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

The adaptation of mental health services in response to the COVID-19 pandemic has significantly impacted access to mental health care. ¹ 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. ^{2 –8} 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. ⁹ 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. ^1,9 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. ¹⁰ 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. ¹¹ 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), ¹² 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.

Table 1.

Clinical Services Planning Reflection Questions for Electroconvulsive Therapy (ECT) Providers.

Value	Reflection Question	Example Considerations
Proportionality	If your plan entails not providing ECT under particular circumstances, is the balance of the risks proportionate?	Are exclusions decided only on a case-by-case basis? Have all strategies to maximize the effectiveness of PPE and other IPAC measures failed or been found to be inadequate? Do you have a plan for re-evaluating risks as different testing, treatment, and IPAC methods are developed?
Duty to care	a. How will you continue to provide care if your plan has the foreseeable effect of reducing the provision of ECT services (e.g., result in sessions taking longer, requiring more space, requiring more time between sessions, etc.)? If so, have you explored all avenues to preserve access?	Have you assessed the benefits of offering longer service hours? 13 Have you rethought the use of physical space or the process steps that happen on-site versus remotely or in advance in a different setting? 14
	b. After being resourceful 13 about how to rethink the provision of ECT, is there still going to be some loss of service? If so, do you have a plan for facilitating access to ECT in other ways?	Have you considered reducing the frequency of ECT sessions (e.g., decreasing the number of weekly sessions for acute patients or increasing the interval between sessions for maintenance patients) to make space for more individual patients to have access? Have you explored transferring the care of some patients to facilities that have more capacity? Have you explored the possibility of collaborating with colleagues in other facilities to develop a regional or inter-institutional approach to meeting patients’ needs for ECT?
	c. If all attempts to minimize the impact on patients have been made and still some patients will not have access to ECT, have you identified avenues for providing continued care in the absence of ECT?	Have you developed a prioritization system that would divert some patients toward other interventions? Have you used your institutional and professional relationships with other care providing organizations in order to advocate for the needs of your patients and maximize the supports available to patients who cannot be offered ECT?
Equity	If you have developed a prioritization system, does your system incorporate the multiple sources of client vulnerability and client strengths into the scoring or weighting process so as to avoid compounding disadvantages?	Will prioritization respond to the impacts of racial inequities, socioeconomic status, disability, age, institutionalization, etc., on patients’ ability to access care and ability to function without ECT?
Solidarity	If you anticipate shortages that could limit services, have you advocated for the needs of patients who need ECT?	Have you advocated within your institution for greater resources for the ECT program? Have you contributed to advocacy for more attention to the continuity of mental health care in your region?
Inclusiveness	Have mental health providers and patients had the opportunity to participate in decision-making at both the hospital and departmental level?	Have patients or patient groups had the opportunity to provide feedback about how they think providers should respond to limited resources, or what key terms such as “risk” and “acceptable risk” might mean to them? Have mental health patients and providers given feedback about the basis on which prioritization may need to occur?
Transparency	Is there a plan for communicating the contents and implications of your plan to stakeholders (both patients and providers)?	Have you made your pandemic decision-making process public? Does your communication plan use a variety of communication methods to ensure that all stakeholders will know about opportunities to provide input and receive important updates about ECT services?

The 15 key values in pandemic ethics identified in Stand on Guard for Thee ¹⁰ 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. ¹⁰ The remaining 10 values are substantive values, in that they influence what is considered during the decision-making process. The substantive values are individual liberty, protection of the public from harm, proportionality, privacy, the duty to provide care, reciprocity, equity, trust, solidarity, and stewardship. ¹⁰ All 15 values could be relevant to making decisions about the provision of ECT during a pandemic. Indeed, the 5 procedural values are essential features of ethical decision-making processes and so would always apply. ¹⁵ As such, reflection on the ethical defensibility of any plan for modifying ECT would benefit from considering them all.

In this article, we will limit our discussion to 6 values—proportionality, the duty to provide care, equity, solidarity, as well as transparency and inclusiveness—because these have been most at issue in recent publications about providing ECT in the pandemic. ^{16 –18} This should not be taken to imply that other values are not relevant. For example, individual liberty and protection of the public from harm might have been particularly salient if clinicians were planning to require ECT recipients to quarantine before and between ECT sessions or to make patients’ access to ECT contingent on their adherence to public health recommendations in other ways.

Proportionality

Proportionality means ensuring that restrictions imposed in order to control a pandemic do not exceed what is necessary to address the actual level of risk. ¹⁰

ECT is an essential treatment for some patients (e.g., those with psychotic depression or medical frailty), and service interruptions are well known to have negative outcomes. ^2,4 While service disruptions may be justified given the risks associated with COVID-19, proportionality demands that different sources of risk be balanced against each other in a realistic and unbiased fashion when deciding whether and how to make changes to service delivery.

Some writers have expressed concern about guidelines offered by professional associations that advocate that decisions about care should be based on whether a patient has COVID-19. ^16,18 While caution around the provision of ECT during the pandemic is justified, there are problems with not even considering providing ECT to patients with COVID-19. Most relevant for this section, category-based exclusions circumvent the process of weighing risks, potentially leading to violations of the proportionality principle. As a result, some ECT providers have argued that treatment decisions should be made only after weighing the risks and benefits of ECT and its alternatives on an individual patient basis and have even provided ECT to COVID-positive patients while safeguarding the health of staff. ^16,17

From the perspective of proportionality, whether or not a patient—even a patient who has tested positive for COVID-19—can receive ECT should be assessed based on situation-specific risks to both providers and patients (e.g., level of community transmission, the availability of PPE) and the availability of strategies for managing these risks, which depends on our understanding of the disease and on the development of effective therapies and vaccines.

Duty to Provide Care

Duties to provide care are specified in the codes of ethics of all health-care professions. ¹⁰ In general, this duty involves providing care even at some level of personal risk. ¹⁹ The duty to care becomes more contentious in epidemics because the risks posed by providing care are significantly greater than normal. ^6,10,20 While the duty to care is not absolute, ^10,19,20 if the patient will benefit and society is providing the resources for mitigating risks (such as personal protective equipment [PPE]), clinicians have an ethical duty to accept greater than usual risks in providing care. ²⁰

Policies that either specify extremely narrow circumstances under which ECT should be entertained or that propose not providing ECT to whole groups of patients are ethically concerning because they are at risk of undermining clinicians’ duty to care. ECT providers have argued that provision of care to patients generally, including patients needing ECT, should not be derailed by efforts to confront and contain SARS-CoV-2. ¹⁸ The fact that ECT provision has continued in some places despite the presence of COVID-19 suggests that it is still possible for providers to uphold their duty to care by providing ECT while protecting both staff and patients. ¹⁷

Whether not providing ECT during a pandemic counts as not fulfilling the duty to care will depend on what efforts are made to continue psychiatric care in other ways. Because of the need for precautions, ECT may legitimately not be available to at least some patients during the pandemic. For example, infection prevention and control (IPAC) precautions may mean that ECT takes extra time, making it impossible to fit in all patients for treatment. Still, people are candidates for ECT because they are experiencing a severe mental disorder and their need for care does not diminish in a pandemic. So, the duty to care includes powerful advocacy by the clinician to continue an efficacious treatment (i.e., ECT). Clinicians can also uphold their duty to care by closely monitoring their patients for signs of deterioration, regularly reassessing whether ECT would be appropriate and possible, or seeking out other sources of support for their patients.

Equity

Some of the most pronounced concerns about the provision of ECT during the pandemic have revolved around equity. Equity refers to the absence of avoidable, unfair, or remediable differences among economic, demographic, or other socially designated groups. ²¹ Equity deserves significant attention in pandemic ethics because the greatest burdens in public health emergencies are faced by “economically and socially disadvantaged groups” ^{22 –24} —as has certainly manifested in the current pandemic.

One equity-related concern that has emerged related to providing ECT during a pandemic is that policy about mental health often reflects stigma and does not take mental illness sufficiently seriously. ¹⁸ Because policies about mental health are formulated in ways that are not fair-minded or dispassionate, they are not infrequently “suboptimal if not discriminatory.” ¹⁸ The concern is that policies for weighing the risks and benefits of ECT or for rationing scarce resources will not adequately consider the unique needs of people with mental health concerns. Thus, these policies could worsen preexisting health disparities. ²⁵

Also, proposals not to provide ECT to patients with COVID-19 advanced either at the policy or the clinical level have been characterized as category-based exclusions, which are arguably a form of legally and ethically unsupported discrimination. ¹⁶ This is a further reason why individual assessments are recommended; only individual assessments give an accurate picture of a particular patient’s ability to benefit from a treatment ^17,25,26 and the risks that would be involved.

Persons who contemplate reducing ECT services should thus be conscious of two things. First, the way in which they reduce services should not discriminate against patients based on health status, age, race, or other extraneous factors. Second, providers should be attentive to the multiple sources of social disadvantage their patients may face and incorporate these into how they plan to modify their services and (if necessary) triage their patients’ access to ECT. This includes acknowledging the disproportionate prevalence of COVID-19 in racialized and low-income communities already experiencing inequities. Barriers to (or bans on) accessing ECT imposed on people with COVID-19 will compound existing inequities.

Solidarity

Stand on Guard for Thee mainly describes solidarity between institutions (e.g., sharing PPE or coordinating distribution of vaccines) and nations (e.g., mounting a coordinated global pandemic response). ^10,15 But, solidarity also holds between people. ²⁷ Although not uncontroversial, ²⁷ some authors view solidarity as involving equal and mutual relationships with others across social difference rather than as self-interested cooperation between people with similar social status. ^22,27 In looking at solidarity in this way, they urge a focus on promoting the needs of the worst off ^19,22,27 and propose that people with social privilege have special duties in this regard. ¹⁹ One way that ECT providers can act in solidarity with their patients, whose likely social marginalization has already been discussed, is by acting as advocates for their care during the pandemic.

At a systems level during a pandemic, combatting infectious disease is prioritized over the associated need for increased mental health resources. Furthermore, hospital administrators responding to a pandemic surge may not appreciate the importance of ECT or may lose sight of it among the many variables they must consider. Yet, mental health care—including ECT—can be essential care even during a pandemic, ^8,28 as recognized by ECT providers. ^2,4,18 For these reasons, ECT providers may need to advocate to raise awareness of the potential of ECT to contribute to the goal of reducing deaths and serious illness during the pandemic. ²⁸ ECT providers know that in a patient with severe treatment-resistant depression, inability to access ECT in a timely way could result in further deterioration to the point of no longer being able to care for themself or even death by suicide. ^{2 –4}

Seeing these dynamics at work, ECT providers have noted their important role in “stand[ing] up for patients’ rights to continued access to ECT” during the pandemic. ¹⁷ They view advocating for patients’ access to ECT as part of their duties as providers but also compatible with “fulfilling [their] obligations to the rest of society” by supporting public health mandates. ²⁹

Acting in solidarity with patients requires that ECT providers take an active role in advocating for their patients at multiple decision-making levels (e.g., health care system, hospital, unit) sometimes alongside and sometimes on behalf of patients. Advocacy could involve trying to make ECT as available as possible during the pandemic. Or, if it is not possible to preserve adequate access, advocacy could involve reaching out to other organizations to maximize the alternative forms of care and support a patient can receive while ECT is unavailable.

Transparency and Inclusiveness

Finally, transparency means that the processes for making decisions in the pandemic context are open to public scrutiny. ¹⁰ Ideally, this would be partly achieved by engaging stakeholders in the decision-making process as recommended by the value of inclusiveness. ¹⁰ Engagement involves incorporating the views and experiences of stakeholders in clinical planning decisions.

At the level of a hospital, mental health professionals and patients should be included in decision-making about pandemic response. In addition, individual departments should incorporate the perspectives of service users by responding to concerns outlined in public statements from patient advocacy groups or by inviting service users as well as their families and loved ones to be part of the planning process. Engagement also requires ongoing communication about service changes, willingness to accept feedback, and openness to modifying decisions. These are core aspects of what rights advocates see as essential to the acceptability of public decisions affecting marginalized people. ³⁰ And, these approaches are implied by values such as equity and solidarity.

ECT providers have recognized the importance of transparency and inclusiveness. For example, Espinoza and his coauthors have argued that decisions about how to modify provision of ECT must be arrived at through a process that includes (1) early education and communication and (2) identification of key stakeholders who can act as informants. ¹⁸ Although “informants” may be intended to refer to practitioners and other experts, this should be expanded to service users and their supporters since they offer a unique perspective on the implications of service changes.

To make clinical service planning decisions transparently and inclusively, ECT providers should seek stakeholders’ input in the decision-making process and should commit to communicating regularly with them about service changes and what resources are available in the interim. As noted earlier, all of the procedural values are important for ethical decision-making. As such, in addition to being transparent and inclusive, clinical services planning should be reasonable in the sense of being based on relevant evidence, principles and values, and responsive in the sense of being embedded in processes of review and revision. And, mechanisms should be in place to ensure that decision-makers are accountable. ¹⁰

Conclusion

ECT providers should consider the questions in Table 1 as they continue to modify their services in response to the pandemic and its associated ethical challenges. Being mindful of these questions will not guarantee that all possible ethical issues will be avoided. However, reflecting on them should help navigate known concerns identified by colleagues around the world. While this manuscript addresses the ethical challenges faced by clinicians delivering ECT, similar considerations and therefore similar questions will likely be relevant to clinical services planning for procedural treatments that share features with ECT (e.g., repetitive transcranial magnetic stimulation [rTMS] ⁵ ), in navigating local and regional constraints to treatment provision and in other future circumstances that could threaten to constrain the provision of procedural treatments. Thus, insights from this analysis are potentially applicable beyond ECT and beyond the current pandemic.