[Aim] This study aimed to examine the validity of including the patient's preference as an indication for the primary use of acute electroconvulsive therapy (ECT).
 [Methods] We compared the guidelines of various countries and organizations (Australia, New Zealand, Canada, Germany, Japan, Spain, the UK, the USA, and the World Federation of Societies of Biological Psychiatry). Since the question of whether the patient's preference should be included in the medical indications is ethical, we referred to clinical ethics.
 [Results] The relationship between the patient's preference and indications for the primary use of acute ECT is divided into four categories: (i) the patient's preference is included in the indications, (ii) the patient's preference is included only when the patient is depressed, (iii) the patient's preference is included only when the patient is severely depressed, and (iv) the patient's preference is not included. From the perspective of clinical ethics, a distinction should be made between patient preference and medical indications.
 [Conclusion] Guidelines for acute ECT should distinguish the patient's preference from medical indications, and the patient's preference should not be included in the indications for the primary use of ECT. If a competent patient prefers ECT despite the lack of medical indications, the patient's preference should be confirmed, and the medical indications should be reconsidered. If a patient is not competent and their family members or other proxies prefer ECT despite the lack of medical presentations, careful discussion with them is necessary.