Psychosurgery: avoiding old problems, facing new ones

Antonio De Salles, Professor of Neurosurgery – UCLA

Lincoln Frias, postdoct UFMG-Brazil, International Neuroethics Society

Jorge Moll,  D’Or Institute-Brazil, International Neuroethics Society

 

Psychosurgery has a bad name. The destruction or disconnection of brain tissue to treat mental illness was brought into disrepute by controversial figures of the past, who performed lobotomies with poorly defined clinical indications and without respect to even the most basic surgical practices of asepsis and hemostasis. The procedures were irreversible, unsafe, and often done without adequate informed consent. In many cases the surgeries drastically reduced the patients’ well-being and autonomy. To avoid this, governments put in place stringent regulations on these procedures. Coupled with developments in psychopharmacology, this left psychosurgery only as a last resort for extreme cases. The moral problem is that the stereotypes and stigma evoked by this kind of treatment are largely inadequate given current technology.

Neurofunctional surgery – the modern techniques replacing psychosurgery – uses minimally invasive procedures to make very precise lesions and implant stimulating electrodes to treat conditions like Parkinson´s disease, dystonia, epilepsy, chronic pain, severe obsessive-compulsive disorder and medication resistant major depression.  The effectiveness, safety and reversibility of novel surgical procedures directed to psychiatric symptoms (for example, neuromodulation techniques) are attractive for highly suffering patients. If it is already acceptable to prescribe medication to patients, damping some circuitry to a point that their cognition, sexual function, balance and motor function are impaired, so we should also accept surgical procedures to improve brain function, especially given that the specificity of these procedures bypass in large the systemic side effects related to medications.

The regulations for the so-called psychosurgery, although proven necessary in the past, may be outdated for our current knowledge of brain function and clinical evidence, hindering the possibility of patients in great need.  The hideous use of such practices to change the individual minds due to disagreement of political and cultural view has fortunately been abolished from the medical practice. While at the birth of behavioral surgery the procedures were massively aggressive to the brain and practiced indiscriminately, now the multidisciplinary approach, institutional review boards and improved methods of diagnosis of psychiatric disorders make the possibility of poor practice of behavioral surgery very remote. Moreover, some of the current procedures are reversible, such as deep brain stimulation – a brain pacemaker that could be safely removed when needed. In part due to false stereotypes, thousands of helpless patients with intractable psychiatric symptoms (by currently available non-invasive treatments) remain without access to surgical procedures that have been proven to be both safe and effective. The regulations, once created to protect patients’ well-being and autonomy, could now be working against its goals (see this story about a dystonia patient). When these treatments are effective and safe, they should not be regarded only as a last resort for extreme cases.

But although the old worries are largely misplaced, the confusion between patient’s need of surgery and the malpractice of medicine for profit in disregard to patient’s interest is still a matter of worry though. A new source of concern is the recent surge in attempts to secure intellectual property for methods addressing specific areas of the brain, for the treatment of psychiatric conditions.  Is it permissible for a company to ‘patent a brain region’ for treatment of a particular disorder by securing the exclusive use of their own commercial device? Is the finding of an effect in a particular area of the brain an invention that gives the right for the so-called inventor to monopolize the intervention on an area of the human brain for self-profit?

 

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