Informed Consent

Like many others, I’ve never been a big fan of surgery as a solution for mental disorders like obsessive-compulsive disorder (OCD) or depression. A medical procedure done on a bodily organ whose functioning we’re only beginning to grasp — the brain — seems a little premature. It hits too close to the thinking behind frontal lobotomies and the justifications doctors used for them back in the 1950s and 1960s, “By cutting and removing the front part of the brain, we help quiet the unrest in these troubled minds.” As we later found out, we also quieted the entire person to the point of many of those people become drooling vegetables.

That was considered “progress” by many well-educated professionals for many, many years during this time. Amazing.

This time around, docs apparently are taking a far more conservative approach. Yet it is still one fraught with risk and very little research to back up its use. With somewhere around just 500 of these newer, more targeted brain surgeries taking place in the past decade, it appears that the programs that do these kinds of surgeries are really seeking out “surgery as a last resort” patients:

The institutions all have strict ethical screening to select candidates. The disorder must be severe and disabling, and all standard treatments exhausted. The informed-consent documents make clear that the operation is experimental and not guaranteed to succeed.

Nor is desperation by itself sufficient to qualify, said Richard Marsland, who oversees the screening process at Butler Hospital in Providence, R.I., which works with surgeons at Rhode Island Hospital, where Leonard and Ross had the operation.

“We get hundreds of requests a year and do only one or two,” Mr. Marsland said. “And some of the people we turn down are in bad shape. Still, we stick to the criteria.”

For those who have successfully recovered from surgery, this intensive screening seems excessive.

Excessive, perhaps. But given the history of surgery to treat psychological concerns, I think the intense screening is more than necessary. Without it, we’d have way too many horror stories of surgeons who operate on the brain for the insurance reimbursement or fee, rather than caring about actual patient outcomes of such surgeries. Doctors are all too willing to apply what they know (e.g., hammer) to anything that needs fixing (e.g., nail), even if the problem isn’t clearly something their tool will fix (e.g., a piece of glass).

And of course, who does the research into whether these techniques show much effectiveness? Why, who else of course but the surgeons themselves! (Another example of why peer-reviewed journal articles aren’t always all that helpful as a quality filter.)

In a paper published last year, researchers at the Karolinska Institute in Sweden reported that half the people who had the most commonly offered operations for obsessive-compulsive disorder showed symptoms of apathy and poor self-control for years afterward, despite scoring lower on a measure of O.C.D. severity.

“An inherent problem in most research is that innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid,” Dr. Christian Ruck, the lead author of the paper, wrote in an e-mail message. The institute’s doctors, who burned out significantly more tissue than other centers did, no longer perform the operations, partly, Dr. Ruck said, as a result of his findings.

In the United States, at least one patient has suffered disabling brain damage from an operation for O.C.D. The case led to a $7.5 million judgment in 2002 against the Ohio hospital that performed the procedure. (It is no longer offered there.)

I’d hate to see giant lawsuits snuffing out a promising treatment, but it might also help explain why the intensive screening process and reticence of the part of doctors to perform such surgeries.

But hey, this is nothing new — just a part of the never-ending process of, “Oh, gee, look, shiny new treatment ABC for problem XYZ, let’s all use it!” “Wow, treatment ABC has more side effects/problems/isn’t as effective as originally promised as we all thought/were told/imagined. We’ll continue to use it anyway since it’s better than nothing…” “Oh, look, new shiny treatment, let’s try that one instead…!” And so on…

Moreover, demand for the operations is so high that it could tempt less experienced surgeons to offer them, without the oversight or support of research institutions.

And if the operations are oversold as a kind of all-purpose cure for emotional problems — which they are not, doctors say — then the great promise could quickly feel like a betrayal.

“We have this idea — it’s almost a fetish — that progress is its own justification, that if something is promising, then how can we not rush to relieve suffering?” said Paul Root Wolpe, a medical ethicist at Emory University.

It was not so long ago, he noted, that doctors considered the frontal lobotomy a major advance — only to learn that the operation left thousands of patients with irreversible brain damage. Many promising medical ideas have run aground, Dr. Wolpe added, “and that’s why we have to move very cautiously.”

I agree with Dr. Wolpe. Any new treatment has promise, but no matter what the promise, we have to do the foundational research that ties empirical, unbiased data to outcome results for the patient — do they actually get better on a wide range of measures and symptoms not just weeks, but months or even years after treatment? Without that data, we should move forward cautiously and with a healthy skepticism for the new treatment.

Read the full article: Brain Power – New Techniques in Brain Surgery Mix Hope With Risk