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Abstract

Psychosurgery encompasses neurosurgical procedures that are performed to alter a person’s thoughts, emotions, personality, or behavior. Although its history dates back to antiquity, psychosurgery was ﬁrst introduced into modern medicine as a treatment for patients suffering from psychiatric illness in the early twentieth century. Psychosurgery reached its zenith with the widespread performance of the now notorious leucotomy and lobotomy procedures of the 1930s and 1940s. However as a result of adverse patient outcomes and questionable clinical practice, the use of psychosurgery to treat mental disorder became increasingly opposed. This opposition, in conjunction with the introduction of psychotrophic drugs for the treatment of mental illness in the mid-twentieth century, rendered psychosurgery virtually obsolete. However, over the last few decades, advances in neuroscience, imaging technology, and psychiatry have contributed to the development of a new era in psychosurgery (Robison et al 2012). These advances have also heralded a new technique that involves a nondestructive neurosurgical procedure – deep brain stimulation. This entry considers the ethical issues associated with psychosurgery, illustrating why psychosurgery was so problematic in the early twentieth century. It also discusses ethical issues that remain relevant to the contemporary practice of psychosurgery. It concludes by brieﬂy outlining some of the approaches to regulating psychosurgery globally.

Introduction

Psychosurgery encompasses neurosurgical procedures that are performed to alter a person’s thoughts, emotions, personality, or behavior. Historically such procedures involved the destruction or ablation of brain tissue in the form of leucotomy or lobotomy. While performance of these crude procedures ﬂourished in the early-mid twentieth century – its nadir resulted after it became increasingly associated with unethical clinical practices and negative patient outcomes. The resulting public backlash as well as the introduction of psychotrophic medications to treat psychiatric illness in the 1950s effectively consigned “psychosurgery” as it then was to a notorious chapter in medicine’s history.

While contemporary “psychosurgery” is similarly informed by the theory that the manifestations of neuropsychiatric illness occur as a result of underlying neurological dysfunction, its practice is substantially different. Modern psychosurgery is based on a much-improved understanding of neuroanatomy and function. It does not generally involve destructive or ablative surgery, but primarily comprises the insertion of intracerebral electrodes for the purpose of stimulating speciﬁc areas of the brain via an implantable pulse generator. These implantable electrodes allow electrical stimulation/modulation of a targeted area of the brain to attenuate the symptoms associated with the particular neurological or psychiatric illness being treated. Similar to its historical counterpart, this procedure, which is aptly termed “deep brain stimulation” (DBS), inhibits neural activity. However, unlike the earlier ablative lesioning procedures, DBS is nondestructive and generally reversible (Mashour et al. 2005).

This entry brieﬂy describes the evolution of psychosurgery from ancient to modern times. It outlines the theory that underpinned the re-emergence of psychosurgery as a treatment for psychiatric illness in the late nineteenth and early twentieth centuries. It also discusses the current performance of DBS, as well as some of the “typical” approaches to regulating the performance of ablative and nonablative psychosurgery. However, the main focus of this entry is on exploring the ethical dimensions of psychosurgery.

The Early History And Subsequent Development Of Psychosurgery

Attempts to modify aberrant human behavior date back to antiquity. The earliest known instance of psychosurgery was trepanation, which involved boring a hole through the person’s skull to release evil spirits or to provide relief from the manifestation of illness, such as epilepsy or mental disorder (Faria 2013a). Evidence of trepanation has been discovered on prehistoric skulls dating back to 5100 BC, with archeological ﬁndings indicating that trepanation was extensively practiced in pre-Columbian Mesoamerica, particularly in Peru and Bolivia, as well as in Europe and Asia (Mashour et al. 2005). While trepanation continued to be practiced during the Middle Ages as a treatment for psychiatric illness, it dwindled during the Renaissance period (Faria 2013a).

The era of ablative psychosurgery (i.e., leucotomy and lobotomy) brought about a resurgence in trepanation. This emerged in the late nineteenth and early twentieth century as a direct result of the adoption of the concept of cerebral “localization” by the medical and scientiﬁc community. This was the notion that speciﬁc areas of the brain were responsible for particular neurological or behavioral functions. This theory was largely a response to observing the effects of traumatic brain injury or pathology on human capacities and behavior – most famously illustrated by the case of Phineas Gage in 1848.

Gage, a railway worker, was injured in an explosion that resulted in a tamping iron being driven into his cheekbone, which then passed through his temporal lobe before exiting his skull. Remarkably Gage survived, but the effect on his personality and behavior were extreme. Gage changed from being a well-balanced energetic individual, to exhibiting poor impulse control and executive functioning – a phenomenon now identiﬁed as “frontal lobe syndrome.” The insights obtained from this correlation of brain injury with aberrant behavior, along with the work of neurosurgeon Pierre Broca and neurologist Carl Wernicke who both postulated links between particular areas of damage to the brain and language deﬁcits, contributed to the development of the localization theory of neuroanatomy. The localization theory posits that pathological or mentally disordered states are attributable to a particular area of the brain. This theory was a signiﬁcant precursor to the eventual introduction of the psychosurgical procedures: frontal leucotomy and lobotomy. These procedures emerged against a backdrop of extensive, and in some cases debilitating, mental illness for which institutionalization was the only treatment option at that time (Robison et al. 2012).

The Frontal Leucotomy And Lobotomy Era

Portuguese neurologist Egas Moniz and his neurosurgeon colleague Almeida Leima ﬁrst performed frontal leucotomy in 1935 to treat people suffering from mental disorder. This crude procedure originally involved injecting alcohol into the white matter of the patient’s frontal lobe to cause tissue necrosis (death) – a procedure that was subsequently reﬁned to cutting lesions in the white matter with a purpose-built instrument called the leucotomy. When Moniz was awarded the Nobel Prize for physiology and medicine in 1949, the technique had become an established treatment for a range of conditions throughout Europe and the Americas. These techniques effectively severed the neural pathways in speciﬁc areas of the brain to induce personality changes in the patient.

Neurologist Walter Freeman and neurosurgeon James Watts subsequently modiﬁed the procedure, publishing a monograph in 1942 that described the results of 200 frontal lobotomies they had performed (Robison et al. 2012). The notoriety of psychosurgery reached its zenith with the subsequent popularization of the transorbital frontal lobotomy pioneered by Freeman. During this procedure, patients were rendered unconscious using electroconvulsive therapy, after which a surgical tool resembling an ice pick was inserted through the skull above the orbit of the eye and moved laterally through the prefrontal lobe (Mashour et al. 2005). It has been estimated that between 1936 and 1956, 60,000 psychosurgery procedures were performed in the USA and Europe (Robison et al. 2012).

Although the original focus was mental illness, psychosurgery was also proposed as a means of social control. In the mid-twentieth century psychosurgical intervention was suggested as a potential tool to quell civil unrest (in the context of the civil rights movement) as well as violent prisoners (Pustilnik 2009). In 1968, a military surgeon performed psychosurgery on several prisoners (one being a minor) in a United States Penitentiary (Vacaville). Electrodes were inserted into the prisoner’s brains to destroy amygdalar tissue in an attempt to eradicate the prisoner’s capacity for violence (Pustilnik 2009).

However, there was a rapid fall in the popularity of psychosurgery during the 1950s as the associated risks became better known, and there was greater public awareness of the context in which it was being performed. A major contributor to its demise was the discovery of psychotropic medications, such as chlorpromazine and haloperidol, in the second half of the twentieth century. An additional factor in the downfall of psychosurgery was its graphic and negative portrayal in pop culture, such as Ken Kesey’s novel One Flew Over the Cuckoo’s Nest (Robison et al. 2012).

The developing negativity with which psychosurgery came to be viewed is exempliﬁed in the US case of Kaimowitz v. Michigan Department of Mental Health (Civil No. 73-19434-AW) in 1973, an unreported decision of a circuit court in the United State’s Michigan County. Kaimowitz involved a prisoner, Smith, who had killed a nurse and subsequently performed necrophilia on her body. He had been detained for 17 years after being committed to an institution under the criminal sexual psychopath law. With his release imminent, Smith wished to participate in a study comparing the effectiveness of psychosurgery with drug therapy in treating uncontrollable aggression. However, Kaimowitz, a member of the Michigan Legal Services, brought an action on behalf of the proposed study participants to halt the state-funded experiment. Although the proposed research was abandoned following the institution of legal proceedings and the negative public reaction that resulted, the court nevertheless considered that the issues involved were of sufﬁcient public importance to warrant a declaratory judgment. Consequently, the Court sought to determine what constituted a legally adequate patient consent to an experimental procedure in the context of an involuntarily committed patient.

The Court premised its decision on the view that involuntarily detained mental patients reside in an environment that is intrinsically coercive. It found that the inherent subtle, but profound, psychological coercion at play in those circumstances rendered such individuals unable to reason as equals with medical and administrative personnel as to whether they should receive psychosurgery. Given this relative inequality, the Court doubted whether individuals in that situation could give voluntary informed consent. Ultimately, it invoked the Nuremberg Code’s principles to justify its conclusion that individuals, while living in such an environment, could only consent to low-risk high-beneﬁt procedures, which did not include experimental psychosurgery.

As a result of the many critical accounts that chronicled the profound side effects and personality changes experienced by many individuals who underwent psychosurgery, in conjunction with widespread concern regarding its potential use by States to control citizens’ violent or antisocial behavior, a major ethical review of psychosurgery was undertaken in the USA in the mid-1970s. The US National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research released its report in 1977 (Mashour et al. 2005). Contrary to general expectations, the Commission did not recommend outright prohibition, but instead outlined guidelines for the ethical use of neurosurgical procedures for psychiatric disorder.

Over time, the performance of psychosurgery has been reﬁned by the introduction of stereotactic surgery, which enables more precise targeting of areas for ablative lesioning. Advances in imaging techniques such as functional magnetic resonance imaging (MRI) have also enhanced the capacity to examine neuroanatomy and function in the context of illness or disease.

Contemporary Psychosurgery

Mashour et al. describe four psychosurgical procedures that are currently used to treat affective or anxiety disorders that are refractory to drug therapy, psychotherapy, or electroconvulsive therapies. These are anterior cingulotomy, subacute tractotomy, limbic leucotomy, and anterior capsulotomy (Mashour et al. 2005). However, deep brain stimulation (DBS), a relatively new psychosurgical treatment modality introduced in the 1990s, constitutes a signiﬁcant alternative to ablative procedures.

DBS was introduced as a result of the myriad advances in imaging capacity, neurosurgery, neurology, and psychiatry over the latter half of the twentieth century. DBS constitutes the ﬁrst nonablative and nondestructive treatment modality for movement disorders, as well as treatmentresistant psychiatric illness. Although the mechanism of DBS is still not completely clear, it is thought to modulate disordered brain networks. While by no means a mainstream procedure, it has been successfully used to treat Parkinsonian tremor, essential tremor and dystonia (Greely 2008), and has been investigated in the context of treatment-refractory psychiatric illnesses, including obsessive-compulsive disorder (OCD) and major depressive disorder (Robison et al. 2012). Indeed, Robison describes DBS as “a conceptual breakthrough in the treatment of psychiatric illness” (Robison et al. 2012). A more recent focus of DBS research is on determining the neural pathways affected in individuals suffering from treatment-refractory addiction. In this context, DBS is used in an attempt to normalize dysfunction in the “reward” circuitry of the brain. DBS, which is also termed “neuromodulation,” has also been investigated as a treatment for eating disorders, as well as posttraumatic stress disorder (Robison et al. 2012). Although certainly not common, it has been estimated that more than 100,000 people worldwide have received DBS implants (Johansson et al. 2014).

Ethical Implications Of Psychosurgery

A Common Thread

The ethical controversy that was associated with psychosurgery in the early twentieth century turned on the harmfulness of leucotomy and lobotomy. It is pertinent that the kind of harm inﬂicted upon people at that time occurred because it “changed” many of those individuals in profound ways. The personality changes following leucotomy and lobotomy were clearly some of the most alarming harms of early psychosurgery. The extent to which DBS alters personality, or one’s “sense of self,” likewise continues to be an important potential harm to be considered in this context. Consequently a primary ethical question is how beneﬁcence, that is promoting the patient’s health and welfare, is to be weighed against the principle of nonmaleﬁcence, which is the professional obligation to “do no harm.” Ultimately this involves a multidisciplinary clinical team determining with the patient whether the patient’s refractory clinical symptoms are severe enough to warrant the uncertain, and potentially profound, effect of psychosurgical intervention.

Accordingly, many jurisdictions internationally place considerable emphasis on the importance of consent to psychosurgery being fully informed and voluntary. These requirements are premised on the principle of respect for persons/ autonomy. While consent is an important way of ensuring that human beings are accorded the moral status that they deserve, respecting an individual’s “personhood” is also relevant to psychosurgery in a more subtle way. The wrongfulness of the harm caused by leucotomy and lobotomy historically was largely due to the way that it damaged very deeply the essence of those who underwent it. Respecting the personhood of those who are candidates for psychosurgery likewise suggests that clinicians and patients must consider the possibility that it might change that individual profoundly.

Consent And Psychosurgery

A fundamental principle of medical ethics and law is that, in the case of a competent patient, consent should be sufﬁciently informed and voluntary. This can pose challenges in this context given that some individuals who are candidates for psychosurgical interventions may be particularly vulnerable due to their severe, and refractory, neurological or psychiatric illness. Further, if they have not responded to other traditional treatment, the procedure may effectively constitute their “last hope.” In addition, some individuals may have cognitive deﬁcits associated with their illness. The issue of informed consent is also problematic given the inherently complicated nature of psychosurgery. Although assessing the beneﬁts and risks of a procedure is part of routine clinical practice, predicting the likely effects of psychosurgical procedures such as DBS is not straightforward. As experts concede, the “unknowns” regarding the neural mechanisms underpinning many conscious processes, as well as uncertainties regarding the actions of such neurointerventions, makes predicting their likely effects, as well as calculating beneﬁts and risks, extremely difﬁcult (Jotterand and Giordano 2011).

Effect On Personality Traits And/Or Identity: The Experience Of Some DBS Recipients

Clinical reports indicate that some patients experience a change in personality and demeanor following DBS. But although certain aspects of personality may be altered as part of treatment for illness, it cannot be known in advance whether those altered states will be negatively or positively experienced (Jotterand and Giordano 2011).

Clearly the phenomenon of therapy altering an individual’s demeanor or personality is not limited to DBS. For example, some patients receiving the antidepressant Prozac report that it not only relieves the symptoms of their depression, it also enhances mood, energizes and, to an extent, may alter an individual’s personal identity (Jotterand and Giordano 2011). However, it is debatable how much individual “change” is required before a treatment effectively alters a person’s actual “identity,” that is, their self-constructed genuine or authentic self.

When evaluating the claim that DBS may impact on an individual’s identity, it is important to ﬁrst deﬁne which sense of “identity” is being referred to given the competing accounts of identity. One important distinction is between personal identity in an indexical sense – literally being a different person, and qualitative identity – that is being a different kind of person (McMillan 2005).

An “indexical” sense of identity is one that tells us the conditions that make something the speciﬁc thing it is. For example, “the tie that I wore yesterday” is a speciﬁc object and “the tie that I am wearing today” is the same tie in an indexical sense if, and only if, there is continuity throughout time of that object. The tie that I am wearing today could, indexically, be the same that I wore yesterday even if I had spilled ketchup over it and cut the end off in a blender. Likewise, we would all think that we are, indexically, the same person that we were ten years ago, even though we might be qualitatively a very different person from the one that lived ten years ago.

The “indexical” and “qualitative” senses of “identity” are two different ways of talking about what it is that makes a person the person they are. However, it is difﬁcult to see how DBS could change a person so much that they literally become a different person, without damaging them to the extent that their personhood is called into question. For example if after DBS radically changed an individual’s behavior in the way that Phineas Gage’s did when an iron bar passed through his prefrontal cortex, that person would become, qualitatively, a different person, but we would be in no doubt that he/she was “indexically” the same person. The point is illustrated well by Gage himself, who clearly still was “Phineas Gage.” Clearly it is hard to see how there is any version of DBS that could result in an indexically different person.

One account of qualitative personal identity claims that:

All changes and only changes in central attitudes constitute a change in individual identity, i.e., if and only if our central beliefs, values, ideals, plans, projects, ideologies etc. change, we change in a substantial way. (Witt et al. 2013, p. 503.

On this approach, altering an individual’s (qualitative) identity means that a person’s core beliefs (i.e., the central beliefs that inform the way that he/she interacts with the world) have changed, such that it causes a profound cognitive shift in the person, thereby disrupting the continuity of the person pre-and-post DBS (Witt et al. 2013, p. 506). However, while there would be reason to think that a person’s self-conception or qualitative identity had changed markedly over time in such cases, whether changing fundamental beliefs constitutes harm is another question.

As well as having a possible effect on demeanor, or even identity, some patients have reported experiencing a sense of self-alienation following DBS. Johansson notes a study involving 29 patients, 19 of whom self-reported a feeling of not fully recognizing themselves after receiving DBS (Johansson et al. 2014). However participants in that particular study did not consider this feeling sufﬁcient to warrant ceasing DBS therapy.

As well as being a ﬁrst person phenomenon, identity ascriptions can also be made by those that know us well. Clinical reports have described how some families struggle to adapt to what they perceive as a “new” person after a family member has undergone DBS. One such report involved a woman who had received DBS for severe OCD. Her husband observed that while his wife’s condition improved suddenly when the device was switched on, there was no similar button to push to assist her family to adapt to “this new person” (Jotterand and Giordano 2011, p. 481).

The extent to which DBS may impact on identity is unknown in advance. Greater understanding of how a patient’s “sense of self” or identity may be affected by DBS procedures, and its effects on the patients signiﬁcant others, constitutes a rich area for ongoing research. It is important so that future candidates for these procedures may be better informed regarding the possible effects of treatment. Clearly the implications of a DBS-induced alteration in an individual’s personality or “sense of self” may be signiﬁcant, which is such brought sharply into focus when treatment does not go well.

The way in which DBS may impact upon an individual’s behavior and personality was illustrated in a recent coronial investigation into the death of an Australian man following treatment for Parkinson disease (State Coroner of New South Wales Australia 2014). The man had exhibited rapidly ﬂuctuating behavior and moods, as well as impulsive behavior, immediately following DBS. Consequently the DBS settings were altered. However two days after he was discharged from hospital, after experiencing on-going ﬂuctuations in his mood and behavior, the patient unilaterally ceased his medication and turned off his stimulator. While he recommenced the stimulation on medical advice, his moods subsequently continued to swing from being settled and calm, to being agitated and “manic.” Finally after an out-of-character confrontation with his wife, he left the family home and was found dead a short time later having taken his own life.

The coroner’s ﬁndings emphasized the importance of fully informing and preparing patients, as well as their immediate family, for the possible side-effects of treatment. Also emphasized was the need for out-patient review, immediate access to expert care should an emergency arise, as well as postoperative psychological or psychiatric support for the patient.

Control Over Implant And The Potential For “Enhancement”

An issue that triggers some debate (in the case of devices that allow a patient to make self-adjustments) is the degree of control over treatment parameters that a patient should be given. While simply turning a device on or off is not problematic, changes to the intensity and frequency of stimulation may have various effects on the person, such as inducing a state of hypomania or elevating a patient’s mood. While this is an issue that clinicians are likely to resolve by weighing the ethical considerations discussed above, patient control over an implant raises the possibility that (depending on the area of the brain targeted) DBS might be used to enhance cognitive ability such as memory or even emotional ability.

Although DBS is currently used to treat neuropathology, it remains to be determined whether it might, in the future, be used to enhance cognitive ability, or to inﬂuence an individual’s mood in the absence of a clinical disorder. However it is important to bear in mind that DBS involves the insertion of electrodes into the brain. The associated risks, including the physical risks of surgery such as infection or bleeding, might suggest that it is unlikely that such procedures would be performed in the context of a person who is not suffering from a serious neurological condition. Conversely it is clear that an increasing number of people elect to undergo highly invasive cosmetic procedures in the interest of improving their appearance. It is plausible that there may be a similar attraction to undertaking invasive procedures that improve one’s cognitive ability. Further, concerns arising from invasive surgery do not apply to noninvasive means of neurological electrical stimulation, as in the use of transcranial magnetic stimulation (TMS). Consequently whether or not such neurotechnologies should be used in the future to enhance physical, behavioral, and cognitive abilities in otherwise healthy individuals is very much an issue for debate.

Psychosurgery And Crime Prevention

As already indicated above, the use of psychosurgery as a means to control aggression and violent behavior in criminal offenders was a highly controversial issue in the early debates on psychosurgery. In some instances, it led to greater controls being placed on the provision of psychosurgery in particular contexts, such as when an individual is being involuntarily detained under mental health provisions or is imprisoned, because of the risk of coercion.

Of direct relevance to the criminal justice system is recent research conducted by a group of Italian researchers. Franzini and colleagues have described the long-term outcome of posterior hypothalamic DBS in the case of seven “severely impaired patients affected by refractory aggressive behavior and mental retardation” (Franzini et al. 2013). While no discussion was provided regarding the patients’ capacity to give consent, all of the research participants were all described as of “below-average IQ.” The research was approved by an institutional Ethics Committee taking into account “the chronicity and severity of the condition, the related burden to families, and the refractoriness to conservative treatments.” The patients’ relatives provided written consent after receiving information regarding the rationale and risks of the procedure. The authors claimed that given the reversibility of the procedure and the sustained reduction in violent behavior that was witnessed in four of the patients, the procedure was ethically acceptable. It was concluded that in this context DBS “may help patients chronically isolated in mental institutions to be integrate [d] into society.” Signiﬁcant questions raised by the research, such as the effect of DBS on other aspects of the patient’s personality, or the side effects experienced, were not discussed.

It is signiﬁcant that some commentators are now considering the potential use of consensual DBS for repeat criminal offenders with neuropathology (e.g., psychopaths) who have not responded to conventional treatment (Faria 2013b). Using neuromodulation of the reward circuitry to reduce the potential of sexual and/or violent offenders to reoffend is, at least, a theoretical possibility. However one prominent commentator, who is skeptical of using DBS in the criminal context (Greely 2008, p. 1114) observes:

Different reports have linked parts of the prefrontal cortex to criminal behavior, usually on the theory that the criminals lack appropriate impulse control because of under-activation of those regions. Other areas that have been implicated in criminal behavior include the hippocampus, the amygdala, the corpus callosum, and the hypothalamic-pituitary-adrenal axis. DBS provides a plausible method for stimulating greater activity in regions where diminished function is thought to play a role in crime. It could also provide an adjustable, intermittent, and reversible method of inhibiting activity in areas where over-activity may contribute to criminal activity and thus serve some of the functions of neurosurgery, but without its permanence. Of course, at this stage any such uses of DBS are highly speculative. On the other hand, uses of DBS seem to be spreading rapidly as neurosurgeons try different regions for different conditions. The extension of DBS research to criminality … seems likely. Its success is much less certain.

The view that criminal or violent tendencies may be caused by disordered neurobiology has a long and deeply troubled past (Pustilnik 2009). However in recent decades, criminologists have been instrumental in identifying the multifactorial components of criminality, emphasizing the inﬂuence of social, economic, and political factors on criminal behavior. Given the invasiveness of DBS, the lack of conclusive evidence regarding its efﬁcacy and the potentially serious side effects of the procedure, the prospect of using DBS to ameliorate criminal tendencies, at least in the near future, seems dubious. Nonetheless, as DBS becomes more prevalent and the class of conditions for which it is offered increases, it seems likely that its use in treating aspects of criminality will at least be mooted by some (Faria 2013b).

Procedural Preconditions

Given the issues associated with psychosurgery, signiﬁcant steps have been made by professional bodies to establish an internationally consistent approach to performing neurosurgery for psychiatric indications. A group representing the major international psychiatric and neurosurgical societies recently published an international multidisciplinary “consensus on best ethical practices, norms and professional behaviours,” to guide professionals involved with stereotactic neurosurgery for psychiatric disorders (Nuttin et al. 2014). The contributors encompassed representatives from the World Society for Stereotactic and Functional Neurosurgery (SFN), the European Society for SFN, the Latin American Society for SFN, the Asian-Australasian Society for SFN, as well as the World Psychiatric Association. The aim of the guidelines is to establish ethical and scientiﬁc standards to promote patient safety when stereotactic ablative focal surgery or DBS is considered for the minority of patients who are affected by psychiatric illness, but who are not responsive to pharmacological or other evidence-based therapies.

The guidelines are premised on the view that “the accumulated evidence supporting the application of all neurosurgical treatments for psychiatric disorders” requires strengthening and that these neurosurgical procedures remain “at a ‘proof-of-principle’ investigational stage of development” (Nuttin et al. 2014). The guidelines provide that ethical oversight must be provided by an independent Ethics Committee or Institutional Review Board for investigational neurosurgery, and be consistent with local and national regulatory requirements. Further, that care should be taken in determining when sufﬁcient data has been accumulated to warrant a psychiatric neurosurgical procedure being designated a therapeutic, as opposed to an experimental, intervention.

Some jurisdictions have imposed a ban on psychosurgery, such as Australia’s Northern Territories and the state of New South Wales (NSW). However recent amendments to NSW law speciﬁes that “psychosurgery” does not encompass a neurological procedure performed to relieve the symptoms of Parkinson’s disease, Gilles de la Tourette syndrome, chronic tic disorder, tremor, or dystonia. Consequently the NSW law distinguishes between DBS for neurological indications, as opposed to DBS for psychiatric indications.

After a renewed interest in psychosurgery in the early 2000s, Chinese neurosurgeons performed ablative procedures on more than 500 patients on an area of the brain thought to be associated with addiction. Around the same time, Russian neurosurgeons resected a part of the brain associated with compulsive behavior in over 300 patients (Greely 2008). Both countries have since halted the procedures. China’s Ministry of Health now restricts civilian hospitals to performing ablative psychosurgery as a last resort for speciﬁc conditions for which its use is recognized (referencing refractory OCD, depression, and anxiety disorders), but imposes a ban on any “experimental” use (Xiao 2011).

Other jurisdictions only prohibit involuntary psychosurgery, and impose speciﬁc regulatory requirements for those patients who are subject to involuntary treatment for mental disorder under state law. Consequently in the context of civil commitment schemes, typical legislative provisions specify that psychosurgery may only be performed if the patient’s voluntary and informed consent is obtained, and a designated Review Tribunal has approved the procedure (e.g., the Australian states of Victoria, Queensland; Tasmania and Western Australia; as well as

New Zealand – although New Zealand’s law refers to surgery or other treatment “intended to destroy any part of the brain or brain function,” which may not encompass DBS). The UK requires validation of the patient’s consent and their legal capacity to give consent, as well as written certiﬁcation from an authorized (nontreating) medical practitioner that the treatment is appropriate in the circumstances. Additional information may also be speciﬁcally required, such as the qualiﬁcations of the doctors involved, and that all other alternative treatments have provided insufﬁcient beneﬁt (e.g., Western Australia and the Australian state of Victoria).

It is also not uncommon for some jurisdictions to single out psychosurgery as a treatment that, in the case of an incompetent person, a legally appointed substitute decision maker cannot consent to on their behalf (e.g., New Zealand). Alternatively if consent to psychosurgery is within the power of a substitute decision maker, restrictions may be imposed on the circumstances in which substituted decision making can occur, such as only permitting proxy consent in the case of a life-threatening condition which has not responded to traditional therapy.

However the extent to which a nation incorporates rights protections into mental health laws is not consistent across the globe. In an attempt to address these issues the World Health Organization developed a Mental Health Legislation Checklist in 2005 to aid in determining the extent to which a countries mental health laws complied with international human rights obligations (Drew et al. 2013). Signiﬁcantly a recent examination of mental health laws in four countries on the African continent (Ghana, Uganda, Zambia, and South Africa) revealed that only South Africa had regulations governing psychosurgery, while none of the three remaining countries prevented procedures such as psychosurgery being performed without consent (Drew et al. 2013).

Conclusion

The development of psychosurgery in the early twentieth century continues to inﬂuence the way in which modern techniques are perceived. However, the possibility of great harm being done to patients via direct neurosurgical interventions has been signiﬁcantly lessened by the development of stereotactic techniques and nonablative procedures such as DBS. But while much more is now known, the outcome and side effects for individual patients is not always predictable. Given this, the importance of fully informing individuals of the potential outcomes and implications of ablative procedures or DBS (including their immediate family/support persons) is now widely recognized. It also suggests that the current cautious approach, whereby psychosurgery is generally used only as a last resort when other treatments have not been successful, is warranted. Ultimately, the requirement that its performance be reviewed on a case-by-case basis, particularly in the case of a patient who is under a civil commitment regime, is an ethically justiﬁable and arguably necessary requirement.

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