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What is the Brain-Machine Interface
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As with most types of brain devices and manipulation, there is always the danger of adverse and unintended consequences. In the case of deep brain stimulation, the surgery itself carries a risk of damage to other parts of the brain. In using DBS for unremitting depression, we do not know for sure whether electrically modulating a "depression center" may hinder a person's social functioning or completely change the person's personality.
There is also the potential for misuse of the technique. Users may want the voltage on the device turned up to a level that might make the person proactively happy, rather than simply eliminating the depression. In cases such as this, users might want to adopt the procedure as a method of personal or performance enhancement. The risk of inappropriate expectations -- that patients who begin to respond may expect or wish the device to engender more wide-reaching positive changes in their psychological and social existence -- might drive such potential misuses or inappropriate desires. It is therefore very necessary, as in all such situations, to prepare patients to have realistic, scientifically guided expectations.
Finally, there exists the possibility that perhaps the state, in a dystopian futuristic scenario, could mandate that DBS or another implanted device forcibly be used to inhibit violent or criminal activity. Prohibitive cost, healthy medical ethics, public oversight, access to more conventional methods to try to shape behavior (including prison), and the inability of even sophisticated devices to tailor behavior to a specific pattern with certainty, make such scenarios unlikely. Nonetheless, it is important to be aware of the potential for such abuses, and to develop ethical guidelines that would make them very difficult to contemplate, let alone enact.
For some, the idea of brain surgery to implant a DBS stimulator brings up negative memories of the lobotomies that were very invasive, yet in their day, had been hailed as a miracle cure for the psychiatric patient. However, this would be an inaccurate comparison of two very different types of procedures. A form of psychosurgery, also known as a leukotomy (from Greek leukos meaning clear or white, and tomos meaning "cut/slice"), the lobotomy procedure involves cutting the connections to and from, or simply destroying, the prefrontal cortex. By severing neural connections in order to modulate behavior, lobotomies were used as salvage therapy for deeply disturbed individuals or to control unruly or socially unacceptable behavior. In many cases the lobotomized very-subdued, diminished patient also lost much sense of personal identity, the drive to achieve things in the future, and other aspects of basic human psychological status. Lobotomy surgeries were unregulated for decades. Only after forty years and tens of thousands of surgeries was the use of the lobotomy curtailed.
While some compare the action of DBS to the old-school lobotomies, there are many differences: the surgery to implant the DBS device is elective, although it may be prescribed inappropriately for some patients in the future. While it may sometimes have adverse surgical consequences such as unintended destruction of tissue, DBS surgery is not intended as a psychiatrically-controlling tissue-destroying procedure. Rather, it is a means to implant a very thin wire into a very specific brain area in order to stimulate and restore more normal affective functioning. The target brain area, for example in DBS for depression, has been identified based on extensive neurological and neuropsychiatric knowledge as the one most likely to have a pivotal effect on a complex brain network. Also, the effect of the DBS device on the brain can be reversed simply by turning it off. While in the future we may come to think of this intervention differently, and again, any potential for abuse is to be guarded against, the public would be mistaken to consider DBS surgery and lobotomy as directly comparable.
Nonetheless, it is important to consider both the history of psychiatric neurosurgery and the implications of the present and future effects of the current methods. Some fear that the rush toward DBS to treat myriad conditions, not all of them medical, may result in more heartaches and headaches than DBS can cure. Additionally, neurosurgeries ignore underlying psychological issues, treating the symptoms rather than the causes of depression, obsessive behavior, or other maladies. We must acknowledge that to date, like electroconvulsive therapy (ECT), the exact mechanism of action of DBS remains elusive. There may be solutions to psychiatric disorders that are less drastic than brain surgery and the permanent implantation of an electrical regulating device. While DBS may be a perfect fit for particular problems in carefully selected individuals, DBS is not a perfect fit for all psychiatric and neurological problems, and caution is advised before racing to use the most advanced technology in all cases.
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