Why Nobel Should Rescind the Prize

Why Nobel Should Rescind the Prize by Sue Kemsley

It seems to be widely recognized that the Nobel prize committee made a serious error, even given the knowledge at the time, in awarding the prize to Egas Moniz. This article in Science, for example, refers to the decision as “an astounding error of judgment”:

“Historical records fail to explain some astounding errors of judgment. Witness the 1949 prize in physiology or medicine, shared by neuroscientist Antonio Egas Moniz for his development in 1935 of the prefrontal lobotomy. The jury failed to appreciate how widely discredited the procedure had
become by the time it tapped Moniz. “It was a terrible mistake that caused permanent damage to thousands of patients,” says 1981 physiology or medicine laureate Torsten Wiesel of Rockefeller University in New York City.”
(http://www.sciencemag.org/cgi/content/full/294/5541/288a)

It would be nice if the Nobel prize committee would admit to their error, denobelise Egas Moniz and dedicate his prize instead to the victims of psychosurgery. Whilst Sweden defends psychosurgery, Norway has awarded compensation to all surviving lobotomy patients. Of course the difference is
that Sweden still performs psychosurgical operations, and Norway does not.

Incidentally a 1994 Council of Europe report on psychiatry and human rights identified only Sweden, the UK, the Netherlands, France and Ireland as countries in Europe where psychosurgery is still used. The following countries said they no longer used it: Belgium, Cyprus, Finland, Germany Luxembourg, Norway, Poland, Portugal, Spain.

Bengt Jansson says he sees “no reason for indignation at what was done in the 1940s as at that time there were no alternatives!” No alternatives? What about ECT, insulin coma therapy, prolonged narcosis, psychotherapy, as well as various sedative and stimulant drugs?

Of course the Nobel prize committee cannot be blamed for not seeing the discovery of neuroleptics around the corner but the introduction of neuroleptics was only one of the reasons for
the decline in the use of psychosurgery (from, in England and Wales, a peak of about 1500 operations in 1949 to about 500 in 1959). Tooth and Newton, writing in 1961, thought that it was the incidence of undesirable side-effects which, more than any other factor, was responsible for this decline.

The introduction of neuroleptics, used mainly in the treatment of schizophrenia, would not have accounted for the decline in psychosurgery as a treatment for depression or other disorders. Neuroleptics are not a complete cure for schizophrenia, and their use can lead to tardive dyskinesia and other side-effects, so if psychosurgery had been an effective treatment for schizophrenia, with acceptable risks, it would still be used in spite of the introduction of neuroleptics. The inventors of neuroleptics
did not, incidentally, receive a Nobel prize even though their invention is supposed to have been better than psychosurgery.

Jansson cites the “the importance of discharging patients from the state institutions” as a factor contributing to psychosurgery’s popularity in the 1940s. But in England and Wales only about 20 per cent of people operated on for schizophrenia in the 1940s and early 1950s were discharged within one year of the operation., representing about 200 discharges a year even at the peak of psychosurgery, or fewer than two per hospital every year, which was hardly going to empty the institutions.

Of course, psychosurgical operations were not spread evenly amongst hospitals. Some hospitals in the United Kingdom never carried out a single operation (psychosurgery was not, even in
pre-neuroleptic days, “popular” everywhere) whilst others were responsible for far more than their fair share. Graylingwell hospital in West Sussex, for example, was responsible for about one-fifth of all operations carried out in England and Wales in period 1943-45.

This wide variation has persisted to the present day. Even when the number of operations carried out every year in the United Kingdom fell to a few hundred in the 1960s, the operation was not reserved for the most severely or chronically ill patients.

For example, some of the patients operated on at the Brook Hospital in London in the 1960s had never previously been admitted to a mental hospital and some were not even “seriously incapacitated” before surgery.

Neither was psychosurgery limited to strict diagnostic criteria after the introduction of neuroleptics. During the 1960s and 1970, for example, people in the United Kingdom were operated on for
depression, obsessive-compulsive disorder, schizophrenia, anorexia,
personality disorder, anxiety, hypochondria, aggression, and alcohol and drug dependence. In Denmark in the 1970s psychosurgical operations were used for obesity; and in West Germany they were used for “sexual deviance”.

Jansson says: “Lobotomy is an ethically dubious treatment if carried out against the patient’s wishes..”. I have been unable to find any discussion of consent from the 1940s, but one surgeon, F Wilfred Willway (who operated with a paperknife) described most of his patients as resistive and uncooperative, which would suggest that it was common to operate on patients without their consent and even against their wishes.

Many of the patients operated on in those days were detained in hospital: for example, of 50 patients operated on in the early 1940s by Willway at the Burden neurological institute, only three were voluntary patients. Nowadays, in England and Wales, under the 1983 Mental Health Act psychosurgery may only used when a person, whether a detained or voluntary patient, consents; and a
panel from the Mental Health Act Commission has to both approve the operation and verify the patient’s consent.

The Governments recent proposals for a new Mental Health Act include a clause which would allow, with court approval, the use of psychosurgery on patients considered incapable of giving consent.