental disorder” means mental illness, severe dementia, or significant intellectual disability where…”

How can I as someone who had a breakdown and on a temporary basis, simply lost control of my emotional feelings, expect equal treatment under the law when my capacity under that same law is accessed on the basis I exist in the same legal space as a person with intellectual disability!  It is time to talk of mental health not “mental illness”.  Those same spokespeople “supporters” will stand on another platform next week and rail on at the need to reduce stigma, in policy!!

 Society has a duty to protect all its citizens equally, we ask for no more than that.

 Either that or those who in their hearts do not believe we are capable of standing with pride in our own place should walk away from this debate.  It is most encouraging speaking on an ongoing basis to the college of psychiatry at least we both know where we stand.  There is certain honesty to their arrogance, simply put; we need to dismantle their power, granted under the law, we need to do it in cooperation with them, together, for the good and benefit of psychiatry, and all our lives.

  It is as simple, and as complicated as that.

 Sometimes you can be more damaged by your supporters then those opposed in this type of debate.  There were representatives for all parties in the house in attendance; interesting questions were raised.  Finally it would be most remiss of me not tell you of the vital role being played in this debate by Senator Dan Boyle.  But more importantly Minister John Moloney, it is vital in the non political sense that this man, (not politician) stay in his position for the next two years.

 We are grateful to you minister and we thank you from our hearts.

Presentation to Leinster House 23rd February 2010 – Paddy Mc Gowan

Delete Section 59b 2001/06 Mental Health Act.

Good afternoon I would like to thank you for giving me the opportunity to speak to you today. My name is Paddy McGowan; I am a psychiatric survivor and activist. I have been an activist for nearly 25 years. I spent over ten years within psychiatry many of those years in the hospital and the community, I have had ECT carried out on me both voluntarily and forced. In my case, I was told that ECT was my last chance. They had tried all other medicines and treatments on me, but the only treatment I was offered was medicine and ECT. After the first treatment when I was taken back to the ward I lay on my bed, my head felt that it had been driven over by a steam roller, the pain was excruciating, I had problems with my memory, and I was confused. I was informed a few days later that I was going for another ECT treatment I immediately refused and was told that it would be easier for me to have the shock voluntarily, because if I was to refuse that my status could be changed to involuntarily. I was left to think over whether I would consent or not. I was advised by some of the staff and other patients that it would be better for me not to put up a fight. I received a number of other treatments over the years. I cannot honestly say that it did not help me but it has left me with long term memory problems. I would never allow myself to have it carried out on me ever again. If in the future I found myself in a posisition of being detained under the Mental Health Act I would honestly consider suicide. I have recovered from my time of severe distress, largely with the help of fellow survivors and friends, without the use of medication and ECT. I was told for years that I had a disease that I could not recover from; my family were left with absolutely no hope and almost given me up for dead.

I think we have to question what is wrong with our Mental Health Service provision, when we have to force people to use our services and have to use force to treat them. We don’t have to force people with mental health difficulties to use our general health services. We are often told that people who have to be forced with ECT treatment or indeed any other forced treatment within Psychiatry, have no insight, this argument is very often bandied about without any clear research being produced. The reality, is more likely that people have had bad experiences, subjected to these forms of treatments, the side effects are toxic to say the very least. My own experience of ECT is that I suffered from both long and short term memory loss. I have in the last 25 years advocated for people within psychiatric services, and my experience tells me that the majority of people who are deemed to be service users are very much opposed to forced treatments and more so around, ECT. The Irish Advocacy Network as a peer led organisation that provides advocacy to people in hospitals and the community are also opposed to forced ECT they are in favour of deleting section 59b, they are not opposed to ECT per say. People should have a choice around their treatment, and it is not the duty of the Network to make those choices for people. The Irish Advocacy Network is the longest service user group on the island of Ireland working with people for ten years in various states of distress.

The well known and respected Psychiatrist Peter Breggin has spoken in one of his books (Toxic Psychiatry) relating ECT to being the same as a (closed Brain Injury). Indeed other Psychiatrists of standing within the profession are of the same opinion. The Royal College of Psychiatry has also within their own code of practice declared   ECT is unlikely to help those with mild to moderate depression or most other psychiatric conditions. It has no role in the general treatment of schizophrenia. We know from the inspector of mental health services report for 2008 that 73% of people given ECT had a diagnosis of a Depressive Disorder, 27% had other conditions and 24 people given ECT had a diagnosis of Schizophrenia. The fear that most people have with the ECT is that there is no clear consensus from within Psychiatry around the efficacy and safety of the procedure. We are often told that ECT has saved people lives, yet we have never seen any research to prove or discount this statement, on the other hand, some people could claim that ECT has damaged people, and taken people lives. We know from some people that they claim they became suicidal after undergoing the procedure. How many people have died during the procedure? Some would say that deaths during the treatment were recorded as cardiac deaths or natural causes. We just simply don’t know, neither of the two groups either for ECT or against have any clear research or science to base an informed opinion. I would call on the Government to commission independent research on ECT preferably from outside the country. I think we as a country will find ourselves under investigation, similar to the last few reports that have been published we have questions as a country to answer. The institutional abuse scandals that have come to light have close linkages to our past Psychiatric Service Provision and practices.

There is another group that is not being taken into account here, they are a group I call the Service Refuser community. Over the years, I have come into contact with a large number of people who live and work in our communities who encounter mental health distress. When you speak with them, they clearly tell you that they have no faith in Psychiatry, because of fear and the treatments they could or have experienced at the hands of practitioners. People have found alternative ways of managing and living with their distress, they quite often tell me that they would love to be able to have contact with professionals, but don’t believe that they would find people who could understand their belief systems, I remember one individual I met, I asked him why he refused to use the services, his answer to me was I might be mad, but I am certainly not stupid. He believed that he would have no rights in Psychiatric Hospitals he had absolutely no faith in the Mental Health Act. His argument and that of others, coming from refuser community, also indeed from within the service user community was that the second opinion Psychiatrist provided for within the legislation is just a rubber stamping exercise. They would say that they come from the same professional group and in some instances, are friends or colleagues. The argument being that they are not fully independent, and do not provide a sense of security for the user. Fundamentally they come from a pro medical model view point which quite often is at variance with the user’s beliefs.

I would like to point out again that we are not saying that ECT should be abandoned; we are just simply saying that people should have choices. We as a society need to protect the human rights of all our citizens. We have come to a place now that we are starting to listen and respect service user points of view, can we afford to go back to the days of paternalism. I would like to thank Minister Maloney for arranging this meeting. However, I would like to point out that I find it difficult to understand why our meeting was held first and separate from the second meeting, in my opinion, both sides should have given their evidence on the same day to allow the senators and deputies the chance to ask questions of both sides, it begs the question why?. It seems that the opposing side has the opportunity of listening to our presentation, and we have no chance of contributing when they present. Both sides need to be able to contribute in the debate and challenge.  

We have also an online petition Delete Section 59b; the poll has just been alive for around a month or so. To date, we have received 522 signatures given that we had no resources nor did we publicise widely, and a short time span. I think it gives you a flavour of the feeling in society. When we close the poll, I think you will find that we will have obtained a large constituency from across the country who agrees with our position.

I urge you to protect the rights of people and value them as equal citizens in this land of ours, after all this country and ancestors fought for our independence and equality.

Thank You.

Presentation on Proposal to Delete Section 59(B) of the MHA 2001

Dr Pat Bracken

Consultant Psychiatrist and Clinical Director, West Cork Mental Health Service, Bantry, Co Cork

Pat.Bracken@hse.ie

I am a consultant psychiatrist and Clinical Director of the West Cork Mental Health Service. I have worked as a doctor in the field of mental health for nearly 27 years. I trained in psychiatry in Ireland and in the UK. I have worked as a psychiatrist for many years in difficult inner-city settings, in post-conflict situations in Africa and more laterally in a rural part of Ireland. I have publicly challenged my own profession to listen more attentively to the voices of patients and their carers, including those who are critical of psychiatry and I am known and (I hope) respected for promoting the active involvement of patients and carers in the development of services .

I am here today to explain why I believe that Section 59B of the Mental Health Act should be amended and, moreover, why I think that this should be the first step in an overhaul of the 2001 Mental Health Act which, in my opinion, puts far too much power in the hands of psychiatrists.

My essential argument is that Section 59B serves to safeguard the doctor who administers ECT, rather that the patient receiving it.

59(B) allows for ECT to be given to a non-consenting patient simply on the order of a consultant psychiatrist if that decision is supported by any colleague. Under the Act, the consultant is not obliged to consult with non-medical colleagues or the nearest relative, nor is he or she obliged to honour the patient’s wishes if these are written in an advance directive. When treatment is given under the MHA, there is no legal comeback for a patient who subsequently feels they were harmed, or for a relative to intervene if they feel the treatment is wrong. In any other branch of medicine it would be unconscionable to allow a procedure to go ahead, except in the most dire emergency, without procuring consent, if not from the patient, then from a next-of-kin. If Section 59(B) was removed, ECT could still be given to patients without consent, but it would be given under common law . This is the situation pertaining in the rest of medicine when procedures are carried out on patients who cannot give consent. In this situation, the psychiatrist would have to proceed more carefully as he/she would not have the protection of the MHA 2001.

And let us be very clear what this procedure involves. It requires a general anaesthetic and then the passage of an electric current via electorodes attached to the head to the level that will induce a Grand Mal convulsion. It is the most invasive procedure currently used by general psychiatrists. It is now generally accepted that at least a third of recipients suffer substantial memory loss after the treatment . Some people lose large chunks – up to twenty years in some cases – of their remembered lives, including memories of their children’s births, wedding days etc. The writer, Ernest Hemingway, famously blamed ECT for his suicide. In his suicide note he said that the treatment put him ‘out of business’ by destroying his memory.

ECT is a treatment that is gradually disappearing world-wide. It is now used much less frequently across Europe, including the UK and Ireland. In Italy, it is effectively banned, in Germany and Belgium it can only be administered in special centres and in the UK the rules governing ECT without consent have been substantially tightened in the past decade . The WHO now argues that ECT should never be given without consent . I believe that more and more psychiatrists are becoming very wary about it’s use. We are now nearly 10 years on from the date when the current MHA act was passed in Ireland, and the scientific evidence about the benefits and side-effects of ECT has moved on substantially.

As a psychiatrist, I maintain that we have to learn from the mistakes of the past, otherwise we are doomed to repeat them. In many ways, the history of psychiatry is not a happy read. In our enthusiasm to do things to the patients put into our care, we have inflicted terrible damage on many of them. Take, for example, the recipients of interventions such as lobotomy and insulin-coma treatment. For many years, these interventions were hailed as dramatically successful by doctors, families and even patients. For some they appeared as ‘life-saving’. Patients who were catatonic got up and talked and left hospital. If they had not been successful in some way or another they would not have been performed over such lengthy periods of time. At least 40,000 lobotomies were performed in the US, 17,000 in the UK. I don’t know how many were performed in Ireland. In many cases it was only later that dreadful deficits were noticed and eventually lobotomy went out of fashion. Not all doctors recommended lobotomy, but some were enthusiasts and if you came under their care, there was a good chance that you would be given that intervention . The point is that psychiatrists differed greatly in the value they saw in the treatment and most importantly in how much they were open to see its negative effects.

I believe that this is the same with ECT.

There is a large variation in the use of ECT across the State, which suggests that some psychiatrists have much more faith in it than others. The Mental Health Commission figures for this variation of use in Ireland give substantial cause for concern . In 2008, out of 64 approved centres across the country, ECT was used in only 24 (37.5%). Even allowing for some movement of patients between hospitals specifically to receive this treatment, this is a remarkable variance. But if we look further, we find that only 2 programmes of ECT were delivered in the whole of County Cork (with a population of approx 480,000) while in Galway (with a population of approx 230,000, half that of Co Cork) 69 programmes were used. If my calculations are right, this means that, per head of population, ECT was used approximately 70 times more often in Galway than in Cork! This is an extraordinary degree of divergence.

What the figures on ECT demonstrate, I think, is that some Irish psychiatrists are ‘ECT enthusiasts’. The probability of these doctors seeing a patient (whether voluntary or involuntary) as being in need of ECT is going to be much greater than many of their colleagues. Furthermore, it is likely that they will be very aware of colleagues who also use ECT enthusiastically. In these circumstances, Section 59(B) offers no protection whatsoever for the patient. In fact, as I have already argued, the protection offered is in the other direction. This is no longer acceptable.

It brings to mind the enquiry into the practice of the obstetric services in Our Lady of Lourdes Hospital in Drogheda in recent times, where the discrepancy in the rates of Caesarean hysterectomy as compared with the rest of the country led eventually to the exposure of a scandalous situation for the women involved. Dr Michael Neary performed 129 peripartum hysterectomies during his career over 25 years in this hospital. According to Judge Harding-Clarke’s report, the average consultant obstetrician can expect to carry out 4 of these procedures in his or her career, in extreme circumstances. The divergence of Dr Neary’s practice from the average (an excess rate of approx 32 times) was deemed so problematic that he was eventually struck off the medical register. When it comes to ECT usage in Ireland we are talking about a divergence in medical practice that is twice this level.

I believe that we could be looking at a similar situation several more years down the line, when the already well-documented and damaging side-effects of ECT become more widely recognised.

Moreover, the recent television Prime Time investigation about the practice of symphysiotomy has added to public outrage about the way in which certain medical practices can be allowed to continue in the face of well-documented and serious side-effects. One of the most troubling aspects of these questionable obstetric practices, is that is has become clear that we cannot rely on medical colleagues to be the ones to investigate them.

In Ireland, we are struggling to get beyond the culture of medical paternalism that reigned in our health service until recently: the belief that doctors always know best and will act accordingly. The present government health strategy, A Vision for Change, aims to do just that. We need protections for patients that are substantially more transparent, more democratic, and more multi-disciplinary. The MHA 2001 puts enormous power and responsibility into the hands of consultant psychiatrists. It is now out of date.

-I believe that we need to do 4 things:

First, we need to move quickly to remove Section 59(B). This will at least offer detained patients the protection of common law, something that the MHA 2001 currently denies them.

Secondly, we need to develop very clear guidelines for how decisions are made when patients cannot give consent.
Thirdly, we need an external audit of ECT practice in Ireland. This audit should seek to examine the reasons behind the extraordinary level of variance in ECT use. It should also seek to explore, in some depth, the experiences of patients (both positive and negative) of this treatment. This review should not be led by a psychiatrist .

Fourth, we need to rethink our mental health legislation more generally. The current MHA, which essentially serves to endorse the culture of medical paternalism, needs to be replaced by a framework more in line with our mental health policy A Vision for Change.
Pat Bracken MA MD MRCPsych DPM PhD

John Mc Carthy’s presentation to Dail Commitee Feb 23rd 2010

www.madprideireland.ie

Mental Health Act 2001 23 Feb 2010

Thank you minister for your invitation to speak here today on this issue, an issue that breaches the human rights of so many citizens of this country. May I also pay a sincere thanks to Senator Dan Boyle who has worked with me over the last years to bring this debate to the political arena, and finally, may I thank Deidre De Burca and Sen. David Norris in using private members time to propose this amendment in the Senate.
May I also commend the courage of Dr Pat Bracken, the previous speaker. I think we all know how the medical profession closes ranks and hates controversy. It takes a particular man to speak out against the established view and we are lucky to have such a man as Dr Pat Bracken.

So ends the nice bits it is all downhill from here. I have 10 minutes.
I am going to try to encompass the abused lives of 6 people into the first 3 minutes
So Anne 1. A sixty 63 year old grandmother. She was forced incarcerated over 80 times, forced treated, forced ECT I have a statement from her saying she could not stand the inhuman and degrading treatment she was being subjected to by this state in the name of care and she hung herself.
Anne 2. Raped at 16, locked into a mental hospital at seventeen. Seems she got a bit odd her brother told us, there was nothing else her family could do. A neighbour advised them to lock her up and the Dr and her father signed her in. I mean what else could they do? Subjected to forced ECT, forced feeding, forced treatment and assaulted by staff. We interviewed her for a documentary I am producing with RTE right now. She is s78 now, she never got out. Strange that Anne 2 signed herself in as a voluntary patient prior to your enactment of this 2001 Mental Health Act so now of course she has no need of a tribunal hearing, she is so institutionalised she puts a value on nothing but how many cigarettes she has and we have forgotten her.
Anne 3, one of three sisters all put into care as children by this state, all sexually abused. Anne 3 is presently in her third year of incarceration. She is 27. She got drunk and disorderly, had a mental health record. The arresting guard knew her so he kindly arrested her under the Mental Health Act. Had she been arrested under criminal law she would have been released the following day. Her sisters believe they will never get their sister back she is being so radically changed by the treatment and medication, including being forced to take contraceptives, and part of the reasons being given and accepted by her tribunal hearings to prove that she is mentally ill is that she is in danger of being promiscuous if she is released . Let me repeat that she is in danger of being promiscuous if released.

Michael 1. This man’s story breaks my heart. Michael spent nearly sixty years of his life in the so called care of the medical model, the power of which you can begin to dismantle today. What got to me about Michael was how the staff spoke of him.”Michael is such a lovely man, he’s never any trouble, never complains a lovely man” they had cured the life and spirit out of him. I visited Michael every week for six years he eventually got to know me. Nobody spoke to Michael so he lost the art of communication so to fill the silence we, and I have no religion would say the rosary Michael liked that. At 16 Michael won a scholarship from the ESB first in Ireland. I signed on as his next of kin he had family but they were ashamed of him. When he died I went to see his body at one in the morning he had been moved from his private room to public ward to die and the other patients were wandering around in distress. I pulled the sheet from Michael’s face and his head was tied onto the back of the bed with a piece of dirty bandage looped through a roll of toilet paper.
Michael 2 Entered the care of the state at 5, was sexually abused, released at 16, picked up within months as a vagrant locked into a psytchiatric unit and died there at 55 yrs old, 4 years ago. In his life forced ECT, forced treated and forced fed. He is buried in a mass grave that is currently in use in Cork in an unmarked grave
Michael 3. He is 29, I was asked to take up his case last week, he is in his fourth year of incarceration, he is locked up by this law you passed to protect him. When he came into the waiting room ushered in by a lovely young nurse I could smell him from 6 feet, his teeth are rotten stumps from Locatol he tells me and he is dressed in rags.
This has to stop and today can be a beginning delete 59b.
Reality in the medical model of care in 2010 Today. Now, not the past.
This debate is and should not be about services and or resources this debate should be about people. People, you have sworn to protect, to protect their human rights as citizens of this country. The remarkable thing about all of the above is they have never broke any law they were different just that, different in appearance behaviour odd. They lost control as I did of their emotions until it became a crisis, and it is only at the crisis point that you have intervention. Early intervention is not possible because of stigma. Do you think I could admit to my colleagues I was developing the normality of madness? Stigma is fuelled by fear. This law that abuses my rights as an equal citizen of Ireland is the primary force behind that fear and ignorance. How do we all know that Psych institutions are not nice places yet we are all aware of that fact. In as much as my generation knew that Magdalene laundries were not nice places yet we knew and to my shame were silent.
I am not spreading a rumour here, our Inspectors of mental hospitals tell us these places are not fit for human habitation yet that same mental health commission gives a licence to that unit to carry on the abuse. This is a fact for over 20 years. And you in this house do nothing meaningful to stop this. As an honest Td stated in this house recently there are no votes in mental health.
Close them down until the abuse stops.
Establish places like the runaway house where we could have early intervention where I could go in times of distress and given space to allow that distress to dissipate without the fear of force. I know when depression is arriving. Yet there is not an institution in this country where I would feel confident enough to go to for help.
Here is a remarkable thing about those stories I told you. I have told those stories and many more like them to the following:
At the UN New York, the UN, To the EU the EC. To reps of the dept. of Justice, Health, HSE, Mental health commission. To the last two junior Ministers for mental health. To Maurice Manning of the Human rights Commission. I have spoken to Dial deputies Senators and their staff. I have gone to Colm O’Gorman of Amnesty but here is the remarkable thing not one has asked me for a name or address of any of these alleged victims so they could speak for themselves and tell their own stories. Is that strange or is it just me.
We all listened to the Ryan and Murphy reports to the evidence of the victims of how they were so hurt by the silence of those in power to make a difference and by the fact that they did nothing.
Strange is it not how so many of the victims listed in the Ryan report were diagnosed by the medical model with various diseases of the brain while those who abused them and committed these atrocities walked among society not just freely but with dignity. (if Senator David Norris was not such a strong man he could so easily have been given ECT against his will after all the diagnostic box of the medical model listed homosexuality as a disease and one method of cure was ECT)
Its time to stop this delete Section 59b.
I watched it all again on prime time last week of the hopelessness of the victims of a respected medical profession again, Obsitricians, defended their silence at the time the abuse was taking place.
UN Convention on the Rights of the Disabled the purpose of which was to give the same human rights to the disabled, as had been granted to every other citizen of this world by other UN Conventions.
Article 17 states every person with disabilities has a right to respect for his or her physical and mental integrity on an equal basis with others.
This article was to have four sub sections which would have made an exception again of people with so called mental illness and allowed for force. It was impressive to see the united front of every imaginable disability say that there would be no exceptions to the human rights of any person with any disability and if the convention did not apply to all then they would not accept it.
We won the day despite the objections of the Irish delegation. So now, to overturn the power of that convention which Ireland has yet to ratify you are going to be asked to pass into law the new Capacity Act which would disempower Article 17 and allow for the continuation of force and abuse of citizens of Ireland based on no medical evidence whatsoever simply that their behaviour is different
Let me read to you how the Mental Health Act 2001 defines me. Article 3.1, in this Act “Mental Disorder” means mental illness, severe dementia or significant intellectual disability. How can I expect a fair judgement of my capacity when those that are judging me believe that I exist in the same space as somebody with dementia or intellectual disability. People like me, those that live with the normality of madness in our lives are very simply different. We feel at a deep emotional level and we sometimes lose control of those emotional feelings and because of that deep level of emotion we are those that give you music, poetry, art and you stigmatise, abuse and punish us for our difference.
This has to stop we have to delete Section 59 B.
The vast majority of my friends locked into psychiatric institutions in this country against their will have never committed a crime. Their sin is that society has no tolerance for the different ways in which we behave and view life. Article 59B allows for the opinion of 2 psyciatrists without any scientific tests whatsoever to force them to take ECT against their will. This has to stop.
Eugenics There is a basic problem here and that that is you do not believe that those of who live with the normality of madness can exist without force to control us, and you have the research and science to back up that belief. Remember eugenics the science that proved some people were inferior to others! There was a time when I could have paraded research and science before you to prove that women, black people, gays, were inferior. Not only that but i could also have paraded women, black people, and gays who would have stated that this was a fact.
You will witness that reality next week. You have no idea of the weight of fear and ignorance that descends on you when you when you become a victim of stigma as I did when I lost control of my emotions at 45 I am 60 now and it has taken nearly 10 years of campaigning to say this to you .
Get this law off our backs begin by deleting section 59b.
Also that those who purport to speak on our behalf do not in the dark recesses of their minds believe we are equal they simply believe we are not capable orwill allow us of live life on our terms. It makes them feel good to speak out on our behalf, they do nothing but harm.
Despite all I have said, I feel a great sense of optimism that change is about to happen. With the election and appointment of Mr John Moloney as Junior Minister, with the selection and appointment of Mr Martin Rogan in the new position of Head of Mental Health in the HSE (we must give him control of his own budget if he is to be really effective) and with the recent appointment of Mr Hugh Kane as CEO of the Mental Health Commission I sincerely believe that my optimism is based on reality and not just another manifestation madness.
Finally I have told these stories to the office of President Mary Mc Aleese and I have heard not a word. I listened to president Mc Aleese recently state how on reading the Murphy and Ryan reports she was sorry and distressed to hear that those in power who had been informed of the abuse while it was going on; did nothing. She was referring to you today and to herself. The abuse is ongoing in psychiatric units. I would ask her to visit these long term psychiatric units and to talk to the patients without the staff present, to listen and then decide.
So I am today asking, no pleading with President Mary Mc Aleese to be proactive and to open the doors of the Arus and allow these people to tell the conscience of Ireland, their stories, and tell her of their lives not lived but wasted in the long term care of this State in lock up wards across the country. Because of this insane law the 2001 Mental Health Act of Ireland. You can begin the process of reconciliation today by supporting our efforts to delete Section 59B, this is a beginning not an end to a long, long process.
This is not about politics this is way above that, this is about human rights and my right as a citizen to live without fear of this repressive law in my own home, in my own country.
John McCarthy
Mad Pride Ireland.
Johnfmccarthy_90@hotmail.comMy brush with ECT in St Pats Vhi.
Full shilling club

Interesting Article from Mebd Ruane Irish Independent Sat Feb 13th 2010

http://www.independent.ie/opinion/columnists/medb-ruane/medb-ruane-misery-isnt-a-strong-enough-word-for-the-conditions-in–our-mental-health-institutions-2061728.html

Statement from Richard Lakeman

I am a registered nurse of some 20 years experience, and more latterly an academic and founding member of the Irish Institute for Mental Health Nursing (www.iimhn.org). I support the deletion of this section of the Act and I’m in favour of reviewing legislation to ensure that people’s informed choices (including informed refusal of treatments) are respected. Where people’s capacity to make decisions is deemed to be impaired, then the grounds for such judgments need to be robust (not merely based on the person refusal as can be the case in relation to ECT at present) and subject to scrutiny (not merely the professional opinion of a colleague as is the case with ECT at present).

When the issue of section 59b being deleted was raised with members (see http://www.iimhn.org/news/view.asp?ID=19&CID=16) some fairly polarised positions emerged in subsequent debates on local and international e-mail lists. This is not surprising as much psychiatric knowledge is contested but in my experience nurses generally assume exceptionally cautious and often uncritical acceptance of psychiatric knowledge lest they upset the delicate power balance characteristic of their working relationships with their medical colleagues. Doctors generally prescribe treatments and nurses administer them or in the case of ECT are highly instrumental in preparing the person and nursing them in recovery. To assume these instrumental roles and maintain a degree of equanimity the nurse must generally have faith that the treatments will work and that the prescriber has chosen correctly. To question or challenge a treatment can be construed as undermining medical authority generally or the personal integrity of the prescriber and in my experience this can lead to some fairly unpleasant consequences for some nurses. It is therefore even more surprising that this rather minor proposed amendment should cause such polarised views.

Those in favour of leaving well alone from amending the Act have tried to focus the debate towards the efficacy of ECT i.e. does it work? In my view this is not of fundamental importance in relation to this Bill which is more about choice than efficacy.

In summary however, the main arguments are:-
That if involuntary treatment is needed / is allowed (a much wider debate than this one but no less contested from both within and outside the industry) then the full gamut of proven efficacious treatments ought to be available i.e. the best treatments and therefore ECT should be available;
ECT works. It has a fairly long pedigree of use, is safer than many drugs, and probably works much better as well. Resolution of deep seemingly intractable depressed mood is sometimes rapid and this is particularly of benefit for some groups such as new mothers whose bonding with their child may be affected if depression is unresolved;
ECT is a ‘last resort’ / life saving treatment and to deny people who are unable to communicate their wishes this treatment is to consign them to unnecessary suffering;

I’d like to express a few thoughts about these arguments. The first point is germane to this debate and relies very much on the second to support it. Why should ECT be considered differently to any other kind of treatment if it works? It is undoubtedly true that ECT does continue to carry a stigma that psychiatric drugs, or talking therapies no longer do to the same extent. Scenes from popular movies such as ‘One Flew over the Cuckoo’s Nest’ have left an indelible imprint on our collective psyches. It now seems abhorrent that ECT was once administered without anaesthetics and muscle relaxants. However, it was. I worked in a hospital called Lake Alice Hospital where in the 1970s (before my time) many young people were given what is known as ‘unmodified’ ECT and painful injections of paraldehyde to ‘modify’ their behaviour. The New Zealand government has made considerable efforts to achieve reconciliation and to compensate victims. This legacy of abuse of both the technology and people in institutional care does and ought to have some bearing on the processes involved with administering or compelling people to receive specific treatments. We are after all, talking here about ECT being administered against people’s expressed wishes.

Most people whom I’ve been directly involved with in a clinical capacity have had ECT voluntarily. For some it is their treatment of choice. The current Bill doesn’t deny them this choice. However, it is another thing entirely to be given a treatment against one’s will. There is also something qualitatively different from being forced, coerced or cajoled into taking a pill and being involuntarily anaesthetised and shocked. Although the former can be exceptionally traumatic and lead to adverse outcomes as well. There are of course risks with any psychiatric treatment but with ECT there are associated risks of death associated with a general anaesthetic as well as the now well accepted risks of memory loss not just around the time of ECT (which could well be the mechanism of action… why ECT may relieve at least temporarily depressed mood) but also of longer term memory loss. Even in conventional medicine different kinds of treatments with differing attendant risks require stronger evidence of informed consent (usually written for surgical procedures, whilst filling a prescription at the chemist might be sufficient for some drugs). Why shouldn’t ECT be treated differently to drugs? ECT with its attendant uncertainties, controversies, risks, associations, and stigma ought to be treated as a separate case.

Now to whether or not ECT works. To me this immediately begs a second question. What do we mean by ‘works’? Psychosurgery i.e. deliberately damaging a part of the brain to change behaviour was immensely popular at one time and tens of thousands of lobotomies / leucotomies were performed around the world. These worked in that they caused people to be docile, non-aggressive and little problem for those around them. Few people from our current position in history now accept that permanently damaging someone’s brain is an acceptable way to achieve these ends… (And many of us would find these ends abhorrent, I’d hope). So now psychosurgery for psychiatric problems is almost unheard of. When the ‘major tranquillisers’ were popularised in the 1950s they were compared in terms of efficacy to psychosurgery, i.e. leading to docility, compliance and reduced reactivity… hence the original name ‘major tranquillisers’. ECT and other methods of putting people in shock (e.g. insulin coma therapy) were of course tried with the same broad population of difficult people with varying results. Not surprisingly at least anecdotally some people would feel and behave differently after these gross assaults to the body and brain… Who doesn’t feel differently after a shock of any kind… let alone after a full-blown epileptic seizure (which is what is induced via ECT).

Everything it seems has ‘worked’. Psychiatric professionals tend to have considerable faith in their treatments sometimes despite hard scientific evidence. For decades we have asserted that antidepressants work on relieving depression (albeit after a wait of at least a month) and this broad class of drugs has been more prescribed than any other in recent times. We now know that they don’t work that well… not much better than a placebo… which is better than nothing at all… in most people that take them (For some links to commentary on this issue please see: http://www.testandcalc.com/Richard/publications_journals.asp). This hasn’t made much of a dent in prescribing practices… people are still being prescribed antidepressants. There are reviews of reviews of ECT and it seems that it might work for some people… but one can’t be too sure who and what working might mean is a reduction on a standardised scale for depression. At least anecdotally, the more depressed someone is the more dramatic the improvement. My experience as a health professional and of health professionals is that we project certainty even when there is an enormous amount of uncertainty. Perhaps this is necessary to build an alliance whereby the client as faith in their practitioner and hope for the future. However, this misplaced confidence ought not to be the foundation of compulsory treatment.

For many of us our faith in treatments is based on our own experience of responders (not the non responders) and not necessarily science. I and it would seem most health professionals who have been around the block for as long as I can attest to a few people who appear to have responded exceptionally well to ECT… In my career I have encountered a couple of people (literally) whom we describe as catatonic… not eating, talking, and moving for long periods of time. The response to ECT to me seemed miraculous… at least in my lowly capacity as carer who was assigned the task of attempting to feed the person, toilet and wash them. After a couple of weeks of non-communication I recall a man waking in recovery and asking ‘where am I… why am I here?’ He’d forgotten he was depressed! Within days there seemed to be lasting improvement and within weeks the person went home. Interestingly, these examples to my knowledge were so rare, such curiosities to the treating team that we went to extraordinary lengths to obtain consent from the person’s next of kin (using guardianship legislation). In one sense this was the archetypal psychiatric emergency in which ECT might be indicated. However, it is not the kind of emergency in which haste is of the imperative… that one has to act quickly… quite the opposite in my opinion… an exceptionally careful and exhaustive physical assessment needs to take place, supportive interventions (food and fluids) needs to be implemented, and available options carefully considered.

This relates to point 3 above… that ECT is a life saving intervention. As a mental health educator I have been guilty of propagating the idea that ECT is to psychiatry what cardio version (the shock paddles) is to emergency medicine. However, it is never the case (as far as I’m aware) that the only options are ECT or death. Supportive interventions can always be instigated, allowing time to consider options, to collaborate with carers, family or loved ones, consider peoples wishes etc. Presently, as archaic as the Irish laws are in relation to guardianship they do allow for someone without capacity to be made a ward of the court and treatment administered if it is considered life saving.

People generally do get over being depressed… with or without medical intervention. I have also said to students and community groups that should I be depressed I’d certainly consider ECT. We’ll I actually have been… suicidal even… and yes I’ve taken antidepressants etc… In essence I did the right thing in terms of seeking help and putting a degree of trust in the therapist/helper and also trusting that they would respect my choices. I wasn’t offered ECT but had I been offered it, I might well have said yes. When one is in a very dark place one craves the light. However if I’d said ‘No thanks, I’ll sit with my misery for a while and see what comes of it’ then this ought to be respected as well. Would ECT have worked? It might have worked in the sense of lifting mood… but in my view this is an exceptionally unsophisticated way of thinking about efficacy. A better way to thinking about efficacy is whether or not the intervention addresses the reasons why a problem develops, what sustains it and resolves these underlying causal and sustaining factors … In this sense ECT in most instances doesn’t work… although for a very small number of people it might help them reach a place where they can engage in such work.

The last point I wish to make is about the idea of informed refusal. Much lip service is given to ‘informed consent’… That people need sufficient information regarding their options and they can then process this information to reach a decision which might be said to be informed. In relation to ECT and much psychiatric treatment the discourse frequently centres on peoples capacity or lack thereof to process information and to make reasonable decisions. However, what of the responsibility of health professionals to actually provide information? This is tricky enough at the best of times and in relation to general medicine we would expect to be given some options, an explanation of risks and costs associated with each and some idea of the probability of success. In relation to ECT it may well be health professionals who struggle to satisfy the informing component…. convey the risks and probabilities to enable someone to make an informed decision. On this basis a refusal isn’t ill- informed. The Act as it stand allows for someone to be administered ECT if they are ‘unwilling’ and two doctors think it might be in their best interests (or worth a stab in their estimation). What of informed refusal? What if I weigh up the available information and decide I don’t want to risk lasting memory problems? Or, I’d prefer to wait and see? Or if today when I’m feeling well and having appraised the available evidence about treatments commit to paper that I wish not to have ECT? These might be considered informed refusals… and as a matter of justice ought to carry considerable weight.

As citizens we have certain duties, and are never entirely free in the sense that we must adhere to laws in the interest of a just, fair and orderly society. However, we ought to enjoy freedom of choice in relation to our bodies and what can be done to them. Support the deletion of Section 59b as a small gesture towards a more just society which enables people the freedom to choose their medical treatment or at least say no.