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9 Consent for anesthesia for procedures with special societal implications: psychosurgery and electroconvulsive therapy
The Case
A 20-year-old patient suffers from severe psychiatric disorders (agitation, hetero-aggressivity, threatened self-mutilation) for which he had been hospitalized almost continuously for 7 years. His condition is refractory to the usual psychiatric medication, and psychosurgery may reduce his potential for violence and make him less dangerous to himself and to others. The health care team thus hopes the intervention will provide more humane treatment than the prison-like incarceration to which he is currently subjected. However, given the history and grim connotation of lobotomy as well as its irreversibilty, it raises major issues of appropriate consultation and informed consent more than for any other treatment. These concerns continue to be at the forefront of ethical considerations in psychosurgical techniques and other functional psychiatric interventions, such as electroconvulsive therapy (ECT).
Historical perspective
Psychosurgery has a controversial history, in which medical, moral, social, and political considerations intermingle. First described in 1936, and defined as a surgical ablation or destruction of nerve transmission pathways with the aim of modifying behavior, the conventional “lobotomy” of the 1940s and 1950s flourished. There was a strong desire to relieve over-population in asylums and hospitals, and lobotomy came to be seen as a means for calming down and even discharging an appreciable proportion of committed patients,1 or of at least of making caring for them easier. Little attention was paid to patient selection and consent. The unrestrained application of lobotomy makes it difficult to this day to gain an objective evaluation of its true efficacy.
Almost immediately after its introduction, lobotomy was noted to have severe collateral effects on the patient’s personality and their emotional experience of the world. Caregivers described them as listless, dull, apathetic, without drive or initiative, passive, preoccupied and dependent. A horror among the public developed that the operation actually excised free will.
In 1948, Norbert Wiener remarked,
Prefrontal lobotomy … has been recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier.2
In 1950, physicians in the Soviet Union banned lobotomy, concluding that it was “contrary to the principles of humanity,” and that it “turned an insane person into an idiot.”3 Notorious outcomes involving lobotomy, both in real life (e.g. Rosemary Kennedy and Rose Williams, sister of Tennessee Williams), as well as in fiction (e.g. Ken Kesey’s One Flew Over the Cuckoo’s Nest) perpetuated a horror of psychosurgical techniques.
After neuroleptics and chlorpromazine were discovered in the 1950s, psychosurgery declined rapidly, although it continued to be used in cases viewed as otherwise refractory to treatment. Following spirited social controversy in the US, a Federal commission was convened in 1977, which discredited growing public allegations claiming that psychosurgery was used to control minorities, restrict individual rights, and that its undesirable effects were nonethical. The Chairman of National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research, even went so far as to declare:
We have looked at the data and they did not support our prejudices. I, for one, did not expect to come out in favor of psychosurgery. But we saw that some very sick people had been helped by it … The operation should not be banned.4
Nevertheless, lobotomy was subsequently prohibited in a number of states in the US and in other countries such as Germany or Japan. Psychosurgery continues to be performed, but is strictly regulated and controlled in the US, Finland, Sweden, the UK, Spain, India, Belgium, and the Netherlands1.
Psychosurgery techniques
Conventional lobotomy
Prefrontal leucotomy – or “standard” prefrontal lobotomy – and transorbital leucotomy destroyed parts of the frontal lobes or their connections to the limbic system. Significant “frontal lobe” syndrome was a common complication, characterized by permanent apathy or euphoria, inconsistency, puerility, boorishness, impaired judgment, and chaotic behavior. Harmful side effects included epileptic seizures or aggressiveness.
Functional neurosurgery
Earlier techniques have since been abandoned in favor of much more limited – although still destructive – procedures. Grouped under the heading of “psychosurgery,” these procedures based on a “functional” neurosurgical approach are:
(1) anterior capsulotomy – interrupting frontothalamic connections in the internal capsule
(2) cingulotomy – partial destruction of the cingulate gyrus, altering certain connections within the limbic system
(3) subcaudate tractotomy – acting on the lower portion of the frontal cortex to destroy the fibres which connect it to the hypothalamus and the head of the caudate nucleus and
(4) bilimbic leucotomy – combining cingulotomy and subcaudate tractotomy.
Results are generally considered effective, although this is on the basis of small case series due to the paucity of acceptable indications. The severe cognitive behavioral disorders experienced by early lobotomy patients are no longer observed. More recently, the administration of highly focused gamma radiation (“gamma-knife”) has produced clinical results similar to functional neurosurgical techniques, while being minimally invasive.
Cerebral stimulation techniques
New hopes are arising for new, nondestructive techniques based on stereotaxic neurostimulation. Initially used to treat severe Parkinson’s disease, they appear to be comparatively free of complications, as there is no permanent cerebral damage. They achieve psychomodulation, even the equivalent of a reversible anterior capsulotomy, by inducing radiofrquency stimulation to the brain in specific locations of the cerebral parenchyma via implanted electrodes. Although very different from surgery mutilating the cerebral parenchyma, these stimulation techniques will probably always remain less psychologically and socially acceptable than, for instance, cardiac electrical pacing. However, because the patient is free to interrupt the neurostimulation, the voluntariness of the patient’s submission to treatment is preserved. In fact, these new treatments share many points in common with behavioral modification induced by pharmaceutical treatment.
Ethical issues
The present indications for psychosurgery, although exceptional, have not entirely disappeared. In 2001, a prominent specialist stated:
“However, despite the plethora of pharmacological agents that are available today, there remains a small but significant proportion of patients who suffer horribly from severe, disabling, intractable psychiatric illness. It is in these patients that surgery might still be appropriate if intervention is safe, reasonably effective, and without significant morbidity.”5
The main ethical issues connected to these interventions involve the scientific validity of the therapy and its evaluation, the validity of patient consent, and the possibility of conflict between the interests of the patient and those of society – particularly in the case of dangerous or violent individuals.
Accordingly, many questions remain to be answered. What are the indications? How are these techniques being evaluated and researched? What are the limits of informed consent? Are patients able to consent who have, in essence, lost a significant aspect of their freedom of judgment?
Current indications
A primary indication for psychosurgery is obsessive-compulsive disorder (OCD). Treatment-refractory OCD is both tormenting and disabling. About 70% of psychosurgical procedures are currently performed for OCD, with notable objective improvement. Patient consent is not usually an issue, since patients are frequently aware of their disability, competent, and eager to pursue treatment.
Other possible indications include severe depression refractory to extreme pharmacologic therapy and sismotherapy (ECT), selected affective disorders such as treatment-refractory schizophrenic psychosis, and selected cases of aggressiveness to self or others.
Related posts:
Informed consent and the pediatric patient
Communitarian values in medical decision-making: Native Americans
Ethical considerations in interventional pain management
Conflicts of interest in research funding
Physician conscientious objection in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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