Self-Estrangement & Deep Brain Stimulation: Ethical Issues Related to Forced Explantation
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ORIGINAL PAPER
Self-Estrangement & Deep Brain Stimulation: Ethical Issues Related to Forced Explantation Frederic Gilbert
Received: 5 May 2014 / Accepted: 14 October 2014 # Springer Science+Business Media Dordrecht 2014
Abstract Although being generally safe, the use of Deep Brain Stimulation (DBS) has been associated with a significant number of patients experiencing postoperative psychological and neurological harm within experimental trials (i.e. self-estrangement, hypersexuality, hypomania, suicidality, impulse control disorders, etc.). A proportion of these postoperative severe adverse effects have lead to the decision to medically prescribe device deactivation or removal. However, there is little debate in the literature as to what is in the patient’s best interest when device removal has been prescribed; in particular, what should be the conceptual approach to ethically guide the decision to remove or maintain implants. The purpose of this article is to examine the ethical issues raised when patients refuse brain device explantation despite medical prescription. In order to illustrate these issues, we report and discuss a clinical case involving a patient suffering from treatment resistant depression who experienced forms of postoperative self-estrangement, as well as suicidal attempts, but who resists giving consent to device explantation.
Keywords Consent . Deep brain stimulation . Depression . Forced explantation . Forced removal . Harms . Self-estrangement
F. Gilbert (*) Ethics, Policy & Public Engagement, ARC Centre of Excellence for Electromaterials Science (ACES), University of Tasmania, Hobart, TAS, Australia e-mail: [email protected]
Introduction When to Medically Prescribe DBS Device Removal? Every time a medical device is implanted or inserted in a human brain, such as Deep Brain Stimulation (DBS), there are probabilities that it may need to be removed or expelled at some points in time due to medical reasons. Statistically, DBS is generally safe, and most DBS devices will not have to be expelled. However, a significant proportion of devices are medically required to be explanted from patients’ brains. DBS removal involves substantial risk of reversible and irreversible harms, such as requiring additional brain interventions, further hospitalizations, long-term use of antibiotics or other medications, possible loss of the benefits of future stimulation and psychological distress. Due to these potential risks of harms, obtaining patient consent is a sine qua non condition to remove DBS devices. The current uses of DBS for neurological conditions, such as Parkinson’s, teach us that there are standard postoperative physical adverse events that can lead to the medical decision to prescribe removal of DBS devices. These events include (but are not limited to) nonresponse, infection, lead migration and/or dislodgment, lead fracture, erosion, electrical short circuit or open circuit, asymptomatic intracranial haemorrhage, foreign body reactions, cerebrospinal fluid leak, subcutaneous bleed
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