“The Return of the Lobotomy”

In March 1972, readers of the Washington Post learned that “the lobotomy” had returned (Breggin and Greenberg Reference Breggin and Greenberg1972a). A psychiatrist claiming past affiliation with the National Institute of Mental Health (NIMH), Peter Breggin, and Daniel Greenberg, a former news commentator for the journal Science, reported that doctors were once again tampering with the brains of patients in a procedure that proponents called “sedative neurosurgery” and opponents called “the murder of the mind” and “the abortion of the brain” (Trotter Reference Trotter1972; Holden Reference Holden1973).Footnote ¹

In contrast to the original lobotomy, not much has been written about this episode. Many biomedical researchers, with an eye to the present day, have largely ignored or dismissed the controversy as stemming from the comparative immaturity of the psychosurgical field (Kringelbach and Aziz Reference Kringelbach and Aziz2009; Gildenberg Reference Gildenberg and Heilbrun1988). Today's knowledge and technology, they contend, renders obsolete many of the concerns that plagued earlier psychosurgeries. (So, too, went the argument of the psychosurgeons at the center of the controversy during the 1970s.)

Scholars who have reflected on the controversy that followed Greenberg and Breggin's announcement have extracted practical lessons, discussed how the episode reflected societal trends, and subsumed it under the category of trans-historical philosophical debate. Bioethicists have framed the controversy as a cautionary tale and as a stepping stone to the current patient protections outlined in the Belmont Report guidelines of 1979 (Society's choices 1995).Footnote ² Sociologists including Peter Conrad have viewed the issue of psychosurgery for violence management as tied to the medicalization of deviant behavior, the dominance of experts, and the individualization of social problems (Conrad Reference Conrad1975; Conrad and Schneider Reference Conrad and Schneider1980, 259). By medicalizing violence, authorities were attempting to manage a complex cultural phenomenon. Philosophically-minded scholars such as Joseph Fins believe the controversy reflects an eternal anxiety about the meaning of brain science for free will (Fins Reference Fins2004).

Historians who have examined this episode have downplayed its significance, judging it to be the product of public paranoia aggravated by psychosurgeon insensitivity (Valenstein Reference Valenstein1980, 51; Pressman Reference Pressman1998). Cultural and political developments had conditioned the American public's horrified reaction.Footnote ³ Starting in the 1960s, Hollywood, the anti-psychiatry movement, and a series of scandals had turned public sentiment against behavior modification projects. In such movies as One Flew over the Cuckoo's Nest, 1970s Hollywood painted a dark portrait of biomedical authorities as violators of the human body. At a time when the U.S. population was having its greatest interaction with mental health professionals, anti-psychiatry intellectuals declared mental illness to be a socially-constructed category and psychiatry a ruse to control deviance (Nelson Reference Nelson1973a; Szasz Reference Szasz1974, 18; see also Szasz Reference Szasz1977).Footnote ⁴ In addition, as historian Judith Swazey pointed out, public skepticism was primed by a succession of biomedical scandals (most famously the Tuskegee syphilis study) that changed public perception of clinical research from an ethical calling to a dubious enterprise (Swazey Reference Swazey1978, 131; see also McCaffrey Reference McCaffrey1964; Gray Reference Gray1978; Maiorana Reference Maiorana1967; Heller Reference Heller1972; Reverby Reference Reverby2009; Dutton Reference Dutton1987; Brandt Reference Brandt1978). In the broader social context, political fallout from the Watergate scandal and the Vietnam War cast a pall over all government-sponsored research (Meister Reference Meister1979, 14).Footnote ⁵

To these insights, this paper adds that the psychosurgery controversy of the 1970s erupted not simply because questionable medical practices were being performed in a climate of distrust; it erupted because parties to the debate held competing conceptual frameworks. By parsing psychosurgery's opposition into a faction of concerned critics (which included NIMH and bioethicists) and another faction of implacable protestors (who came from both inside and outside the scientific and medical establishment), this latter point becomes clear: Although both protestors and critics opposed psychosurgery they did so from different starting points.

The Spark

The psychosurgery controversy of the 1970s was ignited by a government-sponsored mental health project. As Greenberg and Breggin reported, NIMH awarded a two year, half-million dollar contract, “Organic Brain Disease and Violent Behavior: A Demonstration Program for Diagnosis, Treatment and Research,” to three Boston area doctors, William Sweet Jr., chief of neurosurgery at Massachusetts General Hospital, Vernon Mark, neurosurgery chief at Boston City Hospital, and Frank Ervin, associate clinical professor of psychiatry at Harvard Medical School and director of the Stanley Cobb Laboratories for Psychiatric Research.Footnote ⁶ A few years earlier in a letter to JAMA, these doctors had suggested that disruptive social behaviors (such as the recent Watts riots) might be traceable, in part, to brain imbalances (Mark, Sweet, and Ervin Reference Mark, Sweet and Ervin1967). In their book Violence and the Brain (1970) Ervin and Mark proposed a permanent solution to violent behavior: the destruction of portions of the brain of violence-prone individuals.Footnote ⁷ To this end, their colleague Sweet, a recipient of the American Association of Neurological Surgeons’ highest honor, the Harvey Cushing Medal, appealed to a Senate Appropriations Committee for funding to discover a metric for the identification of potential criminals (Sweet Reference Sweet1970; Mark and Ervin Reference Mark and Ervin1970, 148).Footnote ⁸ Specifically, Sweet's group, the NeuroResearch Foundation of Boston, proposed that violent individuals be screened for neurological irregularities in the limbic system, the network of lower brain structures involved in emotional processing (Thomas Reference Thomas1973).Footnote ⁹

The NeuroResearch Foundation proposal was the explicit application of science and technology to politics; Sweet's group pitched psychosurgery as a potential solution to rising lawlessness (Rosenfeld Reference Rosenfeld1968; Meister Reference Meister1974; Mark and Ervin Reference Mark and Ervin1970, 3–4). Between the mid-1960s and the mid-1970s the homicide rate had nearly doubled.Footnote ¹⁰ Sweet's group banked on the growing political resolve to combat crime. Although government response to crime came mostly in the traditional form of heightened support of law enforcement, some politicians, seeking prevention, turned to medical interventions. In an era of methadone programs to combat heroin-associated crime, some penal system administrators floated the idea of testing psychosurgery's ability to control, and even reform, prisoners (Wilmarth and Goldstein Reference Wilmarth and Goldstein1974; see also Levins Reference Levins1974). As part of a pilot study, the director of corrections for the State of California scheduled surgery for twelve violent criminals with temporal lobe epilepsy. Similarly, in Michigan surgeons seeking to test Mark and Ervin's hypothesis made preparations to operate on twenty-four prison inmates convicted of sexual crimes (M. Hunter Brown Reference Brown1972; Anon. 1973a; Gass Reference Gass, Gaylin, Meister and Neville1975, 75–6).Footnote ¹¹ The Sweet group speculated that such interventions would not only be beneficial to “the individual at risk,” it would “reduce the load on the criminal justice system.”Footnote ¹²

Advocates of such psychosurgery, however, miscalculated public reaction. The American Civil Liberties Union, the NAACP, the Black Panther Party, the Mexican-American Political Association, and the National Organization of Women all denounced psychosurgery (Chavkin Reference Chavkin1976, 401; Meister Reference Meister1979, 8). Students for a Democratic Society interrupted conferences on the biological underpinning of violence (Ballantine Reference Ballantine1972, 49; Anon. 1972c). An organization of concerned psychiatrists, The Committee Opposed to the Psychiatric Abuse of Prisoners, challenged California Governor Ronald Reagan's Center for the Study and Reduction of Violence at UCLA (Nelson Reference Nelson1973b).Footnote ¹³ Ralph Nader's consumer organization, Nader's Raiders, planned an investigation into NIH's role in the revival of psychosurgery (Vaughan Reference Vaughan, Chu and Trotter1974).Footnote ¹⁴ Meanwhile, many private citizens demanded Congress investigate psychosurgery.Footnote ¹⁵

In an era of “public participation in science,” opponents of psychosurgery asserted the public's right to determine appropriate science and technology (Culliton Reference Culliton1976b; idem 1978; Grob Reference Grob1996, 380). Science journalist Barbara Culliton observed that just as welfare rights groups demanded a role in poverty programs and student activists wanted seats on curriculum committees, a newly-aroused public denounced physician paternalism (Culliton Reference Culliton1976a). Gone was the implicit trust in professional judgment that had allowed the lobotomies to proceed without public scrutiny (Thomas Reference Thomas1973; Faden and Beauchamp Reference Faden and Beauchamp1986, 205).Footnote ¹⁶ “The backwards of our institutions are overflowing with the errors of the experts,” asserted a contemporary editorial (Tiernan Reference Tiernan1974).

In response to the public outcry, Congress contemplated a moratorium on psychosurgical operations (Senate Joint Resolution no. 86, 29 March 1973) and prohibition of all psychosurgery in federally-connected health care facilities (House of Representatives Bill 6852, 11 April 1973; Trotter Reference Trotter1973). The director of NIMH, Bertram Brown, was called to testify before a Senate subcommittee. And, in light of what became clear during these hearings – that not even the number of psychosurgical operations being performed was known – the Assistant Secretary for Health and Scientific Affairs at the Department of Health, Education, and Welfare (the future Department of Health and Human Services) requested that NIMH and the National Institute of Neurological Diseases and Stroke (NINDS) formulate position papers on the research and clinical aspects of psychosurgery (Anon. 1973c, 343).Footnote ¹⁷ These position papers informed the final report of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, a panel charged with coordinating investigations into, and arriving at recommendations concerning, emerging controversial biomedical practices (National Commission 1977).Footnote ¹⁸

Psychosurgery and the Missions of NIMH

In his testimony before Senator Edward Kennedy's subcommittee, Bertram Brown distanced psychosurgery from the mission of NIMH. He reassured Congress that NIMH was carefully monitoring Sweet's work through correspondence, quarterly reports, and periodic site visits. NIMH supported psychosurgery, the director reported, only insofar as this last-resort measure promised to contribute to NIMH's humanitarian research mission (Brown, Wienckowski, and Bivens Reference Brown, Wienckowski and Bivens1975, 231; Brown Reference Brown1973, 64).Footnote ¹⁹ Besides the Sweet proposal, NIMH only indirectly and unintentionally supported psychosurgery through basic research projects on brain/behavior relationships (Anon. 1973c, 8). Brown might have added that NIMH funded the Sweet project because Congress had directed it to do so.Footnote ²⁰ (More on this latter point below.)

The late historian of lobotomy Jack Pressman contended that controversies about psychosurgery are fundamentally about the direction of psychiatry (Pressman Reference Pressman1998, 399). In keeping with Pressman's theory, a newspaper reporter during the controversy of the 1970s commented that the debate had exposed a fault line. The controversy pitted neurosurgeons, who tended to emphasize the biological underpinnings of mental illness, against psychodynamic psychiatrists, who tended to place more emphasis on the role of environment (Edson Reference Edson1973, E14). This fault line ran right through NIMH. In the 1970s NIMH supported research on both the biological factors involved in mental illness and on the social and psychological dimensions of mental problems. Both missions were carried out, however, in NIMH's modernist belief that problems could be solved through programmatic initiatives.

Although the Sweet project was atypical, it arguably complemented NIMH's new direction (Brown Reference Brown1977). With the enthusiastic support of President Nixon and the Justice Department, Brown declared at the start of his tenure that the study of “mental health aspects of law and order” would be one of the three new pursuits of NIMH. The aim, Brown later reflected, was to offer psychiatric expertise regarding treatment of inmates with mental problems (Brown Reference Brown1998). In an era that saw research funds shift from social studies of “psychic well-being” to law enforcement, NIMH regarded itself as providing scientific assistance to a nation in crisis (Brown Reference Brown1973, 66).Footnote ²¹ Brown saw NIMH's role as channeling society's punitive impulse towards the “humanitarian and enlightened management” of violence, imparting knowledge that promised to increase the redemptive efficacy of the penal system (Brown and Courtless Reference Brown and Courtless1971, 62).

Through its support of basic biological research, NIMH effectively advanced the medicalization of violence. NIMH-funded geneticists searched for biological markers for violence-propensity, screening individuals in juvenile detention facilities for the presence of an extra Y chromosome. NIMH-sponsored pharmacologists studied correlations between hormone imbalances and aggression (Goldstein Reference Goldstein1974, 17; Nassi and Abramowitz Reference Nassi and Abramowitz1976, 598; Coleman Reference Coleman1974, 677; Boothe et al. Reference Boothe, Rosenfeld and Walker1974, 23; Valzelli Reference Valzelli1984). Such research advanced the notion that at least some criminals are biologically prone to violence.

At the same time – as protestors failed to appreciate – NIMH was equally interested in investigating the problem of violence from non-biological angles.Footnote ²² An NIMH-sponsored review on “Individual Violence” concluded that despite an established link between aggression and lower brain structures, social, environmental, and learning variables remained “of paramount importance.”Footnote ²³ Saleem Shah, Director of NIMH's Studies of Crime and Delinquency Center, declared that social factors had not been sufficiently studied to determine what makes an individual susceptible to delinquency (Shah n.d.).Footnote ²⁴ NIMH monies supported studies on the effects of television, economic disparities, lack of educational opportunities, wartime turmoil, and insensitive police actions.Footnote ²⁵ Looking at the problem of “mass violence,” NIMH-funded sociologists and psychologists found meaning in supposedly senseless riots. They drew historical parallels to white immigrant groups, recounted historical injustices towards minorities, and underscored minorities’ understandable hunger for respect and self-determination.Footnote ²⁶

What is more, NIMH saw itself as a champion of civil rights. At the time of the psychosurgery controversy, NIMH had a director who shared many of the protestors’ concerns for social justice. In the anthology Racism and Mental Health (1973), Bertram Brown declared, “all institutions in the United States are racist, including those in mental health” (Willie et al. Reference Willie, Kramer and Brown1973, 582). According to Brown, however, the problem was not abuse but rather neglect and paternalism. NIMH, in Brown's opinion, delivered insufficient services to minority communities and needed to train and hire minority mental health specialists (ibid., 401). In his expansionist vision of mental health, he stated: “NIMH had a role to play in the broad attack needed against the systematic degradation suffered by minorities” (Brown Reference Brown1998, 9). As one measure to combat racism in American society, NIMH in the early 70s offered minority graduate fellowships in sociology to challenge distorted views of minorities (Anon. 1973d).

Furthermore, NIMH had been seeking to improve community and minority mental health. Through a system of Community Mental Health Centers, NIMH invested in infrastructure that allowed the mentally ill to be treated in their own communities, obviating their exclusion from society (Neighbors Reference Neighbors1987, 349). The expansion of NIH's extramural programs in the 1960s led to the creation of the Center for Studies of Mental Health and Social Problems (1967), which supported wide-ranging field projects including studies of poverty, family breakdown, and intergroup relations.Footnote ²⁷ Recognizing that health disparities result in part from paternalism, NIMH in 1970 established a Center for Minority Group Mental Health Programs with the mission of meeting the needs of minority populations by empowering these groups to help themselves.Footnote ²⁸

Most of all, NIMH saw itself and the whole of NIH as champions of patient rights. NIH had pioneered patient safeguards, if partly out of self-interest to guard against lawsuits and to maintain public trust in medical research (Stark Reference Stark2007; Faden and Beaucamp Reference Faden and Beauchamp1986, 201–2; Kutcher Reference Kutcher2009, 59, 61, 62). The opening of NIH's Clinical Center in 1953 prompted the creation of a review system to protect volunteers, patients involved in non-therapeutic research, and patients undergoing procedures that carried a high degree of risk (Mishkin Reference Mishkin2000, 363). In the next decade, NIH exported this system; by 1966 it mandated that institutions supported by NIH have local institutional review boards to protect the rights and welfare of subjects (Swazey Reference Swazey1978, 138; Gray Reference Gray1978, 34; Faden and Beauchamp Reference Faden and Beauchamp1986, 207).Footnote ²⁹ In the mid-1970s NIMH joined the burgeoning mental patient rights movement by involving mental patients in program development and policy-making (Alvelo Reference Alvelo2009, 5).

The Science of Psychosurgery

Long before psychosurgery became, in the words of Brown, a “lightning rod issue,” NIMH questioned the science of psychosurgery.Footnote ³⁰ As Brown pointed out, the brain remained a black box.Footnote ³¹ Many fundamental knowledge gaps persisted, not least an appreciation of the intricacies of the relations between the neocortex, responsible for higher mental functions, and the limbic system, the older, emotion center of the brain (Goldstein Reference Goldstein1974; Senate Subcommittee on Constitutional Rights 1974, 143). Even when subjects’ brains displayed physical abnormalities, it remained unclear what exactly was physiologically wrong (Beecher et al. 1973, 16). Even when psychosurgeries seemed successful, the exact mechanisms of action were unproven (Gostin and Bridges Reference Gostin and Bridges1980, 151; Healy Reference Healy2002, 307; Valenstein Reference Valenstein1990, 549; Hitchcock and Cairns Reference Hitchcock and Cairns1973, 902).Footnote ³²

Shortly after its founding, NIMH hosted The First Research Conference on Psychosurgery, which had alerted the mental health community about the lack of safety and efficacy standards (National Institutes of Health 1949; Fins et al. Reference Fins, Rezai and Greenberg2006). The final report of this conference pushed for more research to determine guidelines for appropriate case selection and to find the best scales for clinical outcome evaluation. To hasten these changes, NIMH offered external research grants to study the long-term effects of lobotomy.Footnote ³³

The controversy of the 1970s revealed how little had changed. Variations in practice – from diversity in patient populations (epileptics, schizophrenics, intractable pain sufferers, affective disorder patients), to varying operation sites in the brain (for aggression both the amygdala and the posterior hypothalamus were targeted), as well as a variety of lesioning techniques (oil-wax method, electro-coagulation, cryogenic freezing) – precluded judgments about relative efficacy (Gostin and Bridges Reference Gostin and Bridges1980; Narabayashi Reference Narabayashi1964). In addition, the failure to control for environmental influences and the placebo effect made it impossible to separate the effects of surgery from the consequences of changing external circumstances (Scheflin and Opton Reference Scheflin and Opton1978, 281; Hitchcock and Cairns Reference Hitchcock and Cairns1973, 901).

Foremost among psychosurgery's procedural shortcomings was the absence of rigorous peer review (Breggin and Greenberg Reference Breggin and Greenberg1972a, Reference Breggin and Greenberg1972b). In the course of the National Commission's investigation it was determined that only 27 per cent of U.S. surgeons performing psychosurgery published their work in peer-reviewed journals (Silver et al. Reference Silver, Kain, Eisenberg and Fern1978). Psychosurgery was taking place, it seemed, “in a closed system of evaluation that almost inevitably fulfil[ed] the prophecies of the psychosurgeons” (Breggin and Greenberg Reference Breggin and Greenberg1972b). The pioneer of the original lobotomy, Walter Freeman, had claimed that of the first two hundred lobotomy patients 63 per cent showed marked improvement (Freeman and Watts Reference Freeman and Watts1944). Likewise, Hirotaro Narabayashi, a pioneer of the use of surgery to correct hyperactivity, concluded that 67.5 per cent of his cases were successes (Narabayashi and Uno Reference Narabayashi and Uno1966). Ethicists objected that psychosurgeons had an “overly enthusiastic reading” of their results (Annas Reference Annas1977, 12).

Psychosurgery was an uncertain science at a time when the public increasingly demanded protection from science. As historian Harry Marks observed, after mid-century the public came to fear bias and increasingly demanded safeguards against “gullible” medical practitioners and “over-confident” researchers (Marks Reference Marks2000, 349 and 351). In the wake of the Thalidomide disaster of the late 1950s and early 1960s (in which a morning sickness drug caused terrible birth defects), trust in experts eroded. An example of the escalating public scrutiny of researchers was a Baltimore Sun article that looked into investigators’ undue influence on advisory committees (Anon. 1973f).Footnote ³⁴ For society's protection, critics demanded “objective” evaluations such as those required by the 1962 Kefauver-Harris Drug Control Act, which for the first time mandated that new drugs have their safety and efficacy demonstrated (Marks Reference Marks2000, 347; Swazey Reference Swazey1978, 136). Psychosurgery, like most surgeries, did not meet the higher standard of the blinded random control trial (Bridges Reference Bridges1972).

Regarding the Sweet proposal in particular, NIMH reviews of Ervin, Mark, and Sweet's writings faulted their anecdotal nature.Footnote ³⁵ Even before the controversy began, NIMH had sought to better establish the scientific merits of the Sweet project by initiating a peer review process. In the end, not wanting to “thwart the will of Congress” the institute agreed to support the project as a contract.Footnote ³⁶ In a telling exchange with Senator Kennedy, Brown stated that he wanted psychosurgery to be considered an experimental procedure, a procedure that should be set up as a well-controlled scientific experiment (Anon. 1973c, 10; Auerbach Reference Auerbach1973b).Footnote ³⁷

NIMH urged that psychosurgeries be performed only at the few medical centers where brain research could be conducted under rigorously controlled conditions. Recognizing that the lack of thorough, consistent, and long-term record-keeping made assessment of the efficacy and safety of psychosurgery impossible, NIMH called for a national registry, which would include strict pre- and post-operative evaluations (Anon. 1976a). In short, to meet a higher scientific standard, critics wanted psychosurgeons to carefully define the phenomena under study, randomly select candidate patients, include relevant controls, and be more circumspect in deductions (Nassi and Abramowitz Reference Nassi and Abramowitz1976, 603–4). The fallout of the psychosurgery controversy was a step towards evidence-based medicine (Price Reference Price and Hitchcock1979).Footnote ³⁸

Ironically, in the public's horrified reaction to psychosurgery, NIMH found vindication of its mission. The dissatisfaction with psychosurgery's scientific credentials provided an opportunity to promote basic research. During the controversy, Brown sent a clear message that looming funding cuts in basic research threatened improvements in mental health.Footnote ³⁹ The lesson of the psychosurgery uproar, according to NIMH, was that good medicine rests on extensive basic research. NIMH had a modernist faith that best scientific practices lead to best medical practices (Brown, Wienckowski, and Bivens Reference Brown, Wienckowski and Bivens1975, 230).

The Ethics of Psychosurgery

“In all candor,” Brown revealed in an issue of Connecticut Medicine, “it must be admitted that there was considerable controversy during the review of [Sweet’s] project; indeed one would be concerned if there were not controversy in the review of a project so fraught with ethical complexities” (ibid., 230–31). After the scandal broke, many within NIH questioned the validity of psychosurgery. Concerned employees of NINDS and NIMH hosted a debate (Auerbach Reference Auerbach1973a). Paul MacLean, an NIMH researcher who had done foundational work on the limbic system, sided with those who wanted a ban on psychosurgeries performed for behavior modification (Curry Reference Curry1973). Ayub Kahn Ommaya, an NINDS researcher who performed psychosurgeries to alleviate intractable pain, testified in Michigan against the use of psychosurgery for behavior correction, not least because in his experience, psychosurgery was usually not the last resort (Salpukas Reference Salpukas1973). Brown, for his part, understood the protestors’ position. He wrote the Assistant Secretary for Health and Scientific Affairs, “Strong arguments can be made that any form of irreversible damage to however small a part of the human brain is not justified.”Footnote ⁴⁰

Yet, NIMH regarded the psychosurgery controversy as simply a wakeup call that oversight needed to be improved and more attention needed to be paid to the rights of the patient. Believing the controversy illustrated the need for societal consensus, Brown and NIH took steps to involve members of the public – especially minorities – in the review and oversight of human subjects research (Brown Reference Brown1973). NIH increased minority representation on grant review and advisory committees and mandated in 1973 that institutional review boards be composed of individuals of diverse professional, social, and racial backgrounds (Mishkin Reference Mishkin2000, 363–64; Trotter Reference Trotter1973).Footnote ⁴¹

In the middle of the Tuskegee scandal, NIH director Robert Marston had voiced his concerns about securing adequate informed consent (Faden and Beauchamp Reference Faden and Beauchamp1986, 213). Soon after, Brown related his dissatisfaction with existing guidelines, which required that researchers disclose to patients all medical options and the potential risks and benefits of a planned procedure, but which did not make clear what should be done in cases where psychosurgery candidates lacked the ability to consent.Footnote ⁴² Brown informed the Department of Health, Education, and Welfare of the need for better safeguards to “lessen the possibility of casual or cavalier use of psychosurgical procedures.”Footnote ⁴³

The principal ethical concern of critics was the securing of voluntary informed consent. The coercive settings in which psychosurgery was performed (hospitals and prisons) heightened the need for mechanisms to assure voluntary consent. Again, the uncertain outcomes of these operations due to insufficient knowledge about the brain arguably made informed consent impossible (Breggin and Greenberg Reference Breggin and Greenberg1972a; Stevens Reference Stevens1973; Zakowski Reference Zakowski1976). Additionally, there was the troubling fact that psychosurgery seemed to interfere with one's “consenting organ” (Swan Reference Swan1977). In their book Violence and the Brain, Mark and Ervin revealed that they were able to obtain consent from an obstinate patient after the patient had undergone stimulation of the lateral amygdala (Mark and Ervin Reference Mark and Ervin1970, 96–7).Footnote ⁴⁴ Nevertheless, critics had faith that better scientific practices would improve the ethical standing of psychosurgery.

Condemnations of Psychosurgery

In contrast to critics, protestors condemned the psychosurgical approach as irredeemably flawed. Civil libertarians, civil rights leaders, and community activists, though diverse in their politics, were united against what they labeled as sinister “psychotechnology.”Footnote ⁴⁵ Protestors envisioned psychosurgery as an establishment weapon designed to blunt the minds of those who challenged the social order (Breggin Reference Breggin1975, 854; Howard Reference Howard1975). Psychotechnology sought nothing less than the permanent alteration of the emotional and volitional life of individuals and communities.Footnote ⁴⁶

Libertarians worried about government control over “the last citadel of freedom and individuality” (Schmeck Reference Schmeck1973). In his dystopian novel, After the Good War (1972), the man most responsible for setting off the controversy, Peter Breggin, described the ultimate end he feared: an authoritarian regime of psychiatrists who, through the use of electrodes implanted in the pain and pleasure centers of the brain, control the memory, understanding, and will of its citizens (Breggin 1972).Footnote ⁴⁷ Surprisingly, such a futuristic nightmare was not entirely dismissed by government investigators. A Congressional committee investigating the implications of behavioral modification for civil rights, headed by the strict constructionist Southern Democrat Senator Sam Ervin (D-NC), agreed that altering a person's natural reactions threatens personal liberties (Senate Subcommittee on Constitutional Rights 1974, preface). Similarly, the National Commission's final report recognized that, as psychosurgery changes the personality, it arguably poses an existential threat to the individual (National Commission 1977, 8). Brown, in his Congressional testimony, went so far as to agree that in theory psychosurgery could serve totalitarian ends.Footnote ⁴⁸

Minority leaders shared libertarians’ concerns regarding psychosurgery: fearing its true ends and doubting that procedural safeguards could ensure its benign employment. But, in contrast to libertarians, who saw psychosurgery as an attack on individuals, minority leaders viewed the real end of psychosurgery as countering social revolution by attempting to “cure” a new fictive category of mental illness: the revolutionary psychopath (Students for a Democratic Society). Psychosurgery was, in this view, a psychic Billy club that irrevocably (and cost-effectively) beat down threats to the status quo (Coleman Reference Coleman1974, 682; Behavior Control Task Force). One psychosurgeon calculated that a young criminal sentenced to life cost the state $100,000, whereas psychosurgery had a price tag of only $6,000, an attractive alternative, the psychosurgeon implied, in the poor economy of the 1970s (M. H. Brown Reference Brown1972; Silver et al. 1978; Ehrlich et al. Reference Ehrlich, Ehrlich, Bose, Zeffert and Kreiss1975). In light of the disproportionate incarceration rate of blacks, leaders in the African-American community worried about such a calculation (Anon. 1973b).

Psychosurgery easily fit into a narrative of exploitation; physicians were cast as once again using minorities as experimental objects (Anon. 1972b; Payne Reference Payne1973; Thimmesch Reference Thimmesch1973; Snodgrass Reference Snodgrass1973). Editorials in the minority press warned that the white male establishment, threatened by riots in the ghettos and the Women's Liberation Movement, had invented a new means of oppression (Williford Reference Williford1973; Zeiger Reference Zeiger1974; Dejanikus Reference Dejanikus1972). Premised as it was on a theory of undesirable biology, psychosurgery was compared with the Final Solution of the Nazi holocaust. Dr. Charles King, President of the American Orthopsychiatric Association, an organization founded in 1924 dedicated to the multi-disciplinary study, prevention, and treatment of problems of human behavior, wondered if the next step would be the “mass execution of ‘undesirables’”; to which one reader wrote in response (Mason Reference Mason1973): “It seems as if stealing us from our homeland, enslaving us for 400 years, destroying our culture and even denying our basic human rights, is not enough. Now we are threatened with the loss of the most vital part of our brains!” (Evans-Young Reference Evans-Young1973). In a similar vein, one female physician, outraged that the ability to fulfill household duties was considered a measure of psychosurgery success, offered the following historical reflection: “In the Middle Ages, women who deviated from the feminine norm were burned at the stake as witches. How clever men have become in that they have now devised ways to silence our rebellion while retaining the useful functions we perform with our hands, our backs, and our uteruses (they never really wanted our minds anyway)” (Roberts Reference Roberts1972).Footnote ⁴⁹

Protestors believed psychosurgery rested on an offensive, unsound foundation. “The biology of violence-propensity,” they declared to be myth, not science, akin to the discredited criminal anthropology of Cesare Lombroso (Coleman Reference Coleman1974, 681; Dougherty Reference Dougherty1977; see also Gibson Reference Gibson2002; Horn Reference Horn2003).Footnote ⁵⁰ According to this critique, the category of “violence-prone” is a fiction not unlike the nineteenth-century illness “drapetomania,” that explained slaves’ compulsion to escape. “In both cases,” explained a denunciatory pamphlet, “docility was defined as health, and protest as sickness.” In both cases treatment was a crude disfigurement, in one case toes were cut off, in the modern version the brain was cut into (Students for a Democratic Society). “What is the difference,” a protesting physician wrote, “between destroying a part of healthy brain tissue and cutting off the arm or pulling out the tongue that is used in an emotional response?”Footnote ⁵¹ In contrast, another protestor added, affluent whites with mental troubles receive lengthy psychoanalysis, a “safer,” empowering means of self-exploration (New York City Political Psychology Collective).

According to community leaders, the technological pursuit of violence management deliberately ignored the real problem of social injustice (Rafter Reference Rafter2008, 5, 6). Community leaders contended that violence is a symptom of a dysfunctional society, not a dysfunctional individual. One must look at “the context of the social system” (Conrad Reference Conrad1975, 20). Violent behavior that results from unjust conditions is not criminal or pathological (Anon. 1974b). The Kerner Report, the final opinion of President Johnson's committee charged with investigating the causes of urban rioting, had concluded that after all white racism that supported an unequal society was principally to blame for the violence (Racism and Mental Health 1973, 400).Footnote ⁵² Elliot Valenstein, a psychologist contracted by the National Commission to perform a literature survey of psychosurgery, best summed up the opposition's assessment: “a biological solution was being proposed for a social problem” (Valenstein Reference Valenstein1990, 550).

The Case for Psychosurgery

Ervin and Mark objected to what they regarded as a gross distortion of their objectives. They too considered social factors such as poverty, unemployment and poor housing to be causes of inner-city unrest (Mark and Ervin Reference Mark and Ervin1974). Psychosurgeries, they believed, should complement social approaches. Their theory concerned unprovoked violence, which they suggested might be the result of a limbic system unable to “respond appropriately to environmental stress” (ibid., 34). Mark and Ervin insisted that they valued the civil liberties of patients. Mark opposed the use of psychosurgery in prisons, where informed consent is difficult to ascertain (Nelson Reference Nelson1973a). Ervin agreed that no man should have the power to “change another man's personality and dictate the values, thoughts and feelings of another” (Raspberry Reference Raspberry1974). The Sweet group claimed that all their patients were, in fact, “private, consenting, noncommitted, nonadjudicated, nonprisoner individuals” (Mark et al. [1972] 1975, 196).

Though obviously at odds, psychosurgeons shared with the protestors a common sensibility. Both sides focused on ultimate ends. Sweet also thought about the consequences of psychosurgery for both the individual and society. He countered that psychosurgery restores patient autonomy (Senate Subcommittee on Constitutional Rights 1974, 142; Black Reference Black1977). Temporal lobe epilepsy diminishes the sense of self, generates a feeling of unreality about the outside world, and compels undesirable thoughts and stereotyped automatisms that sometimes lead to unwilled self-destructive acts (Delgado et al. Reference Delgado, Mark, Sweet, Ervin, Weiss, Bach-y-Rita and Hagiwara1968; Mark and Ervin Reference Mark and Ervin1970, 61–3). By ostensibly eliminating impediments to self-actualization, psychosurgery promised to save out-of-control, desperate people from the indignities of institutionalization and, more importantly, from the internal prison of their disordered brains (Zoll Reference Zoll1973). The ends of psychosurgery, proponents insisted, were purely therapeutic. The goal of psychosurgery was to make patients more effective (rather than more manageable) so they could lead responsible and dignified lives (Hitchcock and Cairns Reference Hitchcock and Cairns1973, 902; Neville Reference Neville1979; Fins Reference Fins2003, 309). As a bonus, society would benefit through the curtailing of “impulsive socially deviant behavior” that leads to such dangerous antisocial acts as aggressive driving.Footnote ⁵³

Psychosurgeons defended their practice on scientific grounds. Well-accepted brain/behavior discoveries dating back to the 1920s linked brain regions, specifically the amygdala, to violent behavior. It was established, for instance, that cats exhibit attack behavior if their amygdalas are electrically stimulated. Conversely, the removal of rats’ amygdalas was known to decrease aggressive behavior (Egger and Flynn, Reference Egger and Flynn1967; Rosenfeld and Rosenfeld Reference Rosenfeld and Rosenfeld1976). Ervin, Mark, and Sweet's early work had similarly indicated a link between violent behavior and the amygdala in humans: by directly stimulating the amygdala of a violent epileptic they elicited rage behavior; damaging portions of this same organ decreased the number of violent episodes (Mark, Sweet and Ervin Reference Mark, Sweet, Ervin, Fields and Sweet1975; Mark and Ervin Reference Mark and Ervin1970, 107).Footnote ⁵⁴ To this day, research continues to link violence and the amygdala (Blank Reference Blank2005).

Psychosurgeons also defended their work on the grounds of technological progress. They claimed that what made the new psychosurgeries possible also made them safer. Stereotactic surgery allowed surgical instruments to be guided in three dimensions, limiting the destruction of brain tissue to one-tenth the amount damaged by the traditional lobotomy (Gillingham et al., eds. Reference Gillingham1974). Unlike the blind cutting of the old lobotomy, the new procedures targeted areas of the brain with identifiable, aberrant, neuron-firing patterns. The new surgeries seldom produced the seizures, inertia, apathy, social inappropriateness, and decreased attention seen in lobotomy patients (Spiegel et al. Reference Spiegel, Wycis, Marks and Lee1947; Livingston Reference Livingston1969; Snodgrass Reference Snodgrass1973, 919; Brown, Wienckowski, and Bivens Reference Brown, Wienckowski and Bivens1975, 229; Gostin and Bridges Reference Gostin and Bridges1980; Diering and Bell Reference Diering and Bell1991, 180). Third party investigators concurred that few patients suffered adverse effects on their intelligence, memory, visual abilities, verbal fluency, or motor function (Martindale Reference Martindale1977; Wilkins Reference Wilkins1984, 320).

Finally, psychosurgeons defended their practices on libertarian grounds. In the anti-regulation spirit of neo-liberalism, they believed that neither the government nor activists should be allowed to trample on the ancient freedom of doctor and patient choice (Gorman Reference Gorman1981; Massachusetts Medical Society 1975).Footnote ⁵⁵ Like many medical researchers, psychosurgeons often considered oversight to be meddling.Footnote ⁵⁶ They denied the competence of outsiders to determine best practices. NIMH's position paper on psychosurgery did not call for a moratorium precisely because leaders of the institution feared that a prohibition of psychosurgery would be construed as “an unprecedented federal prescription of the parameters of permissible and impermissible surgery.”Footnote ⁵⁷ What is more, psychosurgeons underscored patient demand for such procedures (Anon. 1968). In the Commission's final report at least one consultant raised the possibility that minorities might not be getting sufficient access to psychosurgery (Culliton Reference Culliton1976b).

Outcome of the Psychosurgery Controversy

To the surprise and dismay of opponents of psychosurgery, the National Commission judged the new psychosurgeries to be safe, rational, and, in some cases, necessary. Trying to strike a balance between allowing access to therapy and protecting the American public, the Commission recommended that psychosurgery be allowed in cases where all other available treatments fail and when it can be performed by experts with meticulous pre-operative selection and post-operative tracking (National Commission 1977, prefatory letters and final recommendations).

Unfavorably disposed towards psychosurgery at the outset, the Commission concluded there was credible evidence of psychosurgery's effectiveness, particularly for countering pain and depression (National Commission 1977; Culliton Reference Culliton1976b). Among their many findings, most important was the absence of evidence of systematic abuse of psychosurgery; minorities were apparently not being singled out.Footnote ⁵⁸ Of a subgroup of six hundred psychosurgery patients investigators revisited, only one was black, two Asian-American, and six Hispanic (Donnelly Reference Donnelly1978).Footnote ⁵⁹ Apparently since 1970 only seven psychosurgery patients had been children (National Commission 1977, 30). In so far as women were overrepresented in the psychosurgery population, this reflected the overrepresentation of women in the psychiatric system generally (O’Callaghan and Douglas Reference O’Callaghan and Carroll1982, 261). Similarly, a study from the bioethics center the Hastings Institute (established 1969), found no evidence that behavior modification was employed as an instrument of social control. Underscoring the cumbersomeness and complexity of psychosurgery, Willard Gaylin, President of the Institute, argued that it was unlikely psychosurgery could ever become an effective tool of oppression (National Commission 1977, 10). The chief of neurosurgery at the Howard University College of Medicine, Dr. Jesse Barber, summed up the findings by deeming fears of persecution “unwarranted and unjustified” (Drew Reference Drew1976). As a precaution, however, the Commission affirmed that psychosurgery should never be used “for purposes of social or institutional control” (National Commission 1977, 58).

In essence, the Commission validated NIMH's procedural approach. Putting public sentiment aside, it had sought expert opinion (Toulmin Reference Toulmin, Engelhardt and Caplan1987, 608). It endorsed and only tweaked the institutional review board system, recommending that lay involvement be increased (Anon. 1976a; Gray Reference Gray1978, 35). It set more specific guidelines for informed consent, which included a more easily comprehensible oral explanation of the study and its hazards (Faden and Beauchamp Reference Faden and Beauchamp1986, 209). Echoing NIMH's position, the Commission suggested another layer of oversight, specifically a national psychosurgery advisory board that would make certain any scheduled psychosurgical procedure would likely be of “demonstrable” benefit to the patient (National Commission 1977, 64; Gray Reference Gray1978, 42). Unlike the recommendations of the Senate Subcommittee on Constitutional Rights and the National Minority Conference on Human Experimentation (both of which suggested that psychosurgery never be performed on minors, prisoners, or involuntarily committed mental patients), the Commission initially counseled that psychosurgery be allowed if a local institutional review board, a national psychosurgery advisory board, and a judge assented to the procedure (Senate Subcommittee on Constitutional Rights 1974, 143–145; National Minority Conference 1976; National Commission 1977, 64, 65).Footnote ⁶⁰

The controversy, though, did not die down completely. Opponents found the endorsement of psychosurgery to be as unjustified as it was unexpected (Camellion Reference Camellion1978, 16; Culliton Reference Culliton1976b). Critics found much wanting in the scientific assessment of psychosurgery. MIT psychologist Stephen Chorover called the evidence upon which the Commission based its ruling “tentative, questionable and incomplete” (Greenberg Reference Greenberg1977, 315; Chorover Reference Chorover and Valenstein1980). Representative Louis Stokes, the Congressman who led the move to ban psychosurgery, faulted the Commission for relying too heavily on the experience of only four psychosurgeons (Stokes Reference Stokes1977). Only sixty-one cases of the known five thousand psychosurgeries performed in a ten year period had been scrutinized (Silver et al. Reference Silver, Kain, Eisenberg and Fern1978). What is more, University of Pennsylvania anatomy professor Peter Sterling found a disturbing array of side effects among some of psychosurgery's alleged successes (Sterling Reference Sterling, Brady and Brodie1978, 152–6). And Elliot Valenstein emphasized that rage returned in some patients treated for aggression (Valenstein Reference Valenstein1973, 247).

Both critics and protestors faulted the Commission for not adequately addressing fundamental ethical objections. A Hastings Center report still saw potential for abuse if psychosurgery became an accepted practice and oversight lessened (Annas Reference Annas1977). Protestors took little comfort in the immediate impracticality of widespread psychosurgery. Electro-convulsive therapy emerged in 1938; three years later ECT was used in 42 per cent of American mental hospitals (Sadowsky Reference Sadowsky2006, 10). And “lobotomizing” need only be carried out on a few to achieve conformity (Anon. 1973, 49). Moreover, like all punitive measures, psychosurgery could be effective in breaking the will of transgressors simply through the threat of its use (Coleman Reference Coleman1974, 675).

The Congressional Black Caucus unsuccessfully urged the Secretary of Health, Education, and Welfare to reject the Commission's proposals. The Caucus shared the National Minority Conference's assessment that “the social context of institutionalized racism in this country insures the use of the least powerful as the major source of subjects in human experimentation” (Congressional Black Caucus 1976; National Minority Conference 1976; Chavkin Reference Chavkin1978).

Despite the official endorsement, the controversy – at least in its immediate aftermath – effectively tempered enthusiasm for psychosurgery (Williford Reference Williford1974). Labeling psychosurgery an “experimental therapy” and restricting it to hospitals with a commitment to academic sciences, significantly decreased the number of these operations (Senate Subcommittee on Constitutional Rights 1974, 145). The Veterans Administration began to shy away from these operations, while the Justice Department's Law Enforcement Assistance Administration (which had once supported Sweet) stopped funding psychosurgery and behavior modification programs, deeming them too “fraught with peril and uncertainty” (Auerbach Reference Auerbach1973c; Anon. 1974a; Oelsner Reference Oelsner1974).Footnote ⁶¹ Oregon and California passed laws against psychosurgery (Alvelo Reference Alvelo2009, 57; Grimm Reference Grimm and Valenstein1980).Footnote ⁶² By 1980, the annual number of psychosurgeries dropped from an estimated 414 to less than 300, and few of these operations were for curbing aggression (Burchiel Reference Burchiel1983). Psychosurgery became reserved for affective disorders (Diering and Bell Reference Diering and Bell1991, 175).

The Controversy Seen in the Light of Postmodernity

As NIMH realized at the time, the psychosurgery controversy of the 1970s had multiple dimensions. In its report to the National Commission, NIMH took note of many “unspoken” debates it believed lay behind opposition to psychosurgery, debates about the nature of the self, about the uncertain etiology of mental illness, about the problematic nature of diagnosing mental illnesses, and about the degree to which society rather than biology defines mental illness.Footnote ⁶³ In NIMH's perceptive assessment only on the surface was the debate about the facts of psychosurgery, its scientific justification, its psychological effects, and its selective use. Underneath, broader debates were raging.

I wish to call attention to another, unrecognized underlying debate. In line with Paul Forman's historical argument that a shift in mindset occurred between the 1960s and 1980s, this episode can be seen as a struggle over the cultural status of science and technology (Forman Reference Forman2007). Protestors, psychosurgeons and the NIMH approached the controversy with radically different assumptions and agendas, reflective of a division between what Forman describes as a means-focused “modern” mindset and an ends-focused “postmodern” mindset.

Decrying psychosurgery as human engineering, protestors approached the controversy with a “postmodern” skepticism about disinterested experts, objective science and pure, ethical methods. Protestors started from the premise that science will serve the interests of those who stand to gain through the implementation of its medical and technological products. They feared the purpose, the future, and the meaning of psychosurgery. They joined US Congressman Louis Stokes in rejecting the notion that regulation could ever provide sufficient protection.Footnote ⁶⁴ Banning psychosurgery outright, as one protestor asserted, would “be a giant step forward in preserving the individual's right to humane treatment.”Footnote ⁶⁵

The obvious messiness of the science of psychosurgery (admitted by all sides), as well as the difficulties involved in doing retrospective analyses only underscored the protestors’ point that a pure method of determining the merits of psychosurgery did not exist. Every step of the psychosurgery process was riddled with inexactitude, starting with patient selection. As a Chair of a Department of Internal Medicine mused during the investigations, how does one distinguish between somebody who is “medically ill with certain behavior manifestations” and someone who is not medically ill but who exhibits “anomalous antisocial” behavior?Footnote ⁶⁶ Again, as mental health specialists conceded during the debate, determining the end of a procedure is not easy. The line between mental health treatment (done strictly for the sake of the patient) and behavior control (which may benefit others) is blurry.Footnote ⁶⁷ Finally, the selective nature of the retrospective analyses only further diminished trust in the science of psychosurgery. Protestors were disturbed by the elite closed circle of scientific expertise that evaluated the soundness of psychosurgery. The composition of the National Commission notwithstanding, the Commission failed, in the opinion of the educational psychologist Jerry Coles, to have taken an adequate look at the political, legal, and ethical issues specific to psychosurgery (Coles Reference Coles1977).

Needing to justify their practice, the psychosurgeons at the center of this debate affirmed the disinterestedness of medical science, which they hoped would ultimately vindicate their professional opinion. But, like the protestors, they thought principally in terms of ends. Entrepreneurial psychosurgeons were more preoccupied with the ends of technology (which they envisioned as individual tranquility and social peace) than with the niceties of “proper” consent or matched controls. What mattered more to these psychosurgeons was psychosurgery's apparent effectiveness, not its scientific merits. There was truth to Thomas Szasz's contention that psychosurgeons tended to see mental illness through the potential of surgical intervention: the ability to ablate brain tissue suggested the need for it (Szasz Reference Szasz1970, 192 n.).

In his review of the psychosurgical field, Elliot Valenstein cast psychosurgeons as showmen. He described them as “scientists who for their own reasons had exaggerated the implications of their research while displaying the skill of a public relations expert in obtaining the broadest coverage possible” (Valenstein Reference Valenstein1973, preface). In part driven by a rugged American individualism, but more immediately by competition, psychosurgeons who sought behavior control audaciously pursued the innovative (Veatch Reference Veatch, Engelhardt and Rasmussen2002, 25; Scheflin and Opton Reference Scheflin and Opton1978, 282–4). In their transgressive entrepreneurialism (as Paul Forman described the postmodern character) they believed the end justifies, even “sanctifies” the means (see Forman Reference Forman2007; idem 2010).Footnote ⁶⁸ In the name of progress, they were prepared to go beyond the limits set by both the scientific establishment and large segments of the public. The technological ends the Sweet group feared were the weapons of mass destruction that violence-prone people could now get their hands on. With current weapons technology, Mark argued, those with limbic disease posed a great danger to society (Mark Reference Mark1968).

To a certain extent, the National Institute of Mental Health was also preoccupied with ends. The NIMH of the 1970s was a broad umbrella program of research, training, and service that supported (among many other endeavors) sociological projects and community mental health centers in the name of building a more humane, great society. The director of NIMH shared the protestors’ critique of America's structural injustices and the NIMH sought to correct societal imbalances of power by including minority voices in oversight, by strengthening its means-based approach to mental health.

Founded after the Second World War when science was at the pinnacle of public consciousness, NIMH entered the psychosurgery debate with a methods-oriented bias, a belief that proper scientific methodology assures truth and efficacy. NIMH believed science should be the final arbiter over technology and medicine. As an expression of the modernist faith in elite science, critics in and out of NIMH were convinced that the problem and the solution revolved around processes. NIMH saw the controversy as an opportunity to vindicate its modernist project, its systems of scientific and ethical management.

These conflicting mindsets made the debate ultimately irresolvable. The immovable opposition to psychosurgery was the product, not so much of ignorance or denial of facts, but rather of a different worldview. The parties to the psychosurgery controversy were talking past each other. Protestors thought that the National Commission was engaged in the wrong debate. Both supporters and critics of psychosurgery wanted to have a means-based discussion about which procedures needed to be enhanced, about how to bring psychosurgery up to modern scientific and ethical standards. Protestors wanted to have an ends-based discussion about what needed to be changed: society's structure rather than unruly individuals. The establishment wondered which and how psychosurgeries should be carried out. The protestors rejected the notion that psychosurgery should ever be done in a society in which power is not evenly shared. Because it alters the individual, argued protestors, psychosurgery is necessarily injurious and so ipso facto never therapeutic. Because it quiets those on the margins of society, it necessarily reinforces the status quo.

To a certain extent the National Commission appreciated that protestors wanted to have a different discussion. In the course of the proceedings the chair raised the point that there were unexplored “undercurrents” to the debate.Footnote ⁶⁹ A principal neglected undercurrent, this paper argues, was the diminished faith in science and the rising fear of technology in an unequal society. If Forman is correct, this might help explain why the widespread support in the mid-1960s for the scientific study of violence gave way to “the full retreat” of biological and psychiatric research on violence in the mid-1970s (Meister Reference Meister1979, 1).