Electroconvulsive Therapy Refusal in Severe Psychosis: Navigating Capacity, Surrogate Decision-Making, and Ethical Duty

Abstract

Electroconvulsive therapy (ECT) remains among the most effective interventions in psychiatry for severe depression, catatonia, and treatment-resistant psychosis. Despite its well-established efficacy and safety profile, particularly in medically complex and older patients, its use continues to evoke controversy due to the required medical clearance. Ethical dilemmas arise when patients lack insight or capacity to consent, creating tension between respect for autonomy and the duty of beneficence. We present the case of a 62-year-old woman with a longstanding history of paranoid schizophrenia, general anxiety disorder, hypertension, and hyperlipidemia who was admitted for acute psychosis following medication nonadherence and the recent death of her mother. Her presentation was notable for bizarre delusions, a disorganized thought process, and poor self-care. She was partially compliant with psychotropic therapy, including haloperidol, lorazepam, and lurasidone, but demonstrated limited improvement. Although ECT was considered given the severity and chronicity of her illness, the patient refused treatment. Her family emphasized the gradual deterioration they had observed and advocated strongly for pursuing ECT as the necessary intervention to prevent further decline, given her improvement with past ECT sessions. Over the course of hospitalization, her symptoms improved only mildly with pharmacotherapy alone, and she remained unable to maintain activities of daily living. This case highlights the enduring clinical and ethical complexities surrounding the use of ECT. It underscores the importance of evaluating capacity, engaging families in shared decision-making, and balancing the principles of autonomy and beneficence in the treatment of severe psychiatric illness.