Science in Christian Perspective

Violence, Psychosurgery and Human Responsibility
D. GARETH JONES
Department of Anatomy and Human Biology
University of Western Australia
Nedlands, W.A. 6009

One of the greatest problems confronting the human race at present is the frequency with which violence is resorted to by both individuals and societies. While this is no new problem for mankind, some of the solutions proposed to combat and eradicate the violent behaviour patterns of individuals are new, and these in turn pose further problems. In particular, direct surgical approaches to the brains of violent individuals, while sometimes successful in eradicating the violence, also raise issues such as the inviolability of the human person, the reality of human responsibility and the legitimacy of exerting social control by means of biological manipulation.

Neurosurgical procedures of this kind fall into the category of what is known as psychosurgery. This involves the destruction of brain tissue with the aim of treating behavioural, as opposed to organic, disorders. In other words, it is generally carried out in the ab sence of any identifiable abnormality of the brain itself, the tissue that is destroyed being apparently normal. The main current indication for psychosurgery, and the reason for its emergence into the public arena, is uncontrollable violence and rage.

The controversy surrounding psychosurgery takes us well beyond purely medical considerations, and into medico-legal, ethical, philosophical and theological areas. What is more, it highlights the way in w ic

technological answers to what have been considered as traditional questions may be very different from the traditional responses. It brings us face-to-face therefore, with technocracy and its impingement upon traditional, and these are often religious, values.

Christians therefore, cannot shy away from the issues posed by psychosurgery. This is because much that the Christian considers important is brought. into perspective by this debate. This does not imply that the Christian response is to be one of outright hostility to psychosurgery, as unfortunately would often have been the case in the past. The issues are far too complex and demanding for such a response. Rather they should force the Christian to think hard about his beliefs concerning man as a person, man as a responsible being, man as a biological entity, man as an being advocated as it is as a specific antidote for violence. When viewed in this light, psychosurgery as purveyor of sophisticated technology, and man as sinner in relationship to his creator-God.

The Debate

While psychosurgery is not confined to the treatment of violence and extreme aggressiveness, most of the issues surrounding it are brought to a head in this area, and I will deal mainly therefore with violence. In a realm so bereft of hard data and established ethical guide-posts it is hardly surprising that the lines of battle are drawn in highly emotional terms. It is also not surprising to find the protagonists lined up behind well-defined personalities who have succeeded in reducing the issues to their most simplistic framework.

In favour of the present vogue of 'new wave, psychosurgery we find Dr. Vernon Mark and Dr. Frank Ervin who set the scene for the violence debate with their book Violence and the Brain (Harper and Row, New York; 1970). While Mark, Ervin and their colleague William H. Sweet form just one of a number of groups throughout the world actively involved in psychosurgery, they have succeeded in gaining the public's attention with their pronouncements on the potential value of psychosurgery in combating growing urban violence.

For instance, in 1967 these three wrote a now famous letter to the Journal of the American Medical Association. In this they suggested that in addition to the environmental and social factors that were undoubtedly important in the urban riots then raging throughout the United States, a third factor was being ignored. This was the possible role of brain disease, a factor about which little was known. Consequently they pointed to the urgent need for research to "pinpoint, diagnose, and treat those people with low violence thresholds before they contribute to further tragedies".

This theme was taken up in greater detail by Mark and Ervin in Violence and the Brain, which they wrote in order "to stimulate a new and biologically oriented approach to the problem of human violence". As they do not go into a detailed discussion of the social (or theological) causes of violence, it is easy to gain an unbalanced view of their thesis. Essentially however, they view the problem of human violence as potentially solvable, as a result (one imagines) of biological procedures. Because all behaviour filters through the brain (which is another way of " as a man thinks so he acts") they argue that studying the relationship between the brain and violence is the best way to get to understand the mechanisms of violent behaviour".

It is difficult to know how far Mark and Ervin would take this principle as they readily concede that all violence is not caused by people with damaged brains. They repeatedly emphasize however, the inadequacy of approaches relying either on the enforcement of 'law and order' or on the correction of social injustices, and against these stress that "many of the individuals who act violently have brain diseases that can be described, diagnosed, treated and controlled".

A vital corollary of this approach is the need to detect and treat individuals with malfunctioning brains before they commit serious crimes of violence. It is at this point that psychosurgery takes on some of the apparel of both criminology and preventative medicine being advocated as it is as a specific antidote for violence. When viewed in this light, psychosurgery assumes the mantle of the biological answer par excellence to all forms of social deviance; hence, the bitter opposition of some to any form of psychosurgery.

While it would be quite incorrect to suggest that all advocates of psychosurgery would be prepared to take it to these lengths, some serious proposals regarding its use are nothing less than startling. Dr. Kenneth B. Clark, a social psychologist, put his position in these words:

Given the urgency of the immediate survival problem, the psychological and social sciences must enable us to control the animalistic, barbaric and primitive propensities in man ... We can no longer afford to rely solely on the traditional prescientific attempts to control human cruelty and destructiveness . . . (Instead we) accept and use the earliest perfected form of psychotechnological, biochemical intervention which would . . . reduce or block the possibility of using power destructively (Presidential Address, American Psychological Association, 1971).

The opponents of psychosurgery take sentiments of this nature as their cue, and in fear of the misapplication of this technique reject it in its entirety. The fear most often expressed is that of social control, psy chosurgery being used for the good of society rather than the good of the patient. It is argued by some that doctors have no right to perform operations on the brains of patients in order to make them conform to society's requirements.

T~is point-of-view has been forcefully expressed in a number of quarters. A petition produced by an Ad Hoe Committee on Psychosurgery of the National Institutes of Mental Health contained this warning:

Since psychosurgery can severely impair a person's intellectual and emotional capacities, the prospects for repression and social control are disturbing.

Dr. Peter Breggin, a Washington psychiatrist, and one of the foremost opponents of psychosurgery is more explicit in his condemnation of it. He opposes all forms of psychosurgery on the grounds that not only is there no justification for any of the operations but, to make matters worse, the procedure has a blunting effect on emotions and thought processes. In short, psychosurgery according to him is an "abortion of the brain" and is being used to repress and vegetabilize the helpless, the poor, the female, the black, the imprisoned and the institutionalized. In similar vein, others contend that psychosurgery could be used against dissidents and rebellious groups on the pretext of curbing their antisocial behaviour. More specifically, some lay emphasis upon the threat to blacks suggesting that any increased use of psychosurgery will be used predominantly to suppress blacks.

It should be obvious that the opponents of psychosurgery by-and-large reject it because of its general threats to individuals. The issue of violence as such does not feature highly in their arguments, with the result that the proponents and opponents of psychosurgery are arguing along rather different lines.

The Evidence

The debate about psychosurgery is only of significance if psychosurgery is as effective in practice as the protagonists suggest. After all, there is little point in arguing about social control if it is unable to alter behaviour in a predictable and rigidly controlled manner. Neither is it worth pursuing its influence on violent behaviour, if it eliminates violence only at the expense of other normal, social behaviour patterns. What then is the status of the medical evidence?

Before attempting to answer this question it is important to place present-day psychosurgery in perspective. At present, on the over of 500 psychosurgery operations are being performed each year in the United States, and these are being carried out by about a dozen neurosurgeons. This figure should be compared with the 50,000 or so prefrontal lobotomies performed for a variety of mental conditions in the 1940's and 1950's. While it would be shortsighted to place undue weight on this comparison, it is important to realize that current psychosurgery is relatively limited and is under severe scrutiny.

Psychosurgery itself involves the destruction of very small regions of brain tissue, generally by passing an appropriate current through one or more electrodes imp!anted in the brain. Implanted electrodes have been used for many years to map out functional areas within the brain of experimental animals and man, this technique being referred to as electrical stimulation of the brain (ESB). The part of the brain principally involved in clinical and experimental studies of violence is the limbic system, the so-called emotional brain. Of the constituent areas of the limbic system the one which has come in for most attention in regard to violence is the amygdala.

The basis for believing that the limbic system is involved in some way in aggressive behaviour stems from animal experiments in which this system was either removed or electrically stimulated. When removed, normally aggressive monkeys or cats have been observed to become placid, are easily handled, and do not respond aggressively even to attack by other members of their social group. Conversely, the stimulation of this system converts a quiet animal into one prepared for attack behaviour-as long, that is, as the stimulation is maintained. Numerous studies over the years point towards the same conclusion, that the limbic system and the amygdala in particular are intimately associated with the maintenance of violent behaviour. This applies to human behaviour as well, bearing in mind of course that the violent or aggressive behaviour under examination in most of these studies is essential for 'normal' survival.

A major difficulty with summarizing this type of study is that of generalization. it is very easy to concentrate on the increase or decrease in aggression, as this is the point of interest, and ignore other effects. What is more, far too many of the studies, especially clinical ones, have been inadequately assessed and may therefore prove grossly misleading. It would also be wrong to suggest that the results of the numerous studies undertaken are clear-cut in their results. They are not. Even a small area like the amygdala has a number of probable functions, while it makes numerous connections with other brain regions. This complexity

The issues should force the Christian to think hard about man as a person, man as a responsible being, man as a biological entity, man as an interdependent community of individuals, man as the purveyor of sophisticated technology, and man as a sinner in relationship to his creator-God.

of structure, coupled with the relatively primitive state of our knowledge about the brain, all makes for confusion if great care is not exercised in assessing the available evidence.

A recent excellent study of psychosurgery and its many ramifications is that of Dr. Elliot S. Valenstein whose book, Brain Control: A Critical Examination of Brain Stimulation and Psychosurgery (John Wiley and Sons, New York; 1973), is a mine of information and balanced comment in this hazardous realm. After meticulously analyzing the results of amygdalectomy operations (destruction of a part or the whole of the amygdala), Valenstein suggests that amygdalectomy is not related to aggression in a simple one-to-one manner. Instead he suggests that its effects on aggression reflect more general deficits such as: 1) an inability to relate visual information to past experience, and 2) a noticeable decrease in responsiveness to most stimuli that normally evoke emotional reactions. As Valenstein himself remarks:

The primary changes produced by these operations in animals may have little to do with the regulation of
aggression . . . It would be very surprising indeed if the brain was organized into spatially discrete units that
conform to our abstract categorizations of behaviour.

Psychosurgery in Humans

The decision to use psychosurgery in human patients in an attempt to control extreme violence is rarely a straightforward one. This is because in many cases the violence is associated with temporal lobe epilepsy, while some of the patients are also severely mentally retarded. Not surprisingly, assessment of the results of surgical intervention is accompanied by enormous difficulties.

The drawbacks with using psychosurgery in patients of this type are many. The connection between violence and epilepsy is murky; indeed it is rare. There is no concrete evidence that an individual's violent behaviour is associated with the specific damage located in his brain. As far as amygdalectomy is concerned, it is irreversible and may produce intellectual impairment, a danger of immense significance when contemplating the operation in a mentally normal patient.

Some doctors suggest that psychosurgery should be extended to patients who are only violent, that is, who have no other medical abnormalities such as epilepsy or even an abnormal EEG. It is at this point that psychosurgery takes on overtones of social control. Before becoming embroiled in emotional arguments about this, it is advisable to look at the evidence for the efficacy of these procedures. Again, the evidence is far from clear. While amygdala lesions in some of these patients have been reported to eliminate or at least dimminsh the rage attacks, it remains far from certain that individuals with a history of explosive violence do have specific brain sites triggering violence. Even if they do, are these sites being destroyed by amygdala lesions? The trial and error approach adopted in some instances casts doubt on their alleged specificity.

We are still left with the principle issue connected with psychosurgery and violence. Does it work? To what extent does it eliminate violence per se? After all, if psychosurgery can eliminate violence in individuals, it can be regarded only as an indispensable tool for social reconstruction.

As might be expected with an issue as complex and uncharted as this one, a neat summary is virtually impossible. This is particularly true in view of the subjective nature of any summary. Nevertheless the conclusions reached by Valenstein in his book Brain Control are worth quoting. After considering at some length the relation between brain pathology and violence, he concludes:

Although it is possible that there are more cases of abnormal brain foci triggering violence than may have been suspected, there is little to support the view that this factor is a major contributor to the tremendous proliferation of violent crimes that we are now experiencing.

Because Valenstein's detailed analysis of the results of psychosurgical procedures is characterized by extreme caution and by a reticence about generalizing, his conclusions are worthy of note. He writes:

There seems to be strong suggestive evidence (if not absolutely convincing) that some patients may have been significantly helped by psychosurgery. There is certainly no ground for either the position that all psychosurgery necessarily reduces people to a 'vegetable status' or that it has a high probability of producing miraculous cures. The truth, even if somewhat wishy-washy, lies in between these extreme positions.

A report produced for the National Institute of Neurological Diseases and Stroke in 1974 (Brain Research and Violent Behavior) experienced equal difficulty in reaching a succinct conclusion. In part, the report states this:

Though most of these (psycho) surgical procedures are reported as successful, the evaluation of the outcome is made difficult because of the following reasons: the diversity of symptoms in patient selection. . . . a lack of detail concerning the degree, character, and thoroughness of the follow-up . .

A great deal therefore, is unknown about the effects of and response to psychosurgery. It may have dramatic results for good; it may not. Amazing 'cures' have been reported, whereas the more numerous and less amazing 'non-cures' occupy an insignificant place in the report sheets. Psychosurgery is not alone in this, although the endemic inability or unwillingness of psychosurgeons to assess the overall effects of these operations in a thoroughly objective manner cannot be overlooked. The lack of predictability of psychosurgical intervention comes to the fore as soon as we consider the social and ethical consequences of the operation.

A. Medico-ethical issues. These follow on directly from the status of the medical evidence regarding psychosurgery, and cannot be divorced from it.

1. Social control. As already pointed out psychosurgery is not a clear-cut procedure in any given individual. Violence is not eradicated by destroying the amygdala in the same way that pain is eradicated by removing a diseased tooth. The violence may not disappear; even if it does it may well recur, while other aspects of brain function are inevitably involved. This is simply another way of stating that the brain is so organized that it is just not possible to separate any of its functions in terms of their social implications. The brain is not nearly as simple as some of our cherished ideas. Hence, to suggest that psychosurgery, in anything remotely resembling its present form, is an effective means of social control makes little sense. A dictator wishing to foist his views on society could do so relatively easily using the vast armament of drugs at his disposal. He may resort to psychosurgery in the world of science fiction-it makes exciting reading; in practice though, a few drugs would serve his purpose far more effectively.

2. Biological control. Far more serious is the implication in the arguments of some that aggression, in addition to uncontrollable rage, can be eliminated simply by removing some brain tissue. This is an extreme form of reductionism, in which the brain region A corresponds to goodness, brain region B to aggression etc. It it just as if man consisted of some number n of qualities, each being controlled by a specific brain area. This failure to recognize man's holistic nature and the social forces at work in society is indeed alarming. As Valenstein comments:

It is likely that there are some biological factors that contribute to a propensity toward violence, but we would be in serious trouble if a number of influential people became convinced that violence is mainly a product of a diseased brain rather than a diseased society.

3. Is psychosurgery everjstified? This is, I contend, as much an ethical decision as a medical one, and I believe it is a real decision. I cannot follow those who consider that psychosurgery should be banned, neither can I agree with those who view it as a routine procedure in cases of excessive violence. There may be instances where an individual is so violent and so out-of-control that it may have to be used. However, before a decision is made a number of allied questions must be answered: will the operation benefit the patient?; have all alternative forms of therapy been tried?; what are the likely side-effects of the particular operation?; what is the probable cause of the patient's violence-is it definitely brain damage or is it a psychopathic condition or may it be spiritual in origin?; is it in any sense experimental? The answers given to these and other questions will determine whether or not psychosurgery should be proceeded with.

4. Psychosurgery and consent. The use of psychosurgery on prison inmates to 'cure' extreme violent impulses has led to considerable debate. The question of whether or not free consent is ever possible under these circumstances is a difficult one. This is because, as Willard Caylin has put it: "The damaged organ is the organ of consent". Also of relevance in this debate is the distinction between a prisoner volunteering for an experiment that may help others as opposed to a procedure that may directly affect the condition responsible for his own confinement. While free consent may not be completely out of the question under these conditions, the forces militating against it are so great as to render psychosurgery a very unwise procedure on inmates.

B. Philosophico-theological issues. These introduce questions of more general concern and of particular relevance to Christians. They revolve around our view of man and principally of the ways in which psychosurgery may contribute to a major revolution in this view.

1. The normal individual. Any procedure designed to alter some aspect of an individual's personality immediately raises the question: what is a person's. real nature? This is not a new question of course; it has long been known that damage to the brain or disease of the brain may alter a person's behaviour patterns. The question however, becomes far more ressing. when psychosurgery is under consideration,because what was previously unavoidable now becomes subject to man's control.

This question leads on to another: does each of us have a basic personality on which life imposes distortions, or is our personality simply an amalgam of a lifetime's experiences? If it is the former, the whole aim of psychosurgery is to alter personality so that it fits in better with the accepted norms of society. If the latter, psycbosurgery is itself one of the experiences of the lifetime, and if justified according to other criteria, is not an unwarranted imposition upon a person's private domain.

Clearly, a great deal of thought needs to be given to ways of determining the identity of a person's nature and personality, and to the extent that these are dependent upon the physical integrity of the brain. An allied question concerns the definition of normality. How are we to know when an individual is normal, that is, normal within the limits of his own personality? And to what extent is normality determined by social, rather than biological, expectations?

These are vital questions in the context of violence and psychosurgery. It is essential that we distinguish between 'normal' and 'pathological' anger, as the latter renders an individual liable to psychosurgery or any other form of medical treatment, whereas the former does not. This brings us back, however, to the fundamental question of whether a malfunctioning brain or the dictates of society constitute the hallmark of pahogenicity.

2. The inviolable brain. The preceding point raises the issues of whether the medical profession or society ever has the right to tamper with an individual's brain. Arthur Rosenfeld has spelled out the dilemma very neatly. In writing about ESB he makes this comment: "The notion of a man controlling his own brain is one thing. But the prospect that a man's brain might be controlled by another man is something else again".

It may prove essential to distinguish between psychosurgery in its tasks of remedying medical defects and alleviating suffering on the one hand, and of attempting to improve an individual's capacity and potential on the other.

more specifically and more emotionally with these words:

The brain, I think, should be conceived as a special environment for the person . . . Modifying the brain, since it's the most intimate environment for our humanly prized emotions and thoughts, is likely to have more pervasive effects than modifying certain other kinds of environment . . . A surgeon operating on a person's brain has gone into the inside of his perimeter of defense . . .

This distinction between an internal and external environment may be a specious one. Nobody would query the removal of a brain tumour or the repair of a ruptured vessel within the brain. These of course are examples of obvious pathogenicity, and yet they are in one sense simply illustrations of an abnormal environment, Is it not allowable then to attempt to improve the internal environment of the brain by appropriate surgical intervention in the same way as we attempt to improve the external environment? Our reaction to this suggestion will depend upon our view of personality as outlined in the discussion above on the normal individual.

3. The ideal man. Those who are amenable to the suggestion that psychosurgery could be a legitimate tool for the improvement of an individual's brain, must face a further consideration. What constitutes 'improvement'? Is lack of aggression an improvement over aggression, assuming that the initial aggression does not amount-to self-destruction? Who decides, and what are the criteria?

If psychosurgery is developed far in this direction, its goal-in-view must be that of modifying individuals and ultimately of striving for the 'ideal' individual. If taken to this extreme, psychosurgery would be adoptingr a spiritual or, more correctly, pseudo-spiritual role. Could this happen? Could psychosurgery or allied techniques achieve a revolution in man's thinking and outlook? In other words, may technocracy achieve far more efficiently what religious and political systems have only partially succeeded in accomplishing?

Whatever our reaction to these questions, they suggest another approach to these issues. It may prove essential to distinguish between psychosurgery in its tasks of remedying medical defects and alleviating suffering on the one hand, and of attempting to improve an individual's capacity and potential on the other. As discussed in the section on the inviolable brain this distinction may not be as readily made as previously thought. Nevertheless it is a guiding principle. For the Christian the realization of an individual's full potential is a goal to be strived for, although all that is encompassed by the term 'full potential' is far from clear. Whether psychosurgery will ever have a part to play in this is probably a question for the future.

4. Human responsibility. Basic to a Christian attitude must be the concept of individual responsibility. Each individual, as a being of worth and value in the sight of God, is himself responsible to God for his actions and their consequences. The degree of freedom bestowed upon him by his Creator allows him to respond to his Creator and to develop into a mature, meaningful and worthwhile personality. This development shows itself in his relations with other human beings, and with the emerging niche he occupies in the matrix of the society around him. These, and very many other manifestations of individual human responsibility are true, whether or not the person concerned recognizes the origin of this responsibility in his creatorial dependence upon God.

General statements such as these are fine, but they fail to tackle the extent of this responsibility in individual people. Are we always fully responsible for all our actions? If we are, are there ever any exceptions? However sure we may be of our answers to these questions in the majority of instances, we must sooner-or-later be confronted by those with brain damage or genetic abnormality, which on the surface would appear to diminish their degree of responsibility as normally conceived.

My only point in mentioning these examples is to suggest that in some individuals at least there is a connection between the extent of their responsibility and the state of their brains. Such a statement as this needs to be thoroughly documented, and I hope to do this in another article. Suffice it to say here that 'full' responsibility is an arbitrary term and one which may not have a great deal of meaning.

If my suggestion is valid, psychosurgery would be expected to affect an individual's personality and also perhaps the degree of concern he is capable of displaying for his actions within society. If psychosurgery is contemplated to combat violence, it must first be determined to what extent the individual is responsible for this violence. If it appears that he is responsible for it, psychosurgery would be a gross infringement of his God-given rights, even if he is abusing these rights. Under these circumstances psychosurgery could not be justified on Christian premises. Alternatively, if there are clear indications that the violence is a direct result of some brain pathology, the treatment of this pathology is a means of rectifying something which itself is interfering with a God-ordained pattern, namely normality.

Unfortunately in practice the choice is not always this clear. Strictly speaking the treatment of a pathology removes it from the realm of 'psychosurgery'. More importantly, it may not be possible to decide whether the pathology is actually the cause of the violent behaviour. And herein lies a conundrum. Is the individual responsible or not for his violence? When the answer to this question is shrouded in the mist of ignorance, the responsibility of the doctor to his patient comes to the forefront-and this is no less a God-given responsibility.

It would be easy to dismiss psychosurgery out-of-hand. It is the tip of the iceberg of the technocratic control of the human brain. But is this sufficient ground for howling it out of court? If so, much else within our society should be similarly dealt with. In the bands of some it is an example of extreme reductionisin. But this is not inevitable, as it may also be viewed as a necessary part of the treatment of the 'whole man' in a few exceptional cases. It raises the intriguing question of whether an individual can ever be made whole by removing a part of his brain. However appalled we may be at the thought of this, let us not forget that removal of the appendix, or of a lung, or of a breast, may achieve this in some senses. Is it not preferable that we should function at perhaps 90% efficiency with healthy organs than suffer with all of them intact?

What is human responsibility? How free are we to utilize our responsibility? What man can do to man by way of psychosurgery rightly alarms us, but parents cripple their children emotionally and spiritually every day in every street of our towns by neglect, selfishness and cruelty. Human sin restricts to a terrifying degree the full flowering of human responsibility, and thereby God is denigrated.

Psychosurgery needs to be seen in perspective. The issues it raises are ones of exceptional significance, taking us as they do deep into the realms of human responsibility and freedom. The time is ripe for a closer look at the respective contributions of biology and theology to this general area of debate.