ELSA Project PNS: Psychiatric Neurosurgery ─ Ethical, Legal and Societal Issues
Psychiatric neurosurgery (PNS) is defined as neurosurgery intended for treating psychiatric disorders for which the biological underpinnings are unknown, and are not directly caused by brain diseases, such as brain tumors or epileptogenic tissues.Until the 1970s, crude forms of “psychosurgery” had been used in many mentally ill patients, but following public criticism and the development of anti-psychotic drugs, psychosurgery became nearly abandoned, and was forbidden in many countries.
Comeback of psychiatric neurosurgery since 2010
However, since 2010, there is a renaissance of psychiatric neurosurgery, albeit in a much more refined and safer form. Contemporary PNS procedures include deep brain stimulation (DBS) and ablative neurosurgical procedures. In DBS, there is permanent current delivery to specific areas of the brain through thin electrodes, in order to activate or deactivate these brain areas. The ablative neurosurgical procedures comprise of thermal or radiofrequency ablation procedures, and radiosurgery (Gamma Knife radiosurgery and MR guided focused ultrasound). These procedures create tiny lesions in brain areas, which play a crucial role in psychiatric symptoms.
Ethical issues remain
Although these modern forms of psychiatric neurosurgery have lesser adverse effects and risks, and are much more precise due to neuroimaging studies, many ethical issues remain. For example, is it justified to intervene in the brain of mentally ill patients when it might change their personality and behavior? What is the risk-benefit-ratio for the patients? For which kinds of disorders can the use of PNS be justified – also for drug addiction or anorexia nervosa? In addition, many legal questions are open.
About the project
The PNS consortium has brought together a multi-national team to investigate ethical, legal and societal issues of PNS. In contrast to previous projects, all psychiatric neurosurgical procedures were compared and evaluated, not only deep brain stimulation but also ablative procedures. Completely new procedures such as MR-guided focused ultrasound as well as procedures that are still in preclinical research (optogenetics) were also investigated. The consortium was coordinated by Sabine Müller from Germany and included Tade Matthias Spranger from Germany, Judy Illes from Canada, Roberto Martínez-Álvarez from Spain and Chris Bervoets from Belgium (more about the role of each partner in the consortium is described below).
We recommend that methods with good evidence for effectiveness and an acceptable risk profile should be rapidly transferred into clinical practice… For each patient, the risks and benefits of surgery must be balanced with the risks and benefits of continuing with treatment as usual.
One of the outcomes of the above research project is a recent publication in the journal Neuroethics, by the German, Belgian and Spanish project partners. In this review, the authors identify the main concerns about PNS, from patients and psychiatrists alike, the extent to which these concerns are justified and how they might be overcome, followed by providing recommendations on how to proceed with responsible research in PNS in accordance with the highest scientific and ethical demands.
Four main concerns were mapped:
- reservations based on historical psychosurgery; this concern refers mainly to ablative PNS;
- concerns about personality changes;
- concerns regarding localized interventions as opposed to a holistic approach;
- skepticism due to the lack of scientific evidence.
These concerns are addressed and recommendations for research and care are provided in the review. In this work, the ethics team and the clinical partners of the consortium have worked out and published recommendations for an ethically, legally and societally justifiable development of psychiatric neurosurgery.
Without the support of ERA-Net NEURON, this collaboration project would not have come into being. The dedicated ELSA calls for proposals in neuroscience are very important, because otherwise ELSA research proposals on neuroscience topics would be unlikely to be considered for funding in general ELSA calls.
PNS consortium partners and roles:
Read more about the PNS consortium and its accomplishments on NEURON's website.
For reference: Müller, S., van Oosterhout, A., Bervoets, C. et al. Concerns About Psychiatric Neurosurgery and How They Can Be Overcome: Recommendations for Responsible Research. Neuroethics 15, 6 (2022).
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