Ethical Considerations in Providing Electroconvulsive Therapy during the COVID-19 Pandemic

Abstract

The adaptation of mental health services in response to the COVID-19 pandemic has significantly impacted access to mental health care. Delivery of electroconvulsive therapy (ECT) with its potentially aerosol-generating airway procedures may increase risk of COVID-19 transmission. In light of this risk and other challenges associated with the pandemic, recent consensus statements have outlined approaches to address relevant ECT delivery and systemic factors including COVID-19 screening and infection control, ECT triage (elective, urgent, emergency), reducing ECT caseloads (acute and maintenance treatments) and staffing plans. Because of the urgent needs and precarious situations of many people who require ECT, reducing service availability is morally fraught at the individual, team, and organizational level. Careful ethical reflection about how service changes are to be managed or whether they can be avoided is imperative for mitigating harms to patients and moral injury among service providers. The purpose of this article is to discuss key ethical issues that have arisen related to providing ECT during the COVID-19 pandemic and to recommend questions that should be asked during the process of ECT clinical service planning in the pandemic context. Recent scholarship about the provision of ECT echoes common concerns in pandemic ethics as articulated in a leading resource in this area: Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza. This report was prepared by the Joint Centre for Bioethics at the University of Toronto after Canada’s experience with the SARS epidemic in 2003. Stand on Guard for Thee, like pandemic ethics frameworks developed in other countries, does not specifically address ethical issues involved in providing mental health care during a pandemic. Despite its lack of attention to mental health issues and although there are important epidemiological differences between the SARS epidemic and the COVID-19 pandemic (e.g., predominantly hospital spread vs. community spread), Stand on Guard for Thee remains relevant because Canadian public health responses raise similar ethical issues across time and clinical settings. The following analysis considers recent work about offering ECT in a pandemic and is informed by the values highlighted in Stand on Guard for Thee. We aim to explicitly articulate the often implicit ethical dimensions of providing ECT in a pandemic. Reflection questions stemming from this analysis are offered in Table 1. These questions can be modified to suit different levels of decision-making or local circumstances as appropriate. The 15 key values in pandemic ethics identified in Stand on Guard for Thee are divided into 2 types. Five are procedural values: values that should guide how decisions are made and what decision-making processes should be like. The procedural values are accountability, inclusiveness, openness and transparency, reasonableness, and responsiveness. The remaining 10 values are substantive values, in