psychosurgery in the united states is difficult to estimate but continues at one centre at least in massachusetts. other countries where it continues to be used include korea, taiwan, mexico, spain, and some south american and eastern european countries. psychosurgery had been prohibited by the minister of health in the ussr. in the late 1990s the institute of the human brain in st petersburg developed a programme of cingulotomy for the treatment of addiction. deep brain stimulation is now being used as an alternative to ablative psychosurgery. there is debate about whether or not, for legislative purposes, it should be considered as psychosurgery. effects the purpose of psychosurgery is to reduce the symptoms of mental disorder, and it was recognised that with standard pre-frontal leucotomies this was accomplished at the expense of a person's personality and intellect. british psychiatrist maurice partridge, who conducted a follow-up study of 300 patients who had undergone pre-frontal leucotomy, said that the treatment achieved its effects by "reducing the complexity of psychic life". the operation left people with a restricted intellectual range; spontaneity, responsiveness, self-awareness and self-control were reduced, and activity was replaced by inertia. the degree to which people were damaged by these early operations varied greatly. a few people managed to return to responsible work, while at the other extreme people were left with severe and disabling impairments. most people fell into an intermediate group, left with some improvement of their symptoms but also with emotional and intellectual deficits to which they had to adjust, for better or worse. on average, there was a mortality of rate of approximately 5 per cent during the 1940s. freeman coined the term "surgically induced childhood" and used it constantly to refer the results of lobotomy. the operation left people with an "infantile personality"; a period of maturation would then, according to freeman, lead to recovery. in an unpublished memoir he described how the "personality of the patient was changed in some way in the hope of rendering him more amenable to the social pressures under which he is supposed to exist". he described one 29-year-old woman as being, following lobotomy, a "smiling, lazy and satisfactory patient with the personality of an oyster" who couldn't remember freeman's name and endlessly poured coffee from an empty pot. when her parents had difficulty dealing with her behaviour, freeman advised a system of rewards (ice-cream) and punishment (smacks). the risks of psychosurgery have been greatly reduced by modern stereotactic techniques, where more discrete lesions are made in the brain. adverse effects of capsulotomy and cingulotomy include seizures, fatigue and personality changes. the risk of death or vascular injury is extremely small. success rates for anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy in treating depression and ocd have been reported as between 25 and 70 per cent. there remain concerns however about the poor quality of studies and the lack of systematic reviews and meta-analyses. ethics psychosurgery has always been a controversial treatment, and ethical concerns about its use were raised early in its history. psychoanalyst donald winnicott wrote to the lancet in 1943 about the "special objection that is easily felt to the treatment of mental disorder by any method that leaves a permanent physical deficiency or deformity of the brain", even if favourable results could sometimes be shown to follow. in the 1950s, winnicott continued to explore the ethics of psychosurgery, arguing that it altered "the seat of the self", "put a premium on the relief of suffering" and created teams of neurosurgeons with vested interests that could affect evaluation of the operation. by this time, he pointed out, there were many people in the community who had been left with distressing effects of psychosurgery, even though they may have originally had had illnesses that were not without hope of remission. by the late 1970s, when modified techniques with less devastating consequences had replaced lobotomies, and the number of operations carried out had dropped considerably, ethical concerns revolved around consent. a report in 1977 by the us department of health, education and welfare highlighted the fact that psychosurgery was an irreversible procedure and that the data regarding its effects were unsatisfactory. there were concerns about consent, especially when the patients were children, prisoners, or detained. there were also concerns about particular uses of psychosurgery, for example in the treatment of aggression or violence, or as a treatment for children. in england in 1980 lawyer larry gostin called for psychosurgery to be subject to "the strictest legal and ethical scrutiny". he identified a number of problems with the newer forms of psychosurgery: the lack of any reliable theoretical position relating to psychosurgery, with different forms of surgery used in similar cases, and similar surgery used for a wide range of psychiatric conditions; the absence of controlled trials; the difficulty in assessing changes in character caused by the surgery; and the irreversible nature of surgery on brain tissue that appeared to be structurally normal. in spite of these ethical concerns, he noted, there had never been in the uk any "guidelines, controls, regulations or monitoring arrangements relating to its use". gostin argued that psychosurgery should only be given with the consent of the patient and approval of an independent body comprising a multi-disciplinary legal and lay element. his proposals were largely incorporated into the mental health act 1983, and led to a significant fall in the use of psychosurgery in england and wales. ethical debate relating to psychosurgery in the twenty-first century still revolves around questions about benefit, risks, consent and the lack of a rationale for the operation.