France, along with Germany, Spain, Scotland, Wales, Belgium, the Netherlands, Finland, Sweden and Italy (that I know of, there may be others) is one of the Western European countries that still practises psychosurgery. Along with, for example, Spain
it is one of the few where agressive behaviour in psychiatric patients is still considered an indication for surgery.
In 2002 the National Committee for Medical Ethics (CCNE) produced a report on psychosurgery, Opinion no 71
. The report was prompted by two different requests for guidance on the ethical implications of psychosurgery. One concerned the following case:
"a 20 year old patient, suffering from severe psychiatric disorders (agitation, hetero-aggressivity, threatened self-mutilation) for which he had been hospitalised almost continuously since 1995. Since his condition is proving refractory to the usual psychiatric medication, surgical procedures are being considered so as to try and reduce his potential for violence and make him less dangerous to others. The health caring team hopes in this way to be able to provide more humane treatment than the almost prison-like incarceration which is his present lot."
The other request came from neurosurgeons in Grenoble who use Deep Brain Stimulation to treat people with Parkinson's disorder and want to expand into psychiatric disorders.
Opinion no 71 was largely favourable to psychosurgery, with the usual caveats about consent, committees and follow-ups, although they stopped short of recommending its use for agressive behaviour.
The report provoked a critical response from one French psychiatrist, Alain Bottero, who wrote a spirited twenty-page article
, L'ethique au secours de la psychochirurgie? (When medical ethics come to the aid of psychosurgery), in the French psychiatric journal L'evolution Psychiatrique, vol 70, 2005. Bottero expresses his disappointment at his fellow psychiatrists' silence in the face of the report - apparently psychiatrists in France have traditionally been less enthusiatic than neurosurgeons about psychosurgery.
Bottero begins his article with a scathing attack on the National Committee for Medical Ethics (CCNE) for having produced a report that is rambling, repetitive, error-ridden and at times incoherent. Was there, he asks, so much pressure from neurosurgeons who were waiting for the go-ahead to operate on psychiatric patients that there was no time to proofread the document? If, he points out, Boileau was right in saying "Whatever we well understand we express clearly", then there are certainly some doubts about the Committee's understanding of psychosurgery.
The author criticises the report for claiming that new functional neurosurgery treats symptoms whilst leaving the personality intact, unlike old lobotomies. New techniques are just less mutilating, and they are not even new, he says.
Bottero takes the Committee to task for its failure to address the concerns of psychiatrists, in particular the lack of a scientific rationale for psychosurgery (and here he points out that the hypotheses of the neurosurgeons haven't advanced much since the 1940s)and the lack of evidence for both the efficacy and safety of psychosurgery.
Finally, Bottero takes issue with the concept of "treatment-resistant" disorders. Psychosurgery is usually justified - and Opinion no 71 is no exception to this - by stressing the intolerable suffering of the patients and their failure to respond to other treatments. But Bottero argues that neurosurgeons are ill-equipped to understand the fluctuating course of mental disorders and their responsiveness to environmental influences. The best response to treatment failures, he says, is not necessarily ever more drastic treatment until the treatment of "last resort" is reached; a completely different approach may be called for in order to build up a therapeutic relationship which will give the patient hope.
"The CCNE has been too hasty in taking up its position on neurosurgery for mental disorder. It is up to psychiatrists to make it clear that such interventions remain ethically dubious for at least three reasons that can no longer be ignored. Their efficacy remains unproven; they are dangerous and have serious irreversible side-effects; there are other therapeutic options available which, even if proof of their efficacy is lacking, should nevertheless be actively explored and encouraged because they are a lot less dangerous.... Consent and protocols won't change anything when it comes to a question that still has no satifactory response: the lack of scientific validity for interventions that carry with them the risk of breaching the integrity of the personality."(Bottéro A. L'éthique au secours de la psychochirurgie ? Evol. psychiatr. 2005 ; 70)