Psychosurgery, Deep Brain Stimulation, and the Re-writing... : Neurosurgery (original) (raw)
In Reply:
Professor Hariz notes that our recent editorial, “Psychosurgery: Avoiding an Ethical Redux while Advancing a Therapeutic Future,” was “an important article” (3). We welcome this opportunity to respond to his comments and make some needed clarifications.
Our main point, then and now, is one of collaboration. It was not about ascribing historical blame to one discipline or another, but to assert that, as neuromodulation moves forward, it must be interdisciplinary in nature. This point is obscured by Dr. Hariz's assertion that past abuses were not done by neurosurgeons and by reminding the readership that Walter Freeman was not a neurosurgeon.
This is a biographical fact that we certainly appreciate. It was embedded in our piece while we were making the larger point about multidisciplinary work. We explicitly commented on the “ … idiosyncratic legacy of the psychiatrist (Freeman) who went it alone and was renounced by the neurosurgeon (Watts)” (3, p 715). We cannot be held responsible for any misstatements or the historical ignorance of the other essayists and commentators cited by Professor Hariz.
Similarly, while we appreciate Dr. Hariz's endorsement of the guidelines of the OCD-DBS Collaborative Group report (8), of which we were also co-authors (BDG, ARR) and senior author (JJF), we cannot comment on patient outcomes from the landmark 1999 study by Nuttin et al. (7). We were not involved in that study, which antedated the aforementioned guidelines. The guidelines were drafted by an interdisciplinary and multinational group during a 2002 meeting convened by Professor Alim Benabid in Aix-les-Bains, France.
But it is the larger point of interdisciplinary work to which we want to return. The careful reader will recall that our editorial was a response to “Surgery of the Mind and Mood: A Mosaic of Issues in Time and Evolution,” by Heller et al. (6). We were concerned that the piece did not articulate the need for a collaborative and interdisciplinary approach for the field (3).
Despite Professor Hariz's assertion, we made the argument (1) for collaboration with “historical _rigueur_” by invoking the wisdom of Wilder Penfield, perhaps the most collaborative and cross-trained neurosurgeon of his, or any other, era. Penfield famously observed that, “When one is alone, it is easy to go off on a tangent” (9, p 174).
It is a curious omission that Professor Hariz did not mention Penfield in his letter, as he was defending against a “misdirected witch-hunt that might jeopardize the credibility of these multidisciplinary ethical efforts.” One would think that, as Dr. Hariz defended the good name of neurosurgery, he would echo our assertion that Penfield be viewed as a “role model” for today's neurosurgeon who is engaged in the field of stereotactic functional neurosurgery. Again, we return to the title of Penfield's posthumously published autobiography, No Man Alone, which elegantly embodies our point (9).
Although collaborative practice is not a guarantee against unethical practice, it is among the best defenses against idiosyncratic behavior that we know. It is unclear why Professor Hariz is so set on defending neurosurgery, and we are concerned by his discursive tack. As he noted, one of us (JJF) has written approvingly of the contributions by Thomas Ballantine, the Harvard neurosurgeon who initiated a collaborative approach to the assessment of patients—an approach that continues to this day (2). There are other historical examples, such as Francisco Garcia-Bengochea, a neurosurgical colleague of Robert Heath, who, according to email correspondence sent to one of us (JJF) by his neurosurgeon son, Dr. Javier Garcia-Bengochea, left New Orleans because of normative concerns: “My father left the Tulane study prematurely (1952) … after ongoing disagreements with Dr. Ernie Sachs (Jr. and Sr.) as well as Bob Heath over the study design and ethics (and morals) of their work (culminated by a scene at the Cushing meeting in Atlantic City that year) to return to Havana, Cuba for a brief period of private practice. He ultimately relocated in exile at UF in Gainesville” (Garcia-Bengochea J, personal communication, October 16, 2006).
These examples speak to the positive role that neurosurgeons have played, and must play, in ensuring the ethical integrity of this contentious work. Our focus on the neurosurgeon was not accusatory but, rather, pragmatic. In today's clinical environment, the neurosurgeon is likely to be the common final pathway for ablative or neuromodulatory procedures, notwithstanding the potentially more interdisciplinary approach associated with gamma knife procedures. For this reason, it is important for neurosurgery as a discipline to take responsibility for the actions of its members because of the central role that neurosurgeons will play in either advancing a therapeutic future or hindering it.
This is more than a speculative worry. It is a real-world concern. We recently read an article in The Wall Street Journal describing the large-scale resurgence of ablative psychosurgery on the mentally ill in China (10). The article describes the actions of Dr. Wang Yifang, head of neurosurgery at Number 454 Hospital in Nanjing. At age 44, he has already performed “ … nearly 1,000 such procedures, mostly for schizophrenia, but also for illnesses ranging from depression to epilepsy, since the hospital started offering the operation in 2004” (10, p A-1). Number 463 Hospital of the People's Liberation Army in Shenyang is reported to have performed “more than 2,000 surgeries since about 2001, with almost all patients reporting progress” (10, p A-1). By way of comparison, from the late 1930s to the late 1950s, 40 000 to 50 000 procedures were performed in the United States, with some 4000 estimated to have been performed or supervised by Walter Freeman in 30 hospitals in 15 states (4).
The report from China is a journalistic account, to be sure. Nonetheless, it is one that was prominently placed on page 1 of a leading newspaper. This is precisely the sort of ethical redux that we had hoped to avoid, in order to move responsible work forward. Instead of arguing about the past, we hope that the international neurosurgery community will confirm or refute these data. If these allegations are true, they constitute an epidemic of ablative neurosurgery in China to treat an illness (schizophrenia) for which the outcomes of past lesion procedures were exceptionally poor (5). This would represent a breach of professional ethical standards to which all must adhere.
Joseph J. Fins
Ali R. Rezai
Benjamin D. Greenberg
New York, New York
1. Fins JJ: From psychosurgery to neuromodulation and palliation: History's lessons for the ethical conduct and regulation of neuropsychiatric research. Neurosurg Clin N Am 14:303–319, 2003.
2. Fins JJ: A Leg to Stand On: Sir William Osler and Wilder Penfield's “Neuroethics.” John P. McGovern Annual Award Lecture. American Osler Society, 2006.
3. Fins JJ, Rezai AR, Greenberg BD: Psychosurgery: Avoiding an ethical redux while advancing a therapeutic future. Neurosurgery 59:713–716, 2006.
4. Frankel GDC: Neurosurgeon pioneered “operation icepick” technique. The Washington Post, April 7, 1980, pp A1–A2.
5. Greenberg BD, Price LH, Rauch SL, Jenike M, Malone D, Friehs G, Noren G, Rasmussen SA: Neurosurgery for intractable obsessive-compulsive disorder and depression: Critical issues_._Neurosurg Clin N Am 14:199–212, 2003.
6. Heller AC, Amar AP, Liu CY, Apuzzo MLJ: Surgery of the mind and mood: A mosaic of issues in time and evolution. Neurosurgery 59:720–733, 2006.
7. Nuttin B, Cosyns P, Demeulemeester H, Gybels J, Meyerson B: Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder. Lancet 354: 526, 1999.
8. OCD-Collaborative Group: Deep brain stimulation for psychiatric disorders. Neurosurgery 51:519, 2002.
9. Penfield W: No Man Alone: A Neurosurgeon's Life. Boston, Little, Brown and Co., 1977.
10. Zamiska N: Harsh treatment in China, brain surgery is pushed on the mentally ill. The Wall Street Journal, November 2, 2007, p A-1.
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