Neuroethics

, Volume 6, Issue 1, pp 115–128 | Cite as

Involuntary & Voluntary Invasive Brain Surgery: Ethical Issues Related to Acquired Aggressiveness

Original Paper

Abstract

Clinical cases of frontal lobe lesions have been significantly associated with acquired aggressive behaviour. Restoring neuronal and cognitive faculties of aggressive individuals through invasive brain intervention raises ethical questions in general. However, more questions have to be addressed in cases where individuals refuse surgical treatment. The ethical desirability and permissibility of using intrusive surgical brain interventions for involuntary or voluntary treatment of acquired aggressiveness is highly questionable. This article engages with the description of acquired aggressiveness in general, and presents a rare clinical case to illustrate the difficulties of treating this population. To expand the debate further, this article explores the ethics related to invasive brain surgery in three parts: a) it examines coercive involuntary invasive brain surgery for the benefit of protecting others on individuals suffering from acquired aggressiveness who lack decision-making capacities to consent; b) it addresses voluntary psychosurgery on individuals suffering from acquired aggressiveness who are competent to consent; and, c) it questions whether acquired aggressive individuals, who are legally competent, have a duty to consent to invasive brain surgery, in order to maintain their autonomy by reducing or even eliminate their aggressive drives. Ensuring the safety and efficacy of surgical brain interventions could increase the ethical permissibility of voluntary treatment, but it would not necessarily entail ethical justification for proceeding with invasive brain surgery for treatment of intractable acquired aggressive behaviour.

Keywords

Acquired aggressiveness Cognitive impairment Decision-making capacity Frontal lobe surgery Involuntary treatment Personality changes 

Introduction

Restoring neuronal and cognitive faculties in aggressive individuals through invasive brain surgery is one of the most controversial interventions within medicine, law, psychiatry and ethics [1]. Contemporary medicine and media’s hostility towards invasive brain surgery, in particular psychosurgery, has long historical roots [2]. This hostility is not without its reasons. Past invasive brain surgeries provided strong examples of why patients should not be subjected to such intrusive intervention when lacking decision-making capacities to consent, even when their condition involves disruptive behaviour such as aggressive tendencies. Nevertheless, the idea of treating patients displaying aggressive behaviours is still defended in today’s literature [3, 4].

Rather than exploring the concept of aggressive behaviours in general, this article focuses on the ethical questions associated with invasive brain surgery for individuals suffering from acquired aggressiveness. In terms of ethics, the difference lies in the ability for rehabilitation and treatment that may successfully curb the underlying acquired aggressiveness propensities compared to ‘innate’ aggressive behaviour in general [41, 47, 61]. This significant difference illustrates ethical concerns that acquired aggressive patients could potentially be subjected to force or compulsory treatment. With regards to ethics, it is fundamental to explore whether forced invasive brain surgery on individuals with acquired aggressiveness can be acceptable.1 To what extent should a person suffering from acquired aggressiveness, but without decision-making capacities to consent, undergo invasive brain surgery to restore her ability to conduct herself in a socially responsible manner? Correspondingly, the ethical desirability and permissibility of using surgical brain interventions for voluntary treatment of acquired aggressive behaviour raises major concerns. Should a person suffering from acquired aggressiveness, but who is legally competent, consent to undergo a psychosurgical procedure to protect others or maintain her autonomy?

This article will proceed in three steps. The first section describes acquired aggressiveness in general and raises preliminary concerns in relation to invasive brain surgery for treatment of acquired aggressive behavior. The second section presents a rare clinical case of acquired aggressiveness in order to address the difficulties involved in treating this population, in particular when the relevant individuals refuse invasive brain surgery. The third section explores the ethics related to invasive brain surgery in three parts: a) we examine coercive involuntary psychosurgery for the benefit of protecting others on individuals suffering from acquired aggressiveness who lack decision-making capacities to consent; b) we explore voluntary psychosurgery on individuals suffering from acquired aggressiveness who are competent to consent; and, c) we question whether acquired aggressive individuals, who are legally competent, have a duty to consent to invasive brain surgery, in order to maintain their autonomy by reducing or even eliminating their aggressive drives.

Brain Disturbances, Personality Changes and Acquired Aggressiveness

Personality changes and cognitive impairments following brain lesions have been reported in the scientific literature for many years [5, 6]. One of the most famous and commented upon clinical cases is that of Phineas P. Gage. Gage suffered from personality and cognitive alterations following an accident in which a large iron rod penetrated and traversed his head, causing multiple irreversible brain injuries [7], in particular to the left frontal lobe [8, 9]. After the accident, it was reported by those who knew him that he was “no longer Gage” [10].

With respect to the spectrum of personality and cognitive changes which follows frontal brain lesions there are less well known cases of acquired aggressive disruptive behaviours. Although less discussed, a number of acquired aggressiveness cases have been reported in the history of medicine. For instance, there is a little known case of John Quigley, described as a “violent lunatic” 2 in the Australian Medical Journal (AMJ) in 1857. Quigley was indicted for a violent crime in Tasmania, but was diagnosed with “dementia” caused by a past fractured skull which had left “a very deep cleft on the frontal bone” [11]. It was reported that Quigley suffered a severe brain injury when he “received a blow to the head around four inches in length” [12]. His conduct was described as “most violent, and his language vociferous”, to the point of “attack[ing] the constables” during his trial [11, p. 67]. Later, he was described as being “one of the most powerful, dangerous, and treacherous lunatics that have ever had to be dealt with in the Island” [12]. Although Quigley was sent to a padded cell with an adjoining yard created just for violent lunatics in order to limit their interaction with officers, his unmanageable acquired aggressive outbursts were described as constantly terrifying to the staff [13].

Although a limited number of cases are reported in the history of medicine, acquired aggressiveness has not been described much per se. This condition can be defined as occurring within individuals who have been free of intractable aggressive behaviour prior to the onset of a brain lesion. Following neuronal impairment, patients manifest intractable aggression as a salient behavioural abnormality. A fundamental characteristic of acquired aggressiveness is that the patient’s propensity to behave aggressively is not motivated by instrumental aggression (goal oriented type) but rather manifests as reactive aggression, which occurs without any purpose, triggered by frustrating parameters in the environment [14, 15].

There is growing evidence that provides a correlation between head injuries and violent behaviour. Baguley et al. [16] conducted a five-year follow-up research project on 228 patients with moderate to severe Traumatic Brain Injury (TBI). The study revealed that in any given follow-up period, 25 % of the participants were classified as aggressive. Another study, based on a larger population (458 patients), showed that lifetime history of mild TBI was coupled with a history of aggression regardless of any history of psychiatric disorder [17]. Tateno et al. have found by using a quantitative scale (the Overt Aggression Scale) that 33.7 % of patients with TBI demonstrated aggressive behaviour as compared to 11.5 % of patients without TBI [18].

Frontal lobe lesions have been significantly associated with aggressive behaviour [19]. It has been observed that frontal lobe lesions may result in impulsivity, loss of self control and altered emotion, which all can lead to disinhibition of aggressive impulses [20]. The mechanism causing acquired aggressiveness through frontal lobe lesions is still far from being well understood. Although no pattern of frontal network dysfunction can yet predict an outcome of violent behaviour, many studies appear to stress the consequences of the disinhibitive mechanism [21, 22, 23, 24] or deficits in frontal executive function [25, 26]. High rates of having a history of frontal lobe injuries—especially those involving the orbitofrontal cortex—were observed in persons with violent and criminal behaviour. These correlations may suggest a link between frontal lobe dysfunction and increased aggressive and antisocial conduct in this population [19]. Grafman et al. [27] studied the relationship between frontal lobe lesions and aggressive and violent behaviour in 336 Vietnam War veterans matched for age, education, and time spent in combat in Vietnam. 279 of these patients had suffered penetrating head injuries during their service. The authors report that ventromedial frontal lobe lesions increased the risk of aggressive and violent behaviour.

Cases of acquired psychopathy following head injury have been reported [15]. Most cases involve types of impulsive behaviour common in developmental psychopathy [28] but distinct in the nature of aggression [14]. Clinical cases of acquired psychopathy have been associated with severe brain trauma causing a decrease in glucose consumption in the right prefrontal cortex [29], bilateral damage to the ventromedial prefrontal region [30] or orbitofrontal cortex lesions [15, 25].

It is fundamental to note that aggressive behaviour can also be the result of a degenerative neurological disease or may be without any visible organic explanation. Many symptoms consistent with early onset dementia, as well as chronic neuropsychological sequelae (including behavioural and personality changes) can be correlated with chronic traumatic encephalopathy [31] which results from the deposition of injury-related tau proteins in the brain. As well, many non-neurological factors can interact with biological elements to produce aggression. More important, frontal lesions do not uniformly implicate anti-social and aggressive behaviour. Matanó et al [32], for instance, report on a clinical case involving large frontal lesions resulting in behavioral and personality changes that nevertheless were compatible with stable functioning in family, professional, and social settings.

Preliminary Concerns over Invasive Brain Intervention for Treatment of Acquired Aggressive Behaviour

The idea that brain lesions of the frontal lobe do not necessarily lead to aggressive behaviour has prompted therapeutic interventions with psychosurgery. Since the late 1940s, medicine has mostly targeted the amygdala for treatment of aggressive behaviour. Based on animal studies, lesioning of the amygdala has been looked upon as fundamental in reducing intractable aggression [33]. Amygdalotomy was performed for many years, with ambivalent results [34, 35]; but mostly unconvincing from today’s point of view. Although ethically controversial at the time, and nowadays viewed as ethically unacceptable [2], past therapeutic programs of ablative amygdala neurosurgery [33] illustrate that treating aggressive disruption in humans has a long and delicate history. Although in the past psychosurgery was linked to permanent lesions of the brain, nowadays in modern procedures, surgery must be non-lesional: i.e. invasive surgery should not cause irreversible functional damage to neuronal tissue. This lessens a first ethical concern, that which is associated with the harm involved in irreversible functional damage. In the case of compulsory lobectomy involving tumor removal surgery, the brain tissue around the tumor is to be maximally preserved. The preservation of brain technique is achieved through meticulous microsurgical technique. Several additional techniques, such as neuronavigation, stereotactic biopsy or cortical mapping additionally add to cortical function preservation during brain tumor removal. Rigorous postoperative follow-up must also be performed given that even if the patient is “symptom-free”, it does not necessary entail a better psychological, behavioural and affective situation for the patient [62].

Although neurosurgery technologies have greatly progressed in the past decades, psychosurgeries are still experimental interventions, in terms of behavioral treatment; they are still far from being an effective treatment. Being an invasive intervention, Deep Brain Stimulation (DBS) is often considered the latest and as the last option in cases for patients with severe, debilitating, and treatment-refractory illnesses that cannot be treated with pharmaceutical drugs. The current generation of DBS treatments have, in the main, been approved to treat Parkinson’s disease, essential tremor and dystonia [36]. DBS has also been used in many experimental trials to treat psychiatric conditions, including aggressive behaviour [4, 36]. The hypothesis that aggressive behavior can be effectively treated might be old, and ethically questionable, but there is still a persistent scientific research agenda to meliorate it, presently with modern brain implants [3]. For instance, experimental high-frequency stimulation of the posteromedial hypothalamus through DBS has demonstrated consistent diminishment of aggressive and disruptive behavior [4]. Arguably, these present-day experimental interventions have been preceded by experimental treatments of the 60s–70s with radiofrequency lesions used for the same purpose [37, 38, 39]. However, many ethical questions in relation to safety and efficacy must be answered before it can become an effective treatment. In cases of psychosurgery involving DBS, besides the two main ethical criteria of requirements of biosafety (minimizing harm to host neurones) and biotolerability (minimizing chronic inflammatory response), the procedure involving the new generation of implants must manage potential acute traumatic responses, such as vascular leakage & edema (hypoxia, introduction of blood-born macrophages and serum components), inflammation, astroglial activation (hypertrophy astrogenesis), microglial activation (phagocytosis) [40]. Even if the safety hurdle could be passed, much experimental testing for efficacy would have to be done before it could be seen as an effective treatment.

It is crucial to improve the experimental nature of invasive brain surgery in order to treat acquired aggressive patients. At the same time, experimental intervention places individuals at risk of harm, often for the benefit of tierce (i.e. society, medical research, etc). Thus restoring neuronal and cognitive faculties of aggressive individuals through invasive brain surgery raises ethical questions in terms of a harm-benefit ratio. Avoiding unnecessary harm to acquired aggressive patients is an ethical goal, however interventions can also be justified when patients and society can benefit indirectly to some extent from this very harm.

However, it must be noted that experimental invasive brain surgery for treatment of acquired aggressiveness can easily fail to fulfil its commitments towards patients and society (i.e. by falling to protect society from aggressive individuals, while contributing to the deterioration of a patient’s health conditions). Harming patients while not achieving effective treatment does not only raise ethical concerns about the scientific validity of the experimental intervention, but it also illustrates the risk of neglecting underlying problems about patient consent to such experimental intervention. Indeed, in any invasive brain surgery, questions of consent have to be addressed, especially in cases where acquired aggressive individuals who lack the decision-making capacity to consent are targeted to undergo invasive surgical intervention. Patients who lack decision-making capacities can, to some extent, be described as vulnerable. Ethical permissibility to use invasive brain surgery on patients who lack capacities to consent have to be addressed when their vulnerability is combined with the fact that experimental invasive brain surgery always carries a risk of negatively affecting patients’ health, as well as that history reports abusive studies where vulnerable patients were included in experimental intervention because they were less able to resist [63]. These sorts of wrongs can occur in the conduct of experimental intervention, and this is a reason why permissibility to use psychosurgery remains ethically questionable. Also it remains questionable whether the use of neurosurgical technologies for the treatment of acquired aggressiveness is ethically desirable for patient’s medical interests.

A Rare Case of Acquired Aggressiveness: Ethical Difficulties of Compulsory Invasive Brain Surgery

A 36-year-old-male was brought to Begunje Psychiatric Hospital, Slovenia, following a year of increasing behavioural and cognitive changes, including peculiar intractable aggressive conduct. Prior to the period of personality change, family members described the patient as socially stable, emotionally involved (married), maintaining a steady occupation and without any history of aggressive behaviour or social misconduct.

The patient was officially admitted to Begunje Psychiatric Hospital for impulsivity, antisocial behavior, and aggressiveness. He also manifested symptoms of apathy and depression combined with suicidal tendencies. Upon the first examination of the patient, the Begunje medical team diagnosed a psychosis and antipsychotic drugs were prescribed. However, several days after his admission, the patient became somnolent and social contact with him deteriorated. A CT-scan was performed. Brain imaging showed a massive lesion in the anterior fossa of the cranial base with surrounding edema, compressing both frontal lobes. A meningioma was suspected. Antipsychotic drugs were withdrawn and antiedematous treatment was administered. The patient’s state of consciousness improved and the patient was immediately transferred to the neurosurgical department of the University Medical Center (UMC), Ljubljana.

In UMC Ljubljana, additional brain imaging was performed (See Figure 1). A homogenius lesion of 7.6 cm in diameter was revealed, invading the ethmoidal sinus. Surrounding edema suggested compression of the ventromedian prefrontal cortex and parts of both orbitofrontal cortex. With respect to symptoms of behavioral misconduct, the medical team reported the patient as manifesting aggressiveness, severe rudeness, and reactive utterance of obscenities. Antipsychotic drugs (haloperidol) were prescribed again to diminish the patient’s impulsivity and aggressive propensities.
Fig. 1

MRI-scan at the time of admission of the 36-year-old patient to the Department of Neurosurgery, showing a large tumor of the anterior fossa of the cranial base, extending into the ethmoidal sinus and compressing both frontal lobes. Prominent edema of both frontal lobes can be observed in figures B and C. a Sagittal view. b Coronal view c Axial view. The neuro-oncology literature rarely reports on cases of aggression caused by a brain tumour. Few cases of unusual aggressive and antisocial behaviours have been correlated with temporal lobe tumours [41, 42], hypothalamic astrocytoma [43], glioblastoma involving left frontal, parietal, and temporal lobes [44], and left anterior temporal lobe ganglioglioma [45]. Also, there are few reports of neuropathologies associated with disinhibitive sexual acts or impulsive sexual conduct leading to aggression. Clinical acquired paedophilia [46] cases have been correlated with many different brain anomalies, such as: right orbitofrontal hemangiopericytoma [47], inflammatory demyelination involving the hypothalamic and septal regions of the basal prosencephalon [48], frontotemporal dementia, bilateral hippocampal sclerosis [49], right frontal arteriovenous malformation extending into the septal region [50], and hypothalamic glioma [51]

Given the life threatening condition due to the invasiveness, size and surrounding edema of the tumor, a surgical removal of the lesion was proposed as the only option to the patient. However, the patient explicitly refused the proposed treatment. This refusal sparked great surprise in the medical team since the diagnosis disclosure addressed the severe health risk, as well as the etiology and effects pertaining to the patient’s behavior. Despite being confronted with clinical evidence including brain images, the patient denied his pathology and, moreover, claimed that nothing was wrong with his behaviour. The patient held the perspective that he was constrained and forced to be hospitalized. Through conversation, it was revealed that his reactive aggression tendencies were significantly related to these false beliefs. His refusal of treatment was argued on the ground that he feared being intentionally hurt by the medical team during the intervention. The situation became an ethical consent problem for the medical team: intervening meant acting against the patient’s decision to refuse treatment, but not intervening would have worsened the patient’s condition since the meningioma would have killed him.

Following the patient’s refusal, the family was informed of the situation. They were in favor of the medical intervention. Despite the family’s efforts to persuade the patient to undergo the treatment, the patient maintained his initial opposition, and became more aggressive, despite sustained treatment with haloperidol. Facing this consent issue, the medical team requested an independent psychiatric evaluation. It was provided by the Ljubljana Psychiatric Hospital. The psychiatric evaluation showed that the patient’s decision-making capacity was not preserved. Plus, the patient’s ability to understand and appreciate the distinction between right and wrong appeared disturbed. The patient’s mental competence was evaluated and the result demonstrated that he was legally incapable, at that time, of understanding the purpose of the surgery. According to Slovenia’s Law regarding Patient’s Rights (Article 29), if a patient lacks decision-making capacities (due, for example, to the experience of acute, mental disturbances), then the patient is judged incompetent and therefore does not have the authority to refuse relevant medical treatment. In these specific circumstances, the Slovenian law indicates that family members (i.e. legal guardians, tutors) may consent on the patient’s behalf. Therefore, following the independent psychiatric evaluation, the family signed a letter of consent (a standard form edited by the UMC Ljubljana) on behalf of the patient. A few days after the family’s consent was obtained, the neurosurgical procedure was performed.

After the surgery, the patient was transferred to the intensive care unit for several days and transferred back to the ward where his condition stabilized. He was given antiedematous treatment. Because of the liquorrhea, the lumbar drainage was inserted and removed after 5 days. The patient’s physical condition quickly improved as did his behavioral and cognitive condition. The medical team noticed amelioration in his behaviour. During the first few days following surgery, the patient was confused, but within approximately a week, he became cooperative, docile and unaggressive. The improvement of his mental condition was also noticed by his family. Most of his cognitive disturbances abated several days before his hospital discharge. Nevertheless, some memory disturbances and mild slowness remained. The patient was released from UMC Ljubljana 15 days after the surgery, in a physical, behavioral and cognitively stable condition. At the time of discharge, he was being treated with only antiepileptic pharmaceuticals and no antipsychotic drugs. The patient remembered that he had previously refused treatment and acknowledged his state of resistance without being able to explain it.

Following the patient’s release, there were no clinical reports of any new aggressive episodes or cognitive deterioration within the next 4 months. His family did not report any disturbing behaviour at home during this same time period. After 4 months, unrelated to the brain surgery and meningioma, the patient suffered from an undiagnosed aneurysm of the posterior-inferior cerebellar artery which abruptly killed him.

The Ethics of Invasive Brain Surgery for Treatment of Acquired Aggressiveness

Involuntary Brain Surgery without Decision-Making Capacity for the Benefit of Protecting Others

This particular case raises ethical questions relating to consent and to forced treatment on patients with intractable acquired aggressive behaviours. As discussed in the section Preliminary Concerns overs Invasive Brain Intervention for Treatment of Acquired Aggressive Behaviour, it also raises specific ethical questions regarding the desirability and permissibility of experimental coercive psychosurgical technologies to restore neuronal and cognitive faculties through direct invasive brain surgery. Although experimental intrusive brain surgery places patients at risk of harm, often for the benefit of tierce, there are many reasons why, one could argue, it should be permissible for doctors to treat patients with acquired aggressiveness coercively [64]. One could argue that any decision that allows the release of individuals who fulfill the diagnosis of acquired aggressiveness into society when the biological basis for the aggressiveness has not been compulsorily treated, are careless ethically, and arguably, legally culpable. Indeed, one could argue that the benefit of third parties has a weight in decisions to treat aggressiveness.

In fact, people are often compelled to do many things for the sake of others: the example of mentally ill patients being detained for the prevention of harm to others illustrates coercive societal interests. It is possible to imagine that in some legislation the safety of others is one of the grounds for compulsory hospitalization and treatment; cases such as seclusion in prison and compulsory quarantine are others examples of coercion on individuals that have no beneficent aim for the individual, but only serve the interests of others. In terms of ethics, this argument -that it is acceptable for doctors to perform psychosurgery for the sake of third parties- asks to what extent should societal interest to protect others outweigh the medical interests (health and safety) of acquired aggressive patients, especially when facing an experimental intervention involving patients without the requisite decision-making capacities to consent? To answer this question, we first must take into account various clinical considerations.

In terms of experimental invasive brain surgery, in particular when it involves acquired aggressive behaviour, a distinction between compulsory frontal lobe surgery and psychosurgery needs to be drawn. Psychosurgery is often associated with--and unfortunately stigmatized by--past uses of leucotomy [2]. Psychosurgery can be characterized by the absence of indications for compulsory treatment: i.e., the psychosurgery is not vital to the patient’s life. By contrast, compulsory frontal lobe surgery is used for cases where the patient’s life would be in danger without the surgical procedure. The purpose of compulsory frontal lobe surgery is to treat a patient whose life is threatened by a brain tumor. The collateral effects of frontal lobe surgery often lead to restoring and normalizing the patient’s behaviour, ameliorating cognitive function and correcting for inappropriate social conduct [41, 47]. However, these collateral effects are the primary goal of psychosurgery; the purpose being to strictly enhance or restore a patient’s conduct without overriding indications. In the above case study, if the brain intervention had been strictly an involuntary psychosurgery, i.e. with the family’s consent, it would have required a different standard of vigilance: more scientific data on the effectiveness of the surgery regarding the behavioural outcomes would have been required to promote ethical clarity in such a heavily value-laden intervention.

The question thus remains as to whether an involuntary invasive surgery would have been ethically permissible for the sake of societal interests of protecting others, if the tumour had not threatened the patient’s life, only causing aggressive behavior that was disruptive. As seen above, given its current experimental nature, its high risk of harming patient, its improbable efficacy, its probabilities to deteriorate patient health conditions, intrusive surgical intervention strictly motivated by behavioral modification to protect others raises ethical difficulties. Bearing in mind that the only potential benefit is that coercive experimental invasive brain surgery could result in an improbable diminution of acquired aggressiveness and that risks of harms associated with the intervention are likely to generate more suffering and disadvantage, it seems ethically weak to justify involuntary invasive surgery exclusively for the sake of societal interests of protecting others. The harms-benefit ratio largely disfavors patients’ medical interests without any guarantee that coercive experimental invasive interventions will in fact be effective in protecting others. In this regard, carrying out coercive experimental invasive intervention with the purpose of restoring cognitive function in an individual with intractable acquired aggressive behaviour solely for societal interests to protect others (in particular family and medical staff) may not be enough to ethically justify the intervention. However, in some cases, coercive invasive brain surgery may be required to promote the acquired aggressive patient’s medical interests rather than for the benefit of tierce. Indeed, in the above case, there was a compulsory treatment indication: the meningioma exercised a severe compression on the brain resulting in severe brain edema, transtentorial herniation and compression of the brainstem, which threatened to result in coma, breathing disturbances and ultimately death. Given the psychiatric evaluation revealed that the level of discernment that would have enabled the patient to understand the implications and consequences of his decision was lacking, from an ethical point of view, the clinical team was justified in showing reluctance to follow the patient’s refusal(s) of treatment.

In the above case, given the risk of harms and the improbable effectiveness of the coercive invasive brain surgery, the intervention was neither necessary nor sufficient, justified on societal interests to protect others (including family and medical staff). On the opposite hand, the coercive invasive brain surgery was necessary and sufficient to promote the acquired aggressive patient’s medical interests. The purpose of this surgery was not to reduce aggressive behaviour (psychosurgery) but to prevent the patient’s death from the tumor. The ethical permissibility was grounded in the fact that the treatment was clearly indicated to save the patient’s life—not treating the brain surgery would have worsened the practical and clinical contexts which are meant to ameliorate patient health. Additionally, the ethical cost due to the need for constraints in order to implement the treatment continually increased. The degree of physical constraints would have increased with time, given that the aggressiveness (and treatment refusal) of the patient would have possibly accentuated with the growth of the meningioma. Delaying the intervention thus would have been unethical as well. In the above case, when contrasting involuntary aspects of the intervention with bioethical principles such as disclosure, beneficence (intervention done for the benefit of the patient) and non-maleficence (not inflicting harm to the patient), an obligation not to allow the patient’s health to deteriorate, and diminishing violent outbursts, seems to prevail.

In the absence of a decision-making capacity to consent, in the interest of patients and their families, some forms of invasive brain surgery to relieve individual suffering seem justified, especially for cases where intrusive surgery is indicated to save the patient’s life (Table 1). However, they are at least three reasons why psychosurgery without an overriding indication based on the patient’s medical interests should not be an option for patients who are unable to consent. The first reason is that coercive experimental invasive brain surgery on acquired aggressive patients without the decision-making capacity to consent is not in the medical interest of the patient per se. The problem is to define the acquired aggressive patient’s medical interest. One possible answer could be to justify coercive experimental invasive brain surgery only in terms of a ‘life threatening’ issue, from which the patient’s medical interest should dictate any intervention. In fact, acquired aggressiveness is a ‘social disorder’ rather than a ‘life threatening disorder’. It entails that any coercive experimental invasive brain surgery for patients without the decision-making capacity to consent can hardly be justified in terms of the patient’s own medical interest if it does not threaten the patient’s life (as seen above, experimental intrusive brain surgery cannot exclusively be justified on societal interests to protect others). The second reason is that invasive brain interventions that might be contemplated as an option are experimental, or at least there could be serious doubt as to their effectiveness. In such cases, it cannot be argued that there is an overriding obligation to perform them. The third reason is that it could be argued that psychosurgery is a problematic brain intrusion because it changes the patient’s personality. Direct invasive interventions in the brain increase probabilities of affecting neuronal regions associated with personality and self [62]. In contrast, for example, with arthroscopic types of surgery to treat the interior of a joint, such as in the knee or shoulder, which are mostly motor-articulation parts of the body, the sense of what a patient makes of herself is inseparable from her brain. This intimate link between the brain and the sense of the self illustrates that experimental psychosurgery raises higher probabilities of resulting in a phenomenon such as adverse personality changes compared to other medical interventions, which involve motor-articulation parts of the body, such as knee or shoulder surgery. In cases such as that described here, of course, it could be argued that the tumor is inducing the current personality of the patient and the patient is not her ‘true self’. More fundamentally, however, the real question might be not so much what the patient’s ‘true self’ is, but rather whether the likely personality change was truly in the patient’s interest or not [52]. Thus, again, an argument based on an overriding interest for the patient would be required. Were the main reason for psychosurgery is social control, rather than following the patient’s interests, conducting such an intrusive brain intervention in an incompetent patient would likely represent an abuse of power, especially if the invasive brain intervention was proven effective.
Table 1

Ethical challenge related to Compulsory Life Saving treatment/Psychosurgery & Decision-making capacity within acquired aggressive population*

 

Patient with decision-making capacity

Patient with no decision-making capacity

Voluntary treatment

Involuntary treatment

X

Involuntary treatment

Invasive brain surgery justified on the grounds of compulsory Life Saving treatment

++

--

X

++

Invasive brain surgery justified on the grounds of Psychosurgery treatment

-+

--

X

--

* = Scale from ethically less permissible (−) to ethically more permissible (+). X = A patient without decision-making capacity cannot consent to a treatment

Voluntary Brain Surgery with Decision-Making Capacity to Consent for the Benefit of Societal Interests to Protect Others

Although very controversial, it is not ethically acceptable to ignore the potential benefits of some psychosurgical procedures on acquired aggressive patients, especially when they are fully in possession of their decision-making capacities to consent. Let us pretend now that the above patient suffering from acquired aggressiveness possessed decision-making capacities to consent and, as a preventive option, decided freely and without constraints to request psychosurgery. In this case, the tumour was not threatening the patient’s life, but his behavioural propension. To what extent could it be ethically desirable and permissible for the patient to undergo an experimental psychosurgery for the societal benefit of protecting others? Moreover, should it be allowed, and under what circumstances, if any, could it be compelled?

It can be argued that a patient competent to consent who wishes an invasive psychosurgery should be legally and ethically entitled to undergo the intrusive intervention, if, and only if, a number of precautionary conditions are respected. For instance, 1) the patient is fully competent to appreciate his/her condition: i.e. if the patient is aware of being too aggressive and freely decides to solicit help in order to restore and prevent his/her condition, 2) all non-invasive alternatives have proven unsuccessful for the patient, 3) there is a guarantee that any neuronal damage done during the intervention is reversible and no permanent functional damage will be done to the patient’s brain tissue: i.e. functional brain damage because even introducing a needle causes some irreversible damage at the tissue level, 4) short- and long-term physical and psychological adverse effects have been proven to be minimized within an acceptable range, 5) the patient is fully informed and freely consents to the intervention, 6) the harms-benefit ratio for the intervention is considered to be favourable for the patient’s medical interests by multidisciplinary expert clinicians. But does psychosurgery call for an obligatory prescription to consent to intrusive brain surgery for the benefit to protect society?

Between obligatory prescription and fully discretionary treatment there may be some middle ground. Indeed, there are cases in which patients may have strong moral reasons to prefer psychosurgery, without that being an overwhelming obligation. For instance, the patient (referred to above) could realize, later in life, that he had become changed and autonomously prefer to have his aggressive drives reduced to avoid any risk of harming his family and friends entourage. This is a moral reason to want invasive brain intervention but not to the extent of being an obligatory prescription given the risk of hurting his entourage is unknown. Indeed, he might or might not have acted on his impulses, nobody knows or could have predicted it. Also, some forms of pharmaceutical treatment may have been able to control his acquired aggressive propensities. At another level, there are cases in which patients may have a legal right to want psychosurgery but still have no moral obligation. For instance, past leucotomy was legally solicited by patients and performed by doctors over the years, but many questions regarding the ethical desirability in terms of patients’ medical interests remained unanswered [2]. Although the legal permissibility of invasive brain surgery as a potential treatment in competent individuals can be argued in rare cases, leucotomy’s history teaches us that psychosurgery cannot be considered an obligatory prescription due to a patient’s medical best interests.

Nevertheless, why shouldn’t a patient be the judge of what is acceptable to her health? In other terms, why couldn’t a patient willingly prefer to have psychosurgery (with all its risks) rather than suffering from acquired aggressiveness? Purely reasoning from an ethical point of view, one could argue there is something above the patient’s medical best interests. For instance, a patient’s voluntary choice could be enough to justify a desirable psychosurgery. However, to guarantee that a voluntary choice is ethically justified and desirable, many concerns related to the circumstances which lead to the decision would require examination. For instance, consent should not be coerced, or based on undue influence or false expectations. In fact, a potential danger for a competent patient who accepts psychosurgery is the subtle transgressions of autonomy through offering psychosurgery when it is not vital to the patient’s life. Most probably, given the nature of acquired aggression, individuals who will want psychosurgery might be incarcerated due to their aggressiveness; then a psychosurgery could be presented as a condition of release, which could involve psychological coercion. Also, as seen above, given the current experimental state of the procedures, risks associated with research participation are also relevant. Patients are at increased risk of conflating participating in an invasive brain intervention with accessing novel experimental procedure(s) – a phenomenon known as the therapeutic misconception [53, 54]. To be more precise, these patients (who unexpectedly find themselves in dire circumstances), may fail to appreciate the disadvantages associated with experimental trial participation, where protocol design (not the needs or interests of patients) determines what interventions patients will receive. Such scenarios highlight that both a patient voluntary choice and the ethical permissibility of psychosurgery are not sufficient to justify an invasive brain surgery. Something is missing. The ethical desirability of a psychosurgical procedure seems to stand on something else than being legally competent to decide.

Accepting an undesirable treatment raises major problems, but the problems are not the same for a competent patient (whose autonomy is transgressed and who may be subjected to physical constraint and abuse of power) and an incompetent patient (where the second is true, but not the first, and sometimes the third, but not always). Acquired aggressiveness suggests that ‘something’ changes in the brain that makes it statistically more likely that the individual has some propensities to aggressiveness; psychosurgery may appear as a desirable treatment on the surface, but the underlying neural mechanisms are unlikely to be so simple to delineate. Given the variety of etiologies of acquired aggression, it seems entirely possible that some individuals could be unresponsive to treatment (which were not custom designed to treat the condition) while still having acquired aggressiveness. Correspondingly, the principle of non-maleficence must be respected in a context where the psychosurgery is experimental and not vital to the patient’s life. It is more desirable not to do harm to patients with acquired aggressiveness, than to try to release them from their conditions.

Ensuring the safety and efficacy of the treatment could increase the ethical permissibility of using intrusive surgical brain interventions for voluntary treatment, but it does not necessarily entail ethical justification for going ahead with invasive brain surgery. If we separate what is permissible from what is desirable for the patient’s interests, in terms of invasive brain interventions, it can highlight the interests of medicine and institutions with respect to those of patients, and accentuate the ethical responsibilities of physicians. Before psychosurgery is considered a desirable option in a legally competent patient, the ethical requirements of non-maleficence have to meet the etiological complexity of aggression; and so far, it is unlikely that a uniquely acquired aggressiveness pattern, or a unique acquired neurobiological cause of aggressiveness, will be targeted to treat effectively disruptive outcomes. We defend that psychosurgery related to neuro-oncology might have a better chance to meet the criteria of ethical desirability for the patient’s interests, since most of the time it involves the removal of a tumour [41, 47].

Is There a Duty to Consent to Invasive Brain Surgery to Maintain autonomy?

Much focus rests on whether, and how, we may proceed with compulsory treatment or psychosurgery in patients who present with acquired aggressiveness and who refuse such interventions. The value we attach to self-determination is thus central, and underlies much of the precautions described above. In some cases, however, this leads us into something of a paradox: when the purpose of surgery includes restoring the patient’s decision-making capacity to consent, in particular when a patient faces the prospect of a rapid mental decline, should our very respect for this ability lead us to mandate the intervention [55]? Put in a somewhat different manner, would the patient (discussed above) have had a duty to consent to invasive brain surgery, when the purpose was to maintain or restore his autonomy by reducing or even eliminating his aggressive drives? If such a duty exists, it would not provide sufficient reason to proceed with involuntary surgery in competent patients, but in the case of proceeding with surgery in incompetent patients would it be stronger? A similar, stronger point is sometimes made in the context of end-of-life choices: that making a choice which could lead to the loss of autonomy may be considered contradictory, as making a choice which ends autonomy (for example in our case study the patient could have chosen to die from the brain tumour) contradicts our duty to respect autonomy. As this argument goes, such choices should not be allowed within the scope of choices we allow persons to make for themselves [56]. Although we argue here that this argument fails, it is worth presenting because it does focus on a rather specific characteristic of invasive brain surgery with the effect of changing behaviour: a concern to prevent or reverse the loss of self. If what we respect in persons is their self or their autonomy, would persons with a disease affecting their capacity have an obligation to take all available chances of maintaining autonomy, including invasive brain surgery?

There are three arguments against this conclusion. First, when the surgical intervention is experimental, as has often been the case in the darker episodes of psychosurgery, accepting it would require that we buy into the therapeutic misconception [57], and presume that research interventions are effective, whereas this is by definition uncertain. Nevertheless, uncertainty cannot truly counter this argument, as the mere chance of maintaining the capacity for self-determination may still be sufficient. This chance, however, does at least have to exist and where it does not there cannot be a duty to accept invasive brain surgery to maintain autonomy.

Second, a duty to maintain one’s own autonomy is a duty to oneself. Unlike duties to others, the very existence of duties to ourselves is controversial [58]. One reason is that their justification rests on distinct views of what constitutes a good human life; in a liberal pluralist context, then, they cannot be imposed on persons who do not share the same view of human flourishing.

Third, as McMahan argues in the context of end-of-life choices, for a person to be worthy of respect is for this person to matter in some ways. True, one possibility is to consider that a person’s ‘rational nature’, or autonomy, provides us with a reason why this person should matter to us. But even under such a view, the end of a person’s ‘rational nature’ does not cause this person to cease to matter [59]. Even if self-determination is central to that which we should protect in persons, this does not make it the only aspect of persons we should protect. Nor does it mean, then, that persons have a duty to protect their own self-determination above all other considerations. Velleman puts it as follows: “Respecting …people is not necessarily a matter of keeping them in existence; it is a matter of treating them in the way that is required by their personhood-whatever way that is” [60, p 616].

In short, a duty to consent to invasive brain surgery in cases of acquired aggressiveness in order to maintain autonomy is conditioned on the effectiveness of the intervention for this purpose. It is problematic as a duty to oneself, because it cannot be grounded in the fact that our respect for persons is—sometimes- based on their capacity for autonomy. Such a duty does not seem justified. There may, however, nevertheless be a duty to consent to invasive brain surgery: in order to avoid harming others and oneself. This would be conditioned on the effectiveness of surgery to limit aggressiveness, rather than to maintain autonomy. It would be a duty to others and not oneself. It would be grounded in our general duty to respect persons, not on the fact that our autonomy is one of the reasons to respect persons. In some circumstances, however, surgery could actually impair the patient’s autonomy. In such cases, consenting would amount to sacrificing self-determination to protect others. Arguably, although such a choice would be praiseworthy, it could not be considered obligatory.

Conclusion

Psychosurgical interventions for treatment indications raise ethical challenges when related to acquired aggressiveness. To illustrate the difficulties attached to disruptive aggressive behaviour, we have discussed a case which featured a patient with acquired aggressiveness which was positively correlated with a diagnosis of a meningioma. Like other cases of acquired aggressiveness involving neuro-oncology aetiologies in the frontal and temporal lobe, one way to explain patient’s disinhibitory aggressive behaviour was to consider neuropathological disruption as an exacerbation of reactive outcomes. The disinhibitory reactive behaviours were coupled with some impairment of executive function, which affects judgment and the ability to inhibit certain behaviours, and manifests in the end as acquired aggressiveness. The patient’s acquired aggressiveness symptoms were resolved with the excision of the meningioma. These results would seem to indicate a strong biological etiology of the aggressive propensities, similar to other cases of tumour removal [41, 47]. Nevertheless, acquired aggressiveness is one rare symptom in the spectrum of cognitive impairments caused by brain lesions. From isolated cases of acquired aggressiveness, it is impossible to draw a general medical prescription for all cases of intractable aggression in the common population, or to defend a neurobiological reductionist cause which can treat aggressive behavior. Many non-neurological factors can interact with biological elements to produce aggression. The clinical assumption that intractable aggression is a unitary phenomenon in both animals and humans has been questioned for many years [61].

Conducting invasive surgery involving human brain procedures is inherently loaded with ethical questions. Prescribing an invasive brain surgery on a patient with impaired capacity to consent should take into consideration the degree of physical and psychological constraint imposed, even in rare cases of disruptive aggressive behaviour. Beyond the fundamental concerns specifically associated with a patient’s inability to consent, is it essential to question to what extent it is desirable for a patient with full capacity to consent to invasive psychosurgery, even when the ethical permissibility of safety and efficacy allow it. Although the maximization of the direct benefits of invasive brain intervention could be desirable, as long as it does not interfere with patient’s medical interest, the therapeutic aim of compulsory treatment should, in general, prevail in psychosurgery. Although there are ethical reasons to advocate a psychosurgical procedure on individuals with intractable acquired aggressiveness who are legally competent, in particular cases, such as to avoid harming others or themselves, it is still far from being an obligation to consent to it. As examined above, even if individuals with acquired aggressiveness show reduced inhibition and personality changes, behave in response to “abnormal” impulsions and urges, and demonstrate evidence of brain lesions, there is, nevertheless, no obvious medical prescription to follow. Prescribing invasive brain surgery aimed at reducing the severity of acquired aggressive behaviours is not an ethical obligation per se. As explored, given the experimental nature of the intervention, unpredictable effectiveness, potential coercive context, intrusive aspects of the intervention, there is no ethical obligation to prescribe an invasive brain surgery. Consequently, an obligation to perform invasive brain surgery should be balanced against the bioethical principles of beneficence and non-maleficence. We believe invasive brain surgery in cases where patient’s lack decision-making capacities to consent can be generalized to most clinical cases involving experimental psychosurgery for reducing intractable acquired aggressiveness, especially with respect to populations where either decision-making capacity or the freedom to make a self-determined choice is absent or limited, as is the case for example with severely mentally ill people and children, or with prisoners.

Footnotes

  1. 1.

    For instance, in England and Wales, psychosurgery is one of the two treatments that cannot be enforced on someone detained under the Mental Health Act 2007. In Slovenia, all psychosurgical procedures are forbidden by law.

  2. 2.

    In the 19th century, the concept ‘lunatic’ referred to an individual suffering from a mental illness.

Notes

Acknowledgements

Thanks to Eliza Goddard and Susan Dodds. Thanks to the anonymous reviewers for their helpful comments and suggestions. This research was funded by the Australian Centre of Excellence for Electromaterials Science (ACES). CE0561616.

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Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  1. 1.Ethics & Bionics/Nanomedicine, Australian Centre of Excellence for Electromaterials Science (ACES)University of TasmaniaTasmaniaAustralia
  2. 2.Department of NeurosurgeryUniversity Medical Centre LjubljanaLjubljanaSlovenia
  3. 3.Institute for Biomedical EthicsGeneva 4Switzerland

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