Informed consent for special procedures: electroconvulsive therapy and psychosurgery

Informed consent has become the cornerstone of the expression of patient's autonomy for ethical and sound patient-physician relationships. However, some severe psychiatric diseases markedly hinder the ability of selected patients to ensure a proper consent. Confronted with mentally disabled individuals whose condition may lead to violence or inflicting it on others, society must carry out its duty of protecting those who are particularly vulnerable, while respecting and protecting these disabled individuals.

The recent update in the indications and more detailed understanding of electroconvulsive therapy, and the technical ability of obtaining less invasive or reversible techniques of psychosurgery, has renewed interest in these impressive and efficient techniques. Specifically, the emergence of new and promising cerebral neurostimulation techniques for treating Parkinson's disease have led to considering their extension to severe psychiatric disorders. This method can mimic the effects of 'conventional' psychosurgery, but in a potentially reversible and adaptable way, thus avoiding many undesirable side-effects of lesional surgery. Ensuring an ethical decision-making process and the appropriateness of consent becomes of paramount importance.

Consent can be relatively easy to secure in selected patients who are often fully aware of their torments (such as those suffering from severe refractory depression of obsessive-compulsive disorders) whose suffering may be such that they are ready to accept, or for that matter demand, such actions. However, the duty of physicians is to realize that pains should always be taken to do as much good (and as little harm) as possible, while respecting the freedom of decision of those who seek to help.