Ethics Quiz: Shock Therapy For The Disabled

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Here is an issue from July that I never had time to write about…

In a 2-1 opinion, the U.S. Court of Appeals for the D.C. Circuit overturned a Federal the ban on the use of electric shock devices to modify destructive or otherwise problematic behavior by students with intellectual disabilities. The Food and Drug Administration sought to prohibit the devices in March 2020, saying that delivering shocks to students presents “an unreasonable and substantial risk of illness or injury.” The court ruled, however that the ban was a regulation of the practice of medicine, which is beyond the FDA’s authority.

The now banned ban only affected a single school, the Judge Rotenberg Educational Center in Canton, Massachusetts. It is the only facility in the United States that employs the shock devices to correct self-harming or aggressive behavior. The center serves and houses both children and adults with intellectual disabilities or behavioral, emotional or psychiatric problems.

What ethics approach do we use to assess such a practice?

“How would anyone feel if they were being shocked on a daily basis and couldn’t get away from it?” said Sam Crane, the legal director of the Autistic Self Advocacy Network. “It’s terrifying that this can happen to people.”

That is a classic Golden Rule analysis: How would you like it if this was done to you?

The United Nations labels the practice “torture”, which is an absolutist approach. The school and many parents of students at the school insist that the practice is effective, that it “works.” Absolutism holds that it doesn’t matter if it works, such a practice is wrong by definition, and can never be justified.

The FDA claimed that the shocking could cause long-lasting trauma, but the practice’s advocates argue that it can still be beneficial, indeed life-saving.

The treatment requires students to wear a special fanny pack with two protruding wires attached to the arm or leg. A staff member with a remote-control device can deliver quick shocks to the skin to stop a student’s behavior. The school provides education and vocational services to about 300 residents whose conditions range from autism to psychosis. The shock devices are used 55 residents. All adults are adults, but some of them started the treatment when they were children after their parents requested and consented to it. Those people demonstrates extremely dangerous behavior such as banging their heads to the point of retinal detachment and blindness, breaking their own bones and violently attacking others. “With the treatment, these residents can continue to participate in enriching experiences, enjoy visits with their families and, most importantly, live in safety and freedom from self-injurious and aggressive behaviors,” the school said in a statement applauding the court’s ruling.

That is a utilitarian analysis. In this case, the ends justifies the means.

Your Ethics Alarms Ethics Quiz of the Day :

Is the school’s use of the elctroshock devices ethical?

25 thoughts on “Ethics Quiz: Shock Therapy For The Disabled

  1. In medicine, the ends quite often justify the means. Open heart surgery is no fun; neither is chemotherapy, or many other procedures, but they help people live longer and more normal lives. People endure them because the alternative is worse. Sound like that may be the case here.

    • But the people who endure those things can give meaningful consent to do so, and there are many people who choose NOT to endure those procedures, regardless of what it means for the length and normality of their lives.

      It does not sound like the students are capable of giving meaningful consent to this. Sure, their guardians might be consenting – but there are limits to what a guardian’s consent should be allowed to let anyone do to another person. Should a guardian be able to consent to a full frontal lobotomy? Or being euthanized? Let’s say this was being done with candle flames instead of electricity – I highly doubt any of us would even hesitate at saying it was fundamentally unethical and torture then, regardless of what the guardian had said was acceptable. What if it was water-boarding? Or exposure to debilitating noise? Aside from our government, would anyone really argue it wasn’t torture then?

      We’re comfortable with allowing it to be done with electricity because we delude ourselves by saying it does no lasting damage – but that’s because we allow ourselves to say that if the damage isn’t visible, and doesn’t take long too heal from, it wasn’t lasting. But clearly it has a lasting effect, otherwise how could it affect change in the person subjected to it? That effect is based in damage – in the conditioning of the person to be afraid of the pain an undesirable course of action will provoke. It’s just a hidden form of damage, inflicted on the psyche, instead of one that we have to look at unsightly reminders of having done.

      • Thanks, but that’s irrelevant to what I wrote, especially with the caveat “Sound(s) like that may be the case here”. I assumed there would (rightly) be considerable speculation on particular circumstances of the application and effects of the treatment, and indeed there has been. Obviously, that’s an important discussion to have.
        My point, however, was to note from the start that whether the process is suspected, or even known, to cause some type of harm does not mean it’s inherently wrong, or fall under the simplistic idea that “the ends justify the means” is <i?always an unethical position.

        • I don’t think it’s particularly irrelevant at all – the need to do some harm to cause a greater good is common in medicine, but those procedures may only be conducted in an ethical manner when all involved (especially the patients) are capable of consenting to both means and end. These patients, by virtually the definition of the program they are part of, are not capable of giving that consent.

          It is because of the fact that the means cause harm that consent is so vital to evaluating the ethical nature of such conduct. To use one of your examples, administering chemotherapy chemicals without consent would be ethically indistinguishable from poisoning another person; Even if you knew they had cancer, and could be absolutely sure that the chemicals would cure them in the long run, administering those drugs without a patient’s consent is ethically indefensible.

          • We seem to be talking past each other. Some or all of what you say may or may not be true, but are all considerations to be resolved subsequent to accepting or rejecting the basic premise that the ends may justify the means in some circumstances.

            • I don’t know why you feel like we’re talking past each other, unless you are assuming an absolutist position I did not take; at no point did I say that the that the ends may not justify the means – indeed, Jack points out that using the ends to justify the means would be taking a utilitarian approach to ethics just before he asks the initial question of the quiz. I feel that I have freely conceded that within medicine, often the desired ends may variously justify or necessitate certain means (there’s a distinction between the use of those two verbs and how they may influence the ethical analysis that I feel could benefit from a much longer and more involved response than I have time to write this morning, alas).

              That is why the utilitarian ethical analysis of a given course of treatment hinges upon additional factors, such as consent, alternatives and safeguards. If there are alternatives possible, then the utilitarian analysis must also account for the relative successes, side effects, and other elements of those alternatives. If this is truly the only valid course of treatment for these individuals, then alternatives become irrelevant – but the consent and safeguards I and the other commenters are exploring remain vital to the analysis of whether the school is (or even could be) capable of deploying this treatment in an ethical manner.

              Personally, my prior comments were intended to argue that even within a utilitarian ethical system, they cannot be capable of deploying this treatment in an ethical manner, on the basis of the consent issues alone. Indeed, on the basis of that factor, I would question if anyone could ever deploy these devices in an ethical manner. But the research and observations of other commenters makes clear this school has failures of safeguards and process which mean that even if my arguments about the general ability to deploy these devices are flawed, it is clear the answer to this particular quiz is that no, this school is not capable of ethically deploying these devices.

  2. Some things are unclear to me, so I’ll offer a qualified answer.

    Are the participants consenting to the devices? Presumably, if they are still underage they can’t do so and their parents must.

    I think generally if informed consent is present, it can be ethical if it is implemented safely and with appropriate discretion (i.e. only when absolutely necessary to permit harm).

    On the downside, this is a system which is rife for abuse by lazy and-or authoritarian teachers. That fact may render it unethical, and given the state of education these days, it’s hard to assume it won’t be abused — more to the point, it’s necessary to assume it will be.

    So ultimately, I can’t render a proper ethics judgment without knowing all the facts — how is it implemented, how is its use monitored, what process is utilized for ensuring it isn’t abused, how transparent is its use to the child’s guardian?

    Absent all these facts, I don’t see how it can be ethical based on what I know about it. Too much potential for abuse, and no clear way to monitor its ethical use. This is a very invasive protocol with the potential for dire mental health consequences — I think the medical argument is unpersuasive, but a developmental argument should probably be dispositive.

    • I can’t directly speak to this case directly, but I’ll note that many adults in institutions like this are incapable of consent (and legally regarded that way.) Usually (though not always) these days, people with enough cognitive functioning to consent have other methods available to treat or manage their self-harming behaviors, so the issue tends to be limited to those who can’t participate in their own treatment (or defense, for that matter.)

      • That makes sense. Having acknowledged that, someone must consent on their behalf — a parent, a guardian, an ad litem, somebody who is the guardian of their interests.

    • “Are the participants consenting to the devices? Presumably, if they are still underage they can’t do so and their parents must.”

      That Parental Consent thingey has been evolving of late, and not necessarily in the direction of strengthening parental involvement.

      One area where parental consent remains a factor is for aspiring underage tattoo recipients.

      “According to data through March 2015 compiled by the National Conference of State Legislatures, at least 45 states have laws prohibiting minors from getting tattoos, with the majority of those states allowing it if there’s parental consent. For example, Florida law requires written, notarized consent of a minor’s parent or legal guardian in order to tattoo a minor.”

      Aspiring underage abortion recipients? Not so much.

      ”According to Guttmacher Institute, a group that tracks abortion policy and statistics, a majority of states require consent and/or notification. In 37 states, minors need parental consent and/or notification, while 11 states and Washington D.C. require neither.

      Nationwide it’s easier, or at least not as difficult, for minors to get an abortion than it is for them to get a tattoo.

  3. This is a classic ‘it depends” response. In this case, yes, because the alternative is far, far worse to the point of being damaging and debilitating. Violent attacks are certainly something that cannot be tolerated. If the alternative were to restrain violent residents by beating them, I think that this shock therapy is a more preferable alternative. The same with the other self-injurious behaviors listed here. When we move away from this particular situation, then fresh analysis is called for.

    • As the mother of a non-verbal (but cognitively functional) seven-year-old, I agree with this. The reality of “special needs” is that these things need to be addressed on a case by case basis — that’s what “special needs” is, by definition — and sometimes the choices people face are the lesser of two evils. I hope I’ll never be in that situation, my daughter and I work hard to avoid it and it looks less likely these days, but it’s within the worst case scenarios I have to consider.

      But I wouldn’t object if a case needed to be made to a court system for it (though looking at the Spears case, it’s hard to say how much good that would do.)

      • What’s your take on the Spears case? I fear she’s a walking natural disaster area who needs all the help she can get. I find the “Free Brittney” tenor of the reportage on her conservatorship hearing distressing and idiotic.

        • My take is that she probably does need assistance of some sort. I think a non-wealthy, non-celebrity in her position would be relying on friends, parents, or other relatives without a court order, just because it would be hard for her to hold a stable job or maintain someplace to live. But that’s a problem with people who are mentally ill and also have “f–k you money,” they’re free to push stable influences away and be as erratic or self-destructive as they want, which can endanger other people (Michael Jackson, anyone?)

          That said, I do think Spears’ father is not a trustworthy guardian, based on both her complaints and the fact she’s been in show business since she was a child. It certainly suggests they have one eye, or both eyes, on her earning potential. And at least non-celebrity people in that situation have some freedom to leave abusive situations, even if their other option is a street corner.

          I think the best that could happen now would be to respect her complaints while still supplying supervision by looking for a different conservator, whether a friend or relative or a court appointed social worker with less financial incentive to direct her in specific ways. If she complains that the new person is also abusive, we’ll recognize a pattern. If that person feels that she is actually under control, the court should take that seriously. But I don’t think the situation they’re in now is healthy for anyone involved.

          • Thanks.

            Yes, her being a cash cow for tons of people is a major problem. But my God, she seems erratic as hell. I wonder why she can’t simply retire. Invest all her money safely and she’ll be more than good for the rest of her life. Why treat her like an organ grinder monkey? Obviously being an entertainer and a celebrity is exacerbating her underlying conditions.

  4. Conditions of the brain are hard. My best high school friend became paranoid schizophrenic as a scholarship freshman at Princeton and never, ever recovered. He died recently in a single fatality house trailer fire. For thirteen years he’d lived under a bridge in the Miami neighborhood I’d grown up in. He wouldn’t take his medicines because he was convinced they were poison. A cousin married a brilliant guy who devolved into a severely bi-polar guy. Again, wouldn’t take his meds because he was addicted to the highs. Her younger daughter is bi-polar but takes her meds and has not born any children. Kay Redfield Jamison’s books are really enlightening on severe mental health issues. She and her father both suffered from paranoid schizophrenia. Being brilliant can be a double edged sword.

    I’m in favor of most any therapy for mental conditions so long as they work and prevent harm. As are all the other human organs, the brain is an organ that can be diseased and in some cases, can be treated. Undiagnosed and untreated mental illness is probably the biggest malady in America (see, eg., the chronically homeless). “Snap out of it,” or “he has a right to be crazy” is not a viable way to go.

  5. I’m going to echo many of the comments here, because they immediately recognize one of the essential principles of decision making and ethical judgment: a course of action doesn’t exist in a vacuum. We have to ask what the alternatives are. We can only judge each option relative to the other options.

    I assume that the other options here are 1) to use some other method of quickly stopping destructive behavior rather than a brief electrical shock, or 2) to not allow such freedom that it would be necessary to quickly stop destructive behavior in the first place.

    From a physical standpoint, brief electrical shocks seem very humane. As I understand it, they don’t cause lasting pain or injury.

    From a mental standpoint, I’m assuming that in the long term, the guardians are trying to reduce the reduce the destructive behavior so that the short-term shocks become less necessary. I’m not sure if the shocks would have any long-term harmful mental effects, or how those effects would be assessed given that a mind prone to destructive behavior is already unhealthy in some way. Best case scenario, the harm cancels out, like the surgery example Willem Reese gave.

    I would hope that if a person’s quality of life were actually worse with the shocks than with lesser freedom or an alternative method of stopping destructive behavior, either they’d be able to indicate as much or someone would be able to notice.

    • The shocks are severe enough to leave burns and cause potential medical complications; some former students have scars.

      They are also described as agonizing by almost everyone who’s experienced them.

      • That changes the premises enough to invalidate my conclusion. It sounds like they’re just trying to control people in the most convenient manner possible, rather than help them. That seems to be a running theme with humans.

        I much appreciate your description of people actually figuring out why patients engage in destructive behaviors, and applying that knowledge. Apparently I was optimistic in assuming that the electric shocks were employed as an emergency measure, or as a harmless way to disrupt the mental link between a common stimulus and a compulsive violent action, which they would have already figured out.

  6. Some additional info on what was considered during the court hearings about this : https://www.nbcnews.com/health/health-care/appeals-court-axes-fda-ban-electric-shock-disabled-n1273572

    Disability rights activists, former residents and the state of Massachusetts have for decades pushed to stop the use of the device, called a graduated electronic decelerator (GED), or shut down the school altogether. The FDA assembled a panel of experts to study the GED, held hearings, and received thousands of pages of testimony and documentation from the school. After two years, the FDA announced it would ban the GED, but took another four years to finalize the rule.

    Opponents point to a history of scandals as examples of how the GED can be abused and why the school should be shuttered. In one case in 2002, a student was tied to a restraint board for seven hours and shocked 31 times after he didn’t take off his jacket when told to. Five years later, another student was shocked 77 times in just one night, after a prank caller instructed staff to do so.

    • So is the therapy inherently objectionable or is the facility just God awful? Seems like two different issues. Maybe the therapy is so prone to abuse it’s efficacy in a clinical situation is obliterated by its harm in the real (incredibly dreary) world of mental health facilities.

    • Absent a process that records each application of the device, along with video evidence of the behaviour of the patient that led to its application, followed by a review by an independent panel of experts with severe penalties for abusers, the abuse you describe is what we can expect. It’s just too easy for a staff member to shift the standards for the device’s deployment from self-injuries or extremely violent behaviour to annoying or obstinate behaviour (and, of course, there will be those who simply enjoy causing pain to others).

      I wouldn’t trust anyone with that kind of power, even myself. I’m not sure how long I could resist the temptation to shock one of my family members for failure to respect my authority (not long).

  7. Unfortunately, Jack, your analysis misses the rather obvious point: The facts of the case aren’t what the Judge Rotenberg Center argued.

    This isn’t a small thing. You essentially started from that premise, ignoring that the facts are in substantial dispute, and reached your conclusion accordingly.

    You should, as a lawyer, know better than this.

    I’ll freely admit that I’m not a neutral party in this fight… but I’m hardly unqualified to comment on it. I’ve been involved in this case for more than a decade now. My master’s degree is not only in psychology, but contains a good bit of specific training in the area of the field specifically applicable to this case. My master’s thesis was on the area of research that these practices are based on. I have a good bit of clinical experience in the field of developmental disabilities — much of which was spent working with kids at all “levels” of disability (not that I like the term).

    Also, a lot of my friends, colleagues, and acquaintances are directly involved in the fight. Sam Crane — who you quoted — is among those, although not particularly close to me by most measures (we’ve met at community events and conferences, and became friendly acquaintances and colleagues… but I haven’t seen her in person in about four years now).

    Basically, this case is a big deal to me. That necessary disclaimer out of the way… the first problem with the Judge Rotenberg Center’s preferred framing should be obvious.

    The Judge Rotenberg Center is the only place in the country that uses the GED, or indeed that still uses any form of such shock “treatment.” This is not because they’re the only place in the country that treats difficult or self-injurious clients. Countless other facilities throughout the country do so… and do so without resorting to contingent electrical shock.

    Modern treatment of such cases is based on the utterly stunning (that’s sarcasm, just to be clear) realization that, as strange as such behaviors may seem to an outside observer, they are neither without reason nor without cause. As such, modern methods focus on figuring out *why* the behavior is occurring and either treating that or teaching the client/patient/student alternative (and hopefully better) ways to accomplish whatever it is they’re trying to do.

    I still remember my first real encounter with “severe” self-injurious behavior of that sort. It was in 2009; I was doing a clinical practicum at a preschool for kids with disabilities and rotating between classrooms. One of the kids I was working with — he was a cute, incredibly sweet if medically complex five-year-old — started melting down, throwing what looked like a tantrum and slamming his head as hard as he could at any solid surface at every opportunity. He’d been engaging in such behavior all week, as it turned out (I saw him on Wednesday), and the teachers in the classroom, who were generally much more experienced and knowledgeable than I, were utterly perplexed as to why.

    We didn’t find out why until after school that Friday. Well, I say “we,” but I didn’t learn the whole story until the next week.

    It turned out that the kid’s mother had decided to try some new magical miracle detox shampoo based on coconut oil in order to remove the magical “toxins” allegedly responsible for her son’s medical issues. Said son was allergic to coconut. His scalp, under his rather thick hair, had been a mess of itchy rashes.

    He physically couldn’t scratch them: he had ideomotor apraxia too severe to let him reliably point a finger, much less get his fingernails to scratch an itch. He couldn’t tell us what was wrong: whether due to developmental delay, low intelligence, apraxia of speech, or something else entirely, he couldn’t talk. All he could do was… bash the itching areas against something, drowning the maddening sensations out with the resulting pain.

    And so, when his mother came in on that Friday to pick him up and cheerfully asked if her latest miracle cure had helped, blissfully unaware of the Hell that she’d put both her son and his support staff through throughout the week, I can only assume that his teachers smiled and corrected her assumptions while desperately restraining the urge to punch her in the face.

    I still can’t smell coconut oil without getting nauseous, and I was nowhere near as involved with that mess as they were.

    Modern standard-of-care would have been a medical exam (which presumably would have found the rash), often followed by behavior-focused attempts to figure out what purpose the behavior was serving (known as a “functional assessment”).

    Until recently, the Judge Rotenberg Center’s website was quite clear on what they thought of such methods: “We are very familiar with the field of functional analysis, but frankly we have little use for it.”

    They would have simply shocked the kid if presented with a similar case. That would have maybe made him slam his head against things less… but would have not only done nothing about the itching that was driving him to do it, but would have left him without even that extremely minimal relief.

    Of course, that’s hardly the only issue I have with the JRC… or their “facts.” Among other things, they haven’t restricted themselves to shocking such “severe” or “bizarre” cases — one notable “study” of theirs assessed the effectiveness of their methods on someone with normal intelligence whose diagnosis was bipolar disorder and *PTSD*, of all things — and they don’t confine the use of their device to “treating” such behaviors (as they’ve been perfectly willing to shock “students” for getting out of their seat, for instance).

    And all of that’s assuming they were competent and trustworthy enough to be relied on to take care of a pet rock, much less vulnerable children. They are not, and never have been.

    But… I’m simply too tired, both physically and emotionally, to get into that right now. I may do a follow-up with some of the many, many other abuses I’m aware of at that place if I have the time… but for now, I’ll simply skip to the conclusion.

    Simply put, that school is almost fractally unethical. It’s virtually impossible to look at *any* part of their program and conclude that it’s okay. This ranges from relatively simple things like the cameras in the girls’ shower areas (that male staff are, or at least have been, allowed to view the feeds from) to the way they starve students, to the more subtle things, like the way that literally every “nice” thing you see on the tour is a form of psychological manipulation… but it does range that far, and further.

    In an ideal world, maybe something like the GED would have legitimate use. We don’t live in that world… and the Judge Rotenberg Center’s use of it is so far from anything justifiable that it’s not even funny.

    • First of all, good to hear from you. I was actually thinking about you when I wrote the post.

      Second, my “analysis” consisted of the ethical systems being argued in the case. You know I don’t have time to investigate and weigh the advocacy in instances like this one. I also don’t have the expertise.

      Third, ethics quizzes are designed to flush out commenters who do have expertise. Like you.

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