The Ethics of Deep Brain Stimulation for the Treatment of Anorexia Nervosa

There is preliminary evidence, from case reports and investigational studies, to suggest that Deep Brain Stimulation (DBS) could be used to treat some patients with Anorexia Nervosa (AN). Although this research is at an early stage, the invasive nature of the intervention and the vulnerability of the potential patients are such that anticipatory ethical analysis is warranted. In this paper, we first show how different treatment mechanisms raise different philosophical and ethical questions. We distinguish three potential mechanisms alluded to in the neuroscientific literature, relating to desire, control, and emotion, respectively. We explain why the precise nature of the mechanism has important implications for the patient’s autonomy and personal identity. In the second part of the paper, we consider practical dimensions of offering DBS to patients with AN in certain cases. We first discuss some limited circumstances where the mere offering of the intervention might be perceived as exerting a degree of coercive pressure that could serve to undermine the validity of the patient’s consent. Finally, we consider the implications of potential effects of DBS for the authenticity of the patient’s choice to continue using stimulation to ameliorate their condition.

[1]  Harry G. Frankfurt,et al.  The importance of what we care about: Freedom of the will and the concept of a person , 1971 .

[2]  J. Savulescu.  Rational desires and the limitation of life-sustaining treatment. , 1994, Bioethics.

[3]  M. Schechtman.  The Constitution of Selves , 1996 .

[4]  J. Savulescu,et al.  Should informed consent be based on rational beliefs? , 1997, Journal of medical ethics.

[5]  B. Barraclough,et al.  Excess mortality of mental disorder , 1998, British Journal of Psychiatry.

[6]  H. Draper.  Anorexia nervosa and respecting a refusal of life-prolonging therapy: a limited justification. , 2000, Bioethics.

[7]  P. Beumont,et al.  Conceptual issues in theorising anorexia nervosa: mere matters of semantics? , 2003, International journal of law and psychiatry.

[8]  A. Wakefield,et al.  Coercion in the treatment of anorexia nervosa: clinical, ethical and legal implications. , 2005, Medicine and law.

[9]  A. Wakefield,et al.  Reflections on coercion in the treatment of severe anorexia nervosa. , 2008, The Israel journal of psychiatry and related sciences.

[10]  A. Stewart,et al.  Competence to Make Treatment Decisions in Anorexia Nervosa: Thinking Processes and Values , 2007, Philosophy, psychiatry, & psychology : PPP.

[11]  Walter Glannon,et al.  Neuroethics , 2019, Encyclopedia of Evolutionary Psychological Science.

[12]  L. Charland.  Anorexia and the MacCAT-T Test for Mental Competence: Validity, Value, and Emotion , 2007 .

[13]  H. Greely.  Neuroscience and Criminal Justice: Not Responsibility but Treatment , 2008 .

[14]  Ting-kai Li,et al.  What Is Addiction? , 2019, Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism.

[15]  Rebecca L. Walker.  Respect for Rational Autonomy , 2009, Kennedy Institute of Ethics journal.

[16]  K. Berridge.  ‘Liking’ and ‘wanting’ food rewards: Brain substrates and roles in eating disorders , 2009, Physiology & Behavior.

[17]  A. Sadikot,et al.  Deep Brain Stimulation in the Subgenual Cingulate Cortex for an Intractable Eating Disorder , 2010, Biological Psychiatry.

[18]  R. Fitzpatrick,et al.  Attitudes of patients with anorexia nervosa to compulsory treatment and coercion , 2010, International journal of law and psychiatry.

[19]  S. Giordano.  Anorexia and Refusal of Life-Saving Treatment: The Moral Place of Competence, Suffering, and the Family , 2010 .

[20]  Edward T Bullmore,et al.  Probing Compulsive and Impulsive Behaviors, from Animal Models to Endophenotypes: A Narrative Review , 2010, Neuropsychopharmacology.

[21]  C. Harmer,et al.  Increased Neural Processing of Rewarding and Aversive Food Stimuli in Recovered Anorexia Nervosa , 2011, Biological Psychiatry.

[22]  S. Athar.  Principles of Biomedical Ethics , 2011, The Journal of IMA.

[23]  Competence, Practical Rationality and What a Patient Values , 2011, Bioethics.

[24]  David Alan Grier,et al.  Free Agency , 2012, Computer.

[25]  Edward T. Bullmore,et al.  Brain functional connectivity in stimulant drug dependence and obsessive–compulsive disorder , 2012, NeuroImage.

[26]  S. Kendall.  Anorexia Nervosa: The Diagnosis , 2013, Journal of Bioethical Inquiry.

[27]  Nir Lipsman,et al.  Subcallosal cingulate deep brain stimulation for treatment-refractory anorexia nervosa: a phase 1 pilot trial , 2013, The Lancet.

[28]  U. Schmidt,et al.  A systematic review of the effects of neuromodulation on eating and body weight: evidence from human and animal studies. , 2013, European eating disorders review : the journal of the Eating Disorders Association.

[29]  T. Hope,et al.  Agency, ambivalence and authenticity: the many ways in which anorexia nervosa can affect autonomy1 , 2013, International Journal of Law in Context.

[30]  J. Treasure,et al.  DBS for treatment-refractory anorexia nervosa , 2013, The Lancet.

[31]  E. Nestler.  Treating the Brain Deep Down: Brain surgery for anorexia nervosa? , 2013, Nature Medicine.

[32]  Roy H. Hamilton,et al.  Ethics of the Electrified Mind: Defining Issues and Perspectives on the Principled Use of Brain Stimulation in Medical Research and Clinical Care , 2013, Brain Topography.

[33]  B. Nuttin,et al.  Deep-brain stimulation for anorexia nervosa. , 2013, World neurosurgery.

[34]  A. Simmons,et al.  Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa , 2013, Trends in Neurosciences.

[35]  G. Finlayson,et al.  Liking compared with wanting for high- and low-calorie foods in anorexia nervosa: aberrant food reward even after weight restoration. , 2013, The American journal of clinical nutrition.

[36]  S. Haber,et al.  Improvements in Anorexia Symptoms After Deep Brain Stimulation for Intractable Obsessive-Compulsive Disorder , 2013, Biological Psychiatry.

[37]  N. J. Davis,et al.  Ethical Considerations in Using Brain Stimulation to Treat Eating Disorders , 2014, Front. Behav. Neurosci..

[38]  C. Ryan,et al.  Treatment Refusal in Anorexia Nervosa: The Hardest of Cases , 2014, Journal of Bioethical Inquiry.

[39]  T. Carney.  The Incredible Complexity of Being? Degrees of Influence, Coercion, and Control of the “Autonomy” of Severe and Enduring Anorexia Nervosa Patients , 2014, Journal of Bioethical Inquiry.

[40]  R. Park,et al.  Hungry for reward: How can neuroscience inform the development of treatment for Anorexia Nervosa? , 2014, Behaviour research and therapy.

[41]  R. Park,et al.  Compulsivity in anorexia nervosa: a transdiagnostic concept , 2014, Front. Psychol..

[42]  D. Parfit,et al.  On What Matters , 2011 .

[43]  Nir Lipsman,et al.  Targeting Emotion Circuits with Deep Brain Stimulation in Refractory Anorexia Nervosa , 2014, Neuropsychopharmacology.

[44]  L. Richards,et al.  Legal and Ethical Issues in the Treatment of Really Sick Patients with Anorexia Nervosa , 2015 .

[45]  Yasin Temel,et al.  Current perspectives on deep brain stimulation for severe neurological and psychiatric disorders , 2015, Neuropsychiatric disease and treatment.

[46]  M. Unterrainer,et al.  The ethics of deep brain stimulation , 2015 .

[47]  J. Voges,et al.  Deep brain stimulation of the subthalamic nucleus modulates reward processing and action selection in Parkinson patients , 2015, Journal of Neurology.

[48]  M. Schermer,et al.  Moral Enhancement: Do Means Matter Morally? , 2015, Neuroethics.