An Ethical Evaluation of Stereotactic Neurosurgery for Anorexia Nervosa

Abstract

Anorexia nervosa (AN) is one of several neuropsychiatric disorders that are increasingly tackled experimentally using stereotactic neurosurgery (deep brain stimulation and ablative procedures). We analyze all 27 such cases published between 1990 and 2014. The majority of the patients benefitted significantly from neurosurgical treatments, in terms of both weight restoration and psychiatric morbidity. A remission of AN was reported in 61% of patients treated with DBS and 100% of patients treated with ablative surgery. Unfortunately, information on side effects is insufficient, and after DBS, severe side effects occurred in some cases. Altogether, the risk–benefit evaluation is positive, particularly for ablative stereotactic procedures. However, fundamental ethical issues are raised. We discuss whether neurosurgery can be justified for treating psychiatric disorders of the will that are seemingly self-inflicted, such as addiction or AN, and where cultural factors contribute significantly to their development. We suggest that although psychosocial factors determine the onset of AN, this is not a legitimate argument for banning neurosurgical treatments, since in AN, a vicious circle develops that deeply affects the brain, undermines the will, and prevents ceasing the self-destructive behavior. Three confounding issues provide ethical challenges for research in neurosurgery for AN: first, a scarce information base regarding risks and benefits of the intervention; second, doubtful capabilities for autonomous decision making; and third, the minor age of many patients. We recommend protective measures to ensure that stereotactic neurosurgery research can proceed with respect for the patients' autonomy and orientation to the beneficence principle.

Keywords:

• neuroethics
• psychiatric neurosurgery
• psychosurgery
• anorexia nervosa
• deep brain stimulation

FUNDING

This research has been supported by the German Research Foundation (DFG), Germany (MU 3321/1-1), and the Swiss Parkinson Association. ▪