Health and Human Services Secretary Patricia R. Harris is considering new federal regulations that would authorize payment of Medicaid and Medicare funds for controversial brain operations on some mental patients.
The proposed regulations, which would also allow limited use of psychosurgical operations in Public Health Service research programs, contain a number of restrictions and would ban the surgery for children, prisoners or the mentally imcompetent.
Even so, the proposals are almost certain to rekindle the longstanding debate over the ethics and effectiveness and psychosurgery, in which physically normal brain tissue is surgically destroyed in an attempt to cure or ease mental illness.
"Psychosurgery is controversial and experimental and the federal government should not be funding it under any circumstances, especially in a program like Medicaid what is supposed to pay only for procedures that are considered safe and acceptable," said Bethesda psychiatrist Dr. Peter R. Breggin, yesterday, a leading critic of the operations.
"He'll have a fit when he hears about it," said an aide to Rep. Louis Stokes (D-Ohio), who has tried unsuccessfully for the last three years to convince Congress to ban all psychosurgery at federally-supported hospitals. Stokes, whose bill is supported by the Congressional Black Caucus, was out of Washington and unavailable for comment yesterday.
Psychosurgery advocates argued that the long list of restrictions in the proposed federal regulations would effectively rule out the operations for those who might most benefit from them.
"It seems to me the restrictions are more political than they are moral or ethical," said Dr. H. Thomas Ballantine Jr., a Massachusetts General Hospital neurosurgeon who is one of the nation's foremost psychosurgical researchers. He said the proposed federal rules could mean that "the incompetent and the prisoners who might be helped will instead continue to suffer."
Psychosurgery was in widespread use in the 1940s and 1950s, the heyday of what was known as "the lobotomy era." During that period an estimated 40,000 to 50,000 Americans underwent brain operations for mental illness, sometimes in "blind-cut" assembly-line-like operations.
Advocates say modern psychosurgical techniques and results bear little resemblance to the early lobotomies, but critics contend any such surgery is experimental "brain mutilation." An estimated 200 to 500 psychosurgical procedures are performed annually in this country.
At Breggin's urging in the early 1970s, Congress set up a national commission to study psychosurgery. Breggin has charged that he and other critics were excluded from participation in the commission's study, which concluded in 1977 that psychosurgery could be beneficial to a small but significant number of mental patients. The commission's staff has denied the charge that Breggin was excluded.
It has taken the Department of Health, Education and Welfare -- recently renamed Health and Human Services -- three years to draft the proposed regulations, a delay that department officials say reflects the controversial nature of psychosurgery.
"It happens to be a procedure in which all the major medical, political and ethical questions come together," said Charles Krauthammer, science director for HHS's Alcohol, Drug Abuse and Mental Health Administration in Rockville.
Besides banning psychosurgery for several categories of patients, the regulations would limit the operations to patients giving "informed consent" and would require hospitals offering the procedure to establish seven-member review boards. Those panels, which would include at least one lawyer and two ohter non-physicians, would have to approve all operations by at least a five-to-two vote after determining all other methods of therapy had been tried and failed.
Similar panels established by law in California and Oregon have had the effect of virtually eliminating psychosurgery in those two states.
Breggin nevertheless contended that the proposed rules were not restrictive enough because they do not state that patients be told that the operations are experimental and controversial. He also derided the review board requirement, saying, "Having someone's medical buddies overseeing their surgery is no guarantee of a safeguard."
Breggin cited a 1973 Michigan case in which a prisoner gave "informed consent" to a psychosurgery operations, which was then approved by two review boards. A state court later ruled against the operation, arguing it was experimental and potentially harmful.
Krauthammer conceded the proposed regulations offered a "paradox" by suggesting psychosurgery was beneficial yet denying it to several categories of patients.
"We're saying this is still a quasi-experiental procedure and that the data is favorable but not conclusive," he said. "But to deny this procedure to everyone would be unconscionable."
A spokesman for Harris said the secretary has received only part of the proposed regulations and will make no ruling for at least a month. He said Harris has not taken a public position on the general question of psychosurgery and he would not predict whether she will decide to publish and eventually implement the proposal.