As we contemplate the emerging era of neuromodulation and imagine the utility of deep brain stimulation for disease entities in neurology and psychiatry, our enthusiasm is immediately tempered by history. Just a generation ago, other confident investigators were heralding invasive somatic therapies like prefontal lobotomy to treat psychiatric illness. That era of psychosurgery ended with widespread condemnation, congressional calls for a ban, and a vow that history should never repeat itself. Now, just 30 years later, neurologists, neurosurgeons, and psychiatrists are implanting deep brain stimulators for the treatment of Parkinson's disease and contemplating their use for severe psychiatric illnesses, such as obsessive-compulsive disorder and the modulation of consciousness in traumatic brain injury.
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TY - JOUR
T1 - From psychosurgery to neuromodulation and palliation
T2 - History's lessons for the ethical conduct and regulation of neuropsychiatric research
AU - Fins, Joseph J.
N1 - Funding Information: Not even chlorpromazine was enough of an advance to remove psychosurgery entirely from therapeutic consideration in the 1960s and early 1970s. Some physicians, such as the Harvard neurosurgeon H. Thomas Ballantine, Jr, maintained that psychosurgical procedures like cingulotomy retained a role in conjunction with standard psychiatric care for refractory patients. He articulated guidelines to regulate the judicious use of the procedure for the relief of the patient's suffering and improvement of functioning in society. Procedures were to be reserved for patients who failed all other methods of treatment. Decisions to operate were to be made in conjunction with a psychiatrist, who would also make psychiatric follow-up available, and patients and family were to be informed of potential risks and benefits. Most critically, he condemned the use of psychosurgery for political or social purposes, articulating instead a solely patient-centered rationale for the procedure  . It was the social uses of psychosurgery for what was called behavior control that, which Ballantine and others condemned, that caused a furor during that era. As distinct from its earlier iteration as a means to address a patient's depression or schizophrenia, this more modern dimension of psychosurgery sought to modify behavior. Amid the social turmoil of that era, sociobiologists began to suggest that psychosurgery might have a role in addressing problems like violence or civil unrest. It is perhaps hard to imagine today that there could be serious concerns about such futuristic attempts at social control, but they were quite real. One news report in the Medical News column in the Journal of the American Medical Association sought to reassure the wary reader that “Logistically, psychosurgery for social control is highly unlikely, simply because there are not enough neurosurgeons”  . This second period in the history of psychosurgery could be said to have begun through the work of Jose M.R. Delgado. Coupling psychosurgery with burgeoning efforts in computer technology and solid state electronics, Delgado advanced the idea of “psychocivilizing society” using an implantable brain implant that could be operated by remote control  . Delgado came to international attention in 1965 when he returned to his native Spain for a now famous publicity stunt in which he demonstrated the potential of his work by stopping a charging bull in Cordoba's bullring using a “stimociever” he had developed  . Delgado's work raised concerns about the possibilities of mind control, and his legacy remains a lingering question for the current era of neuromodulation. Recent reports in the lay press describing a remotely controlled “cyborg” rat with a brain implant  alluded to Delgado's work [57,58] , thus resurfacing the question of mind control, which had explosive political consequences when first introduced. A physician and physiologist working in the Department of Psychiatry at Yale University, Delgado studied aggression in primates and then manipulated their response through the use of implantable electrodes, arguing that “a better understanding of the neurophysiological mechanisms responsible for aggressive and destructive reactions may provide man with greater capacity to educate and direct his own behavior”  . Delgado, some of whose work was funded by the United States Public Health Service, the Office of Naval Research, and the Department of the Air Force [60,61] , argued that society was on the cusp of a new era in which the human mind could influence its own evolution through the use of technology. Using notions of self-dominion, he envisioned an escape from the blind chance of normal evolution to one where man and technology would alter human history, ultimately leading to a “…future man with greater personal freedom and originality, a member of a psychocivilized society, happier, less destructive, and better balanced than present man”  . Delgado analogized cerebral pacemaking to the growing role of cardiac pacemakers as a means to suggest the utility of brain pacemaking in the future. He acknowledged concerns about the ethical implications of his work and urged “intelligent collaboration of the best minds” to address the field's “fundamental medical, social, and even philosophical implications.” Nonetheless, he urged continued scientific progress, noting that “We are certainly facing ethical, philosophic, and practical problems not exempt from risks, but we should also expect important medical application of the new methods to epilepsy, intractable pain, involuntary movements, and mental disorders”  . His position might be best summed up by his observation that “Fears have been expressed that this new technology brings with it the threat of possible unwanted and ethical remote control of the cerebral activities of man by other men, but this danger is quite improbable and is outweighed by the expected clinical and scientific usefulness of the method”  . Leading proponents of psychosurgery for the control of violence were Frank R. Ervin, a psychiatrist at the Neuropsychiatric Institute at the University of California at Los Angeles, and Vernon H. Mark, a Harvard neurosurgeon, who together coauthored Violence and the Brain  . Much of their work hinged on seeking to demonstrate the relation between organic brain disorders, such as temporal lobe epilepsy (TLE), and violent or aggressive behavior. In one early case, they were able to demonstrate a left temporal horn lesion by means of a pneumoencephalogram in a young woman with TLE in whom violent outbursts were inducible using implantable electrodes and telemetric equipment supplied “through the courtesy and assistance of Dr Delgado”  . Echoing Delgado's notion of “greater personal freedom,” Mark maintained that “I believe the correction of that organic condition gives the patient more rather than less, control over his own behavior. It enhances, and does not diminish, his dignity. It adds to, and does not detract from, his human qualities”  . Although many of Mark's aspirations for psychosurgery seem overly optimistic, he did foreshadow developments in psychiatry, moving that field from being dominated by psychoanalysis and “political psychiatrists” toward those having an interest in the organic basis of disease  . He wrote about the “absurd split” and the: …historical dichotomy between ‘purely organic' and ‘purely social' abnormalities. Specifically, physicians tend to categorize a few abnormal behaviors, such as paralysis, blindness and dementia as neurological problems. At the same time, certain other abnormalities, such as depression and aggression, have found a hard niche within the domain of the psychiatrists, sociologists and criminologists. Many of them view these behaviors as nothing but the reflections of particular environments. They tend to believe that brain function or dysfunction is not an important determinant of abnormal behavior  . As much as his work in psychosurgery, these views seemed to have engendered a backlash from the more purely socially oriented practitioners who saw psychiatry in political or sociologic terms  . This schism made Mark the target of what he described as an “anti-psychiatry campaign”  . Reacting to a brief letter he wrote with colleagues to the Journal of the American Medical Association in 1967 on the potential relation between brain disease and urban riots  , Mark was accused of racism by proponents of social psychiatry  . This assault on psychosurgery was led by Peter Roger Breggin, a Washington social psychiatrist. A self-described political conservative and civil libertarian  , Breggin sought to characterize psychotherapy and on a continuum of a totalitarian-libertarian axis in which a “high degree of autonomy and personal freedom characterizes more libertarian therapies”  . In this context, public psychiatric hospitals and psychosurgery were seen as vectors of social control and described as “custodial concentration camps” and “powerful totalitarian technologies,” respectively. In Congressional hearings before the Subcommittee on Health of the Senate Committee on Labor and Public Welfare, Breggin charged that psychosurgeons were unethical because of how they obtained consent for the procedures they performed. He was deeply suspicious of how psychosurgeons sought to regulate their activities through review committees that relied on “professional ethics and medical control” to maintain physician control of the situation. Ultimately, Breggin said, “It creates for themselves an elitist power over the human mind and spirit. If America ever falls to totalitarianism, the dictator will be a behavioral scientist and the secret police will be armed with lobotomy and psychosurgery. And by the way, lobotomy is still with us…Lobotomy and psychosurgery is an ethical, political and spiritual crime. It should be made illegal”  . Breggin's accusations seem more suited to the clinical work of Freeman than to the positions taken by Mark, who was opposed to any social application of his work. In a talk delivered at the Hastings Center's Institute of Society, Ethics and Life Science's Working Group on Behavior Control, he sought to refute the charge of racism lodged against the neurosurgical treatment of violent epileptics  . He asked, “Does the theory that some violence is caused by brain disease lead us to expect it is a characteristic mainly of black people? Certainly not. On the other hand the theory that personal violence is caused exclusively by social conditions might very well lead us to look at the black ghettos. The environmental cues to personal violence may very well cluster around racially differentiated areas”  . Citing the prevalence of domestic violence across all demographics, both rich and poor as well as black and white, he asserted that “From this perspective, claret is the predominant color [of violence], not black or white”  . He would consistently maintain that violence was colorblind in both domestic and international contexts  . Indeed, he was one of the first to advocate an “integrated approach” to psychosurgical care. At Boston City Hospital, where he was Director of Neurosurgery, he sought to overcome the dichotomous practices of his neurologic and psychiatric colleagues and to develop a “holistic” therapy in which “…treatment of a patient should involve not only his brain but his family, living conditions, job and role in society. It is very important, therefore, to imbed a neurological diagnosis of problems of violence into a larger integrated approach to human behavior.” Along these lines of comprehensive care, he also advocated a “committee of some sort” that would oversee consent while not accepting patients who do not want therapy. In retrospect, Mark's attempt to address organic illness with due attention to the patient's voluntary consent comes across as moderate during immoderate times prone to hyperbole, overreaction, and suspicion. There was a prevailing sense of alarm that psychosurgery was being broadly applied in law enforcement. Contemporary accounts of that era observed that one of the “appeals” of psychosurgery was viewed as the willingness of law enforcement agencies to embrace this technology for the purpose of addressing seemingly intractable problems. One international perspective from a New Zealander behavioral scientist observed that: Still another cultural aspect which adds to the appeal of psychosurgery is the readiness of the American government to seek solutions to its domestic problems which hide the causes of the problems. Psychosurgery can be one such solution if used to “cure” the nation's social problems. The Justice Department and several state departments of correction (notably California's) have shown great interest both in establishing that black rioters and aggressive inmates are suffering from brain dysfunction and in curing them through psychosurgery. Three leading proponents of psychosurgery have advanced the view that many of those involved in ghetto rebellions acted violently because of brain dysfunction. The accumulated results of racism and poverty were discounted as causal factors since not everyone rioted  . Although this citation would suggest widespread use of psychosurgery for social control, the data suggest that it was otherwise. A 1974 study conducted by the Behavioral Control Research Group of the Hastings Institute surveyed the Commissioners of Corrections for all 50 states to ascertain the prevalence of behavior control in the nation's prisons  . Forty-seven states and the District of Columbia responded. If behavior modification was done at all, the least coercive treatments, such as group therapy or token economy systems, were employed. None of the respondents used psychosurgery as a treatment procedure, although one added, “not at this time.” Although these data would suggest that things were better than feared, the author of the report cautioned the reader to be wary of the results. Perhaps reflecting the distrust prevalent during the end of the Nixon administration and the Watergate scandal, she notes that “In dealing with prisons, however, the publicly announced programs may be only a small percentage of what is actually occurring”  . This prevalence data concerning psychosurgery for nonmedical purposes was corroborated by a study conducted by the American Psychiatric Association Task Force on Psychosurgery and by the work of the National Commission. As the American Psychiatric Association report put it, “Both reports concluded that there is no reliable evidence that psychosurgery has been used for political purposes, social control or as an instrument for racist repression”  . The National Commission report would later confirm this finding. In a review of 600 psychosurgery procedures performed in 1974, only six Hispanics and one black patient were identified. The Commission noted that “The fact that so few patients from minority groups have undergone psychosurgery…is due not to discrimination on the part of surgeons but to the economic realities and public policy”  . Furthermore, although minority communities were indeed fearful of these procedures, not all were in opposition. Two black neurosurgeons speaking at the 1976 National Minority Conference on Human Experimentation in Reston, Virginia, urged limited use of psychosurgery with appropriate oversight and review boards  . Dr Jesse Barber, Chief of Neurosurgery at Howard University, observed, “I personally feel guilty about not developing a program (of psychosurgery) at Howard University.” He added that “When it was considered we were reluctant to face the opposition and destroy our image in the black community.” Although there was little evidence for the use of psychosurgery for law enforcement purposes, the issue of behavior control dominated the deliberations of advocates of all stripes whether they were physicians, philosophers, attorneys, or nascent bioethicists. In the political climate of that era, there was, it seemed, a fine line between scientific fact and science fiction  . In contrast to the media's favorable—and distorted—depiction of psychosurgery in the early years of lobotomy  , the popular culture of the 1970s heightened fears of abuse. Works like Crichton's The Terminal Man depicted the “treatment” of a violent criminal with implantation of electrodes. The setting for the procedure was a fictitious neuropsychiatric institute located in Los Angeles, which, not so coincidentally, borrowed the name of Ervin's own institution  . In this broader cultural context, fears of psychosurgery transcended the internecine battles of psychiatric subdisciplines, as exemplified by Breggin's less than restrained ideologic attacks. More balanced criticism came from individuals like Edward Mearns, a professor of law at Case Western Reserve University, who observed that: There is something promising about the notion that the effort to cure sick individuals may result in considerable social benefit as well. But there is something disturbing about the conscious effort to use medicine and medical men institutions to cure a “sick” society. For it is one thing to use medicine as an instrument of healing and quite another to use it as an instrument for social control  . The philosopher Robert Neville, who directed the Hastings Center Working Group on Psychosurgery, echoed this sentiment. Neville asserted that “The ethics of good medicine isn't easily transferred to good social control, so there is a danger of having the appearance of therapy, when the real purpose is punishment”  . Hal Edgar of Columbia Law School pointed out that although procedures on the brain are justifiable if they result in a cure of a physical illness like Parkinson's disease without undue side effects, it becomes more complex when the focus of the intervention is mental illness which is “…a concept which is heavily influenced by social norms, and a label which is often imposed in a particular case because people engage in ‘strange’ behavior of one sort or another”  . Echoing the sentiments of the times about questioning authority, he asked, “…how does one know whether the sick are being cured or whether medicine is being used as yet another tool in society's ever present effort to secure comfort through conformity”  . Much of the resistance to psychosurgery—and the broader issue of behavior control—was closely related to emerging concerns about the use of the procedure on prisoners, who might be coerced or unable to give appropriate consent to experimental procedures  . Some of this was related to a fear of somehow legitimizing a deeply flawed penal system through an affiliation with medicine  , but much of it was a central concern about the ability of inmates to give voluntary and informed consent. This issue came to national prominence in the 1973 case of Kaimowitz v. Department of Mental Health, in which a three-judge panel in Michigan sought to determine whether a confined prisoner could voluntarily consent to an experimental procedure that might temper his aggressive and criminal behavior  . The court opined that there was no scientific basis to suggest that psychosurgery would be therapeutic in the absence of a discernible disorder like epilepsy and that the risk-benefit ratio was disproportionate given the current state of knowledge and the known risks of the procedure. More critically, the court went on to cite the entirety of the Nuremberg Code to argue that reasoned and voluntary consent in prison was so greatly impaired as to make lawful consent in that setting impossible [92,93] . Indeed, one of his attorneys, Professor Robert A. Burt, pointed out that the prisoner himself illustrated the coercive nature of incarceration when his confinement was declared unconstitutional and he had the opportunity to revisit his decision after initially consenting to psychosurgery. When these new developments allowed him to imagine being set free, he suspended his consent to reconsider surgery given his new circumstances  . Copyright: Copyright 2017 Elsevier B.V., All rights reserved.
PY - 2003/4/1
Y1 - 2003/4/1
N2 - As we contemplate the emerging era of neuromodulation and imagine the utility of deep brain stimulation for disease entities in neurology and psychiatry, our enthusiasm is immediately tempered by history. Just a generation ago, other confident investigators were heralding invasive somatic therapies like prefontal lobotomy to treat psychiatric illness. That era of psychosurgery ended with widespread condemnation, congressional calls for a ban, and a vow that history should never repeat itself. Now, just 30 years later, neurologists, neurosurgeons, and psychiatrists are implanting deep brain stimulators for the treatment of Parkinson's disease and contemplating their use for severe psychiatric illnesses, such as obsessive-compulsive disorder and the modulation of consciousness in traumatic brain injury.
AB - As we contemplate the emerging era of neuromodulation and imagine the utility of deep brain stimulation for disease entities in neurology and psychiatry, our enthusiasm is immediately tempered by history. Just a generation ago, other confident investigators were heralding invasive somatic therapies like prefontal lobotomy to treat psychiatric illness. That era of psychosurgery ended with widespread condemnation, congressional calls for a ban, and a vow that history should never repeat itself. Now, just 30 years later, neurologists, neurosurgeons, and psychiatrists are implanting deep brain stimulators for the treatment of Parkinson's disease and contemplating their use for severe psychiatric illnesses, such as obsessive-compulsive disorder and the modulation of consciousness in traumatic brain injury.
UR - http://www.scopus.com/inward/record.url?scp=0037399332&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=0037399332&partnerID=8YFLogxK
U2 - 10.1016/S1042-3680(02)00118-3
DO - 10.1016/S1042-3680(02)00118-3
M3 - Review article
C2 - 12856496
AN - SCOPUS:0037399332
VL - 14
SP - 303
EP - 319
JO - Neurosurgery clinics of North America
JF - Neurosurgery clinics of North America
SN - 1042-3680
IS - 2