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Psychosurgery APPENDIX PSYCHOSURGERY THE NATIONAL COMMISSION FOR THE PROTECTION OF HUMAN SUBJECTS OF BIOMEDICAL AND BEHAVIORAL RESEARCH THIS APPENDIX CONTAINS THE REPORTS CONCERNING PSYCHOSURGERY THAT WERE PREPARED FOR THE COMMISSION. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE DHEW PUBLICATION NO. (OS) 77-0002 For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 TABLE OF CONTENTS I. The Practice of Psychosurgery: A Survey of the Literature (1971-1976) Elliot S. Valenstein, Ph.D. II. Final Report on Psychosurgery Pilot Study Allan F. Mirsky, Ph.D. Maressa Hecht Orzack, Ph.D. III. A Study of Cingulotomy in Man Hans-Lukas Teuber, Ph.D. Suzanne Corkin, Ph.D. Thomas E. Twitchell, M.D. NATIONAL COMMISSION FOR THE PROTECTION OF HUMAN SUBJECTS OF BIOMEDICAL AND BEHAVIORAL RESEARCH MEMBERS OF THE COMMISSION Kenneth John Ryan, M.D., Chairman Chief of Staff Boston Hospital for Women Joseph V. Brady, Ph.D. Karen Lebacqz, Ph.D. Professor of Behavioral Biology Consultant in Bioethics Johns Hopkins University Department of Health Sacramento, California Robert E. Cooke, M.D. David W. Louisell, J.D. Vice Chancellor for Health Sciences Professor of Law University of Wisconsin University of California at Berkeley Dorothy I. Height Donald W. Seldin, M.D. President Professor and Chairman National Council of Negro Women, Inc. Department of Internal Medicine University of Texas at Dallas Albert R. Jonsen, Ph.D. Eliot Stellar, Ph.D. Associate Professor of Bioethics Provost of the University and University of California at San Francisco Professor of Physiological Psychology University of Pennsylvania Patricia King, J.D. Robert H. Turtle, LL.B. Associate Professor of Law Attorney Georgetown University Law Center VomBaur, Coburn, Simmons & Turtle Washington, D.C. NATIONAL COMMISSION FOR THE PROTECTION OF HUMAN SUBJECTS OF BIOMEDICAL AND BEHAVIORAL RESEARCH COMMISSION STAFF PROFESSIONAL STAFF SUPPORT STAFF Michael S. Yesley, J.D. Deborah E. Bowery Staff Director Pamela L. Driscoll Duane Alexander, M.D. Pediatrics Arlene Line R. Anne Ballard, M.A. Public Information Officer Marie D. Madigan Tom L. Beauchamp, Ph.D. Coral M. Nydegger Philosophy Lee A. Calhoun, M.A. Erma L. Pender Political Science Bradford H. Gray, Ph.D. Sociology SPECIAL CONSULTANTS Robert Hummel, M.Div., M.A. Research Assistant Miriam Kelty, Ph.D. Donald Bersoff, Ph.D., J.D. Psychology Robert J. Levine, M.D. Bonnie M. Lee Administrative Assistant Stephen Toulmin, Ph.D. Barbara Mishkin, M.A. Bioethics Francis Pizzulli, J.D. Law THE PRACTICE OF PSYCHOSURGERY: A SURVEY OF THE LITERATURE (1971-1976) Elliot S. Valenstein, Ph.D. University of Michigan Contract No. N01-HU-6-2115 ACKNOWLEDGEMENTS Summarizing the heterogeneous and often inadequately described information in a large number of clinical reports can be a huge and frustrating task. It would have been impossible for me to complete the task alone. This report could not have been completed without the help of a small, but very efficient, staff. I am particularly pleased to be able to express my gratitude to one of my graduate students, David M. Marques, for the diligence, dedication, and organizational ability he applied to all stages of the project. David's help in creating order out of disorder often made the difference in our being able to see "the forest for the trees." Mary Browning was involved in the project from the very beginning. Her help in organizing and maintaining our records, locating often obscure articles, corresponding with neurosurgeons and psychiatrists around the world, and in collating and coding information was invaluable. Kenneth Gibb and Susan Cassell also provided valuable assistance in coding the literature. When faced with what seemed to be an impossible deadline, my secretary, Judy Baughn, volunteered (as she always does when needed) to work extra hours typing the manuscript, constructing tables, and completing all of those innumerable tasks required to convert chaos into coherence. It was a great reassurance to me to know that a staff of very competent scientific advisors were available for consultation whenever needed. I am indebted to Drs. Allan F. Mirsky, Ayub K. Ommaya, Gardner C. Quarton, William H. Sweet and Herbert G. Vaughan for their willingness to take time from very busy professional careers to serve on the Scientific Advisory Board. The final report was written solely by me, however, and therefore I must assume full responsibility for its contents. Dr. John Donnelly's cooperation in making available the results of a questionnaire survey on the extent of psychosurgery is gratefully acknowledged. I-i A great many persons around the world answered my letters and questionnaires promptly and with an obvious effort to be as helpful as possible. I am indebted to all of them. Elliot S. Valenstein I-ii TABLE OF CONTENTS Page Acknowledgements I. Scope of Report 1 II. Brief History of Psychosurgery 5 III. Rationale for Psychosurgery 9 IV. Description of Surgical Procedures 18 V. Extent of Psychosurgery 24 VI. The Patients and the Surgical Procedures 37 VII. Postoperative Evaluation 50 VIII. Alternative Therapy 85 IX. Ethical Issues 87 X. Conclusions and Recommendations 95 XI. Bibliography 98 XII. Appendices 144 I-iii I. SCOPE OF REPORT Psychosurgery, the practice of destroying a part of the brain of psychiatric patients, has aroused great controversy. Widely differing views have been expressed on the success of these operations in alleviating psychiatric disorders, on whether or not they are likely to produce serious emotional and intellectual deficits, and whether any ethical principles are violated in the process. The National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research has sought to obtain objective answers to these questions. The present report represents an attempt to contribute to this end by summarizing the evidence available in the published literature. More specifically, the author has been asked to survey the relevant world literature published from 1971 to the present for the purpose of determining the extent of psychosurgery being practiced, the results of these operations, the risks or complications that exist, the new trends in this field, and the ethical or social problems that are peculiar to its practice. Some definitions were necessary to establish the limits of the proposed literature survey. At least among those involved in its practice, psycho- surgery is defined as a destruction of some region of the brain in order to alleviate severe psychiatric disorders. It is implied that the area of the brain destroyed is not known to be pathological and therefore surgery related to tumors, strokes, traumatic accidents, or infections would be excluded from this definition. Operations performed to alleviate movement disorders (Parkinson's Disease, spastic disorders and tremors) and seizures are not considered to be psychosurgical procedures even though it is not always possible to prove that the brain area destroyed was pathological. In some instances, epileptic patients also had severe psychiatric problems and consequently it was not always clear whether the brain operations were performed primarily for the seizures, the psychiatric disorders, or for both reasons. In such cases, information about the results of the surgery was included under the heading, "epilepsy with psychiatric disorders." The subject of brain operations to alleviate intractable pain deserves a special note. Emotional and psychiatric disturbances are frequently present in patients suffering from intractable pain and in some instances it is impossible to distinguish the total preoccupation with pain from similar preoccupations of certain anxious, phobic, or obsessive psychiatric patients. Moreover, the same brain operations (primarily cingulotomies and frontal lobe procedures) may be performed on patients suffering from intractable pain and on these psychiatric patients. For these reasons, it was decided to include information on brain operations for pain in the report. Excluded, however, was neurosurgery for pain that was restricted to the spinal cord or the peripheral nervous system. Lastly, although the vast majority of the psycho- surgical procedures involved the destruction of some region of the brain, those operations that were restricted to the implantation of electrodes for the purpose of therapeutic stimulation of deep brain structures were included in this report. Electroconvulsive shock treatment does not involve surgery and even though there are controversies surrounding its use, the topic was not covered in the present survey. The search strategy used to obtain the literature to be surveyed is explained in the introduction to the bibliography. In brief, all relevant articles published in English were sought. In total, approximately 700 articles that treated some aspect of psychosurgery or related scientific or ethical issues were located. The great majority of these papers did not present firsthand data on the results of psychosurgery. Some of these articles were concerned primarily with the theory and history of psychosurgery. In other instances, the results of brain operations were discussed only in I-2 broad and general terms. Many other articles in this group presented ethical, legal, and sociopolitical views and these varied in purpose and tone from scholarly presentations of reasoned arguments to emotionally-charged polemics by participants in the "psychosurgery controversy." All of this literature was surveyed and is cited
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