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Deep Brain Stimulation: A Principled and Pragmatic Approach to Understanding the Ethical and Clinical Challenges of an Evolving Technology

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Ethical Issues in Behavioral Neuroscience

Part of the book series: Current Topics in Behavioral Neurosciences ((CTBN,volume 19))

Abstract

DBS has emerged in the past few decades as a powerful clinical tool in the treatment of movement disorders such as dystonia and Parkinson’s disease . As a result of its striking effects, the therapeutic utility of DBS has been investigated in a number of different neurological and neuropsychiatric conditions. Ethical discussion has accompanied this evolution of DBS and has led to the identification of a number of important ethical challenges. In this chapter, we review these challenges based on three of the key principles of biomedical ethics (autonomy , justice , and non-maleficence ). Specifically, we adopt a pragmatic perspective by reviewing the ethical issues as they emerge within the context of Parkinson’s disease, as this can serve to guide further ethical thinking on the future of DBS. Through this contextualization, we enrich the meaning of the Ethical principle s and increase their specificity. We hope that this contribution will inform readers and also stimulate discussion related to areas where important questions remain unanswered and where further research would need to be undertaken to understand and enact ethical principles.

For: Current Topics in Behavioral Neuroscience Frauke Ohl, Grace Lee and Judy Illes, editors, Ethics in Behavioral Neuroscience

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Notes

  1. 1.

    We have focused on the three ethical principles of respect for autonomy, justice, and non-maleficence due to space constraints and ability to relate previous work to those three principles.

  2. 2.

    We use the term “clinician” to capture all healthcare providers (e.g., physicians, nurses, social workers).

References

  • Agid Y, Schüpbach M, Gargiulo M et al (2006) Neurosurgery in Parkinson’s disease: the doctor is happy, the patient less so? J Neural Transm Suppl 70:409–414

    Article  PubMed  Google Scholar 

  • Ashkan K, Samuel M, Reddy P et al (2013) The impact of deep brain stimulation on the nonmotor symptoms of Parkinson’s disease. J Neural Transm 120(4):639–642

    Article  PubMed  Google Scholar 

  • Ballanger B, van Eimeren T, Moro E et al (2009) Stimulation of the subthalamic nucleus and impulsivity: release your horses. Ann Neurol 66(6):817–824

    Article  PubMed Central  PubMed  Google Scholar 

  • Beauchamp T, Childress J (2009) Principles of biomedical ethics, 6th edn. Oxford University Press, Oxford

    Google Scholar 

  • Bell E, Mathieu G, Racine E (2009) Preparing the ethical future of deep brain stimulation. Surg Neurol 72(6):577–586

    Article  PubMed  Google Scholar 

  • Bell E, Maxwell B, McAndrews MP et al (2010) Hope and patients’ expectations in deep brain stimulation: healthcare providers’ perspectives and approaches. J Clin Ethics 21(2):112–124

    PubMed  Google Scholar 

  • Bell E, Maxwell B, McAndrews MP et al (2011a) Deep brain stimulation and ethics: perspectives from a multisite qualitative study of Canadian neurosurgical centers. World Neurosurg 76(6):537–547

    Article  PubMed  Google Scholar 

  • Bell E, Maxwell B, McAndrews MP et al (2011b) A review of social and relational aspects of deep brain stimulation in Parkinson’s disease informed by healthcare provider experiences. Parkinson’s Dis 2011:871874

    Google Scholar 

  • Bell E, Racine E (2013) Ethics guidance for neurological and psychiatric deep brain stimulation. Handb Clin Neurol 116C:313–325

    Article  Google Scholar 

  • Benabid AL, Pollak P, Louveau A et al (1987) Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease. Appl Neurophysiol 50(1–6):344–346

    CAS  PubMed  Google Scholar 

  • Benabid AL, Pollak P, Seigneuret E et al (1993) Chronic VIM thalamic stimulation in Parkinson’s disease, essential tremor and extra-pyramidal dyskinesias. Acta Neurochir Suppl (Wien) 58:39–44

    CAS  Google Scholar 

  • Bladin PF (1992) Psychosocial difficulties and outcome after temporal lobectomy. Epilepsia 33(5):898–907

    Article  CAS  PubMed  Google Scholar 

  • Boriani G, Berti E, Biffi M et al (2010) Implantable electrical devices for prevention of sudden cardiac death: data on implant rates from a ‘real world’ regional registry. Europace 12(9):1224–1230

    Article  PubMed  Google Scholar 

  • Canadian Heart Rhythm Task Force MEDEC (2004) Provincial variations in access to implantable cardioverter defibrillators (ICDs), Toronto, ON. http://www.medec.org/webfm_send/794. Accessed 18 Dec 2013

  • Canadian Medical Association (2004) CMA code of ethics. Canadian Medical Association, Ottawa, ON. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf. Accessed 18 Dec 2013

  • Cleveland Clinic (2013) Deep brain stimulation for Parkinson’s disease patients. http://my.clevelandclinic.org/services/deep_brain_stimulation_dbs/hic_deep_brain_stimulation_for_parkinsons_disease_patients.aspx. Accessed 18 Dec 2013

  • Cohen DB, Oh MY, Baser SM et al (2007) Fast-track programming and rehabilitation model: a novel approach to postoperative deep brain stimulation patient care. Arch Phys Med Rehabil 88(10):1320–1324

    Article  PubMed  Google Scholar 

  • Comité Consultatif National d’Ethique pour les sciences de la vie et de la santé (2002) La neurochirurgie fonctionnelle d’affections psychiatriques sévères. http://www.ccne-ethique.fr/sites/default/files/publications/avis071.pdf. Accessed 6 March 2014

  • Cunningham AD, Plummer CJ, McComb JM et al (2005) The implantable cardioverter-defibrillator: postcode prescribing in the UK 1998–2002. Heart 91(10):1280–1283

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  • Dams J, Siebert U, Bornschein B et al (2013) Cost-effectiveness of deep brain stimulation in patients with Parkinson’s disease. Mov Disord 28(6):763–771

    Article  PubMed  Google Scholar 

  • Ector H, Rickards AF, Kappenberger L et al (2001) The world survey of cardiac pacing and implantable cardioverter defibrillators: calendar year 1997—Europe. Pacing Clin Electrophysiol 24(5):863–868

    Article  CAS  PubMed  Google Scholar 

  • Farris SM, Gianola FJ (2009) Ethical issues surrounding deep brain stimulation in Parkinson’s disease. JAAPA 22(2):57–58

    PubMed  Google Scholar 

  • Fins JJ (2000) A proposed ethical framework for international cognitive neuroscience: a consideration of deep brain stimulation in impaired consciousness. Neurol Res 22:273–278

    CAS  PubMed  Google Scholar 

  • Follett KA, Torres-Russotto D (2012) Deep brain stimulation of globus pallidus interna, subthalamic nucleus, and pedunculopontine nucleus for Parkinson’s disease: which target? Parkinsonism Relat Disord 18(Suppl 1):S165–S167

    Article  PubMed  Google Scholar 

  • Ford PJ (2009) Vulnerable brains: research ethics and neurosurgical patients. J Law Med Ethics 37(1):73–82

    Article  PubMed  Google Scholar 

  • Fraix V, Houeto JL, Lagrange C et al (2006) Clinical and economic results of bilateral subthalamic nucleus stimulation in Parkinson’s disease. J Neurol Neurosurg Psychiatry 77(4):443–449

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  • Frank MJ, Samanta J, Moustafa AA et al. (2007) Hold your horses: impulsivity, deep brain stimulation, and medication in parkinsonism. Science 318(5854):1309–1312

    Google Scholar 

  • Gisquet E (2008) Cerebral implants and Parkinson’s disease: a unique form of biographical disruption? Soc Sci Med 67 (11):1847–1851

    Google Scholar 

  • Glannon W (2010) Consent to deep brain stimulation for neurological and psychiatric disorders. J Clin Ethics 21(2):104–111

    PubMed  Google Scholar 

  • Government of Canada (1984) Canada Health Act. Revised Statutes of Canada, 1985, c. C-6. Minister of Justice

    Google Scholar 

  • Grimes D, Gordon J, Snelgrove B et al (2012) Canadian guidelines on Parkinson’s disease. Can J Neurol Sci 39(4 Suppl 4):S1

    PubMed  Google Scholar 

  • Halbig TD, Tse W, Frisina PG et al (2009) Subthalamic deep brain stimulation and impulse control in Parkinson’s disease. Eur J Neurol 16(4):493–497

    Article  CAS  PubMed  Google Scholar 

  • Holloway RG, Ringel SP, Bernat JL et al (2000) US neurologists: attitudes on rationing. Neurology 55(10):1492–1497

    Article  CAS  PubMed  Google Scholar 

  • Kim SYH (2004) Evidence-based ethics for neurology and psychiatry research. NeuroRX 1:372–377

    Article  PubMed Central  PubMed  Google Scholar 

  • Krack P, Batir A, Van Blercom N et al (2003) Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson’s disease. N Engl J Med 349(20):1925–1934

    Article  CAS  PubMed  Google Scholar 

  • Lad SP, Kalanithi PS, Patil CG et al (2010) Socioeconomic trends in deep brain stimulation (DBS) surgery. Neuromodulation 13(3):182–186

    Article  PubMed  Google Scholar 

  • Lee DS, Tu JV, Juurlink DN (2008) Do Ontario patients with heart failure have equal access to life-saving technology? Healthc Q 11(3):20–21

    Article  PubMed  Google Scholar 

  • Lopes M, Meningaud JP, Behin A et al (2003) Consent: a Cartesian ideal? Human neural transplantation in Parkinson’s disease. Med Law 22(1):63–71

    PubMed  Google Scholar 

  • Martin RC, Okonkwo OC, Hill J et al (2008) Medical decision-making capacity in cognitively impaired Parkinson’s disease patients without dementia. Mov Disord 23(13):1867–1874

    Article  PubMed Central  PubMed  Google Scholar 

  • Mathieu G, Bell E, Racine E (2011) Subjective outcomes measurement and regulatory oversight for deep brain stimulation outcomes in Parkinson’s disease. AJOB Neurosci 2(1):16–18

    Article  Google Scholar 

  • McComb JM, Plummer CJ, Cunningham MW et al (2009) Inequity of access to implantable cardioverter defibrillator therapy in England: possible causes of geographical variation in implantation rates. Europace 11(10):1308–1312

    Article  PubMed  Google Scholar 

  • Meissner W, Schreiter D, Volkmann J et al (2005) Deep brain stimulation in late stage Parkinson’s disease: a retrospective cost analysis in Germany. J Neurol 252(2):218–223

    Article  PubMed  Google Scholar 

  • Miller FG, Fins Joseph J (2006) Protecting human subjects in brain research: a pragmatic perspective. In: Illes J (ed) Neuroethics: defining the issues in theory, practice, and policy. Oxford University Press, Oxford, pp 123–140

    Google Scholar 

  • Miocinovic S, Somayajula S, Chitnis S et al (2013) History, applications, and mechanisms of deep brain stimulation. JAMA Neurol 70(2):163–171

    Article  PubMed  Google Scholar 

  • Mond HG, Proclemer A (2011) The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009—a world society of arrhythmia’s project. Pacing Clin Electrophysiol 34(8):1013–1027

    Article  PubMed  Google Scholar 

  • Moro E, Lozano AM, Pollak P et al (2010) Long-term results of a multicenter study on subthalamic and pallidal stimulation in Parkinson’s disease. Mov Disord 25(5):578–586

    Article  PubMed  Google Scholar 

  • National Institute of Neurological Disorders and Stroke (2012) NINDS deep brain stimulation for Parkinson’s disease information page. http://www.ninds.nih.gov/disorders/deep_brain_stimulation/deep_brain_stimulation.htm. Accessed 18 Dec 2013

  • National Parkinson Foundation (2012) Deep brain stimulation. http://www.parkinson.org/Parkinson-s-Disease/Treatment/Surgical-Treatment-Options/Deep-Brain-Stimulation. Accessed 18 Dec 2013

  • Okun MS, Fernandez HH, Wu SS et al (2009) Cognition and mood in Parkinson’s disease in subthalamic nucleus versus globus pallidus interna deep brain stimulation: the compare trial. Ann Neurol 65(5):586–595

    Article  PubMed Central  PubMed  Google Scholar 

  • Perozzo P, Rizzone M, Bergamasco B et al (2001) Deep brain stimulation of subthalamic nucleus: behavioural modifications and familiar relations. Neurol Sci 22(1):81–82

    Article  CAS  PubMed  Google Scholar 

  • Racine E (2013) Pragmatism and the contribution of neuroscience to ethics. Essays Philos Humanism 21(1):13–20

    Google Scholar 

  • Racine E, Van der Loos HZA, Illes J (2007a) Internet marketing of neuroproducts: new practices and healthcare policy challenges. Camb Q Healthc Ethics 16:181–194

    PubMed  Google Scholar 

  • Racine E, Waldman S, Palmour N et al (2007b) Currents of hope: neurostimulation techniques in US and UK print media. Camb Q Healthc Ethics 16(3):314–318

    Article  Google Scholar 

  • Sandvik U, Hariz GM, Blomstedt P (2012) Quality of life following DBS in the caudal zona incerta in patients with essential tremor. Acta Neurochir (Wien) 154(3):495–499

    Article  Google Scholar 

  • Schechtman M (2010) Philosophical reflections on narrative and deep brain stimulation. J Clin Ethics 21(2):133–139

    PubMed  Google Scholar 

  • Schrag A, Banks P (2006) Time of loss of employment in Parkinson’s disease. Mov Disord 21(11):1839–1843

    Article  PubMed  Google Scholar 

  • Schrag A, Hovris A, Morley D et al (2003) Young- versus older-onset Parkinson’s disease: impact of disease and psychosocial consequences. Mov Disord 18(11):1250–1256

    Article  PubMed  Google Scholar 

  • Schüpbach M, Gargiulo M, Welter ML et al (2006) Neurosurgery in Parkinson disease: a distressed mind in a repaired body? Neurology 66(12):1811–1816

    Article  PubMed  Google Scholar 

  • Schüpbach WM, Agid Y (2008) Psychosocial adjustment after deep brain stimulation in Parkinson’s disease. Nat Clin Pract Neurol 4(2):58–59

    Article  PubMed  Google Scholar 

  • Seaburn DB, Erba G (2003) The family experience of “sudden health”: the case of intractable epilepsy. Fam Process 42(4):453–467

    Article  PubMed  Google Scholar 

  • Sevillano-Garcia MD, Manso-Calderon R (2010) nonmotor symptoms in Parkinson’s disease and deep brain stimulation. Rev Neurol 50(Suppl 2):S95–S104

    PubMed  Google Scholar 

  • Simpson CS, O’Neill BJ, Sholdice MM et al (2005) Canadian cardiovascular society commentary on implantable cardioverter defibrillators in Canada: waiting times and access to care issues. Can J Cardiol 21(Suppl A):19A–24A

    Google Scholar 

  • Smeding HM, Speelman JD, Huizenga HM et al (2011) Predictors of cognitive and psychosocial outcome after STN DBS in Parkinson’s disease. J Neurol Neurosurg Psychiatry 82(7):754–760

    Article  PubMed  Google Scholar 

  • Soulas T, Sultan S, Gurruchaga JM et al (2011) Depression and coping as predictors of change after deep brain stimulation in Parkinson’s disease. World Neurosurg 75(3–4):525–532

    Article  PubMed  Google Scholar 

  • Susman E (2001) Deep brain stimulation for Parkinson disease patients should start before medications fail. Neurol Today 1(1):28–32

    Article  Google Scholar 

  • Synofzik M, Schlaepfer TE (2008) Stimulating personality: ethical criteria for deep brain stimulation in psychiatric patients and for enhancement purposes. Biotechnol J 3(12):1511–1520

    Article  CAS  PubMed  Google Scholar 

  • Talan J (2009) Deep brain stimulation: a new treatment shows promise in the most difficult cases. Dana Press, New York

    Google Scholar 

  • Tepper J, Jaigobin C, Wang C (2005) Health human resources for neurosurgical services in Ontario. ICES investigative report. Institute for Clinical Evaluative Sciences, Toronto

    Google Scholar 

  • University of Florida Center for Movement Disorders and Neurorestoration (2013) Deep brain stimulation surgery. http://mdc.mbi.ufl.edu/surgery/deep-brain-stimulation-surgery. Accessed 18 Dec 2013

  • Vitek JL (2002) Deep brain stimulation for Parkinson’s disease. A critical re-evaluation of STN versus GPi DBS. Stereotact Funct Neurosurg 78(3–4):119–131

    Article  PubMed  Google Scholar 

  • Vogel L (2011) Specialty training out-of-sync with job market. CMAJ 183(13):E1016

    Article  PubMed Central  PubMed  Google Scholar 

  • Wolz M, Hauschild J, Fauser M et al (2012) Immediate effects of deep brain stimulation of the subthalamic nucleus on nonmotor symptoms in Parkinson’s disease. Parkinsonism Relat Disord 18(8):994–997

    Article  PubMed  Google Scholar 

  • Woodrow SI, O’Kelly C, Hamstra SJ et al (2006) Unemployment in an underserviced specialty?: the need for co-ordinated workforce planning in Canadian neurosurgery. Can J Neurol Sci 33(2):170–174

    Article  CAS  PubMed  Google Scholar 

  • Woopen C, Pauls KA, Koy A et al (2013) Early application of deep brain stimulation: clinical and ethical aspects. Prog Neurobiol 110:74–88

    Article  PubMed  Google Scholar 

  • World Medical Association (1948, revised May 2006) WMA declaration of Geneva. http://www.wma.net/en/30publications/10policies/g1/. Accessed 18 Dec 2013

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Acknowledgments

Support for this work comes from a grant from the Canadian Institutes of Health Research (Eric Racine, PI; Emily Bell, co-PI) as well as a Career Award from the Fonds de recherche du Québec—Santé (Eric Racine).

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Authors and Affiliations

  1. Neuroethics Research Unit, Institut de recherches cliniques de Montréal (IRCM), 110 Avenue des Pins Ouest, Montréal, QC, H2W lR7, Canada

    Eric Racine, Emily Bell & Natalie Zizzo

  2. Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, Canada

    Eric Racine

  3. Departments of Neurology and Neurosurgery,Experimental Medicine and Biomedical Ethics Unit, McGill University, Montréal, Canada

    Eric Racine

  4. Departments of Neurology and Neurosurgery, McGill University, Montréal, Canada

    Emily Bell

  5. Experimental Medicine and Biomedical Ethics Unit, McGill University, Montréal, Canada

    Natalie Zizzo

Authors
  1. Eric Racine
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  2. Emily Bell
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  3. Natalie Zizzo
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Corresponding author

Correspondence to Eric Racine .

Editor information

Editors and Affiliations

  1. National Core for Neuroethics, University of British Columbia, Vancouver, British Columbia, Canada

    Grace Lee

  2. National Core for Neuroethics, University of British Columbia, Vancouver, British Columbia, Canada

    Judy Illes

  3. Faculty of Veterinary Medicine, University Utrecht, Utrecht, The Netherlands

    Frauke Ohl

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Racine, E., Bell, E., Zizzo, N. (2014). Deep Brain Stimulation: A Principled and Pragmatic Approach to Understanding the Ethical and Clinical Challenges of an Evolving Technology. In: Lee, G., Illes, J., Ohl, F. (eds) Ethical Issues in Behavioral Neuroscience. Current Topics in Behavioral Neurosciences, vol 19. Springer, Berlin, Heidelberg. https://doi.org/10.1007/7854_2014_336

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