The Lobotomy. FINAL EDITION

Transcription

Fourth&Semester&Project&2013:&Lobotomy&–&A&Question&of&Ethics,&RUC,&HIB&3.1.2.&
&Dounia&Boukaouit,&Sofie&Lystoft&&&Kristoffer&Sidenius&
Motivation(
Table&of&Contents
MOTIVATION(
PROJECT(DESCRIPTION(
INTRODUCTION(
PROBLEM(DEFINITION(AND(SUB/WORK9QUESTIONS(
DIMENSIONS(
SEMESTER(THEME(
29YEAR(PROGRESSION(FRAMEWORK(
LIMITATIONS(
METHODOLOGY(
A(SMALL(INTRODUCTION(TO(HOW(THE(BRAIN(FUNCTIONS(
WHAT(IS(A(PREFRONTAL(LOBOTOMY?(
HISTORY(OF(PSYCHIATRY(
THEORETICAL(AND(CONCEPTUAL(FRAMEWORK(
&&RESPECT&FOR&AUTONOMY&
&&&NONMALEFICENCE&
&&&&BENEFICENCE&
&&&&&JUSTICE&
&&&&&&UTILITARIANISM&A&A&CONSEQUENCE&BASED&THEORY&
&&&&&&&DEONTOLOGY&
ANALYSIS(
&&MONIZ’&S&JUSTIFICATION&FOR&PSYCHOSURGERY&
&&&PORTRAIT&OF&WALTER&FREEMAN&
&&&&BREGGIN’S&CRITICISM&OF&PSYCHOSURGERY&
&&&&&DEFENCE&AND&CRITICISM&OF&PSYCHOSURGERY&TODAY&
DISCUSSION(
CONCLUSION(
REFERENCE(LIST(
ABSTRACT&
SUMMARY&
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A common interest for the subject of medical ethics, especially within psychiatry,
brought us together as a group.
Physicians hold a job that demands the trust of their patients, and their duty as
professionals is to respect and protect their patients, to not harm them and treat them
with justice. However, these conducts often become blurred when it comes to
psychiatry. We find it interesting, and we want to understand, how these ethical rules
were taken into consideration at the time when the lobotomy was performed the most.
Furthermore, we are curious in understanding why extreme treatments such as
lobotomies, insulin-treatments and electroshock therapy were fully accepted mere 40
years ago, when in today’s world, these treatments are completely dismissed and
looked upon with outrage.
We want to investigate what has changed throughout time, when it comes to medical
ethics within psychiatry, and why it has changed. Egas Moniz, inventor of The
Lobotomy, was awarded a Nobel Prize in 1949 for his “discovery”. It is hard to
believe that these types of treatments could ever have taken place, and even more
incredible to learn that it occurred not that long ago.
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Project(Description(
This project will investigate issues concerning medical ethics in psychiatry, and
explore how a procedure as invasive as the lobotomy could have been used to cure
mental illnesses.
An explanation of what a lobotomy is and its history, along with the history of
psychiatry in general, will fill a considerable amount of the project. This is done in
order to provide a better understanding of the widespread use of the procedure
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throughout time. Finally, the project will examine the ethical issues concerning
will finish with a conclusion and the findings will be summed up, and seek to answer
psychosurgery.
the problem definition in a constructive manner.
Introduction
Problem(definition(and(sub/work;questions(
The aim of this project is to investigate the ethical issues concerning psychosurgery
How can the use of the lobotomy be ethically and morally justified, and how is
and examine the history of the lobotomy. Our problem definition is: ‘‘How can the
psychosurgery looked upon today?
use of the lobotomy be ethically and morally justified, and how is psychosurgery
- What is a lobotomy? (How does a ‘healthy’ brain function, and what does a
looked upon today?’’.
lobotomy do to it?)
Psychosurgery involves severing or otherwise disabling areas of the brain, in order to
- How has psychiatric treatments developed through time?
treat a personality disorder or a mental illness. Modern psychosurgical techniques
- For which reasons were the lobotomy used?
target the pathways between the limbic system that are believed to regulate emotions,
- Why did physicians use this procedure?
and the frontal cortex where thought processes are seated. The first lobotomy (or
- What methods are used nowadays to cure/help individuals that suffer from mental
leucotomy) was performed in 1935 by Egas Moniz (1874-1955), and it was a
problems?
groundbreaking revolution for treatments of mental illnesses. Egas Moniz won a
- What ethical issues are encountered within psychosurgery?
Nobel Prize in 1949 for inventing the Lobotomy, however, the procedure is now
looked upon as a tragic chapter of medical history. Moniz’s practice was taken up in
Dimensions
the United States by the neuro-psychiatrist Walter Freeman and the neurosurgeon
This project will cover the dimension “Philosophy and Science”. In order to do so, it
James W. Watts. The two devised, what became the standard prefrontal procedure,
will explore the ethical dilemmas concerning the use of the procedure of the
and they named their operative technique lobotomy.
lobotomy. The project will analyse and discuss, taking both a deontological and
Since, it has been discussed whether psychosurgery is ethically acceptable. This
utilitarian perspective, arguments for and against performing lobotomies, using Elliot
project consists of a short historical overview, an account of the brain functions, as
S. Valenstein’s book “Great and Desperate Cures”, “The Psychosurgery Debate”,
well as a theoretical section explaining the theory of the four basic groups of
edited by Valenstein, and articles written by Persuad, Corssley, Freeman,
principles of biomedical ethics and theories of moral obligation: Deontology and
Ramamurthi and Glannon.
Utilitarianism. Furthermore, the project contains an analysis of Moniz’s justification
for the use of lobotomies, a criticism of the use of lobotomies, and finally a defence
(
and justification of the use of psychosurgery today. The project’s discussion will
Semester(Theme(
evaluate the findings of the analyses and compare them to one another. The project
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The procedure of the lobotomy was invented in Portugal in 1935. It then, slowly,
seek to narrow down our use of theories/theorists, so that only the theories really
travelled around the world and became an accepted way of treating patients suffering
suited for the project are applied. In one’s early stages of becoming familiar with
from mental disorders. This project is relevant for the semester theme in the sense
structuring and learning how to make a good project report, it is tempting to use as
that it shows how globalization has played a huge role in allowing this procedure to
many theories as possible, which often blurs the focus of the project. We want to
travel around the world and being performed in many different countries. With
make a project that tells a story from A to B and hopefully states a case without
today’s modern technological societies’ new ways of communicating people an
taking too many detours.
instant access to data to vast amounts of data, compared to the times in which the
lobotomy was performed. Both the social media, and the media in general, play a
huge part in most people’s daily lives. We can, with a single click on the mouse, gain
Limitations(
access to knowledge about what is happening around the world at all times, and gain
In this semester’s project on psychosurgery we have limited ourselves to using
access to knowledge about new groundbreaking procedures, before they are
written material. Ideas about interviewing physicians or historians with knowledge or
introduced in our respective countries. One might claim that we are more informed
maybe experience with psychosurgery were discussed in the early stages of the
about what is going on in the medical world as well as about various procedures and
project, but these ideas were never realized. This is firstly because of not being able
their risks. If a procedure such as the lobotomy was invented today, one could argue
to find material suitable to do so, and secondly due to the group ending up with only
whether it would be as popular as it was at the time of its origination.
three members (we were originally five). Limiting our sources seemed best fitted for
The modern world’s new ways of communicating and sharing information offers
the project. Furthermore, ideas about putting our findings in perspective with the use
people the ability to be critical, well-informed consumers, who are able to take
of e.g. antidepressant pills today were heavily discussed in the project’s early phases.
responsibility for how their health is managed, as well as for the further development
But then again, being only three members left in the group, the idea seemed too
of the treatments used on the general population.
comprehensive. Furthermore, the material, which we have based our analysis part on,
was extracted from books written by authors that were decidedly against the use of
the lobotomy. This might have coloured our analysis. In order to have been more
2;year(progression(framework(
objective, we could have made use of original material, for example using Moniz’ or
In this semester’s project, our last project in the basic house, we will seek to correct
Freeman’s original justifications for the use of this procedure.
basic errors that have been made in previous projects, as it concerns maintaining a
professional standard. In order to make this semester’s project more professional and
Methodology(
valid in a scientific context, we will seek to make a professional footnote and
We have chosen to analyse our case from a theoretical and ethical perspective, using
reference system - two important structural parts of any project that might not have
the four biomedical principles and deontology and utilitarianism in order to explore
been given the needed attention in our respective previous projects. Further, we will
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A(small(introduction(to(how(the(brain(functions(
the controversial field of psychosurgery. The principles and theories will be
explained in a theory chapter and then later applied in order to analyze Egas Moniz’s
justification. Valenstein’s critique of this is taken into consideration while analysing.
When analysing Walter Freeman, information about his background is kept in mind
while doing so. In the discussion part we go into depth with the findings of our
analysis, and discuss how one can come about to justify the use of lobotomies from
multiple perspectives.
(www.caaquaculture.org)
The brain is the most important and complex organ in the human body. The average
brain of a healthy, grown human being weighs around 1,4 kilograms, and it contains
one hundred billion nerve cells. It is the centrepiece of the nervous system, and it
controls all the other organs, our every movement, thoughts, feelings and memories
amongst other things.
The brain is structured into three connected sections, namely the central core, the
limbic system and the cerebral cortex. Each of these parts is made of other smaller
parts, which all have different roles.
The central core is made up of the thalamus, the pons, the cerebellum, the reticular
formation and the medulla.
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(www.webspace.ship.edu)
(www.studyblue.com)
The hippocampus is important to our emotions, the way we learn, and for our
The thalamus initiates the process of understanding sensory information, to then pass
it on to the cerebral cortex, where the process continues.
memory, especially for our short-term memory.
The amygdala plays a role in our aggression, our eating, drinking and sexual
The pons generates, amongst other things dreams, sleep and waking up.
behaviours.
The cerebellum manages movement, balance and posture.
The hypothalamus controls the blood levels of glucose, salt, blood pressure and flow
The reticular formation’s role is to regulate the sleep-wake cycle, and thereby
and hormones. Moreover, it initiates feelings of hunger, thirst, anger and anxiety.
controls the level of alertness, and also keeps the brain active.
Finally, we have the cerebral cortex, which is often called the “grey matter”, and has
The medulla is the centre of breathing, waking, sleeping, and beating of the heart.
a numerous amount of different functions. It is divided up into four different
The limbic system is responsible for our emotional state, behaviour and memories.
“regions” or parts, all containing different roles. First we have the parietal lobes, then
Moreover, it also regulates the body’s temperature, blood pressure and blood sugar
the occipital lobes, the temporal lobes, and finally the frontal lobes.
levels. The limbic system is made up of the hippocampus, the amygdala and the
hypothalamus.
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At last, the prefrontal cortex is responsible for our personality expression, planning of
complex cognitive behaviours, our decision making and diminish our social
behaviour.
It can be acknowledged that the brain contains an immensely complex structure that
is very difficult to understand. Even though some parts have specific roles, they all
are interconnected and rely on each other to function, and play their part in order for
a human being to function properly.
It is important to take into consideration that this is merely a small introduction to
how the brain functions. This aforementioned part is simply included in the project in
order to grasp the complexity of the brain and to get a better understanding of what a
lobotomy is, how extensive a procedure it is, and how it affects the human brain.
(Parker, 74-82: 2007)
(www.braininjury.com)
The parietal lobes are associated with speech management, information processing,
movement and also cognition.
The occipital lobes are mainly in charge of our visual process, but are also in charge
of colour recognition.
The first “lobotomy” ever performed consisted of shaving the patient’s hair on the
head and disinfecting it with alcohol, then injecting the patient with Novocaine for a
general anaesthesia and adrenalin in order to reduce bleeding during the procedure.
The temporal lobes retain control over long-term memory, emotional responses,
Hereafter the patient was prepped for surgery, and the first step of the procedure was
visual and auditory perception and our speech.
making two cuts with a scalpel three centimetres from the skull’s midline on top of
Finally, the frontal lobes, amongst other things, play an important role for our
judgement, impulse control, our memory, our movement, decision-making, planning
making, and problem solving. The frontal lobes are divided into three smaller parts,
namely the prefrontal cortex, the pre-motor area and the motor area. The pre-motor
the head. In the middle of these two cuts, which revealed a small part of the skull, the
doctor would drill two small holes, which would make it possible for the next step.
The grand finale of the procedure involved injecting four small dosages of absolute
alcohol through the small cuts previously made, that would rupture the nerves
and motor areas contain nerves that control the execution of voluntary muscle
connecting the prefrontal cortex to the rest of the brain (Kragh 7: 2007).
movement.
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What(is(a(prefrontal(lobotomy?(
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This technique was performed on seven patients before it was altered. A surgical tool
However, this meant that the surgeon was not able to see exactly which part of the
was specifically manufactured for the eighth procedure: a thin tubular. This was an
brain he would cut into. This surgery required the use of a surgical instrument that
eleven centimetre long instrument, which would function as a knife.
was reminiscent of a letter opener. This blunt tool would be inserted horizontally
through the frontal lobes; thereafter a fan-like cut would be performed on the white
matter of the brain. Freeman and his colleague named this procedure: “lobotomy”, in
Greek, “lobos” meaning lobes (of the brain), and “tomia”, meaning cut.
(www.nobelprize.org)
Through the opening of this instrument, a sharp wire that would form a small halfcircle could be pushed out, in order for it to make round incisions that were about one
centimetre in diameter to the brain’s white substance. This eighth surgery was given
the name the leucotomy. In Greek, “leukos” means “white”, and “tomia”, means
(www.miriamposner.com)
“cut”, and this was exactly what was done: cutting into the white substance of the
brain. This surgical instrument would be inserted four centimetres deep into the
patient’s brain, whereafter the sharp wire would shoot out, so that the physician could
circularly move it and perform a round cut at four different places in the brain,
reached what he was looking for. He simplified the surgery as much as possible and
made it easier and quicker to carry out, in order for the psychiatrists, who were not
severing the nerves connecting the prefrontal cortex to the rest of the brain. The
following lobotomies that were carried out involved making six incisions, instead of
four (Kragh 12: 2007).
renowned for their surgical skills, to be able to perform it without any complications,
and “cure” as many patients as possible. This type of procedure was a lot cheaper, as
it did not require that the patient was under full anesthesia. The new and simplified
It did not take long before this surgery became famous around the world, and the
procedure was “improved” by specifically one other physician: Walter Freeman. His
new technique involved drilling a hole on each side of the skull, instead of on the top
of the head, to eliminate some of the many risks of hitting blood vessels in the brain.
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In the following years Freeman continued to alter his technique, until he finally
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technique involved electrocuting the patient until he was anesthetized. Thereafter, an
instrument, with the appearance of a simple ice pick, would be inserted through the
tear duct, hammer would be used in order to break through the skull through the eye
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socket, in order to reach the frontal lobes with the ice pick and “wiggle” it from side
History(of(psychiatry(((
to side, damaging the white matter that connects the frontal lobes to the rest of the
brain.
The 1900th century was the beginning of a psychiatric revolution. This chapter will
describe the development from malaria treatments to lobotomies, focusing on
(www.infopresser.tumblr.com)
Denmark.
June 14th, 1917, was the first time that the malaria treatment was performed, when
the professor of psychiatry, Julius Wagner-Jauregg, carried it out at a university in
Wien. At the clinic in Wien, Wagner-Jauregg had discovered the positive effects it
had on patients with mental illnesses such as dementia paralytica. 1887 was the first
year when Wagner-Jauregg considered transferring blood from a malaria patient to
one of his mentally ill patients. After some successful experiments, Wagner-Jauregg
continued his treatments, and in 1918, he could report that there was an improvement
on up to 68% of the patients. Seven years later there had been performed more than a
1000 treatments of this type, and the therapy was looked upon as a medical
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breakthrough. In 1921, a Danish doctor from Sct. Hans Hospital went to Vienna and
treatments, like the malaria treatment, were all steps in the right direction toward a
became interested in the treatment, and he took the initiative to bring it to Denmark.
new and improved knowledge when it came to mental illnesses.
In October 1922, the treatment was ready to be imported to Denmark (Kragh,
One of the biggest accomplishments in that given time was the lobotomy.
2010:65).
Antonio Egaz Moniz, of the University of Lisbon Medical School, invented the
In the 1920’s, psychiatrists chose an active rate when it came to modern treatments
procedure of the lobotomy. He served as the Minister of Foreign Affairs and the
and methods, and this tendency continued as the shock treatment became a
Ambassador to Spain. Moniz found that cutting the nerves that run from the frontal
therapeutic option in the end of the 1930’s. In 1937, shock treatments were discussed
cortex to the thalamus on psychotic patients, who suffered from repetitive thoughts,
at a meeting in ‘Dansk psykiatrisk selskab’, where the agenda was to talk about the
“short-circuited” the problem. Together with colleague Almeida Lima, Moniz
first experiences with these new methods. There was a big interest in the new
devised a technique that involved drilling two small holes on either side of the
treatments at Danish mental hospitals, and only a couple of months later, many
forehead, and inserting a special surgical knife, in order to severe the prefrontal
Danish psychiatrists could present their knowledge on the shock treatments. Otto Jul
cortex from the rest of the brain. Some of his patients became calmer, but not all.
Nielsen, a Danish physician, often went on trips around Europe to discover and learn
Moniz advised extreme caution in using the lobotomy, and he felt it should only be
about new methods and treatments, and he visited the developer of the insulin shock
used in cases where everything else had been tried. He was awarded the Nobel Prize
treatments, Manfred Sakel, from Austria. At the clinic of neurology and psychiatry in
for his invention in 1949.
Wien, Sakel had experienced how the method had cured schizophrenia, and Otto Jul
Walter Freeman, an American physician, along with his colleague James Watts,
Nielsen was very impressed with these newly found results. The insulin treatment
performed his first lobotomy operation in 1936. Freeman was so satisfied with the
was carried out in the same way in Denmark as it was in Wien. It began at 7am, when
results that he went on to do thousands more, and started a propaganda campaign to
the physicians would inject the first dose. Shortly after, the patient would start
promote its use. He is also famous for inventing what is called “ice pick lobotomy”.
sweating and produce a large amount of saliva - so much that the doctors were
Impatient with the difficult surgical methods pioneered by Moniz, he found that he
obligated to keep a close eye on the patient, so that he did not choke to death. On his
could insert an ice pick above each eye of the patient with only local anesthetic, drive
way to unconsciousness, the patient would experience spasms and epilepsy attacks.
it through the thin bone with a light tap of a mallet, and swish the pick back and forth
Afterwards, the patient would go into a deep coma and would have no muscle or
like a windshield wiper. Freeman recommended the procedure to cure everything
nerve reflexes. Shortly after, insulin and cardiazol treatments began to spread in
from psychosis to depression.
Denmark, and it became clear that there were more risks connected to the use of the
The first time the lobotomy was acknowledged in Denmark was in 1939. Rapidly
treatment than initially assumed. Nevertheless, the methods were still seen as a big
thereafter many neurologists and psychiatrists attended seminars about lobotomies,
step towards treating people with mental disorders (Kragh, 2010:100).
especially when Walter Freeman visited Denmark that same year. Freeman spoke
It was very important for the Danish psychiatrists to be looked upon with respect, and
about the treatments of 54 American patients and about the positive results, but he
to show that their field of expertise was developing. The newly discovered
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also explained that there were a few negative side effects such as euphoria and
medical ethics are intended to guide a physician when having to treat a patient. The
aggressiveness.
professional needs to weigh and value each of these when confronted when having to
The first patient treated with a lobotomy in Denmark was in 1939, and already from
make decisions concerning a patient.
1944, the operation was performed on a large scale. In 1946, almost all mental
hospitals in Denmark used the method on their patients. Around 2.200 operations
were performed in the period from 1946 to 1956 in Danish government hospitals. It
Respect(for(autonomy(
was not only Danish psychiatrists, who were pleased with this new method, also the
The word “autonomy” is constructed by two words originating from Greek. The first
Danish government was positive towards the use of lobotomy and invested in its
word being autos, meaning “self”, and the second being nomos, meaning, “rule”,
treatments. The lobotomy was especially used on patients with schizophrenia.
“governance” or “ law”. The origin of the word refers to self-rule or self-governance
However, patients, who were aggressive, unhygienic or tense, were also candidates
of independent city-state. It has since been expanded to individuals, and acquired
for this procedure. It was also patients, who needed special care from nurses and
many different definitions. Some of them are: self-governance, liberty rights, privacy,
could be harmful for themselves and others, on whom the surgery was performed.
individual choice, freedom of will, causing one’s own behaviour, and finally being
The most common side effects from the surgery were cramps, nausea, dementia and
one’s own person. It is obvious that autonomy is a very complex term to explain.
aggressiveness, changes in personality could also occur. Most patients would never
However, it seems that all these different meanings at least agree upon that “Personal
recover and were deinstitutionalized after having gotten a lobotomy.
autonomy is, at a minimum, self-rule that is free from both controlling interference
The last lobotomy in Denmark was performed at Rigshospitalet in 1983. It was not
by others” (Beauchamp, Childress, 58:2001).
until 1982 that any profound research had been conducted on the procedure, and due
On the one hand, an individual that is autonomous acts freely and makes his own
to the results of the research, it was decided that every psycho-surgical treatment
decisions, on the other hand, an individual, whose autonomy is abated, is to some
required a written consent from the patient or surrogate and that it had to be approved
extend ruled by others, making him unable to act upon his personal wishes and
by the health ministry. At least 4471 brain operations were performed in Denmark
desires. An example of a person with diminished personal autonomy could be a
before 1983, and it is the highest number for any country relative to the size of the
prisoner or a person suffering from mental illness. However, a distinction between
population (Kragh, 2010:120).
the two has to be made. The illness of the mentally ill person restricts his autonomy,
whereas the prisoner’s autonomy is restricted by force of institutions. Liberty,
(
meaning independence from controlling influences, and agency, meaning the
Theoretical(and(Conceptual(Framework((
capacity for intentional action, are two conditions essential for autonomy.
An autonomous person is characterized as having capacities of self-governance, such
There are four basic groups of principles of biomedical ethics, namely Respect for
as “understanding, reasoning, deliberation and independent choosing” (Beauchamp,
autonomy, Nonmaleficence, Beneficence, and finally Justice. These principles of
Childress, 58:2001). Immanuel Kant also describes an autonomous moral agent as
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being self-legislative (Tubbs Jr. 13:2008). However, it is worth mentioning that an
finally being able to help others make important decisions, when asked to do so of
individual, qualified to act in an autonomous way, at times fails to do so, in the same
course.
way that an individual, considered to be unfit to make autonomous choices, at times
makes these. In other words, an individual, who suffers from a mental illness, and is
One may ask; why do physicians owe this respect to patients? Kant, in the name of
institutionalized and considered to be unqualified to make choices of autonomous
deontology, believes that “respect for autonomy flows from the recognition that all
nature, does in fact make choices such as expressing preferences for meals or
persons have unconditional worth, each having the capacity to determine his or her
refusing treatments.
own moral destiny” (Beauchamp, Childress, 63:2001). All humans are equal,
rational, and they all posses the ability to know what is best for themselves.
In health care, respect for autonomy means, in general, respecting a patient’s various
Moreover, if one does not respect another individual’s autonomy, one takes
forms of self-determination and individual control over one’s own body. When
advantage of this individual and uses him simply as a mean to achieve one’s personal
carrying out his duties, the physician has to recognize and take into consideration his
goals, not paying any attention to this individual’s own goals. This action may result
patient’s rights to hold personal views, to make choices, and to take actions based on
in harming or endangering the individual whose autonomy is not respected.
personal values and beliefs. Respect for autonomy is exercised by obtaining an
Mill, who, in the name of utilitarianism, believes that society ought to allow
informed consent from a patient before undergoing a treatment. This principle
individuals to live however they desire, as long as this does not interfere with the
obligates professionals in health care to inform about, explain and moreover make
freedom of others. “Respect for autonomy has only prima facie standing, and can
sure that their patients have fully understood the terms of their treatment before
sometimes be overridden by competing moral consideration” (Beauchamp, Childress,
signing a consent form.
65:2001). If an individual’s personal choices are a threat to public health, and could
possibly hurt others, one can, with good reason, limit this person’s autonomy. Mill
The physician has to, not simply have a respectful attitude towards his patient, but
also argues, that at times, one may have to try to convince others that their
take respectful action. He must, in addition to not interfere in his patients’ personal
convictions are wrong (Beauchamp, Childress, 64:2001).
affairs, at least in some context build up, or at a minimum maintain his patients’
The act of respecting autonomy does not apply to persons, who do not have the
abilities for autonomous choices, by alleviating fear and obstacles that may stand in
ability to act in an autonomous way. These persons are for example children,
the way of these. However, physicians have to promote reasonable decision-making.
individuals that are suicidal and drug-dependant persons. But how is one “qualified”
to be autonomously incompetent?
The obligations that follow respecting autonomy make it possible to support many
A person, who is deemed unfit to make decisions for themselves, are believed to be
other moral rules such as; telling the truth, respecting the privacy of others, protecting
unable to express and communicate a preference or a choice, unable to understand
confidential information, obtaining consent for interventions with patients, and
their situation and its consequences, unable to understand relevant information,
unable to give risk/benefit-related reasons and finally unable to reach a reasonable
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decision (Beauchamp, Childress, 73:2001). Physicians will undergo numerous tests
The principle of nonmaleficence respects many other moral rules, such as:
on patients that they might suspect are incompetent to take care of themselves, to find
1. Do not kill.
out if they truly are.
2. Do not cause pain or suffering.
If the physician comes to the conclusion that his patient is not autonomous, who
3. Do not incapacitate.
makes his decisions? “... a hospital, a physician or a family member may justifiably
4. Do not cause offense.
exercise a decision-making role or go before a court… to resolve the issues before
5. Do not deprive others of the goods of life.
implementing a decision” (Beauchamp, Childress, 98:2001). These institutions or
(Beauchamp, Childress, 117:2001)
persons are given the name of “surrogates”. These persons are given the right by law
to make decisions for patients that are considered to be non-autonomous. The
The principle of nonmaleficence does not only mean that one should not inflict harm,
surrogates take into consideration the patients’ desires, and have to be thought of as
but also that one should not impose risks of harm upon others. At times, a person
making the same choices that the non-autonomous patients would have made if they
might put others at risk of harm without being aware of it. In this case, law and
were able to.
morality recognize a standard of due care, which determines if this person is legally
To sum up, respect for autonomy, in health care, in a broad perspective means to
or morally responsible. “Due care is taking sufficient and appropriate care to avoid
respect various forms of self-determination and individual control over one’s own
causing harm, as the circumstances demand of a reasonable and prudent person.”
body, of a patient, assuming that the patient has the capacity to form and express
(Beauchamp, Childress, 118:2001). If one, let us say a physician, takes an immense
choices on his/her own behalf. The demands of this principle of biomedical ethics are
risk when treating a patient, the outcomes must be significant, such as having cured
difficult to narrow down, thus leaving room for specification and open to
the patient, before his action can be justified. However, it is important to bear in mind
interpretation.
that the outcomes of an action can never be certain.
Negligence is the lack of due care, and covers two types of situations, the first being
Nonmaleficence(
intentionally imposing risks of harm that are unreasonable, and the second, being
Primum non nocere: “Above all do no harm”. This maxim has been closely
unintentionally, but carelessly imposing harm. Both of these types are culpable,
associated with the principle of nonmaleficence, which, as it suggests, declares a duty
nevertheless, in some conditions, less than others. The Courts have the responsibility
to not inflict harm on others. In the Hippocratic oath, it is written; “I will use
to make the decision of which actions are blameworthy, who ought to take
treatment to help the sick according to my ability and judgment, but I will never use
responsibility, and to what degree. Professional malpractice is an example of
it to injure or wrong them” (Beauchamp, Childress, 113:2001). This moral principle
negligence where the professional standards of care have not been respected.
of nonmaleficence entails a negative obligation – to not inflict harm.
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“Several guidelines have been developed in religious traditions, philosophical
of actions). RDE is used to account for that an act that has two foreseen effects, one
discourse, professional codes, and the law to specify requirements of nonmaleficence
good and one bad, is not always dismissed on moral grounds.
in health care…” (Beauchamp, Childress, 119:2001). Many of these guidelines are
The following four conditions must be met in order to justify an act with a double
very thorough and helpful, however, some of them need to be revised.
effect:
For example “Withholding and withdrawing life sustaining treatment” is a great issue
1. The nature of the act. It is important that the act is good, or at a minimum morally
when it comes to this principle. Many believe that it is justified to withhold, meaning
neutral.
not starting treatment, but not to withdraw, meaning stopping treatment once it has
2. The agent’s intention. The agent has to intend a good effect. If a bad effect is the
been started. “They sense that decisions to stop treatments are more momentous and
result of an action it is tolerated and permitted, as long as it was not the intended
consequential than decisions not to start them.” (Beauchamp, Childress, 120:2001).
outcome.
The reason for this is because stopping treatment that has already been started is
3. The distinction between means and effects. The bad effect must not be a mean to
thought of causing a person’s death, whereas not starting a treatment does not come
reach the good effect. If the good effect were the direct causal result of the bad effect,
across as directly “killing”. So the question remains; what is the right thing to do
the agent would intend the bad effect in pursuit of the good effect. Sometimes in
according to this principle of nonmaleficence? If a patient is known to die within a
order to do the right thing, one cannot avoid doing a wrong thing.
short period of time, for instance as a result of an accident, should one simply not
4. Proportionality between the good effect and the bad effect. It is crucial that the
start a treatment? And what about when a patient has been hooked to a respirator for
good effect exceeds the bad effect.
a great amount of time, and it is known that he will not recover, should one stop his
(Beauchamp, Childress, 129:2001).
treatment? Beauchamp and Childress conclude on this matter by saying that, first of
all, a professional should always do everything in order to save a person, and
If we consider the second and the fourth conditions, clear issues arise to the surface.
thereafter the proper decision of whether their treatment should be withdrawn can be
If we look at the second condition, it is obvious that it is close to, if not impossible to
taken, after having pondered upon the matter. Furthermore, they state that;
determine, if the intention of an agent is truly good - as he is the only one to know the
“Decisions about beginning or ending a treatment should be based on considerations
truth of his intention. Now, if we consider condition four, it is clear that it is
of the patient’s rights and welfare, and therefore on the benefits and burdens of the
impossible to know beforehand the exact outcome of an act. These issues pose
treatment, as judged by a patient or authorized surrogate” (Beauchamp, Childress,
problems to justify an act with a double effect.
122:2001).
When it comes to treating incompetent patients many issues arise. When admitted to
Another example is the rule of double effect (RDE), often called the principle or
a hospital as a result of a mental illness, a designated surrogate decision-maker makes
doctrine of double effect. This rule incorporates a central division of intended effects
decisions for you. The question now remains; who should take on this important
and of merely foreseen effects (the term “effect” is to be understood as consequences
task? Is this person appropriate? A physician has to follow this obligation principle of
nonmaleficence, meaning that his has to do no harm. How does he then make sure
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that the surrogate, designated to the incompetent patient, is not acting out of self-
The term beneficence implies acts of mercy, kindness and charity, and typically also
interest, (because of an inheritance for example)? A solution to this problem might be
includes acts of altruism, love and humanity (Beauchamp, Childress, 166:2001).
for the patient to write, when in a period of competence “…a directive for health care
“Beneficence refers to an action done to benefit others; benevolence refers to the
professionals or selects a surrogate to make the decisions about life-sustaining
character trait or virtue of being disposed to act for the benefit of others; and
treatments during periods of incompetence” (Beauchamp, Childress, 152:2001).
principle of beneficence refers to a moral obligation to act for the benefit of others.”
However, these solutions are not problem-free. It is hard to anticipate all different
(Beauchamp, Childress, 166:2001). Physicians are thus morally obligated to help
medical situations that might occur; the directive therefore may not contain explicit
patients, and to promote their importance and interests.
instructions. Moreover, people change their minds and preferences, and often forget
The following are examples of rules of beneficence:
to change their directive. Also, the chosen surrogates may not be available at the time
1. Protect and defend the rights of others.
of need. In addition, the preferences or decisions of the patient and/or the surrogates
2. Prevent harm from occurring to others.
may be in contrast to those of the physician.
3. Remove conditions that will cause harm to others.
As a physician, one of the most important rules to follow is the principle of
4. Help persons with disabilities.
nonmaleficence. This principle is of negative nature; to not inflict harm. According to
5. Rescue persons in danger.
this principle, a professional must in addition to not cause harm, avoid putting
(Beauchamp, Childress, 167:2001).
patients in uncertain situations. However, this principle has many “loose” ends that
It is important to understand how the principle of beneficence differs from the
may not always have a “correct” solution.
principle of nonmaleficence. Rules of nonmaleficence are negative prohibitions of
action that have to be followed impartially, and must present moral reasons for legal
prohibitions of some forms of conduct. On the contrary, rules of beneficence entail
Beneficence(
positive obligations that do not need to be followed impartially, and do not require
“Morality requires not only that we treat persons autonomously and refrain from
reasons for legal punishment if an agent fails to obey rules. The principle of
harming them, but also that we contribute to their welfare” (Beauchamp, Childress,
nonmaleficence implies that one must not harm anyone, whereas the principle of
165:2001). The principle of beneficence requires more than the principle of
beneficence does not require that one be good towards all, which is generally
nonmaleficence, as it demands that one must take positive steps toward helping
believed to be impossible.
others, and not simply avoid from harming.
At times, in health care, patients’ autonomy stands in the way of the obligation of the
There are two principles of beneficence: positive beneficence and utility. Positive
physician to follow the principle of beneficence. Edmund Pellegrino and David
beneficence demands that individuals provide benefits, whereas utility demands that
Thomasma, two exponents of the preeminence of the beneficence model, state that;
one balances benefits and drawbacks to produce the best overall result.
“the best interest of the patients are intimately linked with their preferences”, from
which “are derived our primary duty towards them” (Beauchamp, Childress,
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176:2001). However, they also view the meaning and authority of beneficence as
choices and actions are informed, voluntary, and autonomous”. The patient’s
being independent and at times in conflict with the patient’s desires, they state; “Both
autonomy is diminished, even though he is perfectly competent and well aware of the
autonomy and paternalism are superseded by the obligation to act beneficently… In
consequences of his choices (Beauchamp, Childress, 181:2001).
the real world of clinical medicine, there are no absolute moral principles except the
Persons, who are against (strong) paternalism, see it as a violation of another person’s
injunction to act in the patient’s best interest” (Beauchamp, Childress, 177:2001).
individual rights and that it restricts free choice, and as being disrespectful and an
Patients know what is best for themselves, however, when their decisions put them
unequal treatment. Those who are for paternalism state that a paternalistic action can
and others at risk of harm, a physician must strip off their autonomies, and make
only be justified if the benefits, or the harms prevented from taking place, can make
decisions for them, ensuring that they receive the best treatment possible, and to
up for the loss of autonomy that the patient’s condition limits his/her ability to make
protect others. The physician is allowed to do so since his position as a professional
an autonomous choice, and finally that the patient has consented, will or would, if
implies that he is more of an expert in the field.
rational, consent to those actions on his or her behalf.
The Oxford English Dictionary defines the term paternalism as being “the principle
A professional treating a patient has to follow a principle of beneficence, but also
and practice of paternal administration; government as by a father; the claim or
take into consideration the costs and risks of this treatment. “Costs are the resources
attempt to supply the needs or to regulate the life of a nation or community in the
required to bring about a benefit”. Costs can be understood as the sacrifices made, to
same way a father does of his children.” This definition presumes that an individual,
try to reach some important goals. Risk “refers to a possible future harm”. Harm
who takes the role of “father” towards another individual, will act beneficently
should be perceived as a setback to interests, especially in life, health and welfare.
towards him, and will make all, or at least some of the decisions for this person,
The term benefit “refers to something of positive value, such as life or health”
relating to his welfare rather than letting him make those decisions. A health care
(Beauchamp, Childress, 194:2001). When a professional is faced with having to treat
professional at times has to take on this role of a “loving parent” towards his patients
a patient, he has to evaluate what will count as costs, harms and benefits, as well as
that are dependent on him, and often ignorant and fearful. “Paternalistic acts typically
how much particular costs, harms and benefits will count. When wanting to conduct
involve force or coercion, on the one hand, or deception, lying, manipulation of
research on humans, the researcher has to submit a research protocol to an
information, or nondisclosure of information, on the other.” (Beauchamp, Childress,
institutional review board for approval. Thereafter he is obligated to present the risks
178:2001). Thus, all paternalistic acts can be viewed as restricting autonomous
to the subjects of the research, and the benefits to them and the society, and present
choices, but for the patient’s own good. Joel Feinberg makes a distinction between
how it is probable that the benefits are greater than the risks. If the research is
soft/weak and hard/strong paternalism. In weak paternalism “…an agent intervenes
approved, then the conductor of the research is bound to explain the risks and
on grounds of beneficence or nonmaleficence only to prevent substantially non-
benefits to his subjects.
voluntary conduct”. In other words, a professional overrides the wishes of a patient
The principle of Beneficence can be best explained as being an action intended to
that is autonomously incompetent. Strong paternalism on the other hand “… involves
benefit or promote the well being of others. A physician has the obligation to provide
interventions intended to benefit a person, despite the fact that the person’s risky
treatments that will benefit his patients in the best way possible. However, many
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issues arise; firstly, the principle clashes with the principle of autonomy. The
moreover is impossible to count. Also, it does not seem fair, for example to not offer
professional is thus placed in a situation of dilemma, where he is caught in the
health care for a minority of a society, if this will benefit the majority of the society.
middle, having to choose between either stripping his patient’s autonomous rights, or
letting his patient make his own decisions, knowing that these decisions will cause
This principle of justice, which entails that a health care professional has to treat his
him harm. Furthermore, when treating a patient, the physician has to take into
patients fairly and with just, take into considerations of costs, puts all the other four
consideration the costs and the risks that come along with the best possible treatment.
principles in question, and sets limits for them. Firstly, a physician must respect the
This means that treatments that are best suitable for a patient may not be available,
autonomy of his patients, however, if a patient wishes for a treatment that is
due to the costs of it.
monetarily out of reach, a problem arises. Secondly, a physician is obligated to not
cause harm, however, if the budgets of a hospital do not allow a patient to get proper
treatment, the patient is put to danger. Furthermore, a professional has to treat his
Justice(
patient in the best way possible. Again here we have an issue reminiscent of the one
Justice can be described by the terms fairness and desert (what is deserved), in other
concerned with the principle of nonmaleficence. It seems as though the principle of
words one can understand justice as “…fair, equitable, and appropriate treatment in
Justice is a restriction to the other biomedical principles, adding even more moral
the light of what is due or owed to persons.”, it is just when a person receives what he
dilemmas to the ones each principle already possess. However, it is obligatory to take
“deserves”, and unjust if he gets something that he does not deserve (Beauchamp,
this principle into account, when having to make a moral decision about a treatment
Childress, 226:2001). A professional must treat all his patients fairly and equally, he
for a patient.
must not make choices between patients. However, this principle makes room for
(
many issues such as the scarcity and competition to obtain goods. How should
Utilitarianism(;(a(consequence(based(theory(
healthcare be distributed?
Many philosophical theories have tried to answer this complex question. Amongst
Utilitarianism is a consequence-based theory, this implies that one should always
many there is utilitarianism, which “regard distributive justice as one among several
seek to produce the most possible balance of good over bad for everybody that get
problems of maximizing values. Utilitarians argue that the standard of justice
influenced by our actions. “The right act in any circumstances is the one that
depends on the principle of utility (which demands that we seek to maximize overall
produces the best overall result as determined from an impersonal perspective that
good).” (Beauchamp, Childress, 231:2001). Utilitarianism approves all actions that
gives equal weight to the interest of each affected party” (Beauchamp, Childress,
increase human happiness, and disapproves of actions that diminish it. Justice should
341:2001). Thus, for utilitarians actions considered by themselves are ethically
make an effort in creating the greatest happiness for the greatest amount of people.
neutral; neither good or bad. The nature of an action is decided by the outcome of its
However, this poses problems, as the definition of happiness is ambivalent, and
consequence. One cannot condemn actions, only the result.
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Utilitarians agree upon that one should always try to maximize value, however, they
would follow from those directly and indirectly affected.” (Beauchamp, Childress,
are in dispute about which values to maximize. Happiness does not have the same
345:2001).
definition to all. One might believe to have produced happiness for a group of
One of the biggest issues with Utilitarianism is that one cannot know what are good
persons, but in fact has not. Many utilitarians believe that an agent should produce
and what are bad consequences, and what consequences count most. Everybody has a
intrinsic or agent-neutral goods; these are things such as happiness, freedom and
different opinion of what a good and a bad consequence is. Not being able to give a
health, which are values all perceived as being positive. Others extend the list by
solution to these issues, or a fixed definition to what good and bad means, makes
adding; friendships, love, beauty, deep personal relationships, success, knowledge,
Utilitarianism not as applicable as it seems. However, this theory should not be
personal autonomy, achievement and enjoyment.
dismissed simply on these grounds. Utilitarianism can be made use of when having to
Utilitarians are divided into two major groups: act and rule utilitarians. The Rule
take many decisions, but not all.
utilitarian “consider the consequences of adopting certain rules”, whereas the act
utilitarian “skips the level of rules and justifies actions by appealing directly to the
Another problem with Utilitarianism is that one can always seem to find a way to
principle of utility” (Beauchamp, Childress, 343:2001). The act utilitarian believes
justify actions. This theory tells me that if I knew that I could get off cheating on a
that moral rules are practical when having to guide an individual’s action, however,
test (which is morally wrong) because I knew that this would raise my grades, thus
he also believes that they are dispensable, if they do not benefit the principle of
leading to my parents being happy and proud of me, which a positive consequence, I
utility. Rule utilitarian, on the other hand, state that “an act’s conformity to a
should do it. If one knows that their action is morally wrong, but also knows that
justifiable rule … makes the act right, and the rule is not expendable in a particular
consequence of this immoral action will be good, one should pursue this action, thus
context, even if following the rule in that context does not maximize utility”
it is justified.
(Beauchamp, Childress, 344:2001). Act utilitarian thus believe that telling a lie is
Lastly, one can never know the exact outcome of one’s actions. There is always that
permitted, if the lie protects an individual, whereas rule-utilitarian are dismissive of
element of surprise, life is not calculable, and human beings cannot predict the future.
this. To clarify this, act utilitarianism allows a professional to not tell the truth to his
This issue does not play a major factor in an “ordinary” person’s life, however, it
patients, if he believes that this will protect the patients from getting worse, give them
does so one for a physician, as one miscalculation on his behalf can result in another
hope, and if it might jeopardize their treatments. The rule utilitarian are dismissive of
person’s life ending. However, when one is obligated to make a decision, one will
this, and believe that one should always be truthful.
take the decision that is the most rational, in the light of the best information at that
Utilitarianism states that the sole absolute principle is the principle of utility. “The
given time. Nevertheless, one may, however, come to find out that one’s decision
rule utilitarian argues that we should support rules permitting killing if, and only if,
may not have been the right one, because of new given information, and the result of
those rules would produce the most favourable consequences.” (Beauchamp,
this action.
Childress, 345:2001). However, utilitarians also say; “we do not presently permit
physicians to kill patients because of the adverse social consequences that we believe
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(
steals your car, then this gives you permission to steal someone else’s car, if you lie
(
to your parents, then your parents are allowed to you.
DEONTOLOGY
According to Deontology the preservation of our own “goodness” is the only thing
that matters, it more important than preventing harm from occurring to someone else.
Deontology is an ethical theory, which is duty-based, meaning that it is concerned
This makes deontology a very “self-focused” ethical theory. It is also absolute,
with people’s actions, and not what their consequences are. The word “deontology” is
constructed by the word deon, meaning duty, and the word logos meaning science.
meaning that one should follow the rules, even if this means bringing about personal
harm.
This theory is in contrast with Utilitarianism, which is consequence based. “...this
Immanuel Kant, one of the world’s greatest deontologists, has established categorical
type of theory is now increasingly called Kantian, as the ethical thought of Immanuel
Kant (1724-1804) has most deeply shaped it’s formulations.” (Beauchamp, Childress,
349:2001).
imperatives, which are rules he feels all must follow. The first rule is that one must
act only in such a way as to treat people as ends and never means. This means that if
one has set their minds on coming up with a solution to the problem of what to do
Deontology does not look at how much good comes from an action, rather it praises
the action itself. Deontologists look at the nature of their actions, and decide whether
they are prohibited or made obligatory by one of their rules.
with mentally ill persons, one must never benefit from others to achieve this goal.
Another rule, which has already been mentioned, is that one should act in the way
one would want others to act towards them.
Deontological rules are usually of negative obligation, for example; “do not lie”, or
One of the major drawbacks of deontology is that it does not take into consideration
“do not commit crime”, but can also be expressed positively; “tell the truth”, “treat all
as beings with rights”. According to Deontology one must not break a rule, and if the
the consequences that actions may have. Even though one may have acted in a
morally correct matter, the outcomes of this might be greatly negative.
consequences of one not breaking the rules turn out to be negative or cause harm, you
have not acted immorally. The outcomes of one’s actions are uncontrollable, and
Analysis(
therefore one is not held responsible.
For deontologists there is always something right or wrong in acts themselves; lying
and killing are acts that simply are wrong, and thus cannot be justified regardless of
the good that may come of it. By killing or lying, in order to prevent harm from
This part will explain Egas Moniz’s justification for performing lobotomies.
occurring, one actually causes evil.
In order to do so, Elliot S. Valenstein’s book “Great and Desperate Cures” (1986) in
Deontology makes use of something called; universalizability, which entails that
what is right or wrong for one person should be right or wrong for all. In other words,
this simply means that you believe something to be right, when you could accept to
live in a world in which everyone thought the same as you. For example, if someone
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Moniz’(s(justification(for(psychosurgery(
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which he explains Moniz’s theoretical justification for performing psychosurgery,
will be used, as well as the chapter ‘Rationale and Surgical Procedures from the book
“The Psychosurgery Debate”, which Valenstein edited.
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It is important to mention that Valenstein in his explanation is very critical towards
Valenstein claims, that because of the possibility of being accused by the medical
Moniz’s justification of psychosurgery. Valenstein’s critique, though, is well argued,
world of acting irresponsibly, Moniz wanted people to believe that he had been
and based on a large amount of data that we have not had the time to review or been
thinking about psychosurgery for some years, and had not just come up with the idea
able to gain access to.
of such an extreme treatment overnight. Apparently, the thought of such an
accusation haunted him for many years, for even in 1948, when the procedure of
According to Valenstein, there are two kinds of arguments supporting psychosurgery:
lobotomy was performed in many different countries, he still felt a need to clarify
an empirical-pragmatic argument and a theoretical argument. The empirical-
that he had spent an excessive amount of time thinking about the procedure, before
pragmatic argument essentially states that psychosurgical treatments are effective,
carrying it out in reality (Valenstein, 83:1986). Valenstein, though, claims that
and that psychological or alternative treatments are ineffective, stating that not
Moniz’s argumentation for performing lobotomies was only based on “…a series of
treating a given patient is dangerous. To support these arguments evidence is used to
general, loosely connected, and essentially untestable statements.” (Valenstein,
show that psychosurgery helps the patients and that the risks of this treatment are
84:1986).
minimal (Valenstein, 55:1980). These arguments are typically backed up by statistics,
Moniz believed that thoughts and ideas were stored between cells in the nerve-fiber
showing that patients suffering from different psychiatric conditions have a great risk
connections, and that “fixed thoughts” were the causes of all of mental illnesses –
of committing suicide, thus again stating that doing something is better than doing
generalizing the idea of an “Idée Fixe” by Pierre Janet, and seemingly applying it to
nothing. The theoretical argument for psychosurgery is based on outtakes of
all mental illnesses (Valenstein, 84:1986). These fixed thoughts are, according to
empirical data, often taken from experiments on animals, showing that the
Moniz, maintained by nerve pathways in the frontal lobes, which he called the seat of
destruction of certain brain structures can cause changes in emotional behaviour
man’s “psychic activity”. Moniz believed that for a given therapy to work, the
(Valenstein, 56:1980).
abnormally “stabilized” pathways in the frontal lobes had to be destroyed
(Valenstein, 84:1986). When Moniz was thinking and arguing for the use of
Egas Moniz was a Portuguese neurologist, who in the mid 1920’s, like any other in
lobotomy, there already existed a great amount of material written on the frontal
his profession, had a lot of patients suffering from mental illnesses. Moniz, though,
lobes, and on whether or not thought processes only occurred in certain areas of the
did not give much credit to psychological explanations and solutions as he was
brain, or governed by more holistic brain processes. Moniz chose to ignore this
convinced that real progress could only be achieved through organic orientation
material and pointed out the frontal lobes as the area of the brain where our thought
(Valenstein, 80:1986). Moniz performed the first lobotomy in 1935 on a patient, on
processes occur (Valenstein, 84:1986).
which all other treatment had not helped. The lobotomy was only supposed to be
After the First World War, neurosurgery had advanced a lot, and as a natural
used as a last resort, for patients on whom other less invasive treatments had failed to
consequence of this, a higher percentage of patients survived surgery - making it
work.
possible to study more people who had undergone neurosurgery. In 1923 Erich
Freuchtwanger released a study of soldiers, who had suffered gunshot wounds to the
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brain. The studied soldiers, who had suffered damage to the frontal lobes, were
Moniz claimed to have spent a great amount of time thinking about psychosurgery
characterised as having mood changes, lacking judgement, and being unable to plan
before first performing it on a human being, but Valenstein claims that his reasoning
for the future. The soldiers did not suffer as much when it came to their memory or in
for performing the lobotomy was actually “…such a vague and loosely reasoned
what were generally measured in intelligence tests (Valenstein, 91:1986).
argument, it should have persuaded no one that the risk was worth taking. Prefrontal
Karl Kleist found that damage to the medial portions of the frontal lobes caused
leucotomy was readily adopted, not because of the strength of Moniz’s argument, but
emotional changes, rather than negatively affecting people’s intelligence. If the
– in the absence of any alternative effective somatic treatment…” (Valenstein,
lateral aspects of the frontal lobe area were ruined, the reverse pattern would be seen
80:1986)
(Valenstein, 91:1986). Valenstein claims that Moniz only paid attention to the
literature he found supported his views and ignored the literature that went against.
Valenstein criticizes Moniz, and more or less also the medical and neurologist world
in general, for allowing the procedure of the lobotomy to become an appreciated way
The patient of the neurologist Richard Brickner, Joe A, was of great importance to
of treating patients with mental illnesses. Valenstein criticizes Moniz for ignoring
Moniz as he used the case of this patient in his justification of the lobotomy. Joe A
knowledge that contradicted his arguments on the subject of the brain’s frontal lobes,
was a successful stockbroker, but it was discovered that he had a large tumour in both
at the time when he invented the lobotomy. But the lobotomy was used until 1983,
frontal lobes. The tumour was removed, but great damage was done to both sides of
when much more data on how the brain functions, was available, and it puts
Joe A’s prefrontal area of the brain. Many months after the operation, Joe A was left
Valenstein’s criticism of Moniz into perspective. It seems peculiar that it took so long
feeling restless, but his situation stabilized, and he seemingly returned to being
for the world to realize that the procedure was more damaging than helpful to the
normal again - four neurologists had a long conversation with him and did not find
patients it was performed on, one might ask how come?
that there was anything wrong. But the operation had changed Joe A. He suffered
from mood changes, infantile behaviour, scoring very low in IQ-tests, could not plan
It may be argued that Moniz, when performing lobotomies, did not respect his
for the future or focus his attention; he never returned to work again. Despite these
patients’ autonomy. The fact that he was not aware of the outcome of this procedure,
serious changes in personality and decreased ability to function normally, Moniz
qualifying it as an experiment, makes it impossible for him to have explained what
stated that Joe A functioned “appreciably better than the majority of the insane”,
the risks were to either his first patient, or the family of the patient. This goes against
thus, according to Valenstein, not acknowledging the seriousness of Joe A’s inability
the principle of autonomy, as he was not able to procure a proper informed consent
to function normally. Moniz repeatedly referred to this case and similar ones in his
from neither the patient nor the family. Furthermore, it suggests that he might have
papers (Valenstein, 91:1986).
been taking advantage of his patients, as their autonomy was abated, in order for
Moniz to achieve personal goals.
The principle of nonmaleficence requires a physician to not inflict harm, and not
endanger his patients. By not knowing the outcomes of his new procedure, it is
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impossible for him to be certain that he was not inflicting harm, or endangering his
medicine, but in the end he decided on this field, and was accepted at the university
patients. Thus it is clear that by inventing this procedure, he did not keep in mind this
of Pennsylvania medical school. Freeman ended up practicing as the first neurologist
principle.
of the city of Washington DC. He began work, directing laboratories at St.
As a professional in healthcare, one must always treat his patients in a way that will
Elizabeth’s Hospital. It was his work at the hospital and witnessing the pain and
benefit them the most. If we assume that Moniz’ intentions for inventing the
distress suffered by patients that encouraged him to continue his education in the
lobotomy was good, that he truly was concerned for his patients, and that he was
field. Freeman got a PhD in neuropathology and secured a position at George
desperate for finding a solution to help alleviate his patients’ symptoms, his actions
Washington University as head of the neurology department. As soon as he became
of performing this surgery can be justified to some extent, as it may be qualified as
head of neurology, he made many changes to improve the students. Freeman started
doing the right thing; trying to help.
presenting neurological patients, demonstrating symptoms. His teaching became
Furthermore, analysing the information on Moniz’s way of justifying his procedure,
increasingly dramatic. He was a man that enjoyed being in the limelight. The way he
it could be argued, that he acted out of purely egoistic reasons, trying to earn a name
handled these patients could be viewed as cynical and unsympathetic, but he was
for himself in the world of physicians for inventing an entirely new way of treating
always effective and memorable. Moniz became a mentor for Freeman, and in 1936
people with mental illnesses.
he performed the first prefrontal lobotomy in the United States on Alice Hood
It is difficult to justify Moniz’s actions, as it seems he did not respect any biomedical
Hammatt, and began his career as a neurosurgeon. Freeman was assisted by his
principles. If one must think of an argument to support him, it must be that he acted
partner James Watts, when performing the procedures. Together they developed the
to create a better treatment – seeking to create the greatest happiness for the greatest
ice-pick lobotomy and travelled across the country visiting mental institutions in his
amount of people.
van, which he named the “lobotomobile”. Freeman’s name gained popularity and he
toured the nation performing lobotomies and spreading its use by educating staff to
perform the operation (Valenstein, 1986:139).
Portrait(of(Walter(Freeman(
Just like Egas Moniz, Walter J. Freeman, had a tradition of achievement to live up to.
Freeman’s upbringing in a wealthy and successful family could have blindsided him,
Freeman was born in 1895 and was raised in a wealthy family. His grandfather,
and made him strive for success. He was always looking for ways to impress,
William Williams Keen was a leading figure in American medicine and his father,
especially his own family and be the best at everything. The lobotomy was key to his
the first Walter Jackson Freeman, was a physician and a specialist in otolaryngology.
fame and opened up to the success he got later in life. Freeman's motives for
Freeman was born with a silver spoon in his mouth. He had gone to many good
performing lobotomies could be questioned. It seems as though his main motivation
private schools and had all the advantages that money could buy. When Freeman
was fame and acknowledgment.
began his senior year, he had no plans for his future. His parents advised him against
Like Moniz, Freeman was not sure of what the outcomes of the lobotomy was, as it
still was an entirely new procedure, at least when performing the first ones. This
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again goes against the principle of autonomy, as he could not inform his patients
allowed to exist, and the reasons why he has fought to make sure that the lobotomy
about the consequences of the surgery, furthermore, this also means that he could not
did not come to witness a second wave of success.
have been entirely sure of not inflicting harm, or endangering his patients. Moreover,
Peter R. Breggin, an American psychiatrist and also a contributor to Elliot
having altered Moniz’s original procedure, that was very complicated to perform, to a
Valenstein, Professor Emeritus of Psychology and Neuroscience at the University of
more simplified and cheaper version, Freeman enhanced the risks of consequences of
Michigan and former Chairman of the Biopsychology Program’s book “The
inflicting harm that followed this procedure.
Psychosurgery Debate” (1980), defines the arena of psychiatry as being “the activity
However, after having performed hundreds of lobotomies, the results were very clear.
of persons – their thoughts and feelings, and their actions” (Valenstein, 468: 1980).
Patients would often become emotionless, less intelligent and suffering from mood
According to Breggin, psychosurgery and psychiatric treatments attempt to alter
changes, at times they would even die. Freeman looked past these consequences, as
“human life”. It is therefore of crucial importance to take into consideration broad
the symptoms he originally wanted gone, were removed. For him, the procedure was
philosophical considerations such as “the nature of the human being” or “the purpose
a success, however, the majority of his patients would never come to function
of human life”, in order to make any safe or sensible progress in this field of
properly again, having to be committed to an institution for the rest of their lives.
medicine (Valenstein, 469:1980).
Travelling in his “lobotomobile”, promoting his new and cheap procedure, could
Reason – is described by Breggin as being “systematic choice making” (Valenstein,
suggest that he truly believed that it was an immense success, and that he had come
470:1980), meaning that the person who reasons, makes choices, between various
up with a solution to society’s problem, of what to do with mentally ill persons. It
real or imagined alternatives. It is the one thing, which firstly set humans apart from
seems as though Freeman’s actions can be justified from a Utilitarianistic point of
animals, secondly allows human beings to evaluate facts and theories, and finally
view. His actions benefited, according to himself, the majority, meaning the entire
permits individuals to carry out the simplest daily tasks, such as communicating with
society, as he had come up with, a quick and cheap solution to one of the major
and understanding others. Thus one cannot mention reason, and not mention free will
problems society had at that time, and “curing” diseased persons. For Freeman the
or volition, the two go hand in hand. Breggin describes the aforementioned as “the
results of the lobotomy were positive, thus counting as utility, however, others may
inner experience of choosing, deciding and ultimately making up one’s mind”
say that the consequences of getting a lobotomy were negative. It is here that one of
the greatest issues with Utilitarianism appears, the definition of “good” and “bad” are
On the other side of reason, we have emotion, which suggests the idea of involuntary
very ambivalent.
reactivity. Emotions are connected to bodily processes that lie beyond individual
control. However, these are crucially important, as they serve as signals, reflecting
the well being, needs and desires of an individual. In order for reason to function
Breggin’s(criticism(of(Psychosurgery
properly, being able to feel and identify different emotions is crucial. This means that
In this part, we will present Peter R. Breggin’s criticism of the Lobotomy. The
an individual must properly understand his emotional signals, understand what makes
reasons why he believed that this type of psychosurgery should not have been
him happy, and what makes him miserable in order to guide his decision-making and
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his conduct. Therefore, when an individual’s emotional responsiveness is damaged or
physician makes him less troublesome to himself and to others (Valenstein,
weakened, leading to him not fully understanding his emotions, or becoming
475:1980). Breggin states that he is in no doubt that psychiatrists knew exactly what
emotionless, the individual’s ability to make choices in life gets compromised.
they were doing. The effects of lobotomies were stated to be difficult to document
Moreover, the general emotional state of the individual plays a crucial role for the
Breggin is dismissive of this. He cites P. Macdonald Tow that came to some
individual’s capacity to think and make use of his will. In other words, if one does
conclusions on the effects of lobotomies on patients in his book Personality Changes
not feel good, because for example of a chronic illness or fatigue, one will not put too
Following Frontal Leucotomy (1955). Tow says that he observed a decrease in
much effort, willpower, or concentration in exercising his ability to think and act.
patients’ abilities to “deal with complex situations, planning, and thinking out of the
Some somatic treatments, such as the lobotomy, can produce this feeling of chronic
next action and its consequences”. He also believed “these patients to be more
illness or fatigue and therefore render the patient unable or unwilling to reason and to
“schizophrenic” after their lobotomies” (Valenstein, 489:1980). In Breggin’s words;
act, particularly when confronted or suppressed (Valenstein, 471:1980).
these patients’ personal sovereignty was removed as a result of lobotomies. Tow’s
Breggin gives the name of Personal sovereignty to the inner experience of free will,
results on the effects of lobotomies on patients should, according to Breggin, have
reason and emotion; “A person who is “personally sovereign” can choose to
put an end to the use of it. However, even though Tow was a first hand witness to
experience his emotional signals and to reason systematically” (Valenstein,
these awful consequences of lobotomies, he was a loyal defender of this procedure,
472:1980). Personal sovereignty is equal to inner freedom; it is both a capacity and a
stating “ that the lobotomy would make them less morally sensitive to their awful
right. Breggin goes on to talk about Personal freedom, which he explains as being
condition and plight” (Valenstein, 490:1980). The mental state hospitals were
“the external or public expression of personal sovereignty” (Valenstein, 472:1980).
overcrowded with patients for whom there existed no cure. Thus psychosurgery
He sees personal freedom as being the right and the ability of an individual to express
became the answer to gain the upper hand for professionals, turning “madhouses into
his thoughts and emotions through actions.
storehouses” (Valenstein, 486:1980).
According to Breggin, normal brain function gets disrupted by psychosurgery and
Breggin states that the introduction of the major tranquilizers, and his role playing in
produces brain damage, which results in one’s personal sovereignty and personal
letting the public know what was going on in the state mental hospitals, were one of
freedom getting diminished. More specifically, he says that the goal of psychosurgery
the reasons that the lobotomy did not witness a second wave of success. He presents
or psychiatric surgery; “Is to modify thoughts, feelings, or conduct, and it
three reasons why he was so determined with raising concern about this procedure
accomplishes this by compromising the brain functions required for personal
and why he believed that lobotomies should not have existed, or at least continue to.
sovereignty or personal freedom” (Valenstein, 473:1980). He insists that, no matter
First he states that the procedure itself was “a very harmful and irrational
what, psychosurgery, electroshock and the major tranquilizers “always compromise
intervention”, second he believes that “ there is the ever-present danger of a much
normal brain function”(Valenstein, 473:1980). According to Breggin, a psychiatrist
more wide-scale application of the surgery, if and when the psycho-surgeons find
or psychosurgeon performs psychosurgery on his patient in order to gain control over
access to the large state mental hospital, the prisons, or the institutions for the
him. By reducing a patient’s ability to think, to feel, to choose and to act, the
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retarded”, and finally that some psychiatrists “were explicitly advocating the surgery
original prefrontal leucotomy continues to haunt the meaning of the word
for the control of black violence in the ghetto” (Valenstein, 487:1980).
psychosurgery. Moreover, there is no evidence for efficacy, and it can never be
There were many reasons why Breggin was against the lobotomy. Firstly that he
gathered because of the extreme ethical difficulties of carrying out controlled trials in
considered the procedure to be very harmful, as it removed individuals’ humanity,
this area.
leaving them to become emotionless beings, thus going against the principle of
The development of new approaches in neurosurgery is ever continuing, and makes
nonmaleficence, and beneficence. Secondly he condemned the motivation and the
up for the negative connotation that psychosurgery has had in the past. The
reasons for why psychiatrists performed this “surgery” on their patients. In his point
approaches include forms of deep-brain electrical stimulation and vagus nerve
of view, psychiatrists’ main motivation was not to help these people, but in fact gain
stimulation. Therefore it could seem that now is a good time to reconsider whether
control over them, so that their work would become easier. Many of the patients were
psychosurgery should continue to be performed, given the recent advances made in
aggressive as a result of their condition, removing a part of their brain to make them
medicine (Persuad, Corssley & Freeman, 196:2003).
more “simple”, and less active, was a way of gaining control of the overcrowded
The scientific breakthroughs concerning psychosurgery rarely credit the humans who
mental hospitals.
were subjected to the unnamed horrors to produce some of the benefits for the
Furthermore, psychiatrist saw the lobotomy to be a solution to the violence in black
populace. This means that Kaimowitz disapproves of the use of humans, when it
ghettos. For them, performing a surgery on a few people would benefit many more,
comes to scientific experiments, and treatments with high risks of death, and negative
thus justifying the principle of utility. This is something that Breggin was against,
outcomes. The goal of performing these experiments was, and still is, to try to perfect
and one of the reasons why he raised attention among the public about what was
the population, meaning coming up with an improved way to create better human
going on in the mental hospitals, and about the true consequences of the lobotomy.
conditions.
Taking ethical consideration to the subject of matter, Kaimowitz states that, until
Defence(and(criticism(of(psychosurgery(today
proper justification for why these treatments should or should not be allowed to be
In this part of the project we will look at the opinions and dilemmas concerned with
performed is shed some light upon, science ought to wait to make use of them.
psychosurgery today. Doctors have to follow four different principles of biomedical
Because what is the agenda of these surgeries? Is it to create perfect humans? And is
ethics; Respect for autonomy, Nonmaleficence, Beneficence, and Justice.
this a valid reason? These attempts to create perfect species have side effects, which
result in suffering, and in some cases death (Kaimowitz, 508: 1980).
Additionally, modern neurosurgery is safer than ever before, and appears to offer
An argument against brain surgery is that personality should not be altered, because
clinically meaningful symptom relief for untreatable patients with chronic
of the concept that personality is something sacrosanct. The fear caused by the
depressions and obsessional compulsive disorder (Persuad, Corssley & Freeman
196:2003).
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The fear once caused by the original prefrontal leucotomy still haunts the thoughts of
It is clear that clinical neuroscience has advanced in the last 25 years, and
the word psychosurgery today, however, with the precision available for modern
improvement in radiology has provided new insight to the relation between the
techniques, brain surgery has become safer and more reliable.
human mind and the brain. Not only has this helped us achieving a better
Psychosurgery has developed to become a safe alternative to therapy and medicine.
understanding of the brain, but also the aetiology and progression of diseases of the
As Bullock says:
brain. It has been stated that psychosurgery can eliminate the symptoms of mental
disorders that are refractory to all other treatment. Techniques that target the brain
“A dispassionate examination of the possibilities of precise surgical procedures on
can modify the source of the mind and affect the will and identity of us. These core
the brain is called for, especially for the relief of specific psychiatric conditions like
features of philosophy of mind overlap with the ethical notions of benefit and harm,
schizophrenia, obsession, addictions, aggression and violence. From the perspective
since whether an action benefits or harms one depends on whether and how it affects
I have gained, as a non-physician neuro-scientist, the most widespread criticism of
one’s mind. Intervening with the brain can reveal and affect the nature and content of
psychosurgery is not the abuse in a limited number of cases but the serious
our minds and therefore also who we essentially are (Glannon, 1: 2006).
shortcoming in a larger number of cases in respect to pre-operative and postoperative evaluation. It is clear that the climate of today in this part of the world
It is obvious that the discussion of psychosurgery is far from solved, and there are
demands a marked increase in the detail, the time-span, and the multidisciplinary
many different opinions on the issue. The question now is; can modern
character of evaluation, with the corollary requirements for the experts beyond those
psychosurgery be ethically defended?
minimally needed for surgical and medical care - in particular for objective,
By performing psychosurgery on mentally ill patients, does their autonomy stay
professional assessment of social behaviour. Every patient should be properly
intact? The proponents of these surgeries believe that the positive effects and the
evaluated, followed up and reported. The bias against functional neurosurgery based
improvements of neurosurgery are worth risking one’s life and altering one’s original
upon the untoward results of the original leucotomy operation, the confusion of the
personality. If the person is deemed unfit to make decisions about themselves and are
idea of the soul with the mind and unjustified fears about the personality changes -
unable to express a preference, consequences and unable to understand relevant
all these need dispelled by a calm analysis of the indications and results of
information, it should be up to the surrogate to know what is best for the patient.
psychosurgery as is being done in the other realms of surgery and their publication
Furthermore, by eliminating mental illnesses and thereby improving the general
of informed criticism.
mental health of the population, surgeries can improve the population and become a
Only this can make functional neurosurgery available for those who need it’’
way to better many human lives. In other words; eliminating mental illnesses can
(Ramamurthi, 2: 1988).
improve the economy and the society.
This is a utilitarianistic way of looking at the discussion of neurosurgery, since it
states that action should be taken to benefit the general population as much as
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possible. Individuals that are against psychosurgery state that all humans have a right
our discussion and conclusion more in depth, giving a more definite answer to our
to choose what is best for themselves. This is a deontological way of viewing the
problem statement.
issues concerning psychosurgery. The sources against surgery, do not believe that
performing brain surgery is morally correct and not necessarily the right choice of
It is important to clarify that the discussion carried out about Moniz’s justification is
treatment in the cases concerned. Many patients subjected to psychosurgery are not
inevitably influenced by Valenstein’s critique. We are aware of the fact that our
in a state to be responsible of such life decisions due to their illness. Kaimowitz, who
opinion of Moniz’s actions might have been coloured by Valenstein’s critique, but
is against psychosurgery, believes in that the principle of autonomy is important. He
this was kept this in mind while discussing the particular matter. Nonetheless, it has
states that the importance of human rights and personal autonomy is significant. This
proven to be beneficial as it has both allowed us to analyze, and discuss Moniz’s
ethical dilemma will be further discussed in the project discussion.
justifications with two different points of views; firstly presuming that his intentions
were bad and secondly that they were good.
Discussion(
Regardless of whether Moniz’s intentions were good or bad, (good meaning that he
In this part the collected material and our findings will be discussed in relation to the
theories and the ethical principles. The material and the findings will be compared
only had in mind helping his patients, and getting them out of their misery, and bad,
meaning that he either wanted to become famous, or that he purposely overlooked
and discussed within the problem field, where the main assumptions will be
data for some unknown reason) his invention must be qualified as an experiment.
highlighted in order to further investigate the material and the problem formulation.
First we will look at Moniz and discuss his justification for inventing and performing
lobotomies on patients - Valenstein’s critique of Moniz will be taken into
Thus he was not able to follow any of the biomedical principles. Due to the fact that
Moniz could not possibly have known what the exact consequences of his invention
would be, it must inevitably have been impossible for him to inform his patient or
consideration when doing so. Thereafter, we will discuss Freeman’s reasons for
his/her family about the accurate consequences of the procedure. Thus he did not
performing lobotomies, taking information about his background into consideration.
Furthermore, we will discuss Breggin’s criticism of lobotomies, and lastly we will
follow the first biomedical principle: respecting the autonomy of a patient, which
includes informing patients/surrogates about the dangers of a given surgery.
focus on the use of modern psychosurgery. The negative and the positive reasons for
why lobotomies were used will be put up against each other. This will hopefully shed
some light on how the use of the lobotomy on mentally ill people can be ethically
Furthermore, not being aware of the consequences of his procedure, he could not
have known if he would harm his patients or not - he therefore did not follow the
second biomedical principle: Nonmaleficence. By not respecting this principle, he
justified, and if there could have been another solution to the issue of what to do with
automatically did not respect the third: Beneficence.
these individuals. Furthermore, we will discuss how the discourse of the analysis
would have been if the choice of resources were different, and if it would have made
If we presume that Moniz experimented on his patients, his actions cannot be
justified according to deontology, as he would have used them as means to reach an
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end - possibly using the results of his experiments to further develop the procedure.
impossibly have been true. If one agrees with Moniz, his decision can to some extent
However, if Moniz performed the procedure because he saw it as the best possible
rightfully be claimed to be rational. If one agrees with Valenstein, Moniz’s actions
solution to his patients’ mental problems, thus making the most rational choice based
were not rational. Whether the actions were rational or not, they have since proven
on the data he had, it can be argued, that his actions were justifiable according to
not to be the right ones, as the consequences were negative, damaging people’s lives
deontology.
and even causing death.
If Moniz’s reason for inventing the lobotomy was that he wished to help his patients
By not following the biomedical principles, one might call them rules in this context,
and society, his actions can, according to utilitarianism, be justified to some extent.
Moniz did not act accordingly to rule utilitarians as he should have sought to keep
The outcome might have benefitted the greater good, however, by not knowing the
these principles in mind when performing the procedure (As Moniz claimed to have
exact consequences of his invention, his actions can be qualified as negative.
spent an excessive amount of time thinking about the procedure, it seems odd that he
Nonetheless, one of the major drawbacks of utilitarianism becomes clear here; his
did not keep in mind the principles), and these principles should have been followed,
actions were negative, but the outcomes of them can to some extent be qualified as
especially when performing the first lobotomy on a human being.
good and as benefiting the majority. Though, one can always say that one’s negative
actions were carried out with the intention of serving the greater good. Furthermore,
If one assumes that Moniz’s intentions were in fact bad, and that he simply invented
if one looks at Moniz’s procedures in a very cynical way, his actions can be argued to
the lobotomy in order to gain fame and acknowledgment, his actions cannot be
be justifiable, because he might have acted to serve the overall societal good. The
justified. Valenstein’s critique of Moniz’s justification states that he overlooked too
reason for this is that it might have been cheaper for society to keep institutionalized
much data. This could have been because Moniz was simply blinded by his own
patients, on whom a lobotomy had been performed, compared to the costs of keeping
eager to help persons with mental illnesses, and that he wanted to help them as soon
a patient on whom a lobotomy had not been performed.
as possible. However, it is more probable that Moniz was in a rush to create a name
for himself. It is hard to come to grips with the fact that Moniz, by being a
Being surrounded by mentally ill patients all day, witnessing their suffering and pain
professional, could have overlooked that much data. If acknowledgement was
- not being able to do anything about it, one can surely understand how this could
actually the reason for Moniz’s invention, such a purely egoistic motive can surely
have been frustrating, and could have led Moniz wanting to invent a procedure that
not be justified by deontology, as he did not seek to do the moral thing, but to serve
would help these patients.
his own personal agenda.
However, it seems as though his invention was too rushed and under-researched, at
least according to Valenstein - and this should be kept in mind when discussing this
So what is the answer, can Moniz’s actions be justified? We have found that whether
specific matter. It is claim against claim. On the one hand there is Moniz, who states
his intentions were good or bad, his actions were unethical. In both cases Moniz was
that his procedure was not invented overnight, but was the result of a long and
not sure of what the consequences were, qualifying his first surgery as being
profound research. On the other hand, Valenstein implicitly claims that this could
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experimental. He was therefore using his patients as means to an end, which is
benefit from this, including the society. It can be suggested that from a utilitarian
immoral.
point of view to be a positive utility, thus qualifying his actions as morally correct.
Utilitarianism states that one’s actions are neutral, and that it is the result of an action
However, if Freeman’s motivation for changing the Lobotomy was fame and money,
that counts. However, this leaves space to an issue, for utility is a complex term to
his actions cannot be defended. He went about harming people for his own benefit.
define and means something different to all. Freeman surely believed that the
This is an immoral action from both a deontological and a utilitarian point of view.
outcomes of the lobotomies he performed on his patients were of positive nature, he
would otherwise have not been so eager to promote it as a cure for all mental
If we try to conclude on this; are Freeman’s actions then ethically justifiable?
problems. Others may state the contrary. So the question remains, can his actions be
According to our findings we cannot go about to justify his actions. The negative
justified?
consequences of his actions, weigh more than the positive ones. Freeman’s acts are
solely justifiable in the cases where we assumed that his intentions were good, and
If we include Freeman’s background in our thought process, it could be suggested
that the outcomes counted as utility. However, taking into consideration his
that his intentions were bad, and that he was seeking fame and acknowledgment. If
background, the family in which he grew up in, and the pressure that was laid upon
this were the case it can be presumed that Freeman was aware of the negative side-
him, everything points to his intentions being bad. It seems as though his sole
effects of this surgery, but chose to focus on the positive outcomes in order to gain
motivation was to gain fame and acknowledgment. Nevertheless, it is important to
recognition. This goes against the principle of autonomy. Freeman assumably did not
underline that our conclusion here is only a presumption, as it is impossible to know
inform his patients/surrogates about the negative side-effects, thus misleading them.
if his intentions were good or bad solely based on how his background is interpreted.
Furthermore, he also did not respect the principles of beneficence and
Primuim no nocere, above all do no harm; this is one of the most important rules that
nonmaleficence, as he knew that he was, to some extent, going to harm his patients.
a physician has to follow. A professional must at all times try to do what is best for
Moreover, Freeman’s actions were immoral, in this case, as he took advantage of his
his patients. According to Breggin, the psychiatrists that were performing lobotomies
patients, using them as means to his personal goals; getting acknowledgment in the
on their patients did not follow theses rules. He believed that they knew exactly what
world of medicine.
they were doing. He presents literature in which the consequences of getting a part of
your frontal lobes removed were clearly not positive. Professionals knew exactly
The fact that Freeman altered Moniz’s lobotomy, making it easier and cheaper to
what the consequences of lobotomies were, still he believed that it was a way for
perform, can be looked upon as firstly something positive and secondly as something
them to control their patients. So we can assume that for Breggin, the actions of the
negative. If we assume that Freeman changed the original Lobotomy for the reason
psycho-surgeons were not justifiable, according to both a utilitarian and
that it would benefit the majority of the society, his actions can be suggested to be
deontological point of view.
good. By performing this procedure on a handful of individuals, many more would
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Later in his criticism of the lobotomy, Breggin mentions a book named “Personality
In the time of Moniz and Freeman, respecting a patient’s autonomy was probably less
Changes Following Frontal Leucotomy” (1955), in which Two, psychiatrist and
important than it is today. Physicians are much more preoccupied with the value of a
author, explains the consequences of lobotomies. Tow was a defender of the
human being’s life, and this obligates professionals to respect patients’ autonomy
lobotomy, and stated that by performing this surgery on persons that were
much more, inform them or their family/surrogates about the dangers and expected
institutionalized would turn them into “good inmates”. If we look at it from the
results of a surgery. If a patient/family/surrogate refuses a surgery, this is respected.
perspective of the professionals that proudly offered this surgery as a solution to
Firstly, because many other treatments are available, secondly, because of
mental disorders, it seems as though one can to some extent justify their actions.
globalisation and the rising of social media; if a professional makes a wrong choice
These doctors were surrounded by mentally ill patients every day and saw the horrors
the entire world would be aware of this and finally, because of more strict laws, and
and the poor conditions of their patients. This may have led to a feeling of
establishments of institutional review boards (ethical review boards). Moreover, due
helplessness. In this sense, one might come to better understanding the decision of
to technological advancements we are much more in control of the options when it
doing something instead of doing nothing. Moreover, it might have seemed to the
comes to our treatment, and also more knowledgeable about the true consequences of
doctors that by diminishing their patients’ emotions and free will, they were actually
surgeries. We are today not as obligated to blindly trust physicians.
doing good, lifting weight from both society and the families’ shoulders. Thus their
decisions can be qualified as understandable. Moreover, the problem with
However, it is important not to forget that no matter what, the result of any given
utilitarianism comes to the surface once again. The psycho-surgeons viewed the
action is never certain. Even though that medicine has advanced, and brain surgeries
results of lobotomies as being positive, others may perceive them as negative, thus
have become a lot safer, there is always a risk of negative side-effects. The outcomes
leading us again to question the nature of their actions. Furthermore, Breggin was
of a surgery are always uncertain even if this is just a simple removal of an appendix.
also dismissive of using the lobotomy as a solution to the violence in the black
Does this mean that one should never undergo a surgery, knowing that this would
ghettos, as it was suggested by the psycho-surgeons. Their proposal of doing this
save one’s life? Some risks are worth taking, however these risks must be minimal.
could be to some extent justified by utilitarianism, as they were acting to benefit an
Because psychosurgery is safer today, the choice of getting a brain surgery is a lot
entire society by harming only a few.
more rational than it was before, however, we cannot be certain, as there might be
invented a new and safer procedure/treatment in the future that will make us regard
When it comes to psychosurgery today, it is no secret that it is a lot safer than it was
today’s procedures and treatments as being inhumane and damaging.
when first psychosurgical procedures were introduced by Moniz and Freeman. A
great amount of time has passed and along with it medicine has advanced. Brain-
Viewing modern psychosurgery from a utilitarianistic perspective, it is a way of
surgery has become safer. This makes performing complicated brain-surgeries a lot
improving health and reducing society’s expenses. Mentally ill persons can be said to
more justifiable than it was in the past. It is the most understandable, most rational
be an expense and a problem for our society. Minimizing this issue as much as
and right act to take, according to both deontology and utilitarianism.
possible could benefit society and improve the economy to some extent.
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Taking action that would benefit the general population is from a utilitarianistic point
rules of deontology, meaning not performing lobotomies on individuals, as this is
of view justifiable.
immoral (because of not knowing the consequences) many individuals would not
have received help in the future. It is important to take into consideration that it is no
A final point that can be made with respect to modern psychosurgery is that we can
longer necessary today to experiment on people to the same extent than back in
ask ourselves; where would we be today, when it comes to advances within this field,
times, as so many advances have already been made. In other words, many of the
if individuals such as Moniz were not willing to take risks and performing outrages
diseases that were once lethal are now under control and treatable. This might be the
procedures such as lobotomies on patients? Does this then justify using patients as
reason that people today regard the use of lobotomies and other treatments such as
guinea pigs? It is a very hard, if not impossible question to answer, as we cannot say
electroshock therapy and malaria treatments as being inhumane. If we did not have
for certain where we would be today, when it comes to treating mental illnesses. Had
treatments for mentally ill persons today, is it not possible that we would have done
there not been experimented with procedures, we might still be dealing with the same
the same as Moniz and other psychiatrists?
issues of not knowing what to do with mentally ill persons. However, there is also the
possibility that it was not necessary to go through the horrors that lobotomies resulted
It is important to mention that the sources used have influenced the view upon
in, in order to come up with safer and better treatments. This is impossible to know.
psychosurgery stated in the project. The analysis would have had a different
Nonetheless, the consequences might have been worse if Moniz and other psycho-
discourse if there had been included first hand sources, such as an interview with
surgeons had not experimented on individuals, meaning that the field of neurosurgery
Moniz or a surgeon who had performed the lobotomy. The chosen material has
might not have advanced as much, making it impossible for professionals to help
formed the project angle and is therefore important to take into consideration when
their patients nowadays. If we think of it in this manner, the fact that experiments
discussing our end results.
have been conducted on persons throughout time is somewhat positive for the world
today.
Conclusion(
It is necessary and natural for the world to develop, especially within the field of
medicine. When inventing simple remedies such as vaccinations against polio or
With this project we tried to answer the question: ‘’How can the use of the
chicken pox, experiments were also conducted on individuals. If some people had not
lobotomy be ethically and morally justified, and how is psychosurgery looked
been experimented on, these treatments would not have been invented and this would
upon today?’’. In order to do so we have given an introduction to how the brain
have caused great suffering for many people. It is harsh to say, however true, that
functions and how complex an organ it is. Furthermore, we have explained what
some individuals have to be experimented on and at times harmed, in order to invent
performing a lobotomy consists of, and what illnesses it was supposed to cure.
treatments that can save many more.
Moreover, we have dedicated a part to the history to the development of psychiatric
It seems appropriate to make use of a utilitarianistic point of view, when it comes to
treatments throughout time. Our method consisted of applying theories about
experiments on individuals in the world of medicine. It appears that if one follows the
biomedical ethics in order to analyze justifications and critiques of the use of
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lobotomies and modern psychosurgery. In the discussion we reflected on the use of
were bad. Moreover, the consequences of lobotomies were documented to have been
modern psychosurgery. We finished off our discussion with reflecting upon how the
of negative nature. Despite of all this, it must be taken into consideration that if
invention and use of lobotomies might have played a role for the advances of
different material was analyzed - possibly first hand sources, an alternative
psychosurgery and medicine in general today, and if this is a valid justification for
conclusion might have been reached.
having caused harm to some individuals.
The invention of the lobotomy might have helped professionals to acquire more
Based on the discussion chapter, the use of lobotomies can both be justified and
knowledge about the brain and mental diseases, and helped develop psychosurgery,
criticized from a deontological and utilitarianistic point of view.
making it safer to perform today. If we assume that this is the case, the act of having
performed lobotomies on patients can, to some extent, be justified by a utilitarianistic
From a deontological perspective, the actions of performing lobotomies could be
point of view.
justified if it is assumed that the intentions of the surgeons were good, and that they
On the other hand, if we assume that it has not helped advance modern medicine, the
only wished to help their patients, thus making the right and moral choice. However,
act of performing lobotomies cannot be justified from this perspective, as the results,
their actions could not be justified if their intentions were bad. This is because they
as well as the actions, were negative.
were taking advantage of their patients in order to reach personal goals.
Our project does not provide any definite answer to whether or not Moniz and
From a utilitarian perspective, the act of performing lobotomies can be justified
Freeman’s actions were justifiable or not. Nevertheless, our use of theories has
because the positive results outweigh the negative actions. In terms of numbers, many
enabled us to analyse and discuss the subject of psychosurgery in a constructive
more individuals have benefitted from having undergone this treatment than not.
manner and raise the level of the different analyses.
However, this justification is only valid if one perceives the results of lobotomies as
Law and ethics are in many ways similar; however, there are many differences
being positive.
between them. The law defines what actions are wrong and right, according to the
It is impossible to know whether the intentions of the psycho-surgeons were good or
majority of a population, thus serving as guidelines to our decision-making. This
bad, moreover it is also impossible to come to an agreement on whether the results of
project could have gone further, and could maybe have been more fulfilling if we had
lobotomies were negative or positive. Thus making a decision on whether their acts
included a part which focused on what the law states when it comes to this specific
were justifiable or not a matter of opinion.
matter, and put up against the ethical theories which were made use of
However, taking Valenstein’s critique into consideration, it is more probable that the
actions of Moniz were justifiable from neither a deontological or utilitarian point of
view, as Moniz seemed to have overlooked too much data. Furthermore, having
taking Freeman’s background into consideration, it seems as though his intentions
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(
• Valenstein, Elliot (1986) Great and Desperate Cures, The Rise and Decline of
Psychosurgery and Other Radical Treatments for Mental Illness. Basic Books,
Reference(List(
Inc., Publishers/ New York
Books
Websites
• Beauchamp, Childress (2001), Principles of Biomedical Ethics, Oxford
University Press 5th edition
• merriam-webster.com/dictionary/id%C(http://www.m3%A9e%20fixe)
•
Glannon, Walter (2006), NEUROETICS, bioethics ISSN.
Pictures (in order of appearance)
• Hope, Tony (2004). Medical ethics: A very short introduction. Oxford
• http://www.caaquaculture.org/2013/03/08/human-brain-evolution-and-eating-
University Press
fish-from-shoreline-environments/
• Kragh, Vaczy Jesper (2010). Det hvide snit, Psykokirurgi og dansk psykiatri
• http://www.studyblue.com/notes/note/n/psychology-202/deck/1958583
1922-1983. Syddansk Universitetsforlag 2010
• http://webspace.ship.edu/cgboer/limbicsystem.html
• Parker, Steve (2007), Menneskekroppen, translated by Jerk W.Langer
• http://www.braininjury.com/symptoms.shtml
• Persuad, Raj. Corssley, David and Freeman Chris (2003). Should
neurosurgery for mental disorders be allowed to die out?
• http://www.nobelprize.org/nobel_prizes/medicine/laureates/1949/monizarticle.html?print=1
• Ramamurthi, B (1988), Ethics of functional Neurosurgery, springer-verlag.
•
http://www.miriamposner.com/lobotomy.html
• Valenstein, Elliot (1980). The Psychosurgery debate. Scientific, Legal and
•
ethical Perspectives
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http://infopresser.tumblr.com/image/4367261679
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psykokirugi er etisk korrekt, men at man skal vurdere hver enkelt sag, og derfra
vurdere dets grundlag. Udfra fra teorierne kan vi konkludere, at lobotomien ikke kan
retfærdiggøres. Opgaven giver dog ingen definitive svar, og set fra lægernes
perspektiv, kan udførelsen af lobotomi virke nogenlunde forståelig.
Abstract
This project offers an insight into the history of psychosurgery and into the history of
the lobotomy especially. The project analyses the ethical issues concerning the use of
the lobotomy both then and now. More specifically, it will analyse Egas Moniz and
Walter Freeman’s justifications and reasoning for performing the procedure, and it
seeks to shed light on this by applying utilitarianism and deontology as well as the
four biomedical principles.
In the discussion it will be discussed if the use of lobotomy can be justified in any
way, and especially if the justification for the procedure was unethical.
Summary(
Dette projekt undersøger de etiske dilemmaer, når det kommer til psykokirugi. Der
redegøres for lobotomiens historie og hjernens funktion. Derefter gennemgås de fire
biomedicinske principper og den valgte teori: utilitarisme og deontologi, som bruges
som redskab i analysen. Analysen arbejder med forsvaret og kritikken af psykokirurgi
før og nu - især bliver der fokuseret på Moniz og Freemans handlinger, og om disse
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kan forsvares etisk. Derudover består analysen af en kritik af lobotomien og en
analyse af tekster, der forsvarer og kritiserer psykokirugi i dag ud fra etiske normer
og regler. I diskussionen diskuteres hvorvidt operationerne kan retfærdiggøres etisk,
og om grundlaget for at udføre psykokirugi kan begrundes og retfærdiggøres i dag.
Projektet afsluttes med at konkludere at der ikke er noget entydigt svar på, om
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The Lobotomy. FINAL EDITION

Transcription

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