Psikiyatrinin etkin biyolojik tedavisi olan elektrokonvülsif tedaviye tıp etiği ve hukuku açısından güncel bir bakış

Öz

Elektrokonvülsif terapi EKT birçok psikiyatrik hastalığın tedavisinde kullanılan etkili bir biyolojik sağaltım yöntemidir. Bu tedavinin etik ve hukuki boyutu, ruhsal hastalıkların tedavisinde kullanılmaya başlandığından beri tartışılmaktadır. Uzun süredir kullanılan bir tedavi olmasına rağmen, elektrokonvülsif terapi alan hastaların olumsuz ifadeleri, sağlık çalışanları ve kitle iletişim araçlarının uygulamayı “şok tedavisi” olarak nitelendirmeleri, tedaviyle ilgili çeşitli konularda standart yaklaşımların net olmaması, uygulamanın yöntemsel sorunları elektrokonvülsif terapinin toplum nezdinde tedaviden ziyade ceza yöntemi olarak görülmesine ve önyargı oluşmasına sebep olmuştur. Psikiyatrik bozukluğu olan hastaların klinik araştırma ve tedaviye katılma konusundaki karar verme yeterliği hem yasal hem de tıp etiği zemininde hala tartışılan bir konu olmakla birlikte yaygın bir şekilde araştırılmaktadır. Psikiyatrik hastaların zorunlu ve istemsiz şekilde yatırılarak tedavi edilme gerekliliği birçok ülkede müstakil ruh sağlığı yasalarıyla güvence altına alınmıştır. Ancak, ülkemizde farklı yönetmelik ve yasa maddelerinin varlığı bu hastaların gözlem ve tedavileri hususunda sağlık profesyonellerini çoğu zaman zaman ikilemde bırakmaktadır. Ülkemizde 2006 yılında yürürlüğe giren EKT yönergesi uygulamanın esaslarını belirtse de, hukuki açıdan geçerliği ve Hasta Hakları Yönetmeliği ile çelişen içeriği, benzer ikilemlerin EKT uygulamalarında da kimi zaman yaşanmasına neden olmaktadır. Bu yazıda, elektrokonvülsif terapinin etik ve hukuki boyutu güncel yaklaşımlar ve bilgiler ışığında irdelenmiştir.

Anahtar Kelimeler

• Elektrokonvülsif terapi
• etik
• hasta hakları yönetmeliği
• ruh sağlığı

Current ethical and medicolegal perspectives on electroconvulsive therapy, an effective biological treatment of psychiatry, at a glance

Öz

Electroconvulsive therapy ECT is an effective biological treatment method used in the treatment of many psychiatric disorders. The ethical and legal aspects of the aforementioned treatment have been discussed since it began to be applied in the treatment of mental illnesses. Although it has been used for a long time, negative feedback of patients about ECT, derogatory definition of ECT as “shock therapy” by health professionals and the mass media, the lack of clear standards and well defined scientific approach of the various issues related to the treatment and methodological problems regarding the treatment caused a prejudice for the society, and therefore ECT is considered as a punishment rather than a treatment. Decision-making competence of patients with psychiatric disorder in clinical research and their participation in the treatment process are still a matter of discussion in terms of both legal and medical ethics and the aforementioned issues are still being investigated. The necessity of hospitalization of psychiatric patients in forced and involuntary way is assured by extensive mental health laws in many countries. However, most of the time the existence of different regulations and legal provisions in our country leave the health professionals in dilemma regarding observation and treatment of these patients. In our country, ECT directive that came into force in 2006 define the principles of the treatment, nevertheless, legal validation and contradictory context of the legal framework with respect to the Patients’ Rights Directive cause similar dilemma. In this paper, the ethical and legal aspects of electroconvulsive therapy were examined in the light of current scientific approaches and knowledge.

Anahtar Kelimeler

• Electroconvulsive therapy
• ethics
• mental health
• patients’ rights directive

Kaynakça

1. Benbow S, Crenstil J. Subjective experience of electro- convulsive therapy. Psychiatric Bulletin 2004;28:289-91.
2. Tosun M. [Depresyon tedavisinde elektrokonvülsif terapinin yeri] [in Turkish]. Symposium on Depression, Somatization and Psychiatric Emergencies. Istanbul. 1999. s. 107-20
3. Bolwig TG, Madsen TM. Electroconvulsive therapy in melancholia: The role of hippocampal neurogenesis. Acta Psychiatr Scand Suppl 2007;433:130-5.
4. Victoria State Government Department of Health, Mental Health Services, Mental Health Actbook. Melbourne, Vic- toria, Australia published: September 2008 , Available at: http://www.health.vic.gov.au/mentalhealth/patientrights/ downloads/ect.pdf. cited: 18 November 2015
5. National Institute for Clinical Excellence, Guidance on The Use of Electroconvulsive Therapy, London, UK. published: April 2003 , Available at: http://www.nice.org.uk/ TA059. cited: 16 November 2015
6. Balcıoğlu İ. Forensic Psychiatric Aspects of ECT. [in Turkish] Istanbul University Cerrahpasa School of Medicine Lecture Notes. Istanbul, 2011
7. Tomruk NB, Kutlar MT, Mengeş OO, Canbek Ö, Soysal H. Clinical Practice Handbook of Electroconvulsive Ther- apy. [in Turkish] Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Diseases Training and Research Hospital, Istanbul: Ece Press, 2007.
8. Sartorius N, Gaebel W, Cleveland H.-R, Stuart H, Aki- yama T, Arboleda-Flórez J, Baumann AE, Gureje O, Jorge MR, Kastrup M, Suzuki Y, Tasman A. WPA guidance on how to combat stigmatization of psychiatry and psychiatrists. World Psychiatry 2010;9 3 :131-44.

9. Walter G, McDonald A, Rey JM, Rosen A. Medical student knowledge and attitudes regarding ECT prior to and after viewing ECT scenes from movies. J ECT 2002;18:43-6.
10. Gazdag G, Sebestyén G, Ungvari GS, Tolna J. Impact on psychiatric interns of watching live electroconvulsive treat- ment. Acad Psychiatry 2009;33:152-6.
11. Hoffmann-Richter U, Alder B, Finzen A. Electroconvul- sive therapy and defibrillation in the paper. An analysis of the media. Nervenarzt 1998;69:622-8.
12. Leong GB, Eth S. Legal and ethical issues in electro- convulsive therapy. in: Kellner CH, ed. Electroconvulsive therapy, The Psychiatric Clinics of North America. Phila- delphia: WB Saunders Co, 1991: 14 4 :1007-16.
13. Sözen Ş. Psychiatric evaluation of forensic cases: Pa- tient’s rights and physician’s liability. The Turkish Annual of the Studies on Medical Ethics and Law. Istanbul. 2011- 2013;4-5-6:73-9.
14. Volmann, J. Aufklärung und einwilligung in der psychiatrie, Ein Beitrag zur Ethik in der Medizin. Darmstadt: 2000:43.
15. Namal A. Ethical overview of forced therapy of psycho- logically Patients in the light of the history of psychiatry. The Turkish Annual of the Studies on Medical Ethics and Law. Istanbul. 2011-2012-2013;4-5-6:41-72.
16. Koptagel-İlal G. Patient’s Rights and Ethical Rules at Psychiatry. [in Turkish] In: Hatemi H, Doğan H, eds. Medi- cal Ethics. Istanbul: Psychiatric Association of Turkey, :119.
17. Frey R, Schreinzer D, Heiden A, Kasper S. Use of electroconvulsive therapy in psychiatry. Nervenarzt 2001, :661-76.
18. Pallanti S. Ugo Cerletti 1877-1963 . Am J Psychiatry ; 156 4:630.
19. Rottleb U, Steinberg H, Angermeyer MC. The image of psychiatry in the “Leipziger Volkszeitung” – historical lon- gitudinal study. Psychiatr Prax 2007;34:269-75.
20. Maio G. Zum bild der psychiatrie im film und dessen ethische implikationen. In: Gaebel W, Möller H-J, Rössler W eds. Stigma - Diskriminierung - Bewältigung, Der um- gang mit sozialer ausgrenzung psychisch Kranker. Stutt- gart: Kohlhammer, 2005:99-121.
21. Steger F. From the person to an isolated case: Frank Schmökel in the discourses of power and stigmatization. Psychiatr Prax 2003;30:389-94.
22. Pupato K. Psychiatrie in den Medien. In: Gaebel W, Möller H-J, Rössler W eds . Stigma-Diskriminierung - Bewältigung, Der umgang mit sozialer ausgrenzung psy- chisch Kranker. Stuttgart: Kohlhammer, 2005:83-99.
23. McDonald A, Walter G. Hollywood and ECT. Int Rev Psy- chiatry 2009;21:200-6.
24. Walter G. The psychiatrist in American cartoons, 1941- 1990. Acta Psychiatr Scand 1992;85:167-72.
25. Gabbard GO, Gabbard K. Cinematic stereotypes con- tributing to the stigmatization of psychiatrists. In: Fink PJ, Tasman A eds . Stigma and mental illness. Washington: American Psychiatric Press, 1992:113-26.
26. Gabbard GO, Gabbard K. Psychiatry and the cinema, 2nd ed. Washington: American Psychiatric Press, 1999.
27. Kesey K. One Flew Over The Cuckoo’s Nest. New York: Signet, 1962.
28. Soygür H, Arda B. Electroconvulsıve therapy: A general review in the light of ethical issues. Turkish Clinics J Med Ethics 1996;4 1 :28-33.
29. Bener E. Tekilleşme. [in Turkish] Istanbul: Bilgi Press, 1993.
30. Düşünen Şarkılar Albümü [Album of Thinking Songs] İstanbul. published: August 12nd, 2014 Available at: http:// www.istanbulajansi.com/haber/bakirkoy-hastanesindendusunen-sarkilar/19377. cited: 22 November 2015 .
31. American psychiatric association. Task force on elec- troconvulsive therapy. The practise of ECT: Recommenda- tions for treatment, training and privileging. Convuls Ther Jun;6 2 :85-120.
32. Zeren T, Tamam L, Evlice YE. Electroconvulsive Thera- py: Assessment of practice of 12 years’ period. Yeni Sympo- sium Journal 2003;41 2 :54-63.
33. Ministry of Health of Turkey, National Psychiatry Plan of Action 2011-2023 published: 2011 Available at: http:// www.saglik.gov.tr/TR/dosya/1-73168/h/ulusal-ruh-sagligi- eylem-plani.pdf cited: 12 November 2015
34. Kaneko T, Kanazawa T, Nishiguchi M, Kikuyama H, Tsu- tsumi A, Uenishi H, Kawabata Y, Kawashige S, Nishizawa Y, Maruyama S, Koh J, Yoneda H. Microarray analysis of human blood during electroconvulsive therapy. J ECT 2015 Dec;31 4 :234-7.
35. Leong GB, Eth S. Legal and ethical issues in elec- troconvulsive therapy. Psychiatr Clin North Am 1991 Dec;14 4 :1007-20.