[Ethical issues for the further development of psychiatric deep brain stimulation]. / Ethische aandachtspunten bij de verdere ontwikkeling van psychiatrische diepe hersenstimulatie.

BACKGROUND: Except in the case of obsessive-compulsive disorder, deep brain stimulation (DBS) for psychiatric indications is an experimental treatment, reserved for the most severe and treatment resistant cases. AIM: To discuss ethical aspects for the further development of DBS in psychiatry. METHOD: Ethical reflection. RESULTS: The low number of patients and the experimental character of the treatment hamper the collection of scientific evidence and the safeguarding of patients being indicated for DBS. Apart from that, special care should be taken in assessing competency and the ability to provide informed consent. CONCLUSION: Interest in the subjective experiences of patients being treated with DBS, proactive ethical reflection and an increase in the scale of research efforts are essential for the acceptance and further development of DBS for psychiatric indications.

Ethics of Deep Brain Stimulation in Adolescent Patients with Refractory Tourette Syndrome: a Systematic Review and Two Case Discussions.

INTRODUCTION: Tourette Syndrome (TS) is a childhood onset disorder characterized by vocal and motor tics and often remits spontaneously during adolescence. For treatment refractory patients, Deep Brain Stimulation (DBS) may be considered. METHODS AND RESULTS: We discuss ethical problems encountered in two adolescent TS patients treated with DBS and systematically review the literature on the topic. Following surgery one patient experienced side effects without sufficient therapeutic effects and the stimulator was turned off. After a second series of behavioural treatment, he experienced a tic reduction of more than 50%. The second patient went through a period of behavioural disturbances that interfered with optimal programming, but eventually experienced a 70% tic reduction. Sixteen DBS surgeries in adolescent TS patients have been reported, none of which pays attention to ethical aspects. DISCUSSION: Specific ethical issues arise in adolescent TS patients undergoing DBS relating both to clinical practice as well as to research. Attention should be paid to selecting patients fairly, thorough examination and weighing of risks and benefits, protecting the health of children and adolescents receiving DBS, special issues concerning patient's autonomy, and the normative impact of quality of life. In research, registration of all TS cases in a central database covering a range of standardized information will facilitate further development of DBS for this indication. CONCLUSION: Clinical practice should be accompanied by ongoing ethical reflection, preferably covering not only theoretical thought but providing also insights in the views and perspectives of those concerned, that is patients, family members and professionals.

[Ethical issues relating to deep brain stimulation for psychiatric disorders]. / Ethische overwegingen bij de behandeling van psychiatrische aandoeningen met diepe hersenstimulatie.

BACKGROUND: Deep brain stimulation (dbs) can improve the quality of life of patients with therapy-resistant obsessive compulsive disorder (ocd). For other psychiatric indications, dbs should still be regarded as an experimental treatment.
AIM: To discuss potential ethical issues associated with the use of dbs in the treatment of psychiatric disorders.
METHOD: Ethical discourse.
RESULTS: The ethical issues associated with the use of dbs to treat psychiatric disorders are no different from those that may arise during psychotherapeutic or pharmacological treatments. However, in view of the intensive and invasive nature of dbs, special attention should be given to establishing the indication for dbs treatment and discussions about the continuation or cessation of dbs in case of side-effects or lack of effect. Except in the case of ocd, dbs in psychiatry is provided mainly in a research context in which ethical questions, such as those relating to competence, need to be carefully considered.
CONCLUSION: The basic ethical principles in medicine generally provide an adequate basis for guiding clinical decisions relating to the use of dbs in the treatment of psychiatric disorders. However, as dbs treatment for psychiatric disorders continues to develop, proactive reflection on ethical issues is warranted.

[Biology and psychiatry: ethical aspects of the prevention of antisocial behaviour in children]. / Biologie en psychiatrie: ethische aspecten van de preventie van antisociaal gedrag bij kinderen.

BACKGROUND: Genetic and neurobiological research into the causes of antisocial behaviour is playing an increasingly important role in forensic psychiatry. AIM: To contribute some ethical and societal reflections on the possible consequences of this kind of research for the prevention of antisocial behaviour. METHOD: In this ethical analysis, which gives attention to the concepts of 'informed consent' and 'best interests', we investigate which persons and which interests need to be taken into account when new preventive measures are implemented. RESULTS: It is important to differentiate between distinct target groups. From an ethical point of view it makes a difference whether measures are related to the early identification of a-symptomatic high-risk children and appropriate preventive interventions, or whether they are directed towards the (sub)typing and preventive treatment of children who already have behavioural problems or whether they are concerned with the treatment of children with conduct disorders whose parents have asked the child psychiatrist for assistance. CONCLUSION: From an ethical point of view it is not really important whether prevention measures are based on genetic and neurobiological research or on societal and psychological research. What is more important is that these measures target particular groups of children and that prevention is implemented in an appropriate manner.