Introduction: Tourette Syndrome (TS) is a childhood onset disorder characterized by vocal and motor tics and often remits spontaneously during adolescence. For treatment refractory patients, Deep Brain Stimulation (DBS) may be considered. This paper deals with ethical issues associated with DBS of adolescent TS patients (10-25 years of age).

Methods: We describe our experiences with the treatment of two adolescent TS patients and systematically review the scarce literature on this subject. We discuss the ethical issues and specific difficulties that physicians may encounter when treating adolescent patients.

Results: Following surgery one patient experienced side effects without sufficient therapeutic effects and the stimulator was turned off. After a second series of behavioural treatment, he experienced a tic reduction of more than 50% after two years. The reduction may be due to natural waning of tics that often follows adolescence and due to an additional behavioural treatment for tics after the DBS. At present, he is satisfied with the level of symptoms and would not consider the surgery anymore. The second patient is responding well to the stimulation but went through a period of behavioural disturbances which are not uncommon during adolescence but interfered with optimal programming. We believe that the experienced stress before, around, and after the surgery might have provoked the excessive use of cannabis and caused the related behavioural disturbances. After one year he experienced a 70% tic reduction. Sixteen DBS surgeries in adolescent TS patients have been reported. So far, detailed case descriptions are lacking and no attention has been paid on the ethical issues and specific difficulties that physicians may encounter when treating adolescent TS patients. As such we conclude that there is yet no literature on ethical aspects of performing DBS on TS patients, let alone on adolescent TS patients (Table 1).

Discussion: Specific ethical issues arise in adolescent TS patients undergoing DBS relating both to clinical practice as well as to research. Attention should be paid to selecting patients fairly, thorough examination and weighing of risks and benefits, protecting the health of children and adolescents receiving DBS, special issues concerning patient’s autonomy, and the normative impact of quality of life. In research, registration of all TS cases in a central database covering a range of standardized information will facilitate further development of DBS for this indication.

Conclusion: DBS surgery for TS patients has lately been considered at an earlier age because more stress has been placed on the potential long lasting harmful effects of the disorder. Specific ethical issues arise in this age-group relating both to clinical practice as well as to research. Clinical practice should be accompanied by ongoing ethical reflection, preferably covering not only theoretical thought but providing also insights in the views and perspectives of those concerned, that is patients, family members and professionals. Examining the ethical issues of DBS may help to realize its entire potential for benefiting severely suffering TS patients.

We propose to determine the level of agreement across a set of evidence- based guidelines for management of the psychiatric disorders and with a focus on neurosurgical treatments.