Psychosurgery, Ethical Aspects of

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PSYCHOSURGERY, ETHICAL ASPECTS OF

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As long as patients with problems of feeling, thinking, and behavior are assumed to be capable of making a free and informed decision on the question of a brain operation intended to improve some aspect of their mental state, there is no logical reason to object to such treatment. Ethical and legal problems regarding psychosurgery should arise primarily because of issues relating to consent to treatment, about which there certainly can be argument.

The Peculiar Case of Psychosurgery

The peculiar problem of psychosurgery arises in part because the brain, which is the instrument of consent, is also understood to be the source of the disability that requires cure. In itself, this is scarcely an objection. Perhaps no one gives a second thought to the specific justification for obtaining consent to the removal of a brain tumor, even if the patient is confused and a proxy consent is necessary. In contrast, it is plausible that much of the hesitation and obstruction that attend discussions of consent to psychosurgery are based upon an unwillingness to view mental illness in the same way as physical illness. Frequently, equality of treatment is denied for all sorts of psychological illness compared with physical illness, as can be seen in numerous health insurance policies. With respect to psychosurgery, there is concern that informed consent must depend upon the adequate function of a large part or wide area of the brain, and there is a valid fear that such function is liable to be absent in those to whom the operation is offered.

Even more aptly, it may be supposed that the effect to be abolished is a prime source of virtue, so that if leukotomy (the cutting of the white matter in the brain; also known as lobotomy) abates guilt it may also impair admirable features of the personality. While there can be sympathy with some of these concerns, they are judgmental questions for which practical answers can be demanded. They ought not to operate as presumptive justifications for refusing practical treatment to anyone. Sometimes there are practical problems in ensuring that the consent of a particular patient to a particular procedure is genuinely free. Nevertheless, psychosurgery attracted enough hostile comment from various quarters to lead to the creation in the United States of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research to look into this topic and related issues after "Widespread expression of public and congressional concern … including allegations that these procedures were … being used for 'Social Control' of dissidents and violence-prone individuals and … were performed disproportionately on members of minority populations" (HEW, p. 53242). Thus, the ethical issues of psychosurgery must be considered against a historical background of success.

The commission demonstrated that there was no substance to the claims being made. For example, only 100 procedures meeting the definition of psychosurgery were being performed annually in the United States in the years leading up to 1977 (when the commission issued its report on psychosurgery). It also determined that no significant psychological deficits were attributable to the psychosurgery undertaken; that the treatment was efficacious in more than half of the case studies; that there was no evidence that the procedure had been used for psychosocial control; and that only a few operations were conducted on minority or disadvantaged populations. Correspondence with the most active psychosurgeons in the United States revealed that out of 600 patients, only one was black, two were Asian, and six were Hispanic Americans. Between 1970 and 1980 only seven operations were reported to have been performed on children, and only three prisoners underwent psychosurgery. In fact, psychosurgery was largely limited to middle-class individuals. In a 1988 study, English investigators E. S. Hussain, H. Freeman, and R. A. C. Jones showed that psychosurgery provided valuable benefits for a selected small group within a cohort of patients from a defined population, particularly those with depression, agoraphobia, obsessional neurosis, and certain aspects of schizophrenia. Such findings show that the ethical aspects of psychosurgery have to do with the conditions under which it is offered, not with the inherent nature of the procedure.

Axioms and Rules

In psychiatric practice, there are some common axioms and some derivative rules. The following may apply to psychosurgery (Merskey, 1991):

Ordinarily, medical advice is just advice, and the patient is not obliged to follow it. Even the imposition of treatment to save life (e.g., a surgical operation for kidney disease or cancer) is ethically and legally permissible only if the patient consents.
Children and others in a condition that precludes them from deciding rationally may have decisions made for them by people, usually their next of kin, who have appropriate concern for their interests and welfare.
Special care is needed when decisions are made for children and other incompetent persons. Careful scrutiny of the status and motives of the person who makes the decision for the patient is necessary. Given that care, treatment can be ethically undertaken.
Ethical actions may or may not be sanctioned by law. The legality of a physician's conduct is a separate issue from its ethical basis.
Coercive treatments for the benefit of a third party are unethical, and healthcare professionals should not use behavior modification, drugs, or lobotomy against an individual's wishes to prevent that person from hurting someone else.
Likewise, coercive treatment for the benefit of society rather than the patient is repugnant to ethical physicians.
Patients may consent to treatment that benefits either themselves or others, but there are peculiar difficulties in confirming the presence of free consent in some circumstances, particularly with prisoners.

Overall, the critical issue for the physician is to recognize whether the problem receiving attention is one that is seen by the patient as needing treatment or whether it is seen by others as requiring treatment in the patient's interest. The relationship of physicians to patients is principally based on an implicit contract that the physician will care for the patient provided that the physician is not expected to violate the legal and ethical interests of other people in order to provide that care (Merskey, 1986). Given these presuppositions, the issues surrounding brain surgery can be considered with and without consent in mind.

Brain Surgery with Consent

The easiest case in which to accept the validity of leukotomy is the relief of severe depression. While leukotomy and related operations such as cingulotomy (destruction of a part of the medial portion of the cerebral hemispheres) are now rarely required for this purpose, a patient with this protracted and life-threatening condition may wish to undergo a surgical operation with relatively small risk in order to relieve the condition. Prior to the introduction of physical methods of treatment, there was a high death rate in patients with severe depression (Huston and Locher).

When leukotomy was more common in the 1950s and 1960s, a written agreement might not have been obtained—schizophrenic patients are notoriously unwilling to sign documents—but the patient was not actively opposed. Relatives would support the procedure, and, at least in Britain, the relatives' consent was accepted as legally sufficient. A large number of chronic schizophrenic patients in some countries were submitted to bilateral standard leukotomy operations under the above conditions. If operations failed to relieve fully the schizophrenic illness, at least they reduced agitation or aggressive outbursts and produced a more manageable state in some extremely disturbed patients. Was this process used for "social control?" The available options included locked or padded rooms and physical restraint. Though most psychiatrists did not regard these options favorably, leukotomy operations were not necessarily undertaken to provide otherwise unattainable control but rather to provide the patient with a quieter and easier life. If the patient did not object, and if he or she was substantially disturbed and likely to benefit from the operation, there could be no reasonable objection to such treatment, given the consent of those most likely to have the patient's best interests at heart. It remains the case that such treatment is still appropriate in the same circumstances.

Although the numbers of brain operations for depression, anxiety, and obsessive-compulsive disorder decreased in the 1970s and remained low in the 1980s and the 1990s, their accuracy was much enhanced by the use of stereotactic surgery for movement disorders (especially Parkinson's disease), intractable pain (usually cancer), and the modern developments from leukotomy. Such surgery, undertaken with the help of a fixed framework attached to the cranium, radiological control through magnetic resonance imaging, and radiofrequency ablation of the chosen area, has provided very acceptable results for a number of patients with depression, anxiety, and obsessive-compulsive disorders.

Four related operations stand out as having been the most successful and as having been usefully employed since the 1970s in the treatment of depression, anxiety, and obsessive-compulsive disorder: subcaudate trachtotomy, the implantation of pellets of radioactive yttrium below the head of the caudate nucleus to destroy the neighboring tissue over some six to eight weeks; cingulotomy, the bilateral destruction of the cingulate gyrus; anterior capsulotomy, ablation of the anterior limb of the internal capsule; and limbic leukotomy, in which lesions are placed in the orbito-fronto thalmic and limbic circuits. In 2001 Robert P. Feldman, Ronald L. Alterman, and James T. Gooderich detailed success rates and complications with these methods and described their neuroanatomical bases and physiological implications. In 1997 P. Sachdev and J. Sachdev concisely reviewed psychiatric considerations and the social setting.

With the improvements in technique and results, the discussion of ethical issues appears to have been reduced to a minimum. Only a few centers are known to perform these operations in Australia and New Zealand, Canada, Sweden, the United Kingdom, and the United States. In their 1988 book, Physical Treatments in Psychiatry, Leslie G. Kiloh, J. Sydney Smith, and Gordon F. Johnson observed that in 854 stereotactic operations the operative mortality rate was 0.1 percent, the rate for epilepsy was 0.4 percent, marked personality change affected 0.4 percent of patients, and mild personality change affected 3 percent. With a complication rate of this order, and results generally in which 50 percent of patients get considerable benefit and the majority get some benefit, the operations present a rate of risk that is highly acceptable for most individuals who have suffered from disabling chronic depression, anxiety, or obsessive-compulsive disorder for many years. Of the four operations, anterior capsulotomy appears to have the best results overall.

In addition to the treatment of depression and schizophrenia, stereotactic neurosurgical operations—especially amygdalotomy (the amygdala being the gray matter of the brain's frontal lobe)—have been used for the control of aggression, which may be directed against the patient's own self or at others (Kiloh et al.). Also, such an operation was sometimes considered for a number of chronic self-mutilators. The availability and relatively specific effect of serotonin reuptake inhibitor drugs have eased the symptoms of many patients who were prone to self-damage. That medication might produce such a radical change in self-harm means that a surgical operation when medication fails can be seen as a logical and reasonable effort to modify an aberrant portion of the brain. Many patients with such tendencies are not intellectually retarded and have no organic brain damage. Nevertheless, although most of them can respond to antidepressant medication, others need more radical treatment, suggesting that psychosurgery still has a role to play for a few patients.

Psychosurgery for individuals who are dangerous only to others but who might be willing to consent is the most difficult issue in this field. If the patient can consent, one might ask why the person should not be allowed the treatment? This problem is exemplified by the 1973 case of Kaimowitz v. Department of Mental Health. A patient who had behaved aggressively, but was a prisoner, consented to treatment but was refused it on the grounds that his consent in prison could not be truly free. The patient, who had spent eighteen years in prison for murder, had satisfied an "informed consent" review committee comprising a law professor, a priest, and an accountant that he wanted the operation. A suit was brought by an attorney, Kaimowitz, and others belonging to a medical committee for human rights who had never consulted the prisoner. The lawyer appointed by the courts to represent the prisoner thought that the prisoner desperately wanted the operation. Coincidentally, the prisoner's appointed lawyer satisfied the court that his client was held unconstitutionally as a prisoner. He went free, but the discussion continued on the question of whether as a prisoner he had given free informed consent to psychiatric surgery. The court held that he could not have. Once the prisoner was released, he changed his mind about wanting the operation. According to Robert A. Burt (1975), imprisonment and medical surveillance at least contributed to the prisoner's consent without any attempt having been made by physicians to press the prisoner to agree. Some commentators have argued that no prisoner's consent should be accepted for psychosurgery if its purpose is to alter the type of behavior that caused imprisonment. To guard against the possibility that a prisoner might be deprived of the right to medical care, some framework should be contemplated that would provide for exceptions. Exceptions would include independent professional examination of the individual's motives as well as separation of the question of release from the outcome of the operation.

Incompetent Patients

Certain incompetent patients might undergo surgery provided that it can be demonstrated that the action is not against their wishes. This would apply particularly to schizophrenic patients, who might accept a surgical operation but would never be able to comprehend or fill out a form requiring them to indicate informed consent. Patients should not undergo surgery if they give the merest hint of refusal.

Children with significant brain damage may benefit from psychosurgery, not so much to treat epilepsy caused by the brain damage as for the reduction of aggressive behavior against either themselves or others (Balasubramaniam and Kanaka). If the interests of the child are paramount, then the child should not be deprived of the possibility of beneficial surgery, even though the child is either unable to consent or appears hostile to almost any physical intervention by nursing staff or attendants. This would apply both to patients who gravely damage themselves—and sometimes have been kept for weeks or months in canvas clothing to protect themselves from such injury—and to patients who, while retarded and clearly incompetent, attack others if allowed the minimum opportunity for human contact. Such a patient also may benefit if a paternalistic approach to treatment is recognized, acknowledged, and followed.

Nevertheless, there is no justification for the forcible use of psychosurgery with individuals who are thought to be political prisoners by the family, the patient's proxies, the treating doctor, or indeed any rational contemporary.

In summary, psychosurgery should never be forced, but it might be performed on noncompetent individuals or prisoners without their formal consent, subject to stringent safeguards that require extensive consideration.

harold merskey (1995)

revised by author

BIBLIOGRAPHY

Balasubramaniam, V., and Kanaka, T. S. 1975. "Amygdalotomy and Hypothalamotomy—A Comparative Study." Confinia Neurologica 37(1–3): 195–201.

Burt, Robert A. 1975. "Why We Should Keep Prisoners from the Doctors." Hastings Center Report 5(1): 25–34.

Fabrega, Horacio, Jr. 1974. Disease and Social Behavior: An Interdisciplinary Perspective. Cambridge, MA: MIT Press.

Feldman, Robert P.; Alterman, Ronald L.; and Gooderich, James T. 2001. "Contemporary Psychosurgery and a Look to the Future." Journal of Neurosurgery 95(6): 944–956.

Greenblatt, Steven Jay. 1977. "The Ethics and Legality of Psychosurgery." New York Law School Law Review 22(4): 961–980.

Hussain, E. S.; Freeman, H.; and Jones, R. A. C. 1988. "A Cohort Study of Psychosurgery Cases from a Defined Population." Journal of Neurology, Neurosurgery, and Psychiatry 51: 345–352.

Huston, P. E., and Locher, L. M. 1948. "Involutional Psychosis: Course When Untreated and When Treated with ECT." Archives of Neurology and Psychiatry 59(3): 385–394.

Kaimowitz v. Department of Mental Health. Civil Action No. 73–19434-AW (Wayne County, Mich., Cir. Ct. 1973). Reprinted in Operating on the Mind: The Psychosurgery Conflict, ed. Willard M. Gaylin, Joel S. Meister, and Robert C. Neville. New York: Basic, 1975.

Kiloh, Leslie G.; Gye, R. S.; Rushworth, R. G.; et al. 1974. "Stereotactic Amygdaloidotomy for Aggressive Behaviour." Journal of Neurology, Neurosurgery, and Psychiatry 37: 437–444.

Kiloh, Leslie G.; Smith, J. Sydney; and Johnson, Gordon F. 1988. Physical Treatments in Psychiatry. Melbourne: Blackwell Scientific.

Merskey, Harold. 1986. "Variable Meanings for the Definition of Disease." Journal of Medicine and Philosophy 11(3): 215–232.

Merskey, Harold. 1991. "Ethical Aspects of the Physical Manipulation of the Brain." In Psychiatric Ethics, 2nd edition, ed. Sidney Bloch and Paul Chodoff. New York: Oxford University Press.

Sachdev, P., and Sachdev, J. 1997. "Sixty Years of Psychosurgery: Its Present Status and Its Future." Australian and New Zealand Journal of Psychiatry 31: 457–464.

U.S. Department of Health, Education, and Welfare (HEW). Public Health Service. 1978. "Determination of the Secretary Regarding the Recommendation on Psychosurgery of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research." Federal Register 43(21): 53242–53244.

U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. 1977. Appendix, Psychosurgery. Washington, D.C.: U.S. Government Printing Office.

U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. 1977. Psychosurgery: Report and Recommendations. Washington, D.C.: U.S. Government Printing Office.

Encyclopedia of Bioethics