“Electroconvulsive therapy (ECT) against the natural will” is a topic that has gained some attention recently. Several publications have reported mostly positive outcomes [Reference Finnegan, O’Connor and McLoughlin1–Reference Chiu, Lee and Lee4], which is in line with earlier findings [Reference Nordenskjold, von Knorring and EngstromFootnote 5, Reference Wheeldon, Robertson, Eagles and Reid6]. Accordingly, the author’s attitudes and conclusions concerning involuntary ECT treatment are predominantly positive.

The option to treat mentally ill and legally incompetent patients against their natural will within a closely described legal framework is ethically indispensable and there is no reasonable argument to exclude ECT from this general imperative. Nevertheless, involuntary treatment should not be implemented if negative effects prevail. Within the recent discussion on ECT against the patient’s natural will we missed some disadvantageous arguments that need to be considered for a balanced judgement.

Some arguments are concerning the patient himself or his caretakers. The loss of autonomy and the experience of being powerless towards involuntary measures might cause lasting negative effects at least in some patients suffering from psychotic anxiety or reality loss. Furthermore, in case of an unsuccessful treatment, the disturbed therapeutic relationship could jeopardize any further therapy. In addition to that, potentially serious personal conflicts could be triggered. For example, within the family of one of our patients, a serious conflict break open when the legal guardian, her husband, tried to legally enforce ECT treatment.

Other disadvantages go beyond the individual patient. Involuntary treatment measures are carefully and anxiously observed by the environment, trigger stress and cause high levels of emotions ranging from fear, affright and empathy to anger and aggression. People, casually involved, as visitors, fellow patients or unprepared psychiatric or non-psychiatric staff, easily get a wrong or incomplete impression of the situation. They react instinctively and pass on their unfiltered experiences, thereby nourishing rumors about violence in psychiatry. These side effects of involuntary treatments are often underestimated, difficult to predict, hard to prevent and rarely discussed. They have the potential to complicate cooperation between clinics, to keep patients from searching help, to badmouth therapies and to have a negative impact on the perception of psychiatry.

ECT is especially vulnerable to negative myths and has often falsely been associated with violence against patients [Reference Buccelli, Di Lorenzo, Paternoster, D’Urso, Graziano and Niola7–Reference van der Wurff, Stek, Hoogendijk and Beekman9]. We have to be aware of this background and keep in mind that involuntary treatments have the potential to damage the image of ECT. This could negatively affect the 99, 5% of patients who receive the treatment with their full consent, who want it and who need it [Reference Loh, Nickl-Jockschat, Sheldrick and Grozinger10].

Generally, ECT against the natural will of patients should be a very last resort, independent of it’s legitimacy. A serious search for alternative strategies should always be undertaken beforehand. These could for example consist of involving outside resources, providing additional time, using other therapeutic options or getting the support of successfully treated ECT patients. In our experience, such workarounds can sometimes be surprisingly successful.