The aim of the operation is to sever some vital connections between this part of the brain and the rest. These include the fronto-thalamic pathways, upon which the cells in the medial nucleus (of the thalamus) depend for survival in a one-on-one manner. Within the nucleus the cells project to the orbit, the frontal pole and the convexity of the frontal lobe, from medial to lateral, respectively. The neurons in the frontal lobe project to the internal capsule and the peduncle, and indirectly to the basal ganglia for the most part. While other frontal lobe-cortical connections do exist, the only important pathway for the purpose of psychosurgery is this pathway. Thus, cutting this pathway at thalamic level (thalamotomy) or during its course (frontal lobotomy), or at its end (topectomy, lobectomy or cortical undercutting) is the aim of psychosurgery.
The goal of surgery has not changed over the decades, but the technique has been highly refined and altered to make the lesions very reliable as to location, using modern imaging techniques and stereotactic surgery. The most recent trend is to forego surgery in favor of non-ablative techniques, namely, deep brain stimulation (DBS) for the same conditions that psychosurgery was indicated in. These include depression and obsessive-compulsive disorder (OCD) resistant to other therapies.
The ethics of psychosurgery involve questions of moral philosophy and pragmatism in alleviating human suffering. The weighing of scientific data along with philosophical oughts and shoulds is required. The medical literature indicates definite efficacy for some kinds of limbic surgery, mainly cingulotomy and capsulotomy, in some kinds of conditions, namely major depression, pain and anxiety. The relative utility of these procedures given the severity of the illnesses and the safety of the procedures described is significant. Ethical and moral conflicts over altruism, autonomy and suffering require recognition before their due considerations (Kleinig 1985). The following recommendations emerge from these considerations:
Politics should be denounced as the most serious ethical problem in medical decision making. Political intrusion into the scientific matters and the doctor-patient relationship has created ethical problems with psychosurgery and continues to do so today.
The first significant foray into psychosurgery in the twentieth century was conducted by the Portuguese neurologist Egas Moniz who during the mid-1930s developed the operation known as leucotomy. The practice was enthusiastically taken up in the United States by the neuropsychiatrist Walter Freeman and the neurosurgeon James W. Watts who devised what became the standard prefrontal procedure and named their operative technique lobotomy, although the operation was called leucotomy in the United Kingdom.
In spite of the award of the Nobel prize to Moniz in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard Freeman-Watts type of operation was very rare, but other forms of psychosurgery, although used on a much smaller scale, survived. Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK, it is only used in a few centres on small numbers of people with depression or obsessive-compulsive disorder (OCD); in others it is also used in the treatment of schizophrenia and other disorders.
Psychosurgery is a collaboration between psychiatrists and neurosurgeons. During the operation, which is carried out under a general anaesthetic and using stereotactic methods, a small piece of brain is destroyed or removed. The most common types of psychosurgery in current or recent use are capsulotomy, cingulotomy, subcaudate tractotomy and limbic leucotomy. Lesions are made by radiation, thermo-coagulation, freezing or cutting.
Advances in surgical technique have greatly reduced the incidence of death and serious damage from psychosurgery; the remaining risks include seizures, incontinence, decreased drive and initiative, weight gain, and cognitive and affective problems.
Currently, interest in the neurosurgical treatment of mental illness is shifting from ablative psychosurgery (where the aim is to destroy brain tissue) to deep brain stimulation (DBS) where the aim is to stimulate areas of the brain with implanted electrodes.
Has been used in the treatment of psychiatric illness, intractable pain, and, controversially, as ameans to control and modify violent human behavior. Prefrontal lobotomy, a procedure developed in the 20th century, arose as a result of pioneering research, including work done at Yale University in New Haven. Prominent clinicians throughout Connecticut contributed to the development of modern psychosurgery. Neuroethics or ethics of neuroscience is essential to the study and practice ofpsychosurgery. New technology has provided improved accuracy with less morbidity. The progressive replacement of ablative procedures with deep-brain stimulation and restorative neurosurgery offers new perspectives in the treatment of some psychiatric conditions1).
Swiss neuropsychiatrist Gottlieb Burckhardt was among the first to dabble with modern psychosurgery. With no formal surgical training, in 1888 he performed craniotomies and induced cerebral white matter lesions in six psychiatric patients described as aggressive and chronically excited and as having paranoid delusions.
The history of psychosurgery may seem shocking, but perhaps it's not so outlandish after all. Today, neurosurgical interventions show promise in treating disorders of the brain. Implanting electrodes and simply lesioning certain areas of the brain are used as a last resort in patients with mood and anxiety disorders, including OCD. These procedures include anterior cingulotomy, limbic leucotomy, anterior capsulotomy, and subcaudate tractotomy, techniques that could be considered more localized lobotomies
But modern psychosurgery does have one thing in common with psychosurgery of 100 years ago: in both cases, the surgery produces some interruption in communication between different brain regions, often involving the limbic system and frontal cortex, which are involved, respectively, in emotions and complex planning and cognition.
As long as patients with problems of feeling, thinking, and behavior are assumed to be capable of making a free and informed decision on the question of a brain operation intended to improve some aspect of their mental state, there is no logical reason to object to such treatment. Ethical and legal problems regarding psychosurgery should arise primarily because of issues relating to consent to treatment, about which there certainly can be argument.
The peculiar problem of psychosurgery arises in part because the brain, which is the instrument of consent, is also understood to be the source of the disability that requires cure. In itself, this is scarcely an objection. Perhaps no one gives a second thought to the specific justification for obtaining consent to the removal of a brain tumor, even if the patient is confused and a proxy consent is necessary. In contrast, it is plausible that much of the hesitation and obstruction that attend discussions of consent to psychosurgery are based upon an unwillingness to view mental illness in the same way as physical illness. Frequently, equality of treatment is denied for all sorts of psychological illness compared with physical illness, as can be seen in numerous health insurance policies. With respect to psychosurgery, there is concern that informed consent must depend upon the adequate function of a large part or wide area of the brain, and there is a valid fear that such function is liable to be absent in those to whom the operation is offered.
The commission demonstrated that there was no substance to the claims being made. For example, only 100 procedures meeting the definition of psychosurgery were being performed annually in the United States in the years leading up to 1977 (when the commission issued its report on psychosurgery). It also determined that no significant psychological deficits were attributable to the psychosurgery undertaken; that the treatment was efficacious in more than half of the case studies; that there was no evidence that the procedure had been used for psychosocial control; and that only a few operations were conducted on minority or disadvantaged populations. Correspondence with the most active psychosurgeons in the United States revealed that out of 600 patients, only one was black, two were Asian, and six were Hispanic Americans. Between 1970 and 1980 only seven operations were reported to have been performed on children, and only three prisoners underwent psychosurgery. In fact, psychosurgery was largely limited to middle-class individuals. In a 1988 study, English investigators E. S. Hussain, H. Freeman, and R. A. C. Jones showed that psychosurgery provided valuable benefits for a selected small group within a cohort of patients from a defined population, particularly those with depression, agoraphobia, obsessional neurosis, and certain aspects of schizophrenia. Such findings show that the ethical aspects of psychosurgery have to do with the conditions under which it is offered, not with the inherent nature of the procedure.
Psychosurgery for individuals who are dangerous only to others but who might be willing to consent is the most difficult issue in this field. If the patient can consent, one might ask why the person should not be allowed the treatment This problem is exemplified by the 1973 case of Kaimowitz v. Department of Mental Health. A patient who had behaved aggressively, but was a prisoner, consented to treatment but was refused it on the grounds that his consent in prison could not be truly free. The patient, who had spent eighteen years in prison for murder, had satisfied an \"informed consent\" review committee comprising a law professor, a priest, and an accountant that he wanted the operation. A suit was brought by an attorney, Kaimowitz, and others belonging to a medical committee for human rights who had never consulted the prisoner. The lawyer appointed by the courts to represent the prisoner thought that the prisoner desperately wanted the operation. Coincidentally, the prisoner's appointed lawyer satisfied the court that his client was held unconstitutionally as a prisoner. He went free, but the discussion continued on the question of whether as a prisoner he had given free informed consent to psychiatric surgery. The court held that he could not have. Once the prisoner was released, he changed his mind about wanting the operation. According to Robert A. Burt (1975), imprisonment and medical surveillance at least contributed to the prisoner's consent without any attempt having been made by physicians to press the prisoner to agree. Some commentators have argued that no prisoner's consent should be accepted for psychosurgery if its purpose is to alter the type of behavior that caused imprisonment. To guard against the possibility that a prisoner might be deprived of the right to medical care, some framework should be contemplated that would provide for exceptions. Exceptions would include independent professional examination of the individual's motives as well as separation of the question of release from the outcome of the operation. 59ce067264