Rev Med Hosp Gen Méx. 2015;78(1):47---54

www.elsevier.es/hgmx

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REVIEW ARTICLE

The role of bioethics in the neurosurgical treatment ofpsychiatric disorders

F. Jiménez-Poncea,∗, L. García-Munoza, J.D. Carrillo-Ruiza,b

a Mexico General Hospital, Mexicob Universidad Anáhuac, Mexico

Received 15 January 2015; accepted 6 April 2015Available online 14 April 2015

KEYWORDSBioethics;Psychiatricneurosurgery;Psychosurgery;Stereotactic surgery

Abstract Psychiatric neurosurgery or psychosurgery remains as an alternative for treatmentof psychiatric disorders. However, its historical antecedents, the vulnerable specific conditionof psychiatric patients, the high cost of instrumentation and the ethic dilemma about theautonomy of subjects whose are candidates to this kind of procedures condition to get a inter-disciplinary and specialized staff and at less supervision for ethic local committee. There areablative or deep brain stimulation procedures accepted as compassionate or investigationaluse. Into systematic review four International Ethic Guides are accepted for the indication, theimplantation and the follow up of these treatments. 24 bioethics essays were found them and9 ethics specific dilemmas were published. Expectancy and development of this medical issueare inherent to financial or biotechnological aspects, consequently is important to promote ascientific and philosophical discussion.© 2015 Sociedad Médica del Hospital General de México. Published by Masson Doyma MéxicoS.A. All rights reserved.

PALABRAS CLAVEBioética;Neourocirugía

El papel de la bioética en tratamiento neuroquirúrgico de los desórdenespsiquiátricos

Psiquiátrica;Psicocirugía;

Resumen La neurocirugía psiquiátrica ó psicocirugía continúa siendo una alternativa detratamiento para las enfermedades psiquiátricas. Sin embargo, sus antecedentes históricos, el

neurocirugíaestereotáctica

estar dirigida a una población vulnerable, los altos costos de instrumentación y el dilema sobrela autonomía del sujeto a decidir sobre este tipo de cirugía, condicionan a que estos casos seanabordados por equipos interdisciplinarios, altamente especializados y al menos bajo la super-visión del Comité de Etica de la institución donde se realicen. Existen procedimientos ablativos

∗ Corresponding author at: Reforma 30 casa 1, Col. Tizapán-San Ángel, México, D.F. CP 01090, Mexico. Tel.: +52 55 51353645;fax: +52 5551353630.

E-mail address: fiacrojimenez@yahoo.com (F. Jiménez-Ponce).

http://dx.doi.org/10.1016/j.hgmx.2015.04.0010185-1063/© 2015 Sociedad Médica del Hospital General de México. Published by Masson Doyma México S.A. All rights reserved.

48 F. Jiménez-Ponce et al.

y por estimulación eléctrica cerebral profunda, los primeros aceptados como tratamiento de usocompasivo y los segundos se encuentran en fase de investigación. En la revisisón sistemáticaexisten 4 guías éticas internacionales aceptadas respecto a la indicación, la aplicación y elseguimiento de estos tratamientos. 24 ensayos éticos fueron encontrados y 9 dilemas éticosfueron publicados. Las expectativas y el desarrollo de esta rama médica están inherentementeligadas a la aplicación tecnológica, así como a los aspectos financieros, por lo que es importantedesarrollar una discusión científica y filosófica del tema.© 2015 Sociedad Médica del Hospital General de México. Publicado por Masson Doyma MéxicoS.A. Todos los derechos reservados.

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eurosurgery has been applied as a treatment to solvesychiatric disorders since the beginning of the past cen-ury. In its origins, this chapter of neurological surgery wasenominated as Psychosurgery, today this term has beeneplaced by Psychiatric Neurosurgery or Neurosurgery forental Disorders; however, they still handle differently. Why

s neurosurgery considered as an alternative in the treat-ent of mental disorders? Fundamentally because of four

easons: The high prevalence of psychiatric diseases andheir social repercussions,1---5,8 the existence of a group ofatients refractory or hard to control with conventionalethods whether adjuvant pharmacologic or therapeutic

physical or psycodynamical),1,6---13 the abundance of infor-ation regarding the physiopathologic brain substrate ofental disorders and the remarkable technological devel-

pment that has transformed neurosurgery in a safer andore precise speciality. However, neurosurgery for mentalisorders must be revised from the ethical and moral per-pective. In this essay we will evaluate some ethical andegal considerations regarding the use of psychiatric neuro-urgery.

istorical background

sychosurgery was defined by the World Health Organiza-ion as: ‘‘The selective surgical resection or destructionf the neural pathways or normal brain tissue, in order toodify the behaviour’’.14 Neurosurgery for the treatment

f psychiatric diseases might be one of the most contro-erted scientific activities of the twentieth century. In theeginning of humanity, trephine (based in mystical and mag-cal aspect rather than scientific) was the first attempt ofurgical treatment for psychiatric disorders. Later on, inhe anecdotic case of Phineas Cage, clinically describedy John Harlow in 1860, demonstrated that lesions of therontal structures produced disinhibition of social learnedonducts.15 Because of the absence of psychopharmaco-ogical treatments, in 1888, Gottlieb Burckhardt a Swisssychiatrist performed the first surgical procedures in psy-

hiatric patients with the anatomic and physiologic theoriesf that time. Burckhardt treated patients with behaviourlterations, ‘‘eliminating or diminishing’’ the areas ofrain with pathologic behaviour. On December 29 of 1888,

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e performed the first topectomy and in 1891 publishedis experience with six patients described as dementednd aggressive, mentioning three important successes, twoartial results and a failure that led to the patients’eath.16

At the start of the twentieth century, the psychiatricffects induced by injuries in the frontal lobes on woundedoldiers of the First World War revealed new information.n 1935 Fulton and Jacobsen, presented, in the Secondorld Congress of Neurology in London, their works per-

ormed on chimpanzees, detailing the changes on behaviourfter frontal lobectomy. These experimental findings onon-human primates encouraged the possibility to influ-nce, via surgical procedures, the control of psychiatricisorders.17

Thus, the series of events that led to the massive devel-pment and use of psychiatric neurosurgery, during thefties, cannot be appreciated without the comprehensionf the political and social environment that surroundedhe psychiatric disease at the start of the century. Psy-hiatrics and neurologists were the responsible for takingare of these patients. The number of psychiatric patientsncremented according to the population growth and theseatients were secluded on mental institutions and asy-ums. It must be noted that the debate between Sigmundreud against the functional approach that Emil Kraeplinresented, regarding mental disorders, induced psychia-rists to become independent from the medical branch,hich explains why neurologists involved themselves more

n the diagnosis and treatment of patients with mentaliseases. In fact, neurologists rather than psychiatristsere the ones who became the strongest supporters ofsychosurgery, given that, generally, the patients fromhat time received years of psychotherapeutic treatmentnd ‘‘somatic therapies’’ (such as induced coma, bynsulin or metrazol, and electroconvulsive therapy), with-ut achieving the adequate therapeutic effects nor socialeadjustment.13

Properly speaking, it was Egas Moniz who ‘‘started’’ psy-hosurgery on humans when he proposed to the scientificommunity the surgical interruption of the front-thalamicract a cross of bifrontal burr holes. Egas Moniz and Almeidaima performed more than 100 prefrontal leucotomies and

espite their data never being systematized nor havingny clinical follow up, in 1949 he received the Nobelrize in Physiology and Medicine for his work ‘‘Prefrontal

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The role of bioethics in the neurosurgical treatment of psyc

Leucotomy’’.18,19 These works encouraged American neu-ropsychiatrist Walter Freeman together with neurosurgeonJames Watts to ‘‘optimize’’ the original procedure fromMoniz-Lima and instead of performing frontal trepans toapproach the front-thalamic tract, they would apply analternate approach by supraorbital via, denominating it‘‘frontal lobotomy’’ applying an surgical instrument similarto ‘‘ice pike’’. Unfortunately, this procedure was massivelyapplied, in the United States and around the world, for anykind of mental illness, without achieving specific beneficialresults, so in 1955 more than 50,000 surgeries had been real-ized. Psychosurgery was then considered as a set of highlyinvasive surgical procedures. Frontal and temporal lobec-tomies were stigmatized by their poor efficiency, high riskof collateral damage and limited scientific basis.20

Functional stereotaxic neurosurgery was born in the firstthird of the twentieth century, due to the lack of phar-macological treatment for functional neurologic diseasessuch as movement disorders, epilepsy, pain and psychiatricdiseases. The main objective of this general neurosurgerybranch was to perform minimal injuries, in specific sites(nucleus or tracts), thus achieving equilibrium of neuralactivity. The theories of James Papez and the contributionsof Paul Mac-Lean, made that the cingulum, the amygdala,the hypothalamus and the thalamus were recognized asimportant components of a regulatory system for emotionsand instinctive conduct, hence, being adequate sites for thechirurgical treatment of mental disease.21 Nowadays, thefollowing neuronal structures are identified as chirurgicalsites for the treatment of psychiatric diseases: the anteriorcingulum, the subcaudate tract, the anterior limb of theinternal capsule, the hypothalamus, the mammillary bodies,the fornix, the subgenual region, the accumbens nucleus,the amygdala and the subthalamic nucleus.22

In 1954, the pharmaceutical company Smith, Kline& French received the approbation by the Food andDrugs Administration for the use of antipsychotic drugdenominated chlorpromazine.19 By the end of 1954, thechlorpromazine had already been administrated in morethan 2,000,000 mentally ill patients in the United States,establishing with it the premise that ‘‘drugs were effectiveand safer that psychosurgery’’, bringing an end to the firststage of psychosurgery.23

Psychosurgery still produces fear in many countries forit is considered it could be used as a mean of politi-cal or social control.24 Despite the severe restrictions andpublic denounces, psychosurgery continued and continuesbeing performed restrictively in the United States. On theother hand, countries like Mexico, Brazil, Finland, Sweden,England, Spain, India, Italy, Germany and Belgium allow theperforming of these procedures with humanitarian purposes.Psychiatric neurosurgery is prohibited in Japan, France, ElSalvador and Australia.

Non stereotaxic psychiatric neurosurgery from the firsthalf of the twentieth century was characterized for beingunspecific, highly invasive and mutilating, performed withthe use of craniotomies, frontal and temporal lobectomiesand, more refined, front-thalamic leucotomy by trepans and

by trans-orbital via. On the second half of the twentieth cen-tury, stereotaxic psychiatric neurosurgery proved to be veryprecise based on the polar or cartesian localization (Fig. 1),

tca

ic disorders 49

eproducible by the milimetrical human brain atlas, with sci-ntific bases using well defined physiological concepts anderforming proof of electric stimulation before to perform

lesion (confirm the result prior to use thermo-coagulationith radiofrequency). Ablative neurosurgery is less knownnd entails humanitarian purposes when applied on patients,nder the bioethics concept of the less damage possibleo improve the functional result, and has been a commonractice in many developed and undeveloped countries.

Deep brain stimulation has (DBS) has been an efficientnd save alternative for the treatment of chronic neuro-ogic diseases such as epilepsy, Parkinson’s’ disease andeuropathic pain (Fig. 2).10 Since 2002 the first informsegarding the use of DBS on psychiatric diseases have beenublished, more concretely in respect to the treatment ofayor depression disorder8,10,25 and obsessive-compulsiveisorder.8,10---12,25 In short time, other psychiatric disor-ers were included such as Tourette’s syndrome, violentehaviour, nervous anorexia, addiction to substances andther neuropsychiatric disorders such a dementia.9,10,25---27

he main advantage of DBS lies on the possibility to ‘‘modulehe brain function’’ in such a way that it leads to the desiredlinical effect and avoid collateral effects; its action mech-nism different from the stereotaxic selective lesion allowshe possibility to liberate a dose of electric current onnatomic structures very circumscribed using a combina-ion of amplitude, frequency and duration of the electricmpulse.25 The main disadvantage of DBS is the cost thatimits in almost all the world its application and could evene considered an ethical dilemma.

Despite the increase of scientific papers discussing thisubject, the present evidence, even for the mayor series, istill incipient and DBS for this kind of disorders is still consid-red an experimental treatment. Additionally, the numberf randomized and masked clinical essays designed for DBSn mental disorders is small. This is justified because propos-ng a ‘‘placebo’’ manoeuvre over a neurosurgical procedureould be ethically questionable. However than DBS offers

he possibility to effectuate clinical trial with a ‘‘sham’’rm, if it is consented to the individual subjected to thetudy to be included randomly on a transitory period with-ut electric stimulation to later be subjected to DBS therapy.n any case, the increasing interest in this area of neu-osciences has encouraged the establishment of specificthical guides. The more broadly diffused is the one pub-ished on 2009 by Rabins et al. In it specific aspects are takennto account, such as considering all scientific evidencereclinical and clinical before performing a new researchroject with DBS, not forgetting the historical experienceegarding the unmeasured and uncontrolled use of this ther-py, establishing very specialized and interdisciplinary workeams, assuring the wellbeing of the research subjects notnly in their clinical conditions but also in their wellbeingnd quality of life, establishing a sustainability program ofhe DBS therapy that assures the patients the possibility toontinue with their treatment specially when this has had

beneficial effect, maintaining supervision over the workroups of the local ethical committees on research to ensure

he observance of research subjects rights and continuinglinical studies with more evidence regarding the effectsnd action mechanisms of DBS.28

50 F. Jiménez-Ponce et al.

Figure 1 In this picture on left side it is showing a stereotactic procedure. The head of patient is fixed inside of Cartesiancoordinates system (X: red, Y: black, Z: white) in order to localize a specific target through a burr hole in the skull. Prior thec ic rei

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oordinates were found out by software that analyzed magnetnto basal ganglia (yellow arrows).

Schermer in 2011 published than DBS practice is struc-ured in the four basic principles of medical ethic: (1)on-maleficence, ‘‘first do no harm’’ (to calculate risk,hysical and psychical side effects, to avoid personal-ty changes or developing brain). (2) Beneficence, ‘‘doell’’ (effectiveness and need of psycho-social cares), (3)roportionality and subsidiarity, ‘‘risks and benefits in pro-ortion,’’ ‘‘choose least burdensome alternative?’’ and‘refractory to others treatments’’, (4) Justice, ‘‘treatike cases alike’’ respect patients’ well-informed choices’’rationing and prioritizing, inform consent, avoid despera-ion and unrealistic expectation, competence to consent andpecial evaluation in minors).29

The aim of this review was to analyzed the ethical andegulatory aspects of psychiatric neurosurgery.

ethod and material

or this review the authors made a bibliographic researchooking up non-mesh combination terms: ethical issueND psychosurgery; ethical issue AND psychiatric neu-osurgery; ethical considerations AND psychosurgery andthical considerations AND psychiatric neurosurgery. Lim-ts were English or Spanish language, 10 years prior toearching (from 2005 to 2014), abstract available, contain-ng statements about ethical discussion or regulatory issuesbout psychosurgery. Further analysis in order to find papershared in different searchers. The information was classifiedo present ethical discussion for specific surgical procedures,thical or regulatory aspects and ethical dilemmas. Exclu-ion criteria were containing animal model information ornspecific conclusion.

esults

nitially, this searching strategy allowed finding 77 studies.9 papers completed inclusion and exclusion criteria.

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sonance and CT-scan images. Right side shows two electrodes

our articles were guide or regulatory works.40---42

wenty-four were ethical discussion18,38,43---65 and 9 ethicalilemmas.46,66---74

More important essays included: Consensus on guidelinesor stereotactic neurosurgery for psychiatric disorders, pub-ished in 2014 where is commented about the necessityf increase the level of evidence and design randomizedlinded clinical trials in order to get information of abla-ive or DBS procedures. Always is mandatory to observe tonhance patient safety. Expert committee conducted thistudy.

Algorithm of study and treatment of this kind of patientsas proposed in Fig. 2.

iscussion

sychosurgery has many aspects to be analysed from theioethical point of view. One of these, as mentioned before,s the controversial history of the first half of the twentiethentury. Psychosurgery had its origin in a moment in whichhere were no psychopharmaceutic treatments and the onlyption to treat psychiatric signs was surgery. The fact thatn operation alleviated the psychiatric symptoms was theotif that gave the Nobel Prize to Egas Moniz during the thir-

ies and both society and the scientific community validatedhese therapeutic procedures. Yet, despite the evident lackf clear indications for its application, the beneficial resultsometimes not very tangible and the great quantity of sec-ndary effect of psychiatric neurosurgery of the fifties, Dr.reeman was convinced that what he was doing was helpingatients in their suffering, always acting under the principlehat his patient could improve. However, the acting of Dr.reeman and other neurosurgeons created a tension in soci-

ty clearly reflected in movies like One Flew Over Cuckoo’sests. Despite scientific data of the beneficial effect of psy-hosurgery when performed specific indications, stereotaxicechniques and radiofrequency, the social pressure made the

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Psychiatric diagnosis according toDSMIV-R or DSM V

Abscence of neurological diagnosisIncluding EEG and MRI orNeurpsychological Battery

Chronical hystory of psychiatricdisorder (at least 5 years) for expert

psychiatrist

Supervised pharmacological treatmentincluding: Neuroleptics, anticonvulsant,IRSS, benzodiazepine, beta-bloquers,

lithium and combinations.

Electroconvulsive therapy andcontention

Expert Psychosurgery Committee inorder to review selection criteria and

target

Inform Consent and /or EthicalCommittee

Surgical procedure into expert centerwith adequate technological

instrumentation according to specificprotocol

At least 10 years of follow up for theExpert Psychosurgical Committee

Figure 2 Algorithm of study and follow up of patients

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candidates to psychosurgery. IRSS means Inhibitors re-uptakeselective serotonine.

United States Congress to limit the use of psychosurgery,thus, for a few decades, only some areas in the AmericanUnion allowed these procedures. Something similar hap-pened in other countries. In Japan, professor Narabayashiwas taken out from the back door of the hotel in whichhe presented some of his data, for a crowd nearly lynchedhim. From heaven, by receiving the Nobel Prize, to hell,with limitations that almost extinguished the procedure.Two events provoked the stigmatization of psychosurgery:The rise of psychopharmaceutic, which allowed the control

of the symptomatology, and the ethical disdain of avoid-ing to fall in the hands of neurosurgeons apparently withoutscruples. Is very valid to make a reflexion to consider thereal ethical dilemma regarding surgical techniques and the

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ic disorders 51

hysiopathology of psychiatric diseases during these period.nfortunately, up to this point no animal model will sufficeo understand the physiopathology of every human mentalisorder. In consequence, the neurosurgical treatment ofsychiatric disorders was and will be many times extrap-lated from the experience of the neurosurgeon during thereatment of other diseases such as Parkinson’s, dystonia orhe very mental disease. Despite the possible limitations ofsychiatric neurosurgery; if used correctly the ethical princi-le of the lesser bad, psychosurgery was and is preferable toaving patients in which no concrete therapy can be offeredTable 1).

Another aspect to analyse is the one implying theoexistence of relatives with a psychiatric patient with-ut adequate or refractory control. The practice hasemonstrated that certain aggressive patients with mentaletardation have provoked a wear syndrome on their rela-ives, very common on personal working in chronical andsychiatric hospitals. Psychosurgery has diminished auto andetero aggression, thus preventing injuries to the patientsnd others. Every time a psychiatric patient is proposed for

surgical procedure that improves their psychiatric symp-oms, its case must be presented to a Hospital Committeef Bioethics or to a Committee of Research Ethics, depend-ng on the case, and the rights and wellbeing of the patientust be evaluated same as his reinsertion on familiar, social

nd, if possible, working life.The best ethic model for this kind of problems remains

unctually projected only to man. The great advantagesf DBS in comparison with stereotaxic brain lesions hasroduced a very important resurgence of psychiatric neu-osurgery; the reversibility of the effects that avoids directamage over the neurons or the fibbers, the adjustment oflectric parameters by telemetry from the outside with-ut need of invasion to the patient with the exception oflacing the system and the versatility regarding the stim-lation programs, make the new implantable systems ableo help patients. Yet again the counterpart of disadvantagesmerges, which could become real ethical dilemmas: an DBSystem is very expensive, with costs that go from 17 to 33housand dollars only for the equipment, adding the cost ofedical assistance and follow up.Which psychiatric patients can be candidates to this type

f treatment? In the case that this could be consider aherapeutic alternative in state of art and not only an exper-mental alternative: Could systems of a social or privateecurity accept that psychiatric disorders are a valid sur-ical indication? There are some research projects, like inhe case of Tourette’s syndrome, where four stimulators inifferent targets have been placed, which complicates con-iderably their use. Additionally, the lifespan of the pulseenerator or battery is very limited and can vary, becauseepending on the clinical improvement is how the parame-ers are adjusted, mainly in amplitude. It has been reportedhat batteries can last from one to six years before a changes needed; therefore their replacement will be limited to

good medical expenses insurance that covers said equip-ent, or else, to the existence of donations to the matter.

t is also needed a good expert medical team in the area toonitor the patient.Another important bioethical question emerges, one

spect is to diminish the psychiatric symptoms and another is

52 F. Jiménez-Ponce et al.

Table 1 This table shows main targets and their indications for psychiatric disorders by original authors.

Author Indication Anatomicstructure

Year Improvement Side effects

Gabriëls30 OCD IC 2003 44---59% NoneSturm31 OCD NAc 2003 Significant NoneJiménez32,33 MDD/OCD ITP 2005/2009 100/50% AnxietyMayberg34 MDD Area25 2005 Sustained remission NoneVisser-Vandewalle35 Tourette InLThN 2006 Significant HypomaniaMallet36 OCD STN 2008 32% Edema, bleeding

and infectionKuhn26,27 Addiction

alcohol/tobaccoNAc 2007/2009 100/20.30% None

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o modify thoughts and feelings of the patient. This aspects more tangible. One thing is to manipulate only neuro-hysiologic sensitivity and motor skills, and another is toodify cognition or will. In the case that a depressed patient

hat has had various suicidal attempts DBS seems to be jus-ified. In a patient with obsessive compulsive behaviourshe actual evidence seems to prove that its functionalityepends on the implantation and the equipment effect,gain psychosurgery seems justified.

Koivuniemi and Otto published this year a paper that dis-usses the meaning of ‘‘Mind Control’’ in the context of DBS.hey postulate three conditions that can clearly define what

n the context DBS would mind control mean: The criteria ofesults that implies an objective change in the behaviour ofhe stimulated subject, the criteria of approval which meanshat the subject in question has not manifested its approvalor the DBS to modify his behaviour and the third criteriaould be of intention, this means that the researcher man-

fests that he intentionally looked for that change in theehaviour.38 These three criteria have not been present inny case up to now. However, in the case of the patients thatannot manifest their approval for the change of behaviourike in patients in vegetative state where Yamamoto hastimulated the thalamus to improve their vigilance state,r in cases in which the researcher finds a collateral effecthat could be beneficial yet not the one desired (in 2007hun tried to diminish the anxiety of an alcoholic patienttimulating the accumbens nucleus and what he obtainedas a diminishment in the desire to consume alcohol).27 On

hese cases if the researcher does not informs the patient,nce observed the unexpected effect, we could talk aboutind control.Yet, this type of therapy opens the door to other col-

ateral aspects. Is it ethic or moral the neuromodulationn order to increase the executive capacities not only ofatients but also from sane subjects? This aspect of DBS isenominated ‘‘enhancement’’. Is it licit to use certain brainreas to manipulate behaviours, which could be the case oflacing electrodes in the amygdala and by stimulating thisrea favouring braver soldiers during battle? Could a modu-ation be placed that makes a person submissive? There is a

hole bioethical discussion that can barely be seen.39

The purpose of bioethics is to encourage the reflexionn which individuals understand that the most important ishe respect and dignity of people. Some years ago it was

13 85% None

nthinkable that through an electrode thoughts could beodified, nowadays, this is a reality. Is technology bad?o; technology is nor good nor evil, it depends on how it

s used and who uses it to make man complement what isore important as a prerogative after life, which is his free-om. However, in the case of psychosurgery is fundamentalo understand that many of these patients are ‘‘tied’’ to asychiatric disease that undermines their consciousness andhus limits their freedom.

Finally, psychosurgery opens another possibility: trans-umanism, meaning, the colocation of prosthesis orttachments that replace lost functions. The Cyborg neol-gism, conceptualized as a cybernetic organism, makesllusion to this fact. When a patient is implanted with arain electrode, technology that tries to recover a functionhat is no more is being applied. Here could enter all sci-nce fiction literature that has generated in the last fiftyear regarding human being that have become half robotalf human beings. The bioethical discussion on this point islso very important.

Psychosurgery remain been a medical, social and philo-ophical challenge that must not forget the most importantspect which is the comprehension of the disease and thebservance of the subjects’ human rights per se, maxim in

psychiatric patient.

onflict of interest

he authors declare that they have no conflict of interests.

cknowledgment

iacro Jiménez Ramírez for translation service.

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