Legal Issues in Behavioral Surgery

Surgery for psychiatric illnesses (SPI) is still shrouded by ethical, governance and public concerns because of what happened in the past. There is a need to develop, agree and implement stringent guidelines and protocols to manage patients referred for SPI appropriately. These consensus guidelines are required to safe guard patients and surgeons. Patients considered for SPI must have failed adequate therapies: in obsessive compulsive disorders (OCD) failure of at least three adequate trials of Serotonin reuptake inhibitors (SRIs) including clomipramine and augmentation and behavioural therapies and in depression (MDD) failure of at least four adequate antidepressive therapies including antidepressive medicines, psychotherapy, and electroconvulsive therapy (ECT). Patients should be assessed by psychiatrist-led multidisciplinary team of experienced healthcare professionals, who must confirm the diagnosis, adequacy of previous treatments, and the ability of patients to give informed consent. Ability of patients to give informed consent and the diagnosis must be verified by an independent authority designated for this purpose under jurisdiction of the state where SPI will be carried out, e.g. Mental health welfare commission (MHWC) or Behavioural Surgery Review Boards. The independent body or authority must also decide whether the treating team is adequately trained to perform the procedure and provide aftercare. These procedures should only be performed in adequately resourced centers subject to annual inspections and robust clinical and regulatory governance frameworks. Postoperative assessment should be blinded to avoid placebo effects and biases, i.e. the assessor should be blinded as to what procedure did the patient receive to avoid bias. Adhering to these principles will safe guard the return of SPI and protect those who deliver it to patients.