BRITISH MEDICAL JOURNAL
22
OCTOBER
1081
1977
CORRESPONDENCE ECT and the media J F Anderson, MB, DPM, and others ...... The debasement of consent S J G Spencer, FRCPSYCH .............. ECT in underdeveloped countries ............. L Rose, FRCPSYCH ....... Dispute in Malta ............ L J German, FRCOG ...... Children's eye clinics ............. P A Gardiner, MD ....... Screening children for visual defects Wendy V Mulholland, DBO; M J Gilkes, FRCS .........
.......................
Demand for patient care C S B Galasko, FRCS; H G Pledger, FFARCS Adverse reactions to intravenous anaesthetic induction agents J Watkins, PHD, and others ............ Adverse reactions to Althesin ............ T M Savege, FFARCS ...... Seniority payments and service in HM Forces C B A Lloyd-Williams, MRCGP .......... General practitioner prescribing costs .............. P P Carter, MB ........
1081
1082 1082
1082 1083 1083
1083 1084 1085 1085 1085
Costs of prescribing A R Dewsbury, MRCGP . .......... A tennis elbow support A J Richards, MRCP .................. Bell's palsy and herpes simplex B E Juel-Jensen, DM .................. Questionnaires and abuse of privacy Aline Sullivan, MRCS .................. Vitamin B12 deficiency in a child R Ferguson, MRCP .................... Mobilisation after myocardial infarction
1085
1086 1086
1086 1086
D McC Boyle, FRCP, and others ........ 1086 Immunological deficiency, cancer, and
prostaglandins D F Horrobin, BM, and others .......... Release of copper from intrauterine contraceptive devices M Cohen, FRCS ...................... Effect of oestrogens on postmenopausal bone loss R Lindsay, MRCP, and D M Hart, FRCOG.. Tietze's syndrome M Harkonen ........................ Teaching first aid to children A W Gardner, MD ....................
.......
1086
1087
1087 1087 1088
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors. ECT and the media
SIR,-In recent months our committee has become increasingly aware of the damage resulting from adverse publicity, mainly on television programmes, given to electric convulsion therapy. Three recent examples may be cited. A woman now in her late fifties had an episode of severe biological depression successfully treated by ECT in 1964. She remained well until about six months ago, when again without obvious reason she became depressed. She did not respond well to appropriate antidepressant drugs prescribed by her general practitioner but strove to conceal the extent of her depression, as her husband had remarked some months earlier, after seeing a television programme, that she was lucky to have survived ECT and should never have had it. Her depression deepened, but when she had reached a point of trying to communicate her distress her efforts unfortunately coincided with yet another midsummer programme (Panorama), which provoked further critical comment from her husband; and in confusion and despair she attempted suicide. Fortunately, her effort was not successful and she has now responded very well to a short course of modified ECT, a treatment which had at no time caused her direct anxiety and which she herself desperately wanted. Another patient with a similar history, treated successfully by ECT in 1960, took a much tougher line with dissenting relatives and presented herself for emergency admission. A 72-year-old woman with no previous psychiatric history presenting with severe agitated depression, convinced that she had terminal cancer and was being put
Place of chlormethiazole in treatment of alcoholics M M Glatt, FRCPSYCH ................ Surgical treatment of trigeminal neuralgia E J R Morgan, FDSRCS, and others ...... Intravenous diazepam and Cyclimorph A W Fowler, FRCS ....... ............. Barbiturates and fractures T B Dunn, FRCP ...................... Sunlighting and medicine D N Baron, FRCPATH .................. Whole-timers and the new consultant contract J M Shennan, FRCS ............ Consultant contract and HCSA P H Setna, FRCS ...................... Consultants' motoring costs R D H Ryall, FRCR .................... Tenure of registrar posts W J Atkinson, FRCS .................. Complaints against GPs J Gyves ........ .................... Junior doctors' salaries T McFarlane, MB ....... ............. GPs' ancillary staff M E Glanvill, MRCGP.
away by her relatives, screamed, "I know it all -I have seen it on television. You'll take me away in a yellow cab and give me electric shocks." Such incidents have become commonplace and there is not one of the seven consultants practising in general psychiatry in Fife who has not recently been faced with a problem of this sort. (For those with an interest, our mean age is 48 5 and our total experience in psychiatry 191 years, 106 years as consultants.) By now the television scenario is a familiar one. At the outset the presenter is at pains to emphasise the neutrality and objectivity that are the keynote of the whole programme. "The majority of psychiatrists," he tells us, "will at some time in their lives have prescribed ECT ... many of them believe that it is an effective treatment for some forms of depression some patients seem to have derived benefit, albeit only temporarily, from the treatment.... BUT ... there is another side." And so, for half an hour or more, we have "the other side." Even in the 45 seconds allowed to orthodox psychiatry the distortion ("benefit . . only temporarily") in the classical tradition of Dr Josef Goebbels has begun. We have at least one patient who has "never been the same since." In response to leading questions she testifies that not only did ECT fail to help her but it devastated her memory. Yet she remembers with a clarity and conviction that would delight any barrister that she was most definitely not warned about possible side effects, that no doctor explained the treatment, and that she signed no consent form. Nowhere in such a programme is there any
1088 1088
1088 1088
1089 1089 1089 1089 1090 1090
1090 1090
mention of the fact that ECT causes some degree of temporary memory disturbance. Then we have a youthful psychiatrist from a teaching centre who assures us that there is no real evidence that ECT works, and only his own carefully designed study will provide the final illumination. He has almost certainly never seen a single patient with untreated depression, and, faced with the intoxicating prospect of a career combining research and television stardom, he never will. To restore the balance we have a more firmly established academic psychiatrist who sounds wary and somewhat tentative. "No, we don't really know how ECT works, but there is . . . quite a lot of evidence that it does . . in some cases." Careful, accurate, and unexceptionable, but hardly likely to stem the torrents of adrenaline flowing from "the other side." Then follow attacks from various sources on the naivety, arrogance, and cruelty of psychiatrists and the crude, unscientific, and sadistic nature of their treatments. Misleading and illinformed comparisons with deep insulin coma treatment are made: there is no appreciation of the fact that insulin treatment was neither better nor worse than other medical treatments of its time that were a substitute for inertia, and the fact that it was rightly displaced by a more effective treatment for schizophrenia, the phenothiazines. There is much condemnation of empiricism and the strange implication that this no longer has any place in other branches of medical science. Much is made of our ignorance of the mode of action of ECT (no one has the least idea of how digitalis works, but this has not hitherto been a sufficient reason for discarding it as a treatment in heart failure). Only now, we are told, have psychiatrists thought to compare the results of modified ECT with those of the modified procedure without actual electroplexy; yet several members of our committee took part in such studies more than 20 years
1082 ago. Someone is sure to tell the story-one that has been told to our knowledge for more than 30 years-of the ECT machine that broke down or was not connected properly, "and the patients did just as well." Throw in an angry MP, a lawyer or two, some confusing references to compulsory treatment under the Mental Health Act, some ancient film of straight ECT from the days of Cerletti and Bini-hardly more frightening than the very poorly modified treatment shown in some programmes-and the picture is almost complete. Few experienced psychiatrists would deny that we need more precise information about the indications for ECT, just as we need more information about other treatments, such as lithium and antidepressant drugs, that have been shown empirically to work well for many patients. And few would deny that ECT, perhaps because it often works wonderfully well, has often been used indiscriminately. But surely the consensus and the uniformity of practice throughout the United Kingdom that have emerged from 30 years of experience confirm its place as the most consistently effective treatment of severe depression that is available to us. The distortions of the media, reinforced by the malign influence of bodies such as the Citizen's Commission on Human Rights that have long campaigned against psychiatry in all its aspects, have produced so much dread and suspicion that we have moved very quickly to a point where psychiatrists are under great pressure to withhold what is often a life-saving treatment, and where patients who could benefit are too afraid to seek help of any sort. Psychiatrists have always tended to regard attacks on themselves and their profession as manifestations of neurotic reaction, the product of society's too heavily defended ego, and have responded with the essentially therapeutic bland tolerance appropriate to any negative transference. To some extent this may be good for society and good for psychiatrists; but it would be tragic if it obscured the fact that in this instance the real victims of such irrational hostility are the most vulnerable members of society. We are not alone in our anxiety, and it is good to learn from Dr Haslam's letter (13 August, p 455) that the Society of Clinical Psychiatrists is shortly to publish a report on public relations in psychiatry. So far as we are aware, only the Guardian has made a reference, somewhat lukewarm, to the Royal College of Psychiatrists' memorandum on the use of electroconvulsive therapy which appeared in the British Journal of Psychiatry in September; the long delay before its publication and its obvious lack of impact suggest that psychiatrists have much to learn about public relations. If we shrink from our responsibilities now, when and where do we make our stand ? It would be a salutary exercise for anyone who, for whatever motive, seeks to criticise ECT to read Aubrey Lewis's classic 1934 study of melancholia. No doubt enterprising journalists will soon discover that lithium sometimes causes myxoedema and tricyclic antidepressants can impair cardiac conduction; and then it would be back to 1934, when melancholia has to run its natural course, but without the resources to hospitalise the patient for 312 years. Perhaps by then our patients will fight our battles for us and we can watch the banners of CURE-Campaign Urging the Restoration of Electroplexy-from the sidelines. But that is a long way off and by then
BRITISH MEDICAL JOURNAL
many thousands of patients who could have been effectively treated will have suffered the most terrible of all human afflictions. And many-perhaps the more fortunate-will have died. J F ANDERSON E J MACDONALD A MORRISON K M ARMIT D M MAcGREGOR
P SETHI S F LINDSAY A M MACLEOD I R SHERRET
Medical Committee, Stratheden Hospital,
Cupar, Fife
The debasement of consent
SIR,-YOU published (10 September, p 713), under the heading "Guidelines on ECT," a summary of the memorandum on the use of electroconvulsive therapy issued by the Royal College of Psychiatrists.' In it you allude to two recommendations, the implications of which extend beyond psychiatry to medicine as a whole: (1) "Consent ... should be obtained from ... formal [that is, detained] patients. If ECT is thought essential and the patient is unwilling ... section 26 . . should be applied and ... two consultant opinions obtained"-and then (it is clearly inferred) the treatment given all the same. (2) ". relatives cannot give legal consent. Nevertheless . obtaining relatives' consent is strongly advised"-but if they refuse it and ECT is deemed essential (again the inference is clear) it should still be given. I am in no doubt but the college's advice was given with Mind, and especially its special report A Human Condition2 and possibly Jacob < also, hanging menacingly over its head. I have heard it rumoured that the three defence bodies concur. Yet I am sure all three (or six) are wrong, and dangerously so for the proper practice of medicine. Consent should never be asked unless the decision of him asked is to be honoured. To say to patient or relative, "I seek your consent, but I shall act regardless of it," debases the value of the coin of consent: a coin of value too priceless to be debased without fundamental erosion of the standard of human discourse. The procedure smacks, furthermore, of a subtly cynical type of Hitlerism. May we please have the courage to take decisions where necessary (for the life or health of our patients) fully upon ourselves and not make a charade of shoving them off on to those unqualified to take them ? A postscript: I disagree with the "legal advice" that section 25 of the Mental Health Act is insufficient for ECT and have obtained a lawyer's corroboration of my disagreement. SEYMOUR SPENSER Oxford
Royal College of Psychiatrists, Brirish Journal of Psychiatry, 1977, 131, 261. Gostin, L 0, Mind Special Report, pp 121-2, October 1975. 3Jacob, J, The Modern Law Review, 1976, 39, 17.
ECT in underdeveloped countries
SIR,-As a member of the Special Committee on Electric Convulsion Therapy (ECT) of the Royal College of Psychiatrists I would like to make a few points which arise from the letter of Wendy Farrant (1 October, p 895). The implication is that colleagues recommending ECT are not adequate in the field of
22 OCTOBER 1977
general medical practice to administer the appropriate medication themselves. About 25 years ago I drew attention in these columns to the availability of a short-acting muscle relaxant covered by intravenous anaesthesia. At a meeting some months later of the (then) Royal Medico-Psychological Association I sought, and obtained, agreement that until anaesthetists had acquired the appropriate knowledge and skills (not yet disseminated) it was acceptable for a psychiatrist to administer the anaesthetic and relaxant himself. It was not long before the collaboration of anaesthetists became routine, but this is a professional and ethical safeguard-dare I say not an essential? Is there any reason to think that there are doctors anywhere who could not do this quite simple job ? Literacy and written consent in developing countries obviously present a different problem, but verified oral consent with the aid of an interpreter (which is what most of my colleagues and I obtain for foreign patients) could go some way towards resolving it. Having used chemical, electrical, and inhalant convulsive techniques for over 30 years, less frequently in favour of antidepressant medication since about 1957, I would encourage doctors overseas (or anywhere) to take a good look at the indications for ECT. I am still satisfied that it is the treatment of immediate choice for some patients-but only for some. Perhaps I may add a personal note. In thousands of treatments of general hospital inand out-patients and of private patients at home, in nursing homes, and here I have had two operation mishaps, both dental, before I decided not to remove incomplete dentures supporting spaced teeth. (There is no masseter jerk with flurethyl induction.) L ROSE London Wl
Dispute in Malta SIR,-With reference to the appeal launched by the British Medical Journal (10 September, p 708), allow me to draw your readers' attention to the plight of the Maltese medical profession. The current dispute between the Maltese Government and the Medical Association of Malta (MAM) arose out of disagreement over new legislation affecting newly qualified doctors and the powers of the Medical Council. In protest, the MAM directed its members to take limited action involving outpatient clinics and non-urgent surgical operations, while continuing to provide the necessary cover for emergencies. The Maltese Government reacted by ordering a lock-out of doctors and specialists from all State hospitals and by importing foreign doctors from Libya, Czechoslovakia, Pakistan, and the Palestine Liberation Organisation to man emergency hospital services. Within a few days punitive legislation was rushed through parliament prohibiting the Maltese doctors and specialists from practising in private hospitals. Further legislation culminated in their dismissal not only from their government posts but also, in some cases, from their university appointments. The latter included the professors of medicine, surgery, and obstetrics and gynaecology. The lock-out affected local as well as British external examiners, with the result that final year medical students who were due to qualify last June could not complete their
22
OCTOBER
1081
1977
CORRESPONDENCE ECT and the media J F Anderson, MB, DPM, and others ...... The debasement of consent S J G Spencer, FRCPSYCH .............. ECT in underdeveloped countries ............. L Rose, FRCPSYCH ....... Dispute in Malta ............ L J German, FRCOG ...... Children's eye clinics ............. P A Gardiner, MD ....... Screening children for visual defects Wendy V Mulholland, DBO; M J Gilkes, FRCS .........
.......................
Demand for patient care C S B Galasko, FRCS; H G Pledger, FFARCS Adverse reactions to intravenous anaesthetic induction agents J Watkins, PHD, and others ............ Adverse reactions to Althesin ............ T M Savege, FFARCS ...... Seniority payments and service in HM Forces C B A Lloyd-Williams, MRCGP .......... General practitioner prescribing costs .............. P P Carter, MB ........
1081
1082 1082
1082 1083 1083
1083 1084 1085 1085 1085
Costs of prescribing A R Dewsbury, MRCGP . .......... A tennis elbow support A J Richards, MRCP .................. Bell's palsy and herpes simplex B E Juel-Jensen, DM .................. Questionnaires and abuse of privacy Aline Sullivan, MRCS .................. Vitamin B12 deficiency in a child R Ferguson, MRCP .................... Mobilisation after myocardial infarction
1085
1086 1086
1086 1086
D McC Boyle, FRCP, and others ........ 1086 Immunological deficiency, cancer, and
prostaglandins D F Horrobin, BM, and others .......... Release of copper from intrauterine contraceptive devices M Cohen, FRCS ...................... Effect of oestrogens on postmenopausal bone loss R Lindsay, MRCP, and D M Hart, FRCOG.. Tietze's syndrome M Harkonen ........................ Teaching first aid to children A W Gardner, MD ....................
.......
1086
1087
1087 1087 1088
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors. ECT and the media
SIR,-In recent months our committee has become increasingly aware of the damage resulting from adverse publicity, mainly on television programmes, given to electric convulsion therapy. Three recent examples may be cited. A woman now in her late fifties had an episode of severe biological depression successfully treated by ECT in 1964. She remained well until about six months ago, when again without obvious reason she became depressed. She did not respond well to appropriate antidepressant drugs prescribed by her general practitioner but strove to conceal the extent of her depression, as her husband had remarked some months earlier, after seeing a television programme, that she was lucky to have survived ECT and should never have had it. Her depression deepened, but when she had reached a point of trying to communicate her distress her efforts unfortunately coincided with yet another midsummer programme (Panorama), which provoked further critical comment from her husband; and in confusion and despair she attempted suicide. Fortunately, her effort was not successful and she has now responded very well to a short course of modified ECT, a treatment which had at no time caused her direct anxiety and which she herself desperately wanted. Another patient with a similar history, treated successfully by ECT in 1960, took a much tougher line with dissenting relatives and presented herself for emergency admission. A 72-year-old woman with no previous psychiatric history presenting with severe agitated depression, convinced that she had terminal cancer and was being put
Place of chlormethiazole in treatment of alcoholics M M Glatt, FRCPSYCH ................ Surgical treatment of trigeminal neuralgia E J R Morgan, FDSRCS, and others ...... Intravenous diazepam and Cyclimorph A W Fowler, FRCS ....... ............. Barbiturates and fractures T B Dunn, FRCP ...................... Sunlighting and medicine D N Baron, FRCPATH .................. Whole-timers and the new consultant contract J M Shennan, FRCS ............ Consultant contract and HCSA P H Setna, FRCS ...................... Consultants' motoring costs R D H Ryall, FRCR .................... Tenure of registrar posts W J Atkinson, FRCS .................. Complaints against GPs J Gyves ........ .................... Junior doctors' salaries T McFarlane, MB ....... ............. GPs' ancillary staff M E Glanvill, MRCGP.
away by her relatives, screamed, "I know it all -I have seen it on television. You'll take me away in a yellow cab and give me electric shocks." Such incidents have become commonplace and there is not one of the seven consultants practising in general psychiatry in Fife who has not recently been faced with a problem of this sort. (For those with an interest, our mean age is 48 5 and our total experience in psychiatry 191 years, 106 years as consultants.) By now the television scenario is a familiar one. At the outset the presenter is at pains to emphasise the neutrality and objectivity that are the keynote of the whole programme. "The majority of psychiatrists," he tells us, "will at some time in their lives have prescribed ECT ... many of them believe that it is an effective treatment for some forms of depression some patients seem to have derived benefit, albeit only temporarily, from the treatment.... BUT ... there is another side." And so, for half an hour or more, we have "the other side." Even in the 45 seconds allowed to orthodox psychiatry the distortion ("benefit . . only temporarily") in the classical tradition of Dr Josef Goebbels has begun. We have at least one patient who has "never been the same since." In response to leading questions she testifies that not only did ECT fail to help her but it devastated her memory. Yet she remembers with a clarity and conviction that would delight any barrister that she was most definitely not warned about possible side effects, that no doctor explained the treatment, and that she signed no consent form. Nowhere in such a programme is there any
1088 1088
1088 1088
1089 1089 1089 1089 1090 1090
1090 1090
mention of the fact that ECT causes some degree of temporary memory disturbance. Then we have a youthful psychiatrist from a teaching centre who assures us that there is no real evidence that ECT works, and only his own carefully designed study will provide the final illumination. He has almost certainly never seen a single patient with untreated depression, and, faced with the intoxicating prospect of a career combining research and television stardom, he never will. To restore the balance we have a more firmly established academic psychiatrist who sounds wary and somewhat tentative. "No, we don't really know how ECT works, but there is . . . quite a lot of evidence that it does . . in some cases." Careful, accurate, and unexceptionable, but hardly likely to stem the torrents of adrenaline flowing from "the other side." Then follow attacks from various sources on the naivety, arrogance, and cruelty of psychiatrists and the crude, unscientific, and sadistic nature of their treatments. Misleading and illinformed comparisons with deep insulin coma treatment are made: there is no appreciation of the fact that insulin treatment was neither better nor worse than other medical treatments of its time that were a substitute for inertia, and the fact that it was rightly displaced by a more effective treatment for schizophrenia, the phenothiazines. There is much condemnation of empiricism and the strange implication that this no longer has any place in other branches of medical science. Much is made of our ignorance of the mode of action of ECT (no one has the least idea of how digitalis works, but this has not hitherto been a sufficient reason for discarding it as a treatment in heart failure). Only now, we are told, have psychiatrists thought to compare the results of modified ECT with those of the modified procedure without actual electroplexy; yet several members of our committee took part in such studies more than 20 years
1082 ago. Someone is sure to tell the story-one that has been told to our knowledge for more than 30 years-of the ECT machine that broke down or was not connected properly, "and the patients did just as well." Throw in an angry MP, a lawyer or two, some confusing references to compulsory treatment under the Mental Health Act, some ancient film of straight ECT from the days of Cerletti and Bini-hardly more frightening than the very poorly modified treatment shown in some programmes-and the picture is almost complete. Few experienced psychiatrists would deny that we need more precise information about the indications for ECT, just as we need more information about other treatments, such as lithium and antidepressant drugs, that have been shown empirically to work well for many patients. And few would deny that ECT, perhaps because it often works wonderfully well, has often been used indiscriminately. But surely the consensus and the uniformity of practice throughout the United Kingdom that have emerged from 30 years of experience confirm its place as the most consistently effective treatment of severe depression that is available to us. The distortions of the media, reinforced by the malign influence of bodies such as the Citizen's Commission on Human Rights that have long campaigned against psychiatry in all its aspects, have produced so much dread and suspicion that we have moved very quickly to a point where psychiatrists are under great pressure to withhold what is often a life-saving treatment, and where patients who could benefit are too afraid to seek help of any sort. Psychiatrists have always tended to regard attacks on themselves and their profession as manifestations of neurotic reaction, the product of society's too heavily defended ego, and have responded with the essentially therapeutic bland tolerance appropriate to any negative transference. To some extent this may be good for society and good for psychiatrists; but it would be tragic if it obscured the fact that in this instance the real victims of such irrational hostility are the most vulnerable members of society. We are not alone in our anxiety, and it is good to learn from Dr Haslam's letter (13 August, p 455) that the Society of Clinical Psychiatrists is shortly to publish a report on public relations in psychiatry. So far as we are aware, only the Guardian has made a reference, somewhat lukewarm, to the Royal College of Psychiatrists' memorandum on the use of electroconvulsive therapy which appeared in the British Journal of Psychiatry in September; the long delay before its publication and its obvious lack of impact suggest that psychiatrists have much to learn about public relations. If we shrink from our responsibilities now, when and where do we make our stand ? It would be a salutary exercise for anyone who, for whatever motive, seeks to criticise ECT to read Aubrey Lewis's classic 1934 study of melancholia. No doubt enterprising journalists will soon discover that lithium sometimes causes myxoedema and tricyclic antidepressants can impair cardiac conduction; and then it would be back to 1934, when melancholia has to run its natural course, but without the resources to hospitalise the patient for 312 years. Perhaps by then our patients will fight our battles for us and we can watch the banners of CURE-Campaign Urging the Restoration of Electroplexy-from the sidelines. But that is a long way off and by then
BRITISH MEDICAL JOURNAL
many thousands of patients who could have been effectively treated will have suffered the most terrible of all human afflictions. And many-perhaps the more fortunate-will have died. J F ANDERSON E J MACDONALD A MORRISON K M ARMIT D M MAcGREGOR
P SETHI S F LINDSAY A M MACLEOD I R SHERRET
Medical Committee, Stratheden Hospital,
Cupar, Fife
The debasement of consent
SIR,-YOU published (10 September, p 713), under the heading "Guidelines on ECT," a summary of the memorandum on the use of electroconvulsive therapy issued by the Royal College of Psychiatrists.' In it you allude to two recommendations, the implications of which extend beyond psychiatry to medicine as a whole: (1) "Consent ... should be obtained from ... formal [that is, detained] patients. If ECT is thought essential and the patient is unwilling ... section 26 . . should be applied and ... two consultant opinions obtained"-and then (it is clearly inferred) the treatment given all the same. (2) ". relatives cannot give legal consent. Nevertheless . obtaining relatives' consent is strongly advised"-but if they refuse it and ECT is deemed essential (again the inference is clear) it should still be given. I am in no doubt but the college's advice was given with Mind, and especially its special report A Human Condition2 and possibly Jacob < also, hanging menacingly over its head. I have heard it rumoured that the three defence bodies concur. Yet I am sure all three (or six) are wrong, and dangerously so for the proper practice of medicine. Consent should never be asked unless the decision of him asked is to be honoured. To say to patient or relative, "I seek your consent, but I shall act regardless of it," debases the value of the coin of consent: a coin of value too priceless to be debased without fundamental erosion of the standard of human discourse. The procedure smacks, furthermore, of a subtly cynical type of Hitlerism. May we please have the courage to take decisions where necessary (for the life or health of our patients) fully upon ourselves and not make a charade of shoving them off on to those unqualified to take them ? A postscript: I disagree with the "legal advice" that section 25 of the Mental Health Act is insufficient for ECT and have obtained a lawyer's corroboration of my disagreement. SEYMOUR SPENSER Oxford
Royal College of Psychiatrists, Brirish Journal of Psychiatry, 1977, 131, 261. Gostin, L 0, Mind Special Report, pp 121-2, October 1975. 3Jacob, J, The Modern Law Review, 1976, 39, 17.
ECT in underdeveloped countries
SIR,-As a member of the Special Committee on Electric Convulsion Therapy (ECT) of the Royal College of Psychiatrists I would like to make a few points which arise from the letter of Wendy Farrant (1 October, p 895). The implication is that colleagues recommending ECT are not adequate in the field of
22 OCTOBER 1977
general medical practice to administer the appropriate medication themselves. About 25 years ago I drew attention in these columns to the availability of a short-acting muscle relaxant covered by intravenous anaesthesia. At a meeting some months later of the (then) Royal Medico-Psychological Association I sought, and obtained, agreement that until anaesthetists had acquired the appropriate knowledge and skills (not yet disseminated) it was acceptable for a psychiatrist to administer the anaesthetic and relaxant himself. It was not long before the collaboration of anaesthetists became routine, but this is a professional and ethical safeguard-dare I say not an essential? Is there any reason to think that there are doctors anywhere who could not do this quite simple job ? Literacy and written consent in developing countries obviously present a different problem, but verified oral consent with the aid of an interpreter (which is what most of my colleagues and I obtain for foreign patients) could go some way towards resolving it. Having used chemical, electrical, and inhalant convulsive techniques for over 30 years, less frequently in favour of antidepressant medication since about 1957, I would encourage doctors overseas (or anywhere) to take a good look at the indications for ECT. I am still satisfied that it is the treatment of immediate choice for some patients-but only for some. Perhaps I may add a personal note. In thousands of treatments of general hospital inand out-patients and of private patients at home, in nursing homes, and here I have had two operation mishaps, both dental, before I decided not to remove incomplete dentures supporting spaced teeth. (There is no masseter jerk with flurethyl induction.) L ROSE London Wl
Dispute in Malta SIR,-With reference to the appeal launched by the British Medical Journal (10 September, p 708), allow me to draw your readers' attention to the plight of the Maltese medical profession. The current dispute between the Maltese Government and the Medical Association of Malta (MAM) arose out of disagreement over new legislation affecting newly qualified doctors and the powers of the Medical Council. In protest, the MAM directed its members to take limited action involving outpatient clinics and non-urgent surgical operations, while continuing to provide the necessary cover for emergencies. The Maltese Government reacted by ordering a lock-out of doctors and specialists from all State hospitals and by importing foreign doctors from Libya, Czechoslovakia, Pakistan, and the Palestine Liberation Organisation to man emergency hospital services. Within a few days punitive legislation was rushed through parliament prohibiting the Maltese doctors and specialists from practising in private hospitals. Further legislation culminated in their dismissal not only from their government posts but also, in some cases, from their university appointments. The latter included the professors of medicine, surgery, and obstetrics and gynaecology. The lock-out affected local as well as British external examiners, with the result that final year medical students who were due to qualify last June could not complete their
