Shock Machine Company Pays Up!

MECTA is first to pay for brain damage

For the first time, a product liability suit against a shock machine manufacturer has resulted in a successful settlement for the plaintiffs. The suit was brought by Imogene Rohovit of Iowa City, Iowa, and her daughters, alleging that Mrs. Rohovit, a single mother and former nurse, has been brain damaged and rendered unable to work by shocks inflicted by the MECTA Model D machine in 1989.

MECTA Corp. and the Model D were also the subjects of the very first product liability lawsuit against a shock machine company in 1987. The suit claimed that MECTA’s machine was designed to produce and did routinely produce permanent memory and brain damage (not that the machine was defective in any way). A judge initially ruled against MECTA, which then offered a settlement of $105,000. The offer was rejected, but an appellate judge then ruled MECTA did not have to go to trial.

No shock machine has ever been pulled off the market, but even shock doctors now warn others not to use the powerful Model D. It was sold in the early 1980s and many are still used. However, self-proclaimed shock “expert” Harold Sackeim testified at trial that he does not use the Model D on human beings, but only on research animals. MECTA President Robin Nichol has testified that MECTA has never performed a single safety test on its machines.

MECTA insisted on a gag order, meaning that the exact amount of the settlement cannot be disclosed by the parties. It is believed to be higher than the first settlement offer, but the plaintiffs expect to see little of the money due to the high costs of bringing their case against Mrs. Rohovit’s doctors to trial. The trial lasted three weeks and the case was lost. Mrs. Rohovit’s attorney, Marc Humphrey of Des Moines, Iowa, cites recent attempts to limit or eliminate all types of product liability lawsuits as a factor in the settlement decision. But if these attempts fail, the Rohovit case could encourage other suits.

From Linda Andre, CTIP

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ECT Experts’ Ties to Shock Machine Industry

The Washington Post
September 24 1996, Page Z14

ECT Experts’ Ties to Shock Machine Industry

Among the small fraternity of electroshock experts, psychiatrist Richard Abrams is widely regarded as one of the most prominent.

Abrams, 59, who retired recently as a professor at the University of Health Sciences/Chicago Medical School, is the author of psychiatry’s standard textbook on ECT. He is a member of the editorial board of several psychiatric journals. The American Psychiatric Association’s 1990 task force report on ECT is studded with references to more than 60 articles he has authored. Abrams, whose interest in ECT dates back to his residency in 1960s, has served on the elite committee that planned the National Institutes of Health’s 1985 consensus conference on ECT. In addition he has long been a sought-after expert defense witness on behalf of doctors or hospitals sued by patients who allege that ECT damaged their brains.

What is less well known is that Abrams owns Somatics, one of the world’s largest ECT machine companies. Based in Lake Bluff, Ill., Somatics manufactures at least half of the ECT machines sold worldwide, Abrams said. Most of the rest are made by MECTA, a privately held company in Lake Oswego, Ore.

Yet Abrams’s 340-page textbook never mentions his financial interest in Somatics, the company he founded in 1983 with Conrad Melton Swartz, 49, a professor of psychiatry at East Carolina University in Greenville, N.C. Neither does the 1994 instruction manual for the device written by Abrams and Swartz, the company’s sole owners and directors, which contains extensive biographical information.

Financial ties between device manufacturers, drug companies and biotech firms “are a growing reality of health care and a growing problem,” said Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania School of Medicine.

For doctors “the questions that such financial conflicts of interest generate are, do patients get adequate full disclosure of options or are you skewing how you present the facts because you have a financial stake in the treatment and you personally profit from it every time it’s used?” Caplan asked.

“It’s especially disturbing with ECT because it’s so controversial” and public mistrust of the treatment is so great, he added.

Abrams said his publisher at Oxford University Press knew about his ownership of Somatics. “No one ever suggested I list it,” said Abrams. “Why should it be?” Abrams said he has disclosed his directorship of Somatics after several medical journals began requiring information about potential conflicts of interest. Caplan said that a growing number of medical journals are requiring disclosure of payments greater than $1,000.

Abrams said he sees “no specific conflict” between his role as an ECT expert and his ownership of a company that makes shock machines. He said he has not decided whether to list his ownership in the third edition of his book, which is due out next year.

Abrams declined to say how much he has earned from Somatics. Approximately 1,250 machines, priced at nearly $10,000, have been sold to hospitals worldwide, he said. Between 150 and 200 machines are sold annually, according to Abrams. Somatics also sells reusable mouthguards for $29, which are designed to minimize the risks of chipped teeth or a lacerated tongue.

Swartz, 49, declined to be interviewed. Last year USA Today reported that he considered his financial interest in Somatics to be “a non-issue.” Swartz is quoted as saying that the company was founded to provide better machines and to “advance ECT.”

“Psychiatrists don’t make much money and by practicing ECT they can bring their income almost up to the level of the family practitioner or internist,” Swartz is quoted as saying. Swartz also said that the profits from Somatics are comparable to having an additional psychiatry practice. (Last year psychiatrists earned an average of $132,000, according to the American Medical Association.)

Abrams and Swartz are not the only ECT experts with financial ties to the industry.

Max Fink, 73, a professor of psychiatry at the State University of New York at Stony Brook, whose passionate advocacy is widely credited with reviving interest in ECT, receives royalties from two videos he made a decade ago. Fink is one of six ECT experts who served on the APA’s 1990 ECT task force, which drafted guidelines for the treatment.

In 1986 he made two videos about ECT, one for patients and their families, the other for hospital staff. Each sells for $350 and is used by hospitals that administer ECT. Fink said that Somatics paid him $18,000 for the rights to the videotapes; he said he receives 8 percent of the royalties. He declined to disclose how much money he has earned from the videos.

Duke University’s Richard D. Weiner, 51, chairman of the APA task force on ECT, appears on a MECTA videotape. Weiner said he served as a consultant to the company about 10 years ago but has not “received any money directly” for his services. Instead MECTA deposited between $3,000 and $5,000 in a university account that Weiner controls which, according to a Duke spokesman, is earmarked for “research support and other educational functions.”

Harold A. Sackeim, director of ECT research at New York’s Columbia-Presbyterian Hospital, is also a member of the APA task force on ECT. Sackeim, who has consulted for both MECTA and Somatics, says he has not accepted cash payments from the manufacturers because he does not want to be perceived as “benefiting personally” from ECT. Instead both companies have made payments to his lab. Sackeim estimates that his lab has received about $1,000 from Somatics and “several tens of thousands of dollars” from MECTA.

Ethicist Caplan said that he believes such donations raise fewer ethical questions than do direct payments to a doctor or an equity interest in a company. Even so, he said, it is up to physicians who receive such payments to disclose this to the public an d especially to prospective patients.

“There needs to be full disclosure in writing and the information needs to be repeated over and over again,” Caplan said. “Doctors need to give patients the opportunity to ask questions if they want, not to make those decisions for them by saying they won ‘t be interested.”

Managed Care: How Are Psychiatrists Surviving?

Psychiatric Times
by Michael G. Wise, M.D
April 1996

The spread and growth of managed care has had a profound impact on psychiatric practice, especially in large metropolitan areas. In regions of the United States where penetration rates of HMOs are high and the competition fierce, premiums are being cut and services reduced. In psychiatric practice, this has meant reduction, if not abandonment, of coverage for many inpatient psychiatric services and all long-term psychotherapy. It has also brought about such rapidly growing trends as mental health carve-outs, development of clinical protocols and capitation of providers.

Psychiatrists buffeted by these forces fight for survival and reasonable psychiatric services for their patients. This article will provide the psychiatrist with practical tips for survival in this managed care environment.

Managed care has transformed our ability to treat patients as well as the way we view the future. According to Psychiatric News (Jan. 5, 1996), managed care has also decreased psychiatrists’ median income. In 1991, the number of HMO enrollees in the United States was 38.6 million. Enrollment was projected to top 56 million in 1995.

Rising membership and declining premiums indicate that the managed care market is expanding and becoming more competitive. A Group Health Association of America survey projected a 1.2 percent decline in premiums for 1995 compared with 1994. While membership was growing, HMO premiums declined during the last four years.

Given these rapid changes, what are psychiatrists doing to survive managed care?

To answer that question, I conducted a quasi-scientific survey. I interviewed by telephone or in person 50 psychiatrists who practice in different settings including academic, private, public and military practice in different regions of the United States. Questions asked included: “What percentage of your patients are ‘managed care’ patients?”; “What impact has managed care had on your practice?”; and “What changes are you planning or have you already made to help survive managed care?” Additional information was also requested, such as number of years in practice. The following are my impressions from this survey.

Important Variables

Several variables seemed to influence the impact of managed care on psychiatrists. These variables included location, competition, years in practice as a psychiatrist and type of practice. The penetration of managed care varied from state to state, as well as within most states. In some states, including Massachusetts, Minnesota, California, Maryland and Oregon, the percentage of residents who belong to HMOs is greater than 30 percent. In other states, such as Mississippi, North Dakota, Idaho, Montana and Arkansas, the percentage of residents who belong to HMOs is much lower (e.g., less than 5 percent). In addition, locations with fewer mental health providers and fewer competitive health care systems had less managed care. For example, a psychiatrist in private practice in Monroe, La., reported that managed care has had a small impact on practice patterns in his area. In contrast, a psychiatrist practicing in an academic setting in Boston reported major upheaval and changes in practice patterns.

During interviews, psychiatrists expressed particular angst with utilization review, the loss of reimbursement for inpatient services and long-term psychotherapy, and the infringement of many people upon the patient-physician relationship. One psychiatrist stated, “All managed care wants us to do is manage medications.”

Number of years in practice seemed to strongly influence the psychiatrists’ reactions to managed care. Older and more clinically experienced psychiatrists were, in general, more angry and disillusioned by the changes that have occurred. These psychiatrists described the changes with terms such as “mangled care,” or statements like “Managed care is a misnomer; it’s all about money, not care. It’s managed money.”

Many younger, recently trained psychiatrists were less bothered by the language and philosophy of managed care. Some, especially residents, were perplexed and somewhat put off by the strong negative reactions of their teachers or senior colleagues. Younger psychiatrists were more comfortable than older psychiatrists with terms like “short-term treatment strategies” and “alternatives to inpatient hospitalization.”

Why is there such a difference? It seems likely that experience creates resistance to change, especially if changes are perceived as negative. Clinically experienced psychiatrists “know” that some patients benefit from longer hospital stays and long-term psychotherapy. To deny patients effective treatments and psychiatrists the ability to use hard-earned skills is frustrating, demoralizing and, in some cases, unethical. On the other hand, many younger psychiatrists who have trained using short lengths of hospital stay and short-term psychotherapy “know” these approaches are also effective.

Psychiatrists also reacted to managed care based upon their location on the managed care “food chain.” Psychiatrists who are consultants to employers are employees of managed care companies, are capitated or at financial risk for overutilization, and more likely to support managed care. Unfortunately, the psychiatrist in private practice in a community where most residents belong to HMOs becomes the “plankton” in this food chain and suffers most from these changes.

Survival Strategies

In spite of the adversities previously described, psychiatrists are attempting to adjust and adapt to changes that have occurred.

Many psychiatrists in solo private practice have joined a group or merged practices. A group offers a defense against the powerlessness felt by many psychiatrists, as well as more bargaining power when dealing with managed care organizations. A psychiatrist in solo practice in Texas joined a large group of physicians who had formed a group without walls (GWW). Because this particular GWW included most of the physicians in the community, the managed care companies couldn’t dictate unreasonable benefits for patients or reimbursement rates for physicians.

Greg Zinzer of Vista Foundation, a nonprofit organization for the advancement of managed care, made the following suggestions for psychiatrists who affiliate with a managed care organization (MCO): 1) Form or affiliate with a multidisciplinary group (i.e., a group that includes psychologists, social workers, nurses, etc.) in order to offer a full range of mental health services; 2) Join an MCO that has good administration and leadership; 3) Join the highest-quality MCO in the area (“If you wait [to join], it may be too late”); 4) Get to know the MCO’s top administrators so that you can have input into decisions that affect patients who have psychiatric disorders.

Diversify your practice. The old adage, “Don’t put all your eggs into one basket” seems to apply. If most of your patients are long-term psychotherapy cases, this is unlikely to continue. You might learn or develop additional clinical skills. For example, learn brief, focused therapies or specialized treatments, such as electroconvulsive therapy (ECT). One psychiatrist whose practice was self-described as “strictly inpatient” took a week-long practicum in ECT and has since developed an inpatient and outpatient ECT service. Several psychiatrists who previously had not done much forensic work now accept legal cases. The legal cases were typically interesting and fees were not discounted. One psychiatrist commented, “Managed law is probably not around the corner.”

A frequently mentioned practice strategy was capitation and other types of financial risk arrangements. In a capitation arrangement, the psychiatrist or a psychiatric group would, for example, provide psychiatric services for an agreed amount per month per managed care member. One psychiatrist with less than two years’ postresidency experience works in a small group practice, and was offered a capitation contract to provide several thousand people with psychiatric services at 17 cents per member per month. The psychiatrist was quite naive about capitation and wondered aloud if this was a reasonable offer. This contract, if accepted, would have led to a financial disaster for the group.

Capitation and other types of financial risk arrangements traditionally have not been taught in psychiatry residency training programs. Capitation is complicated business and is not for those who lack business sense. In areas of the country where MCOs control access to health care for most patients, survival for the psychiatrist will likely require in-depth knowledge about business arrangements that place the physician at financial risk. Financial arrangements such as these are problematic for other reasons. The potential for conflict of interest exists whenever the delivery of less treatment means more money for the physician. This bottom-line business approach to patient care is a source of angst for many psychiatrists.

One area within psychiatry, consultation-liaison, could potentially benefit from a managed care organization’s cost-consciousness. Medical services research has shown that psychiatric disorders are frequently unrecognized by primary care physicians and, if recognized, are often not appropriately treated. In addition, individuals who are medically ill and also have untreated or inadequately treated psychiatric disorders stay in the hospital longer, use health care services at markedly increased rates, and have increased rates of morbidity and morality. These data are especially important for consultation-liaison psychiatrists, because they contain cost-offset information necessary to justify improved psychiatric treatment. In order to improve patient care and decrease overall cost, managed care organizations need psychiatrists to work closely with “gatekeepers” to ensure that psychiatric disorders are identified and appropriately treated. This can occur through rapid consultation and collaboration with psychiatrists or liaison between psychiatrists and primary care physicians to improve the latter’s diagnostic and treatment skills.

With some exceptions, such as military and public practice, psychiatrists reported that utilization review and utilization reviewers were the bane of their existence. The anger and frustration created by utilization review was considerable. One psychiatrist described it as an obstacle course supervised by untrained people that is placed between the patient and the needed treatment. Another psychiatrist had to hire a full-time individual to manage utilization reviewers because the time required of the psychiatrist had become a financial drain. Although the utilization review process allegedly determines whether recommended treatment is medically necessary, psychiatrists described it as adversarial and very unpleasant. Capitation eliminates this type of utilization review, because the treating physician, who is also at financial risk, must decide if treatment is medically necessary.

Two psychiatrists from different states had left group practice for solo private practice. This seemed incongruous given the widely held belief that solo private practitioners are destined to become an extinct species. Their stories were similar.

These psychiatrists disliked the changes brought by managed care, especially limitations on treatment options and direct intrusion of managed care organizations into the psychiatrist-patient relationship. In their private practices they avoided, as much as possible, any contact or contracts with MCOs. They said they now enjoy their practices more and remain busy.

Several psychiatrists interviewed talked about retirement. Two mentioned the possibility of going into another medical specialty, primary care. Although psychiatrists had heard of colleagues retiring or leaving the specialty because of managed care, no one interviewed could name a specific psychiatrist who had done so. One psychiatrist who was a member of a busy psychiatric group practice reported the group had sold 50 percent of the practice to a health care company. This may be an isolated event for psychiatrists, although it is not uncommon for health care or managed care companies to purchase primary care practices as a way to gain patients (“market share”).

In summary, this survey indicates that the impact of managed care on psychiatrists varies greatly. Important factors that influence the size of this impact include geographic location, number of years in practice, type of practice and position on the managed care “food chain.” Despite the pessimism, anger and frustration frequently expressed during these interviews, psychiatrists are using creative and adaptive strategies to survive in a managed care environment.

Michael G. Wise, M.D., is clinical professor of psychiatry at Louisiana State University School of Medicine, Tulane School of Medicine and Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine.

How do psychiatrists decide to use forced electroshock?

by Linda Andre
Director of CTIP

Have you ever wondered how psychiatrists make a decision to shock a person against his or her will? Who’s a candidate for forced shock, and why?

These questions were publicly answered by the two psychiatrists who signed the papers seeking a court order for involuntary shock of Paul Henri Thomas.

In some but not all states—New York is one of them—a person must be found to be legally incompetent before he or she can be shocked against her will.

The general public, upon hearing this, sighs in relief: of course; that’s as it should be; that could never happen to me; of course there must be safeguards in place, and standards as to what constitutes competence; a person must have to be really bad off, really crazy like catatonic, to be ruled incompetent.

Treating psychiatrist Andre Azemar and supervising psychiatrist Bob Kalani of Pilgrim State Psychiatrist Hospital both testified against their patient Paul Henri Thomas in hearings held in March and April 2001.

They were asked how they decided that Paul lacked the capacity to make this own treatment decisions.

They made it clear.

Having a diagnosis of mental illness helps you get ruled incompetent, but it’s not enough by itself. And you sure don’t need to be catatonic or psychotic. Here are the rules:

Rule # 1: You’re incompetent if you think you’re not crazy.

“Lack of insight” was cited an overwhelming number of times by witnesses against Paul as justification for forced treatment. Both doctors said, in essence, that any person who says that he is not mentally ill when a doctor says he is lacks “insight into his illness”, and that this means he lacks the capacity to make his own treatment decisions.

Paul’s lawyer Kim Darrow was thorough in his questioning, trying to elicit from the doctors any other factors they might have weighed in making their decision that Paul lacked capacity and therefore qualified for forced shock.

There were none. On further questioning, Dr. Azemar was asked why Paul doesn’t think he is mentally ill. His answer: “Because mental illness clouds his judgment.” It was clear to everyone who watched this trial (except the judge) that this was a Catch-22, no-win situation. As long as you say you’re not crazy, you’re considered crazy.

The audience waited in vain for further justification of the claim that Paul was mentally ill. He was said to have various diagnoses, including schizoaffective disorder (also the diagnosis of this reporter), bipolar disorder, and mania. Neither doctor had enough evidence against Paul to justify these diagnoses by DSM criteria. Paul was said to be “loud”, “noncompliant”, “threatening”, to have worn inappropriate clothing on the ward and to have hoarded food (which would have been entirely appropriate for someone looking to escape from the hospital, former patients concurred later). His hygiene was said to be poor; he was accused of cluttering his hospital room with books and dirty clothes—”dirty clothes on top of clean clothes!” in the words of Azemar.

The other shrink, Kalani, conceded that on the day he testified—as well as on the day he signed the petition for forced shock—his patient had no symptoms of mental illness other than denying he had a mental illness.

An independent, unpaid psychologist who examined Paul in the hospital at the end of March, interviewing him as well as performing some psychological testing, testified that he found no evidence of psychosis, mania, or mental illness. He testified that Paul is competent to make his own decision regarding ECT.

Rule #2: When you say yes, you’re competent; when you say no, you’re incompetent. Either way you get shocked.

“The staff would ask him, are you going to consent or are we going to have to go back to court?” —Bob Kalani

If Paul was really incompetent, he was incompetent not only to reject treatment, but to accept it. His yes would not have been legal. Yet both shrinks testified about attempts to talk the legally incompetent Paul into saying yes to shock.

“Did you try to get Mr. Thomas to consent to ECT in January? If he had consented, would you have sought a court order?” asked Darrow of the treating psychiatrist.

The judge objected.

“If Paul had said yes, would you have tested his competency?” Azemar looked baffled and answered, “If they say no, we have to do it.”

At this point the judge interrupted, saying, “I don’t understand the question”. No one else in the courtroom seemed to have any difficulty understanding the question or the point that had been made.

“If he accepts the illness then he can make his own decisions and we don’t have to force him,” Dr. Kalani had testified. Sure Paul can make his own decisions—-as long as he consents.

Rule #3: If you disagree with what your doctors say about treatment in general or your treatment in particular, you’re incompetent.

When asked: What constitutes capacity? Azemar replied as follows:

—Capacity depends on the person understanding what the treatment is about.
—Capacity means he understands the consequences of the treatment, and has the ability to assess benefits and risks.

Paul has had over 60 ECTs, but no one thinks this makes him qualified to understand what the treatment is about, or to understand its consequences. Only a psychiatrist can know these things.

Both doctors said Paul was incompetent because he refused to acknowledge that previous ECT had been beneficial for him. Azemar said, “Even when we tell him he is improved, he never accepted the fact that he had any benefit from it.”

Both doctors said that Paul was incompetent because he “is unable to assess the risks and benefits of ECT.”

Further questioning from Darrow clarified the situation. Did Paul have the mental capacity to understand that his doctors thought he had improved with ECT? Yes. He understood this. “Did he understand what you thought were the benefits and risks?” Yes, the doctors said. Paul was perfectly capable of hearing and understanding what his doctors were telling him.

He just didn’t agree with them.

As long as patients and doctors disagree about the nature, risks and benefits of ECT, and as long as doctors get to define the “right” answers to these questions, everyone is at risk of forced ECT. Persons who have previously had ECT, know about it from personal experience, and will not deny what they know to be true, are most at risk.

Dr. Kalani testified that he “knew” about ECT from reading a book. All books about ECT for professionals are written by financially compromised ECT proponents like Richard Abrams, shock machine company owner. Kalani couldn’t remember which book he had read…Fink’s, Kellner’s, Coffey’s? He went on to make further blatantly false statements about what he “knew”. He knew the FDA had approved shock machines. (Never happened.) He knew the FDA had conducted animal trials of shock. (Not only has it never conducted animal trials, neither the FDA nor anyone else has ever conducted human trials.) Kalani’s source was revealed when he claimed that the FDA had studied baboons. The baboon line comes�from Harold�Sackeim, prolific ECT advocate and shock machine company consultant. Even Sackeim, famous for his lies, did not say that FDA studied baboons; his claim was that epilepsy researchers had studied baboons and concluded that seizures didn’t damage their brains. Kalani got his misinformation garbled. The Pilgrim shock doctor went on to testify that there have been “lots of” before-and-after MRI studies showing that ECT doesn’t cause brain damage. Wrong again. There have been less than a handful, and they don’t show that.

Dr. Azemar wasn’t any more knowledgeable. He claimed that his own facility did not do “bipolar” ECT (the correct term is bilateral), that this was the “old fashioned way” of doing ECT that’s still done in Haiti but not here. In fact, Paul has been getting bilateral ECT at Pilgrim.

If capacity is determined by what you know about ECT’s risks and benefits, then both Kalani and Azemar flunked the test, and can now be legally forcibly shocked.

Unfortunately Darrow did not challenge Dr. Kalani’s false statements. The judge was left with the impression that ECT has been proven safe because no one contradicted it.

If Darrow had been able to raise doubt about ECT’s efficacy and safety—by invoking the FDA classification of ECT devices, for instance—a logical further question would have been: “If it were true that Paul did not benefit from ECT, would he be incompetent? What if Paul is right that the risks of ECT outweigh its benefits? Is he still incompetent?”

The judge got very upset once Darrow made the point that Paul understood but did not agree with his doctors, yelling at him to move on. This was one of three outbursts on the part of the judge that day, each one louder than the last. The judge was very, very loud.

Forced treatment and biological psychiatry go hand in glove.

If biological psychiatry is a kind of law—if we as a society have decided it is the only acceptable or permissible way to think about and treat problems—then it must have its police force for those who don’t find it helpful or agree to abide by it. It must have the doctors and judges who force treatment on these people.

Both shrinks testified that drugs and ECT were the only treatments available for Paul. When challenged, however, they claimed to be doing psychotherapy. They were questioned further about what that meant. It turns out that psychotherapy doesn’t mean what it used to mean.

“Psychotherapy consists of making him understand his mental illness and accept therapy and understand the impact of medication and ECT. Noncompliance is the issue,” said Bob Kalani. He also explained that there had been family psychotherapy, consisting of trying to talk Paul into consenting to ECT.

Dr. Azemar called his brand of psychotherapy “insight psychotherapy”. “Insight psychotherapy” consisted of trying to get Paul to accept that “It’s all chemicals. There are all these chemicals in the brain—for anxiety, for appetite, for sleep. It’s getting him to understand what these chemicals do and what drugs he needs to take.”

The drugs he has been taking have caused liver damage and tardive dyskinesia. Dr. Azemar testified that Paul wanted to take a computer class, but his hands now shake so badly that he is unable to type. He characterized TD as a “disorder of the fingers”—it’s actually permanent brain damage.

It was nearing the end of the last day of the trial when the topic of drug-induced brain damage came up. Darrow began a dramatic summing-up type question. “They’ve damaged his liver, they’ve damaged—” he might have been beginning to say “His brain”.

He didn’t get to say it because he could not longer be heard over the judge. Judge Hall pounded on his desk, stood up, and yelled at the top of his lungs: “You should be ashamed at yourself!” He said it twice. It was far from clear to anyone in the courtroom what, exactly, he was referring to. Should Darrow be ashamed because he was bringing up tardive dyskinesia in a case that was just supposed to be about ECT? Was Darrow being reprimanded because he was only allowed to talk about ECT brain damage, not drug brain damage? Was the judge himself, who is known for signing forced drugging orders, actually ashamed of himself and simply projecting those unmanageable feelings onto Darrow? Why the emotional outburst?

It was a better ending to the case than the State’s lawyer, Laurie Gatto, could have hoped for. She’s clearly clueless on shock, and her idiotic questions had her much more educated audience laughing—-like when she claimed that the MiniMental Status Exam (which you can hardly do poorly on unless you’re in a coma) could measure memory loss from ECT, or when she tried to disparage Paul’s good performance on an IQ test by saying that math doesn’t involve problem solving. But even she could sense that she didn’t need to add a single word.

Had anyone wandered into the courtroom at 4:20 p.m. on April 2nd, observed the behavior and demeanor of both Paul Henri Thomas and Judge Hall, and been asked to pick out which man was suffering from mania, there would not have been any doubt that it was the one in the black robe.

If you think you can protect yourself against forced ECT with an advance directive, think again.

Paul had an advance directive. He had signed it on October 19th, the day before his doctor signed the petition for forced shock. Paul couldn’t have executed a legal document like an advance directive if he were considered incompetent. Dr. Azemar clearly found him competent on the 19th; in fact, he even signed the advance directive as a witness. Azemar’s position at trial was that Paul became incompetent the very next day.

But wait—even if that were the case, wouldn’t the advance directive have been valid? After all, this is exactly the situation an advance directive anticipates. It specifies what should be done should a person become incompetent. Paul’s directive said that his brother would act as his proxy to make his health care decisions. He should have been consulted, and his yes or no would have been the final decision on shock for Paul. But the hospital disregarded the advance directive and went ahead with its forced shock petition.

In the words of Judge Hall: “What that document said at that time, it doesn’t say now.”