A writ petition in the High Court of Bombay at Panaji challenged the practice at the Institute of Psychiatry and Human Behaviour (IPHB), Panji, Goa, of administering electro-convulsive therapy (ECT) without anaesthesia. The petition was filed on the basis of a complaint from a patient's relative recently committed to the IPHB for treatments.

According to the petitioner, Advocate Caroline Collasso:
Patients at the IPHB were administered ECT without anaesthesia because no anaesthetist was available and the anaesthesia machine was in a state of disrepair. The IPHB administered a minimum of 200 procedures a month, with staff members holding the patient down during the procedure.

The practice was barbaric, inhuman and hence in violation of Article 21 of the Constitution; in violation of Section 81 (Chapter VIII) of the Mental Health Act, 1987, providing that no mentally ill person be subjected during treatment to indignity or cruelty.

The use of anaesthesia and muscle relaxants for ECT is recommended medical practice, eliminating the major problems associated with ECT without anaesthesia - patient discomfort, fractures of the spine and long bones, and dislocations particularly of the jaw. In fact, the IPHB followed this practice till 1992 when its anaesthetist left.

ECT was being administered without the patients’ informed consent.
The petitioner filed the petition on behalf of patients and their relatives, since patients are in no position to approach the court, and relatives are reluctant to come forward, given the stigma attached to mental illness.

Dr John Fernandes, director of the IPHB, replied:
ECT without anaesthesia is a recognised procedure, known as ‘direct’ or ‘unmodified’ ECT, as opposed to ‘modified’ ECT, with anaesthesia. The former caused convulsions but no pain.“... pain especially in the jaws occurs in modified ECT due to the effect of muscle relaxants which is overcome by giving anaesthesia....” The only complication of unmodified ECT is fractures, which can be avoided if precautions are taken.

While modified ECT minimises fractures, it has other major complications. It has to be administered under general anaesthesia with the use of a muscle relaxant which also has complications: occasional hypersensitivity, and respiratory paralysis resulting in death. Also, “Several patients have to be anaesthetised in a short period, which can cause some compromise in the standard of anaesthetic care. When patients are administered six to eight ECTs with anaesthesia in a span of two to three weeks, the mortality rate is higher for modified than unmodified ECTs.”

Direct ECT is the only option for patients with certain health conditions who cannot be anaesthetised.

“Direct ECT... is not a discarded . . . procedure though today modified ECT is a preferred form of treatment in cases where patients can take anaesthesia. The advantages and disadvantages of‘ ECT in its direct and modified form are still being debated.”

The Institute started modified ECT in 1988. However, it stopped the practice in 1992 after the anaesthetist left. In 1995 the government instructed them not to ffill up the post; the senior resident in anaesthesia attached to the Goa Medical College would be at their disposal. On September 22, 1998, the Goa Medical College deputed an anaesthetist twice a week to the Institute.

“Since the inception of the establishment of the Institute in 1980, (it) has been treating patients requiring ECT with direct form without administering anaesthesia without any hazards.. . our procedures have been free of incidents of fractures.”

ECT is conducted after taking consent of patients or when appropriate their relatives. The director attached a list of 11 mental hospitals in India, practicing only direct ECT, and eight practicing both.

Advocate Collasso responded:
Affidavits from doctors and psychiatrists state that ECT without anaesthesia is barbaric, causes needless pain and injuries, and has no medical justification today. The use of anaesthesia, muscIe relaxant and oxygen is now standard practice in the administration of ECT.

Direct ECT is not a medically indicated choice but a practice based on non-medical grounds such as non-availability of anaesthetists and the accompanying infrastructure. “Lack of such facilities are due to socio- political reasons and not germane to sound medical practice and procedure.”

At least two of the hospitals listed by the respondent have been severely criticised by the Supreme Court. Also, the High Court of Maharashtra (PIL Shukri vs. State of Maharashtra, 1989, regarding conditions in the Central Institute of Mental Hygiene and Research, Yervada, Pune) stated: “Hospital authorities should review the effects of direct ECT on the patient and should decide whether the method should be continued in view of the fright taken by the patients. Modified ECT is recommended.”

As a teaching institute, the IPHB must adopt modified ECT in order to instruct its students in the procedure.
Only a proper enquiry would disclose whether the Institute had been doing ECT without injuries.

The consent form for patients being administered direct ECT at the IPHB contains no information on the treatment, the need for it, and its pros and cons.

Finally, anaesthetists deputed to the IPHB are reluctant to administer anaesthesia due to the lack of supportive monitoring equipment such as a cardioscope and pulse oximeter.

The final order of the high court in Writ Petition 357/ 98 delivered on October 14, 1998:
“Learned Advocate General appearing on behalf of the Respondents states that Hospital Authority would as far as possible give modified ECT on patients and would also decide whether the unmodified form of ECT should be continued or not depending upon the medical advice. He states that if there are any further directions issued by the High Court in judgement delivered on 10th November, 1989, in the case of Shukri vs. State of Maharashtra, other directions would also follow.”

Note:The above report has been condensed from documents sent courtesy of advocates Caroline Collasso and Peter D‘souza.