Jrournal of medical ethics, I980, 6, 149-154 J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from Ethical considerations of psychosurgery: the unhappy legacy of the Ethcal considerations of psychosurgery: the unhappy legacy of the pre-frontal lobotomy Larry 0 Gostin MIND (National Association for Mental Health) Author's abstract by earlier research on animals by Professor John Fulton and Dr Carlyle Jacobsen of Yale University,7 There is no subject at the interface oflaw, psychiatry and used alcohol injections and later a 'leucotome' to pro- medical ethics which is more controversial than duce lesions in fibres connecting the subcortical areas psychosurgery. The divergent views ofthe treatment begin of the brain and the frontal lobes. This 'pre-frontal with its definition. The World Health Organisation' and leucotomy' was conceived as a method of treating others2 define psychosurgery as the selective surgical psychiatric illness by a generalised 'blunting' of the removal or destruction ofnerve pathways or normal brain emotions. Fulton, who helped form the theoretical tissue with a view to influencing behaviour. However, basis for the surgical intervention, reported that his proponents ofpsychosurgery demur on the basis that the most ferocious animals had been 'reduced to a state of 'modern' treatment is concerned predominantly with friendly docility'.2 In I949 Moniz received the Nobel emotional illness, without any specific effect upon Prize for his work. behaviour. The alternative definition offered is 'the Wider use ofpsychosurgery began when two Ameri- surgical treatment ofcertain psychiatric illnesses by means can surgeons, Drs Walter Freeman and James Watts, of localised lesions placed in specific cerebral sites.3 developed a form of psychosurgery similar to that It is difficult entirely to accept this definition because, as introduced by Moniz.8 The 'standard pre-frontal examined below, scientificpsychiatry is notyet in aposition lobotomy' of Freeman and Watts involved the use ofcopyright. a to directly treat psychiatric illness solely through surgical blunt knife which was swept with a free hand in an arc intervention. There is no reliable theoretical relationship in the coronal plane and divided as much of the white between particular cerebral sites (which are normal and matter as possible. The procedure was carried out by healthy) and an identifiable psychiatric illness or making a burr hole in the side of the head. The opera- symptomatology. Given this state ofpsychiatric tion was repeated on both sides of the brain. The understanding, it is misleading to suggest fine distinctions pre-frontal lobotomy was considered to be most effec- between generalised alteration of behaviour or mood and tive in the treatment of depressive illness. However, treatment of an illness. Highly divergent practices and the surgery was used predominantly for schizophrenia theories (relating to the multiplicity ofconditions treated, where there was little evidence of its positive effect.http://jme.bmj.com/ surgical methods adopted and areas ofthe brain operated More importantly, there were potentially serious side- upon) further undermine exaggerated claims that effects which included intellectual and emotional psychosurgery can scientifically 'treat' specific illness impairment and personality change (a 'flattening' and a through precise surgical intervention. Nonetheless, 'withdrawal' effect which were sometimes character- contemporarypsychosurgery does not contain quite the same ised as 'vegetable states'), prolonged incontinence, 'broadbrush' approach ofits ancestors and it can lay some epilepsy and certain metabolic disorders.3 legitimate claim as an effective empirical treatment in It is estimated that there were approximately 50.000 on October 2, 2021 by guest. Protected narrowly limited circumstances. Major ethical problems such operations carried out in North America; there still, however, arise and these will be discussed in this were over I0 ooo in Great Britain between I942 and article. 1954. Two-thirds of the British patients were schizo- phrenic of whom only i8 per cent were considered to be recovered; up to 50 per cent of those with affective Historical antecedents disorders were reported to have socially recovered or Much of the controversy concerning psychosurgery is improved.9 based upon an ill-informed view of the nature of the The association of Freeman and Watts was discon- contemporary treatment. Psychosurgery, more than tinued when the former advocated a lesion produced any other psychiatric treatment, suffers from the leg- through the roof of the orbit, performed immediately acy of its rather crude predecessors. Psychosurgery on after two applications of unmodified electro- human subjects was first introduced by Dr Gottlieb convulsive therapy to act as an anaesthetic.'0 The end Burckhardt of Switzerland in I89I4 and Dr Ludwig of the decade of the I950S saw a diminishing in Puusepp of Russia in I9I0,5 but results were poor. enthusiasm for psychosurgery which was due in part to There was little further interest in psychosurgery until discontent with the severity of reported side-effects the work of the Portuguese neurologist, Dr Egaz and to the advent of the phenothiazines for the treat- Moniz, was published in 1936.6 Dr Moniz, encouraged ment and control of schizophrenia. iso Larry 0 Gostin J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from The renaissance of psychosurgery (diathermy or radio-frequency), or by way of a cutting wire introduced via the probe. Alternatively, radio- THE NUMBER OF OPERATIONS PERFORMED IN THE active seeds, such as Yttrium-9o, may be placed in PREVIOUS TWO DECADES position and the centre destroyed over a period of The previous decade witnessed the 'renaissance of time'.' However, as indicated below, the older 'free psychosurgery'. This renaissance was no more clearly hand' methods are still very much in use in this country illustrated than by the Lancet in 1972 when it identified and, even with the stereotactic approach, there intractable psychotic depression as the 'indication par remains a wide range of cerebral target sites. excellence' for the 'modern' psychosurgery. The Lan- A survey of the 44 neurosurgical units in the British cet maintained that, if no more effective treatment Isles for the years 1974-76 showed marked variation in becomes available, 'it can be taken without further the preferred site for placing lesions and in lesion- argument that some form of lobotomy is here to stay. making techniques.'3 No less than i6 different types of The results are excellent, usually permanent, and on lesions were made in a minimum of 14 particular cere- occasion almost miraculous'. The Lancet concluded in bral sites. Free hand methods (eg using a leucotome or an incredulous manner, which was later characterised suction) were used in 26 (84 per cent) of the 31 units by Dr Raymond Levy of the Maudsley Hospital" as conducting neurosurgery. This represented approxi- not 'scientific' but 'revivalist' in tone: "This is no field mately 40 per cent of the patients, as those units doing for the euphoric novice; but the caustic advice to the fewest operations tended to use the older methods. beginners can be passed on to the whole profession - By contrast, stereotactic methods were used in i i units 'don't give it up, take it up' ".I2 More recently, Drs (35 per cent) on approximately 6o per cent of the Bridges and Bartlett of the Geoffrey Knight patients. Psychosurgical Unit at Brook Hospital advised, 'it is There was also great variation in the clinical indica- now unnecessary for an illness which fails to respond to tions for the use ofpsychosurgery. In three units which routine treatments to be left very long before operation were responsible for 248 ofthe operations, some 85 per (sic) is considered'.' cent of the diagnoses were related to mood - ie depres- There is a great deal of uncertainty concerning the sion, anxiety states, obsessive compulsive neuroses, number of operations which have been performed in schizo-affective psychoses and manic depressive this country. In 1970, Dr Geoffrey Knight then of the psychoses. It should be noted that several studies showcopyright. Brook Hospital, Britain's largest psychosurgical unit, good outcomes in respect of these medical indica- gave evidence of several hundred of his own cases, tions.'4 However, the Royal College survey showed most of which had been since i960.2 An enquiry spon- that there were numerous operations on patients with sored by the Royal College of Psychiatrists suggested diagnoses unrelated to mood disorder. These ranged that in the United Kingdom, I 58 operations were per- from repeated violence or aggression, anorexia ner- formed in 1974, 154 in 1975 and II9 in 1976."3 On 17 vosa, intractable pain, schizophrenia and self- January, I980, in a written Parliamentary Answer, Sir destructive behaviour. It is important to observe that George Young, Minister ofState, announced that there there is very little empirical or even theoretical evi- had been44 operations in both I977 and 1978, and that dence of the effectiveness of surgical intervention in http://jme.bmj.com/ the returns for 1979 were not yet available. Three respect of these clinical conditions.3 weeks later Sir George was obliged to retract his state- The multiplicity of existing psychosurgical tech- ment in a further Parliamentary Answer (8 February) niques and cerebral sites, together with the use ofsuch when Brook Hospital revealed that, at that hospital varied neurosurgical procedures on almost the entire alone, there had been 40 such operations in I974, 47 in range of psychiatric conditions raises valid lay objec- 1975, 37 in 1976, 33 in I977 and 35 in I978. Figures of tions to claims that 'contemporary psychosurgery' is an this magnitude in one hospital had clearly thrown established or specific 'treatment' for particular medi- on October 2, 2021 by guest. Protected doubt on the reliability of the national figures cal conditions. There does not appear to be anyreliable announced earlier.