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From psychosurgery to neuromodulation and palliation: history's lessons for the ethical conduct and regulation of neuropsychiatric research

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Optimism tempered by history

As we contemplate the emerging era of neuromodulation and imagine the utility of deep brain stimulation for disease entities in neurology and psychiatry, our enthusiasm is immediately tempered by history. Just a generation ago, other confident investigators were heralding invasive somatic therapies like prefrontal lobotomy to treat psychiatric illness. That era of psychosurgery ended with widespread condemnation, congressional calls for a ban [3], and a vow that history should never repeat

When psychosurgery was therapy

It is one of those strange paradoxes in history that 2 years after the articulation of the Nuremberg Code and the development of the sterotactic technique, Egas Moniz won the Nobel Prize for the development of the prefrontal leukotomy [22], [23]. He began his work in 1935 [24], just 3 years after the initiation of the Tuskegee Syphilis Study [25]. Both the Tuskegee Syphilis Study and psychosurgery would be criticized decades later as an abrogation of patient rights invoking the same ethical

Psychosurgery and the body politic

Not even chlorpromazine was enough of an advance to remove psychosurgery entirely from therapeutic consideration in the 1960s and early 1970s. Some physicians, such as the Harvard neurosurgeon H. Thomas Ballantine, Jr, maintained that psychosurgical procedures like cingulotomy retained a role in conjunction with standard psychiatric care for refractory patients. He articulated guidelines to regulate the judicious use of the procedure for the relief of the patient's suffering and improvement of

Regulatory bioethics: the National Commission's report on psychosurgery

Elliot S. Valenstein, commenting on this period, observed that “The coalition of civil-rights, anti-psychiatry, and minority groups opposed to psychosurgery proved to be much more effective politically than the earlier opposition to psychosurgery from within the medical profession had been” [95]. Indeed, public sentiment, catalyzed in part by an organized and growing scholarly bioethics movement, led the National Commission for the Protection of Human Subjects of Biomedical and Behavioral

Summary: fairness, palliation, and psychosurgery

Moving forward, we need to create regulatory mechanisms that will balance human subject protections for individuals with intractable neurologic and psychiatric disorders against scientific progress and access to potentially beneficial interventions. This fiduciary obligation of practitioners, clinical investigators, and public policy makers can be facilitated by building on the yet uncompleted efforts of the 1977 National Commission Report on Psychosurgery. This report should serve as a

Acknowledgements

The author thanks Nicholas D. Schiff, Benjamin D. Greenberg, Franklin G. Miller, G. Rees Cosgrove, and Amy B. Ehrlich for their helpful insights, Diane Richardson of the Oskar Diethelm Library of the Payne Whitney Clinic and Chris McKee of the Hastings Center Library for their archival assistance, and Ali R. Rezai and Alim Benabid for the opportunity to present earlier versions of this paper to the neuromodulation meetings held in Aix-Les-Bain, France, in January and June 2002.

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      It was recommended to establish for each hospital where psychosurgery is performed consent review boards (a) whose members are not members of the team treating the specific case and (b) whose members include legal and moral experts (Neville, 1975, p. 110). In 1974 the National Commission for the protection of human subjects of biomedical and behavioral research was created in USA by the National Research Act in the wake of revelations about the Tuskegee Syphilis Study and other research ethics abuses (Fins, 2003). It recommended strict oversight of psychosurgery by specially constituted institutional review boards (IRBs) with a subcommittee of Department of Health, Education, and Welfare (DHEW)-sanctioned experts or consultants in neurology, neurosurgery, psychology, and psychiatry.

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