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

Part of the Current Topics in Behavioral Neurosciences book series (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.

Keywords

Parkinson’s disease Deep brain stimulation Ethics Pragmatism 

Notes

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).

References

  1. 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 70:409–414CrossRefPubMedGoogle Scholar
  2. 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):639–642CrossRefPubMedGoogle Scholar
  3. Ballanger B, van Eimeren T, Moro E et al (2009) Stimulation of the subthalamic nucleus and impulsivity: release your horses. Ann Neurol 66(6):817–824CrossRefPubMedCentralPubMedGoogle Scholar
  4. Beauchamp T, Childress J (2009) Principles of biomedical ethics, 6th edn. Oxford University Press, OxfordGoogle Scholar
  5. Bell E, Mathieu G, Racine E (2009) Preparing the ethical future of deep brain stimulation. Surg Neurol 72(6):577–586CrossRefPubMedGoogle Scholar
  6. 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):112–124PubMedGoogle Scholar
  7. 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):537–547CrossRefPubMedGoogle Scholar
  8. 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 2011:871874Google Scholar
  9. Bell E, Racine E (2013) Ethics guidance for neurological and psychiatric deep brain stimulation. Handb Clin Neurol 116C:313–325CrossRefGoogle Scholar
  10. 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):344–346PubMedGoogle Scholar
  11. 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) 58:39–44Google Scholar
  12. Bladin PF (1992) Psychosocial difficulties and outcome after temporal lobectomy. Epilepsia 33(5):898–907CrossRefPubMedGoogle Scholar
  13. 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):1224–1230CrossRefPubMedGoogle Scholar
  14. 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
  15. 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
  16. 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
  17. 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):1320–1324CrossRefPubMedGoogle Scholar
  18. 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
  19. Cunningham AD, Plummer CJ, McComb JM et al (2005) The implantable cardioverter-defibrillator: postcode prescribing in the UK 1998–2002. Heart 91(10):1280–1283CrossRefPubMedCentralPubMedGoogle Scholar
  20. 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):763–771CrossRefPubMedGoogle Scholar
  21. 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):863–868CrossRefPubMedGoogle Scholar
  22. Farris SM, Gianola FJ (2009) Ethical issues surrounding deep brain stimulation in Parkinson’s disease. JAAPA 22(2):57–58PubMedGoogle Scholar
  23. Fins JJ (2000) A proposed ethical framework for international cognitive neuroscience: a consideration of deep brain stimulation in impaired consciousness. Neurol Res 22:273–278PubMedGoogle Scholar
  24. 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–S167CrossRefPubMedGoogle Scholar
  25. Ford PJ (2009) Vulnerable brains: research ethics and neurosurgical patients. J Law Med Ethics 37(1):73–82CrossRefPubMedGoogle Scholar
  26. 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):443–449CrossRefPubMedCentralPubMedGoogle Scholar
  27. Frank MJ, Samanta J, Moustafa AA et al. (2007) Hold your horses: impulsivity, deep brain stimulation, and medication in parkinsonism. Science 318(5854):1309–1312Google Scholar
  28. Gisquet E (2008) Cerebral implants and Parkinson’s disease: a unique form of biographical disruption? Soc Sci Med 67 (11):1847–1851 Google Scholar
  29. Glannon W (2010) Consent to deep brain stimulation for neurological and psychiatric disorders. J Clin Ethics 21(2):104–111PubMedGoogle Scholar
  30. Government of Canada (1984) Canada Health Act. Revised Statutes of Canada, 1985, c. C-6. Minister of JusticeGoogle Scholar
  31. Grimes D, Gordon J, Snelgrove B et al (2012) Canadian guidelines on Parkinson’s disease. Can J Neurol Sci 39(4 Suppl 4):S1PubMedGoogle Scholar
  32. 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):493–497CrossRefPubMedGoogle Scholar
  33. Holloway RG, Ringel SP, Bernat JL et al (2000) US neurologists: attitudes on rationing. Neurology 55(10):1492–1497CrossRefPubMedGoogle Scholar
  34. Kim SYH (2004) Evidence-based ethics for neurology and psychiatry research. NeuroRX 1:372–377CrossRefPubMedCentralPubMedGoogle Scholar
  35. 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):1925–1934CrossRefPubMedGoogle Scholar
  36. Lad SP, Kalanithi PS, Patil CG et al (2010) Socioeconomic trends in deep brain stimulation (DBS) surgery. Neuromodulation 13(3):182–186CrossRefPubMedGoogle Scholar
  37. Lee DS, Tu JV, Juurlink DN (2008) Do Ontario patients with heart failure have equal access to life-saving technology? Healthc Q 11(3):20–21CrossRefPubMedGoogle Scholar
  38. Lopes M, Meningaud JP, Behin A et al (2003) Consent: a Cartesian ideal? Human neural transplantation in Parkinson’s disease. Med Law 22(1):63–71PubMedGoogle Scholar
  39. 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):1867–1874CrossRefPubMedCentralPubMedGoogle Scholar
  40. 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):16–18CrossRefGoogle Scholar
  41. 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):1308–1312CrossRefPubMedGoogle Scholar
  42. 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):218–223CrossRefPubMedGoogle Scholar
  43. 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 123–140Google Scholar
  44. Miocinovic S, Somayajula S, Chitnis S et al (2013) History, applications, and mechanisms of deep brain stimulation. JAMA Neurol 70(2):163–171CrossRefPubMedGoogle Scholar
  45. 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):1013–1027CrossRefPubMedGoogle Scholar
  46. 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):578–586CrossRefPubMedGoogle Scholar
  47. 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
  48. 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
  49. 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):586–595CrossRefPubMedCentralPubMedGoogle Scholar
  50. Perozzo P, Rizzone M, Bergamasco B et al (2001) Deep brain stimulation of subthalamic nucleus: behavioural modifications and familiar relations. Neurol Sci 22(1):81–82CrossRefPubMedGoogle Scholar
  51. Racine E (2013) Pragmatism and the contribution of neuroscience to ethics. Essays Philos Humanism 21(1):13–20Google Scholar
  52. Racine E, Van der Loos HZA, Illes J (2007a) Internet marketing of neuroproducts: new practices and healthcare policy challenges. Camb Q Healthc Ethics 16:181–194PubMedGoogle Scholar
  53. 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):314–318CrossRefGoogle Scholar
  54. 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):495–499CrossRefGoogle Scholar
  55. Schechtman M (2010) Philosophical reflections on narrative and deep brain stimulation. J Clin Ethics 21(2):133–139PubMedGoogle Scholar
  56. Schrag A, Banks P (2006) Time of loss of employment in Parkinson’s disease. Mov Disord 21(11):1839–1843CrossRefPubMedGoogle Scholar
  57. 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):1250–1256CrossRefPubMedGoogle Scholar
  58. Schüpbach M, Gargiulo M, Welter ML et al (2006) Neurosurgery in Parkinson disease: a distressed mind in a repaired body? Neurology 66(12):1811–1816CrossRefPubMedGoogle Scholar
  59. Schüpbach WM, Agid Y (2008) Psychosocial adjustment after deep brain stimulation in Parkinson’s disease. Nat Clin Pract Neurol 4(2):58–59CrossRefPubMedGoogle Scholar
  60. Seaburn DB, Erba G (2003) The family experience of “sudden health”: the case of intractable epilepsy. Fam Process 42(4):453–467CrossRefPubMedGoogle Scholar
  61. Sevillano-Garcia MD, Manso-Calderon R (2010) nonmotor symptoms in Parkinson’s disease and deep brain stimulation. Rev Neurol 50(Suppl 2):S95–S104PubMedGoogle Scholar
  62. 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–24AGoogle Scholar
  63. 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):754–760CrossRefPubMedGoogle Scholar
  64. 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):525–532CrossRefPubMedGoogle Scholar
  65. Susman E (2001) Deep brain stimulation for Parkinson disease patients should start before medications fail. Neurol Today 1(1):28–32CrossRefGoogle Scholar
  66. Synofzik M, Schlaepfer TE (2008) Stimulating personality: ethical criteria for deep brain stimulation in psychiatric patients and for enhancement purposes. Biotechnol J 3(12):1511–1520CrossRefPubMedGoogle Scholar
  67. Talan J (2009) Deep brain stimulation: a new treatment shows promise in the most difficult cases. Dana Press, New YorkGoogle Scholar
  68. Tepper J, Jaigobin C, Wang C (2005) Health human resources for neurosurgical services in Ontario. ICES investigative report. Institute for Clinical Evaluative Sciences, TorontoGoogle Scholar
  69. 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
  70. 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):119–131CrossRefPubMedGoogle Scholar
  71. Vogel L (2011) Specialty training out-of-sync with job market. CMAJ 183(13):E1016CrossRefPubMedCentralPubMedGoogle Scholar
  72. 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):994–997CrossRefPubMedGoogle Scholar
  73. 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):170–174CrossRefPubMedGoogle Scholar
  74. Woopen C, Pauls KA, Koy A et al (2013) Early application of deep brain stimulation: clinical and ethical aspects. Prog Neurobiol 110:74–88CrossRefPubMedGoogle Scholar
  75. World Medical Association (1948, revised May 2006) WMA declaration of Geneva. http://www.wma.net/en/30publications/10policies/g1/. Accessed 18 Dec 2013

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Neuroethics Research UnitInstitut de recherches cliniques de Montréal (IRCM)MontréalCanada
  2. 2.Department of Medicine and Department of Social and Preventive MedicineUniversité de MontréalMontréalCanada
  3. 3.Departments of Neurology and Neurosurgery,Experimental Medicine and Biomedical Ethics UnitMcGill UniversityMontréalCanada
  4. 4.Departments of Neurology and NeurosurgeryMcGill UniversityMontréalCanada
  5. 5.Experimental Medicine and Biomedical Ethics UnitMcGill UniversityMontréalCanada

Personalised recommendations