Science in Christian Perspective

Psychosurgery:
A Technical and Ethical Controversy
CORNELIUS TIGGLEMAN, JR.
Fuller Theological Seminary
Pasadena, California 91101

Michael Crichton's book, Terminal Man, has received a great deal of attention from many varied segments of our society, and it has served to heighten public interest in the subject of psychosurgery. As is typical of a subject about which little is understood, the opposing sides in the controversy over psychosurgery are extremely adamant in the support of their positions. I will attempt in this paper to shed some light on the issue by giving a brief history of the practice and use of psychosurgery, by outlining the opposing viewpoints, and by giving some personal feedback in reaction to these data.

Psychosurgery is also known as "psychiatric neurosurgery", "mental surgery', "functional neourosurgery", and "sedative surgery", but it must not be taken to mean all forms of neurosurgery. Psychosurgery is more specifically brain surgery to correct mental and behavioral disorders, i.e., brain surgery to alter emotional or behavioral patterns or personality characteristics. It does not include surgery or the purpose of treating such neurological conditions as tumors, strokes, or paralysis. Much of the controversy over psychosurgery revolves around the question of what conditions can indeed be effectively treated with psychosurgery. For that reason, an exact definition of the term cannot be made until there is some agreement about what can be done therapeutically with the operation. Finding an adequate definition of psychosurgery is the first of two major problems in dealing with this topic. The second problem is the relationship of psychosurgery to the broader field of psychotechnology, which includes electro-shock therapy, drug therapy, and behavior modification and conditioning techniques. The leaders of the opposition to psychosurgery in the contemporary controversy, particularly Thomas Szasz, R. D. Laing, and Seymour Halleck, have directed their attack against all of psychotechnology, indeed against the medical model of mental illness. Nevertheless, in this paper I will use the general definition, "brain surgery to correct behavioral disorders."

The problem of the relationship of the brain to the mind and to behaiour is one that has been examined for centuries. In the 19th Century, the popular belief was that specific behavioral disorders were related to the malfunction of specific brain organs. However, there was very little precise knowledge of the anatomy of the brain so that studies of this relationship could not be done. In 1891, Gottlieb Burckhardt was the first to perform psychosurgery on psychotic patients in an insane asylum in Switzerland, of which he was the supervisor.¹ His theory was that excitement and impulsivity were results of excess neural activity in the cerebral cortex, and, therefore, removal of part of the cortex would correct the psychotic impulses. He met with very little success and with great opposition from his colleagues. It was several decades later before another report of psychosurgery was published.

In 1935, two American brain researchers, Carlyle Jacobsen and John Fulton, reportezees.² They had destroyed the prefrontal regions of the brain and had gotten dramatic behavioral changes, but these changes were almost entirely adverse to the well-being of the animals. However, Antonio Egas Moniz, a Portugese neurologist, was in attendance at this lecture, and he raised the question as to whether such an operation might relieve anxiety in human beings. Fulton was shocked at the suggestion, but Moniz was determined to find out for himself upon return to Portugal. During a 10-week period in late 1935, Moniz and his assistant performed twenty prefrontal leucotomies, or lobotomies as they came to be known.

Moniz claimed great success in treating agitation and depression by use of lobotomy, and this type of surgery soon became widely used in the United States. However, the side effects (blunted emotions and deteriorated intellect) were a rather high price to pay for this treatment. The advent of drugs such as Thorazine and Stelazine, which are as effective in treating agitated schizophrenia but without the serious side effects, brought an end to radical frontal-lobe surgery in the U.S. by the end of the 1950's. Some estimates place the number of lobotomies performed in the U.S. and in Britain during the period of 1935 through the mid-50's around 70,000. The dean of American lobotomies, Walter Freeman, has reported to have personally performed more than 3,500 lobotomies.³

In the present day, psychosurgery has become far more sophisticated. Recent research has given us a very detailed map of the brain as to what functions are performed in what regions. In general, the brain responds as a whole to any stimulus. However, it is possible to localize portions of the brain that control particular behaviors. Also, there has developed a method of surgery called "stereotaxic" brain surgery, by which a surgeon can locate an exact point in the brain in terms of three coordinates, using anatomical landmarks on the head's surface.^{4  B}y use of this method, the surgeon can direct probes or electrodes toward the target point through a very small hole drilled in the skull.⁵ This avoids the problem of possible mutilation of surrounding or overlying areas of the brain, including a complex system of cells, fibers, blood vessels, and neural networks. It also allows for the destruction of the minimum amount of brain tissue in the treatment of a specific behavioral problem.

Four different purposes may be served by the implantation of electrodes at specific points in the brain. The first is that a record may be made of the electrical impulses at the point of the electrode tips. Secondly, the tissue in the vicinity of the electrode tip may be stimulated with a small electric current, which may give a better account of what behavior is actually governed by this region of the brain. Thirdly, the tissue surrounding the electrode tip may be lessioned, or destroyed, by use of stronger electric current. It is also possible now, through the use of miniaturized, wireless telemetry systems, to transmit signals between a freely moving subject and a recording and/or stimulating device some distance away.⁶

The focus of modem psychosurgery has moved away from the frontal lobes of the cortex to the temporal lobes and the so-called "limbic brain", which governs such activity as emotional tone, appetite, sexuality, and so called "fight or flight" behaviors which are involved in one's self preservation. It is in this area where aggressive behaviors are initiated, and aggressive behavior is the focal point of the controversy over the use of psychosurgery. Much of the argument has to do with the question of whether abnormal aggression, resulting in hostility and violent rage, is in fact just too much of a good thing caused by reaction to unfavorable environmental factors; or if indeed it is the result of a disease of the limbic brain, most particularly that of focal epilepsy, which is completely independent of the environment. Proponents and practitioners of psychosurgery, most notably Vernon Mark and Frank Ervin, have given as evidence case studies in which they claim that their patients' aggressive behavioral problems were alleviated by limbic-system psycho-surgery.⁷ After psychotherapy and drug therapy have failed to relieve the epileptic symptoms, surgical removal of the anterior portion of the temporal lobe including several parts of the limbic brain is performed; or these portions of the brain are lessoned by use of electrode implants. Mark and Ervin claim that psychosurgery may relieve up to seventy percent of otherwise untreatable epileptics of their seizures, abnormal aggressiveness, and other psychiatric Symptoms.⁸ They also contend that violent behavior may at times be related to tumors, excess spinal fluid accumulations, internal bleeding, and other disease conditions which can be corrected only with surgery. Their assertion is that a person whose brain is damaged or diseased, especially in the limbic brain, cannot respond appropriately to environmental stress as can a person whose brain is normal. Therefore, environmental factors cannot be adequate in the analysis of behavior without a consideration of organic factors.

The Case of Thomas R.

Eliot Valenstein warns against the danger of oversimplification in the emphasis on the relationship between epileptic seizures and violent behavior. He suggests that the belief that this relationship is higher than it truly is may stem from attention given to a few dramatic cases of violence committed during a psychomotor epileptic seizure.⁹ The National Institute of Neurological Diseases and Stroke sponsored a recent review of the question of the relationship between epilepsy and aggressiveness, which concluded that "the best generalization is that violence and aggressive acts do occur in patients with temporal lobe epilepsy, but are rare, perhaps no higher than in the general population."¹⁰ This would seem to be a strong argument against the need for the psychosurgery performed by Vernon Mark based on his presuppositions. But what about the cases in which the psychosurgery appeared to be successful? A rather strange case develops in the study of one of Mark's and Ervin's patients named "Thomas R." Thomas' case was written up by Mark and Ervin in a paper in 1968, to which case they referred in their book Violence and the Brain.¹¹ Thomas R. was a very intelligent and inventive engineer, who, while generally mild mannered, at times exhibited unpredictable and psychotic behavior, most often manifested in violent rage. This caused problems at his job and in his marriage, of course, such that he sought psychiatric help. After a long term of psycho-therapy proved fruitless, Thomas was referred to Mark and Ervin. After drug therapy and electrode stimulation, it was determined that Thomas' behavior was a result of focal epilepsy, and after "many weeks of patient explanation" Thomas accepted psychosurgically produced lesions. This case was evidenced as a great success, such that this quote appeared in Violence and the Brain: "Four years have passed since the operation, during which time Thomas has had not a single episode of rage.¹² Mark and Ervin made no comment as to Thomas' marital or employment status after the operation.

In 1973, Peter R. Breggin took it upon himself to make a follow-up study of Thomas R. What he found was hardly to be expected from Mark's and Ervin's account. In short, Breggin found out first that Thomas R.'s original psychiatrist had recalled that Thomas was depressed, but not paranoid, and had no incidence of violent rage (which recollection was supported by hospital reports which indicated that he had never been restrained or in any way treated as dangerous during four diagnostic hospitalizations.) Thomas had never been in trouble at work because of violent behavior. However, since the operation Thomas' life has been most miserable. He was admitted into a Veterans Administration Hospital in a west coast city less than one year after his surgery in 1967. He was diagnosed a schizophrenic, paranoid type, and he expressed the concern that he was under constant manipulation through the electrodes in his brain. Shortly after his first discharge from the V.A. hospital, be was readmitted after his first officially recorded violence, having been arrested by the police for fighting. The V.A. declared him totally disabled. In December, 1973, Thomas R.'s mother, into whose care he was released, filed a two-million dollar law suit against Mark and Ervin.¹³ (Valenstein makes several notable comments about Breggin and his motivation for such an investigation. He suggests that Breggin is not above distorting the facts and/or sensationalizing evidence in his attempts to discredit the practice of psychosurgery. One ought to consider Breggin's bias, as well as the evidence he presents.)¹⁴

This is not to say that all psychosurgery patients inevitably end up like Thomas R. But this was a case to which Mark and Ervin had pointed in pride, and it has clearly turned out a disaster. The conclusion to be drawn that is most fair to the proponents of psychsurgery is that such an operation is at best very unpredictable, and for that reason not to be used except as an extreme last resort. But do we have to be that fair? Is psychosurgery a procedure in which specific benefits for the patient reliably follow the production of brain lesions; or is it merely an experimental procedure with consequences that may be not only unpredictable but disastrous? Even proponents of psychosurgery admit that such an operation must not be used except when there is evidence that a specific disease or brain abnormality exists which causes the undesirable behavior, and which could clearly be eliminated through the use of this operation. But, the opponents quickly point out that the complexity of the brain and its function make the localization required for successful psychosurgery without side effects almost impossible.

Use to Control Social or Political Deviance

One of the great fears underlying the stand taken by the opponents of psychosurgery is that it might be used to control or eliminate any and all forms of social or political deviance. There have been many documented cases of operations performed on sexual deviants and drug addicts. Operations have also been performed on hyperactive children.¹⁵ Opponents of psychosurgery see most forms of deviance, particularly hyperactivity and aggression, as something other than merely individual infirmities, but rather as products of the system, whether political, social, or familial. Proponents say that the greater danger to a total view of behavior is not that social considerations will be slighted, but rather that neurological considerations will be ignored. The fight on the front fines of this controversy is so bitterly impassioned that it is difficult to arrive at an objective viewpoint. So far, the government has refused to take a stand. At this time, only one state, Oregon, regulates psychosurgery by law. The first court case in history to limit the practice of psychosurgery took place in 1974 in Michigan, and the

I would welcome an operation that increased one's ability to choose, but I would loathe a operation that decreased his freedom of choice.

result was a ruling that involuntarily confined patients are unable to give legally adequate consent to an experimental, high-risk operation like psychosurgery. However, the ruling does not apply to voluntarily confined patients.¹⁶

Having been given diametrically opposed viewpoints on the subject, and no help from the government, how should a Christian react to the Psychosurgery controversy? First, let us make sure that our reaction is not a quick and easy one, i.e., "I don't understand it, so I'm against it." Let us neither react in fear. Psychosurgery must not be seen as an atheistic plot to subjugate the world to some tyrannical power. Let me say, however, that such a fear isn't completely groundless. Some very gruesome things happened in Germany under Adolf Hitler in the name of medical science, and it is important to remind ourselves that such an occurrence, while unlikely, is not impossible. However, even without psychosurgery, there are many ways and means by which a political tyrant could accomplish his ends, such that psychosurgery is not a necessary addition to his arsenal. It is the tyrant we must protect against, not his methods. Therefore let us not use fear of political oppression as our argument against psychosurgery.

If it is not a means to control the masses, could it be a means to control deviant individuals? And if it is, should we be for or against it on those grounds? As I have documented above, psychosurgery has been used to eliminate deviant behavior, even in young children. However, it is not clear in these cases whether the motivation for the operation was the good of society or the well-being of the individual toward a greater ability to function as a whole person. I'm not sure if one reason is any more a justification than the other, but I personally would be more concerned for the welfare of the individual. Nevertheless, it is most difficult to divorce the individual from society, in that society is so much better off when its individuals are mentally whole (and so much more so if its individuals are spiritually whole). In any case, psychosurgery to eliminate deviance can be justified if one accepts the premise that the individual is deviant because he has a disease which forces him to be deviant, and allows him no choice, nor indeed any ability, to freely react to environmental stresses. On the other hand, psychosurgery to eliminate deviance would be abhorrent if it were done to reduce the individual's freedom to choose right or wrong, for the purpose only of social control. I believe that any individual is less than fully human if he has lost his ability or right to choose. For that reason I would welcome an operation that increased one's ability to choose, but I would loathe an operation that decreased his freedom of choice. Proponents of psychosurgery would say that I should support them because

Just as it may be inhumane and un-Christian to alter one's brain so as to destroy his individuality, it is just as inhumane and un-Christian not to use the tools available to us to help make one whole.

I do not wish to side-step the issue by claiming ignorance of the final answer. I believe that as a Christian I have a responsibility to face an issue such as this that may so profoundly affect the lives of many in need of salvation. So, what do I do until all the facts are in? First, I must seek to be as informed on the issue as I can be. Secondly, I must do whatever I can to insure that all possible safeguards are taken in further use of, and research into, psychosurgery. I believe that because of the limited predictability of the effects of psychosurgery, it should be regulated by a responsible agency. It should be used only in such cases where the evidence proved that nothing reliable, short of psychosurgery, will effect a cure, and where the case is sufficiently severe that the well-being of the patient dictates a necessity for drastic action. No one person, nor small group of friends, no board of "yesmen" should take upon themselves such a large decision. I would encourage further research into the anatomy and physiology of the brain, toward a better understanding of the mind and of human behavior. Experiments should be performed on lower animals for this purpose. When surgery is to be performed on a human subject, it should be done only when a full disclosure of the procedure, the goals of physiological and behavioral change, and the possible side effects is made to a regulatory board, to the patient when he is able to comprehend and make a free choice, and to the patient's nearest relatives who might help him make a choice, or make the choice for him if he is incapable. All of these should give their approval before the operation is done. Mark and Ervin recognize the seriousness of a decision for psychosurgery, and they have proposed some guidelines similar to the above.¹⁷

I have no apprehension that we might be going where God never meant for us to go, nor that somehow out of this we might find a human independence from God. Rather, I feel excited that we might find out more about what it is to be human and how we can grow to be more like Jesus Christ. Our attitude toward psychosurgery ought to be the same as that toward all of psychotechnology, all of medicine, and all of science. It must be used as a tool in the service of mankind; and must never be used to hurt or destroy, only to save and to aid. All possible safeguards must be applied to insure that this is the case, but non-scientific evaluations should not alone be sufficient to stifle scientific progress. If psychosurgery can be shown clinically to be ineffective or harmful in the ultimate, it should be discontinued. But it must not be banned solely on the grounds of anti-scientific, anti-medical, or anti-psychiatric philosophy. As Christians, we must make responsible choices in such matters as this, based on evaluation of the situation on all levels of application. The goal of behavior change is inherent in Christianity, such that a sinful, rebellious child of God is brought back to a loving relationship of service to his Creator. On a spiritual level, this behavioral change is effected by the process of sanctification and commitment to living a life like that of Jesus Christ. Socially, it may be effected by changing one's environment, or by therapeutically increasing one's ability to react more normally to stress. On a neurological level, it may require psychosurgery to medically improve one's ability to react more normally to stress. just as it may be inhumane and un-Christian to alter one's brain so as to destroy his individuality, it is just as inhumane and un-Christian not to use the tools available to us to help make one whole.

Conclusion

Psychosurgery will continue to be debated passionately, both within the field of psychiatry and neurology, and by laymen outside the field. Perhaps the controversy will never be completely solved, because even if the operation were to become completely predictable, it would still be possible for psychosurgery to be used for cruel or evil means by malevolent practitioners or agencies of social control. It is necessary for us as Christians to attempt to understand the controversy as best we can, and to make our decisions based on a love for God and humanity toward improvement of the human condition and a unity with Jesus Christ, our Lord and Savior. I pray that psychosurgery, and all forms of medical and psychological intervention, may increase our ability to know our God and respond to Him. May God bless us to that end.

²1bid., pp. 51-54.

³1bid., p. 55.

⁴1bid., p. 25.

⁵Mark, Vernon H. and Ervin, Frank R. Violence and the Brain. (New York: Harper & Row, 1970.), pp. 72-84. (including Figures No. 8-15.)

⁶Chorover, Stephen L. "Big Brother and Psychotechnology: The Pacification of the Brain." Psychology Today. May, 1974, p. 63.

⁷Mark and Ervin, op. cit., p. 60.

⁸Mark, Vernon H. "A Psychosurgeon's Case of Psychosurgery." Psychology Today. July, 1974, p. 33.

⁹Valenstein, op. cit., p. 262.

¹⁰Chorover, op. cit., p. 64.

^IlMark and Ervin, op. cit., pp. 92-97

¹²1bid., p. 97.

¹³Chorover, op. cit., p. 66.

¹⁴Valenstein, op. cit., p. 237, p. 395.

¹⁵1bid., pp. 212-219. also: Mark and Ervin, op. cit., pp. 56-57.

¹⁷Mark and Ervin, op. cit., p. 157.

BIBLIOGRAPHY

Chorover, Stephen L. "Big Brother and Psychotechnology: The Pacification of the Brain". Psychology Today, May, 1974.

Mark, Vernon H. and Ervin, Frank R. Violence and the Brain. Harper & Row, New York, 1970.

Mark, Vernon H. "A Psychosurgeon's Case for Psychosurgery", Psychology Today, July, 1974.

Offir, Carole Wade, "Psychosurgery and the Law: The Movement to Pull Out the Electrodes". Psychology Today. May, 1974.

Valenstein, Eliot S. Brain Control: A Critical Examination of Brain Stimulation and Psychosurgery. Wiley, New York, 1973.