Science and Engineering Ethics

, Volume 24, Issue 4, pp 1119–1142 | Cite as

Should DBS for Psychiatric Disorders be Considered a Form of Psychosurgery? Ethical and Legal Considerations

  • Devan StahlEmail author
  • Laura Cabrera
  • Tyler Gibb
Original Paper


Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community’s interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS—though a much more precise and refined treatment than its predecessors—is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of psychosurgery can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS.


Deep brain stimulation Neuroethics Psychosurgery Psychiatric disorders Legal regulations 


  1. A.C.A § 28-65-302. (2011).Google Scholar
  2. Aden v. Younger, 57 Cal. App. 3d 662. (1976).Google Scholar
  3. Alonso, P., Cuadras, D., Gabriëls, L., Denys, D., Goodman, W., Greenberg, B. D., Fiacro, J. P., Kuhn, J., Lenartz, D., Mallet, L., Nuttin, B., Real, E., Segalas, C., Schuurman, R., du Montcel, S. T, & Menchon, J. M. (2015). Deep brain stimulation for obsessive–compulsive disorder: A meta-Analysis of treatment outcome and predictors of response. PLoS ONE. doi: 10.1371/journal.pone.0133591.
  4. Annas, G. J., & Glantz, L. H. (1974). Psychosurgery: The law’s response. Boston University Law Review, 54(2), 249–267.Google Scholar
  5. Baumeister, A. A. (2000). The Tulane Electrical Brain Stimulation Program a historical case study in medical ethics. Journal of History of the Neurosciences, 9(3), 262–278.CrossRefGoogle Scholar
  6. Bell, E., Maxwell, B., McAndrews, M. P., Sadikot, A., & Racine, E. (2010). Hope and patients’ expectations in deep brain stimulation: Healthcare providers’ perspectives and approaches. Journal of Clinical Ethics, 21(2), 112–124.Google Scholar
  7. Bergfeld, I. O., Mantione, M., Hoogendoorn, M. L. C., Ruhe, H. G., Notten, P., van Laarhoven, J., & Denys, D. (2016). Deep brain stimulation of the ventral anterior limb of the internal capsule for treatment-resistant depression. A randomized clinical trial. JAMA Psychiatry, 73, 456–464.CrossRefGoogle Scholar
  8. Braslow, J. T. (1999). History and evidence-based medicine: Lessons from the history of somatic treatments from the 1900s to the 1950s. Mental Health Services Research, 1(4), 231–240.CrossRefGoogle Scholar
  9. Breggin, P. (1972a). Lobotomies are still bad medicine. Medical Opinion, 8, 32–36.Google Scholar
  10. Breggin, P. (1972b). The return of lobotomy and psychosurgery. Congressional Record, 118, 5567–5577.Google Scholar
  11. Brock, D. W. (1996). What is the moral authority of family members to act as surrogates for incompetent patients? The Milbank Quarterly, 74(4), 599–618.CrossRefGoogle Scholar
  12. Cal. Welfare & Institutions Code § 5325(g). (2016).Google Scholar
  13. Canterbury v. Spence, 464 F.2d 772. (D.C. Cir. 1972).Google Scholar
  14. Chodakiewitz, Y., Williams, J., Chodakiewitz, J., & Cosgrove, G. R. (2015). Ablative surgery for neuropsychiatric disorders: Past, present, future. In B. Sun & A. D. Salles (Eds.), Neurosurgical treatments for psychiatric disorders (pp. 51–66). Dordrecht: Springer.Google Scholar
  15. Conn. Gen. Stat. § 17a-543. (2011).Google Scholar
  16. Delgado, J. M. (1969). Physical control of the mind: Toward a psychocivilized society. New York, NY: Harper and Row.Google Scholar
  17. Delgado, J. M., Hamlin, H., & Chapman, W. P. (1952). Technique of intracranial electrode implacement for recording and stimulation and its possible therapeutic value in psychotic patients. Confinia Neurologica, 12(5–6), 315–319.CrossRefGoogle Scholar
  18. Doernberg, S. N., & Wendler, D. (2016). Ensuring respect for human research participants institutional review boards and sharing results from research. Jama-Journal of the American Medical Association, 316(11), 1149–1150.CrossRefGoogle Scholar
  19. Dougherty, D. D., Rezai, A. R., Carpenter, L. L., Howland, R. H., Bhati, M. T., O’Reardon, J. P., Malone, D. A. (2015). A randomized sham-controlled trial of deep brain stimulation of the ventral capsule/ventral striatum for chronic treatment-resistant depression. Biological Psychiatry, 78, 240–248.CrossRefGoogle Scholar
  20. Dunn, L., Holtzheimer, P., Hoop, J., Mayberg, H., Roberts, L. W., & Appelbaum, P. (2011). Ethical issues in deep brain stimulation research for treatment-resistant depression: Focus on risk and consent. AJOB Neuroscience, 2(1), 29–36.CrossRefGoogle Scholar
  21. Egan, D. (2015). Adverse effects: The perils of deep brain stimulation for depression. Mad in America, Accessed 20 February 2017.
  22. El-Hai, J. (2005). The lobotomist: A maverick medical genius and his tragic quest to rid the world of mental illness. Hoboken, NJ: Wiley.Google Scholar
  23. Eljamel, S. (2015). Ablative surgery for depression. In B. Sun & A. D. Salles (Eds.), Neurosurgical treatments for psychiatric disorders. Dordrecht: Springer.Google Scholar
  24. Emanuel, E. J., Wendler, D., & Grady, C. (2000). What makes clinical research ethical? JAMA, 238(20), 2701–2711.CrossRefGoogle Scholar
  25. Erickson-Davis, C. (2012). Ethical concerns regarding commercialization of deep brain stimulation for obsessive compulsive disorder. Bioethics, 26(8), 440–446.CrossRefGoogle Scholar
  26. Feldman, R. P., Alterman, R. L., & Goodrich, J. T. (2001). Contemporary psychosurgery and a look to the future. Journal of Neurosurgy, 95(6), 944–956.CrossRefGoogle Scholar
  27. Feldman, R. P., & Goodrich, J. T. (2001). Psychosurgery: A historical overview. Neurosurgery, 48(3), 647–659.CrossRefGoogle Scholar
  28. Figee, M., Schuurman, R., & Denys, D. (2015). Challenges with meta-analysis in deep brain stimulation. Stereotactic and Functional Neurosurgy, 93(2), 147.CrossRefGoogle Scholar
  29. Fins, J. J., Kubu, C. S., Mayberg, H. S., Merkel, R., Nuttin, B., & Schlaepfer, T. E. (2017). Being open minded about neuromodulation trials: Finding success in our “failures”. Brain Stimulation, 10(2), 1–6.CrossRefGoogle Scholar
  30. Fins, J. J., Mayberg, H. S., Nuttin, B., Kubu, C. S., Galert, T., Sturm, V., Stoppenbrink, K., Merkel, R., & Schlaepfer, T. E. (2011). Misuse of the FDA’s humanitarian device exemption in deep brain stimulation for obsessive–compulsive disorder. Health Affairs, 30(2), 302–311.CrossRefGoogle Scholar
  31. Fisher, C. E., Dunn, L. B., Christopher, P. P., Holtzheimer, P. E., Leykin, Y., Mayberg, H. S., Lisanby, S. H., & Appelbaum, P. S. (2012). The ethics of research on deep brain stimulation for depression: decisional capacity and therapeutic misconception. Annals of the New York Academy of the Sciencse, 1265, 69–79.CrossRefGoogle Scholar
  32. Flora, E. D., Perera, C. L., Cameron, A. L., & Maddern, G. J. (2010). Deep brain stimulation for essential tremor: A systematic review. Movement Disorders, 25(11), 1550–1559.CrossRefGoogle Scholar
  33. Fox, S. H., Katzenschlager R., Lim, S., Ravina B., Seppi, K., Coelho, M., Poewe, W., Rascol, O., Goetz, C. G., & Sampaio, C. (2011). The movement disorder society evidence-based medicine review update: Treatments for the motor symptoms of Parkinson's disease. Movement Disorders, 26(S3), S2–S41.Google Scholar
  34. Foley, P. (2014). Deep brain stimulation for Parkinson’s disease: Historical and neuroethical aspects. In J. Clausen & N. Levy (Eds.), Handbook of neuroethics. Amsterdam: Springer.Google Scholar
  35. Food and Drug Administration. (2006). Information sheet guidance for IRBs, clinical investigators, and sponsors. Resource document. Office of Good Clinical Practice. Accessed 20 February 2017.
  36. Getz, M. J. (2009). The ice pick of oblivion: Moniz, Freeman and the development of psychosurgery. Trames, 13(2), 129–152.CrossRefGoogle Scholar
  37. Glannon, W. (2010). Consent to deep brain stimulation for neurological and psychiatric disorders. Journal of Clinical Ethics, 21(2), 104–111.Google Scholar
  38. Graat, I., Martijn, F., & Denys, D. (2017). The application of deep brain stimulation in the treatment of psychiatric disorders. International Review of Psychiatry, 29(2), 178–190.CrossRefGoogle Scholar
  39. Greenberg, B. D., Gabriels, L. A., Malone, D. A., Jr., Rezai, A. R., Friehs, G. M., Okun, M. S., Shapira, N. A., Foote, K. D., Cosyns, P. R., Kubu, C. S., Malloy, P. F., Salloway, S. P., Giftakis, J. E., Rise, M. T., Machado, A. G., Baker, K. B., Stypulkowski, P. H., Goodman, W. K., Rasmussen, S. A., & Nuttin, B. J. (2010). Deep brain stimulation of the ventral internal capsule/ventral striatum for obsessive–compulsive disorder: Worldwide experience. Molecular Psychiatry, 15(1), 64–79.Google Scholar
  40. Hariz, M., Blomstedt, P., & Zrinzo, L. (2013). Future of brain stimulation: New targets, new indications, new technology. Movement Disorders, 28(13), 1784–1792.CrossRefGoogle Scholar
  41. Health and Human Services. (2009). Code of federal regulations. 45 CFR 46. Accessed 20 February 2017.
  42. Heath, R. G. (1954). The theoretical framework for a multidisciplinary approach to human behavior. In R. G. Heath (Ed.), Studies in schizophrenia. A multidisciplinary approach to mind–brain relationships. Cambridge, MA: Harvard University Press.CrossRefGoogle Scholar
  43. Heath, R. G. (1972). Pleasure and brain activity in man. American Journal of Psychiatry, 120, 571–577.CrossRefGoogle Scholar
  44. Horgan, J. (2014). Much hyped brain-implant treatment for depression suffers setback. Scientific American. Accessed 23 May 2017.
  45. Juckel, G., Uhl, I., Padberg, F., Brune, M., & Winter, C. (2009). Psychosurgery and deep brain stimulation as ultima ratio treatment for refractory depression. European Archives of Psychiatry and Clinical Neuroscience, 259(1), 1–7.CrossRefGoogle Scholar
  46. Kaimowitz v. Department of Mental Health for the State of Michigan. (1973). 2 Prison L. Rptr 433.Google Scholar
  47. Kringelbach, M. L., & Aziz, T. Z. (2009). Deep brain stimulation: avoiding the errors of psychosurgery. JAMA, 301(16), 1705–1707.CrossRefGoogle Scholar
  48. Kuhn, J., Lenartz, D., Huff, W., Lee, S., Koulousakis, A., Klosterkoetter, J., & Sturm, V. (2007). Remission of alcohol dependency following deep brain stimulation of the nucleus accumbens: Valuable therapeutic implications? Journal of Neurology, Neurosurgery and Psychiatry, 78, 1152–1153.CrossRefGoogle Scholar
  49. KY Rev Stat §645.170. (1996 through Reg. Sess.).Google Scholar
  50. Lipsman, N., Bernstein, M., & Lozano, A. M. (2010). Criteria for the ethical conduct of psychiatric neurosurgery clinical trials. Neurosurgical Focus, 29(2), E9. doi: 10.3171/2010.4.FOCUS09327.CrossRefGoogle Scholar
  51. Lipsman, N., & Lozana, A. M. (2012). Neurosurgery and deep brain stimulation for psychiatric disease: Historical context and future prospects. AJOB Neuroscience, 3(1), 9–12.CrossRefGoogle Scholar
  52. Lipsman, N., Woodside, D. B., Giacobbe, P., Hamani, C., Carter, J. C., Norwood, S. J., Sutandar, K., Staab, R., Elias, G., Lyman, C. H., Smith, G. S., & Lozano, A. M. (2013). Subcallosal cingulate deep brain stimulation for treatment-refractory anorexia nervosa: A phase 1 pilot trial. The Lancet, 381(9875), 1361–1370.CrossRefGoogle Scholar
  53. Malone, D. A., Jr., Dougherty, D. D., Rezai, A. R., Carpenter, L. L., Friehs, G. M., Eskandar, E. N., Rauch, S. L., Rasmussen, S. A., Machado, A. G., & Kubu, C. S. (2009). Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biological Psychiatry, 6(4), 267–275.CrossRefGoogle Scholar
  54. Mantione, M., Van De Brink, W., Schuurman, P. R., & Denys, D. (2010). Smoking cessation and weight loss after chronic deep brain stimulation of the nucleus accumbens: Therapeutic and research implications: Case report. Neurosurgery, 66(1), 1–4.CrossRefGoogle Scholar
  55. Mashour, G. A., Walker, E. E., & Martuza, R. L. (2005). Psychosurgery: Past, present, and future. Brain Research Reviews, 48(3), 409–419.CrossRefGoogle Scholar
  56. Mayberg, H. S. (2009). Targeted electrode-based modulation of neural circuits for depression. The Journal of Clinical Investigation, 119(4), 717–725.CrossRefGoogle Scholar
  57. Mayberg, H. S., Lozano, A. M., Voon, V., McNeely, H. E., Seminowicz, D., Hamani, C., Schwalb, J. M, & Kennedy, S. H. (2005). Deep brain stimulation for treatment resistant depression. Neuron, 45, 651–660.CrossRefGoogle Scholar
  58. Montgomery, E. B., Jr. (2012). The epistemology of deep brain stimulation and neuronal pathophysiology. Frontiers in Integrative Neuroscience, 6, 78.CrossRefGoogle Scholar
  59. Morishita, T., Fayad, S. M., Higuchi, M. A., Nestor, K. A., & Foote, K. D. (2014). Deep brain stimulation for treatment-resistant depression: Systematic review of clinical outcomes. Neurotherapeutics, 11(3), 475–484.CrossRefGoogle Scholar
  60. Muller, S., Riedmuller, R., & van Oosterhout, A. (2015). Rivaling paradigms in psychiatric neurosurgery: Adjustability versus quick fix versus minimal-invasiveness. Frontiers of Integrative Neuroscience, 9, 27.Google Scholar
  61. Nangunoori, R., Tomycz, N. D., Quigley, M., Oh, M. Y., & Whiting, D. M. (2013). Deep brain stimulation for psychiatric diseases: A pooled analysis of published studies employing disease-specific standardized outcome scales. Stereotactic and Functional Neurosurgy, 91(6), 345–354.CrossRefGoogle Scholar
  62. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1977). Report and recommendations: Psychosurgeries. Washington D.C.: DHEW Publication No. (OS)77-0001. Accessed 23 May 2017.
  63. Nuttin, B., Cosyns, P., Demeulemeester, H., Gybels, J., & Meyerson, B. (1999). Electrical stimulation in anterior limbs of internal capsules in patients with obsessive–compulsive disorder. The Lancet, 354(9189), 1526.CrossRefGoogle Scholar
  64. Nuttin, B. J., Gabriëls, L. A., Cosyns, P. R., Meyerson, B. A., Andréewitch, S., Sunaert, S. G., Maes, A. F., Dupont, P. J., Gybels, J. M., Gielen, F., & Demeulemeester, H. G. (2003). Long-term electrical capsular stimulation in patients with obsessive–compulsive disorder. Neurosurgery, 52(6), 1263–1272.CrossRefGoogle Scholar
  65. Nuttin, B., Wu, H., Mayberg, H., Hariz, M., Gabriëls, L., Galert, T., Merkel, R., Kubu, C., Vilela-Filho, O., Matthews, K., Taira, T., Lozano A. M., Schechtmann, G., Doshi, P., Broggi, G., Reǵis, J., Alkhani, A., Sun, B., Eljamel, S., Schulder, M., Kaplitt, M., Eskandar, E., Rezai, A., Krauss, J. K., Hilven, P., Schuurman, R., Ruiz, P., Chang, J. W., Cosyns, P., Lipsman, N., Voges, J., Cosgrove, R., Li, Y., & Schlaepfer, T. (2014). Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders. Journal of Neurology and Neurosurgical Psychiatry, 85(9), 1003–1008.Google Scholar
  66. Peña, C., Bowsher, K., Costello, A., De Luca, R., Doll, S., Li, K., Schroeder, M., & Stevens, T. (2007). An overview of FDA medical device regulation as it relates to deep brain stimulation devices. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 15(3), 421–424.CrossRefGoogle Scholar
  67. Presidential Commission for the Study of Bioethical Issues. (2014). Gray matters: Integrative approaches for neuroscience, ethics, and society (Vol 1). Washington, D.C. Accessed 23 May 2017.
  68. Pressman, J. D. (1998). Last resort: Psychosurgery and the limits of medicine (Cambridge history of medicine). Cambridge: Cambridge University Press.Google Scholar
  69. Racine, E., Waldman, S., Palmour, N., Risse, D., & Illes, J. (2007). “Currents of hope”: neurostimulation techniques in US and UK print media. Cambridge Quartely Healthcare Ethics, 16(3), 312–316.Google Scholar
  70. Sachdev, P. (2007). Is deep brain stimulation a form of psychosurgery? Australasian Psychiatry, 15(2), 97–99.CrossRefGoogle Scholar
  71. Sachdev, P. S., & Chen, X. (2009). Neurosurgical treatment of mood disorders: Traditional psychosurgery and the advent of deep brain stimulation. Current Opinion in Psychiatry, 22(1), 25–31.CrossRefGoogle Scholar
  72. Saleh, C., & Fontaine, D. (2015). Deep brain stimulation for psychiatric diseases: What are the risks? Current Psychiatry Reports, 17(5), 1–14.CrossRefGoogle Scholar
  73. Schlaepfer, T. E. (2015). Deep brain stimulation for major depression—Steps on a long and winding road. Biological Psychiatry, 78(4), 218–219.CrossRefGoogle Scholar
  74. Schlaepfer, T. E., & Fins, J. J. (2010). Deep brain stimulation and the neuroethics of responsible publishing: When one is not enough. JAMA, 303(8), 775–776.CrossRefGoogle Scholar
  75. Schlaepfer, T. E., Lisanby, S. H., & Pallanti, S. (2010). Separating hope from hype: Some ethical implications of the development of deep brain stimulation in psychiatric research and treatment. CNS Spectrums, 15(5), 285–287.CrossRefGoogle Scholar
  76. Sironi, V. A. (2011). Origin and evolution of deep brain stimulation. Frontiers of Integrative Neuroscince, 5, 42.Google Scholar
  77. Spoonhour, J. M. (1974). Psychosurgery and informed consent. University of Florida Law Review, 26(3), 432–452.Google Scholar
  78. Synofzik, M. (2013). Functional neurosurgery and deep brain stimulation. In C. Anjan & M. J. Farah (Eds.), Neuroethics in practice. Oxford: Oxford University Press.Google Scholar
  79. Synofzik, M., & Schlaepfer, T. E. (2008). Stimulating personality: Ethical criteria for deep brain stimulation in psychiatric patients and for enhancement purposes. Biotechnology Journal, 3(12), 1511–1520.CrossRefGoogle Scholar
  80. Valenstein, E. S. (1986). Great and desperate cures: The rise and decline of psychosurgery and other radical treatments for mental illness. New York: Basic Books.Google Scholar
  81. Valenstein, E. S. (1997). History of psychosurgery. In S. H. Greenblatt, T. Gadi, & M. Epstein (Eds.), A history of neurosurgery: In its scientific and professional contexts. Rolling Meadows, IL: The American Association of Neurologica (Thieme/AANS).Google Scholar
  82. Wagner, T., Valero-Cabre, A., & Pascual-Leone, A. (2007). Noninvasive human brain stimulation. Annual Review of Biomedical Engineering, 9, 527–565.CrossRefGoogle Scholar
  83. (1949). Lobotomy: Surgery for the insane. Stanford Law Review, 1(3), 463–474.Google Scholar

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© Springer Science+Business Media B.V. 2017

Authors and Affiliations

  1. 1.Michigan State Univeristy, College of Human MedicineEast LansingUSA
  2. 2.Michigan State University, College of Human MedicineEast LansingUSA
  3. 3.Western Michigan University Homer Stryker M.D. School of MedicineKalamazooUSA

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