Ms. L. is a 31-year-old female who presents to Dr. Impf, a neurosurgeon. Ms. L. has a more than 25-year history of iteratively worsening Tourette syndrome, characterized by severe motoric and postural tics and respiratory expression (grunting). Ms. L. is a rather shy, somewhat introverted woman who spends her time with her husband and a small group of friends, mostly watching cooking shows. Although she has been, and is generally, a good student, she describes her academic performance as “not stellar.” Following years of unsuccessful attempts at pharmacological therapy, Ms. L. was evaluated and accepted into an investigator-initiated research protocol (with provision for humanitarian care exemption) that Dr. Impf and her team were running for deep brain stimulation (DBS). During the neurosurgical procedure, electrodes were satisfactorily placed at bilateral subcortical targets (within the basal ganglia/striatum), and Ms. L. reported a reduced “urge to tic” and decreased frequency and severity of tics intraoperatively, immediately following surgery, during her recovery, and for 15 weeks following surgery. Then, however, the tics began to return and increased in frequency and progression, although not to the full preoperative extent. Attempts at altering DBS current parameters were not successful in reducing the severity and frequency of tics. Decreasing or terminating DBS current resulted in full rebound tics and respiratory expression, and Ms. L. finds this to be even more problematic than before (stating: “It’s like I’ve felt a new way and don’t want to go back to the other way”). Per definition, DBS did not achieve the desired medical/therapeutic outcomes.

In 2006, our team reported our experience in the use of bilateral high-frequency stimulation of the subthalamic nucleus (STN) in patients with severe levodopa-responsive forms of Parkinson’s disease (PD).1 The aim was to better understand and manage the difficulties experienced by patients who undergo neurosurgery, and by their families.

Implantation of deep brain stimulator (DBS) leads for Gilles de Tourette syndrome was first described by Visser-Vanderwalle et al., with a reported 70%–90% decrease in tic frequency.1 Since that time, several targets, including the basal/ganglia and striatum, have been described. The target remains experimental, and in this case, leads were implanted under an investigator-initiated research protocol. Ms. L. reported an excellent intraoperative reduction in the “urge to tic” that persisted for 15 weeks postoperatively, indicating that the leads were well placed. Furthermore, although her tic frequency has increased, it remains improved from baseline and returns to baseline when stimulation is discontinued. Although her response does not represent what her treatment team would consider the “desired medical/therapeutic outcomes,” there is no question that the patient recognizes benefit from her stimulation. In fact, she clearly states that “it’s like I’ve felt a new way and don’t want to go back to the old way.”

The case of Ms. L. provides a wonderful opportunity to highlight the underlying value commitments that often deeply influence decisionmaking in medicine and more specifically in innovative neurosurgical procedures. In order to give a fair opinion on how Dr. Impf, as clinician and researcher, should act, a much richer and thicker understanding of the actual perspectives of the stakeholders would be necessary. Because this is not available, I highlight three important elements: the terms under which the deep brain stimulation (DBS) is implanted, the proper goals of a healthcare team, and the fallacy of a “natural” or immutable self. These elements are brought together in this case by a set of unexpected effects on the patient that were not intended and that are judged and categorized differently by various stakeholders within the case. In the end, I hope that there was full transparency and agreement about obligations, responsibilities, and outcomes prior to the implantation of the DBS between the physician and patient. Further, it is important to remember that just because a result is serendipitous does not mean that it should be discounted as a proper benefit. Finally, each person authors variations on their own self that are molded by environment and social networks. If Ms. L. continues to demonstrate an ability to author a desired self, the DBS is no more inappropriate a tool than many other artifacts that are used regularly by others to mold themselves.

Here we have a case in which (1) the outcome(s) for the patient do not comport with the projected—or initially defined—outcomes of the research study, and (2) these outcomes represent cognitive and behavioral effects that are positively interpreted by the patient, but not by the patient’s immediate family. The 6Cs approach, which frames the technique or technology—and its effects—within defined considerations of domains and dimensions, can be used as part of a multistep approach to addressing issues arising from the use of neurotechnology.1 The approach recommends that the medical team consider the following domains and dimensions when engaging neuroethical analyses:

• • The capacities and limitations of current neuroscience and technology (neuroS/T), and the capacity of the patient

• • The consequences incurred by neuroS/T on recipients, families, and society in the short, intermediate, and long term

• • The character of the recipient (e.g., patterns of cognition, emotion, and behavior) affected by neuroS/T

• • The continuity of research and clinical care

• • The contexts of need and value that influence the use or nonuse of neuroS/T

• • Consent through provision of the most information possible 2

In 2015, we published an article entitled “The Medicalization of Love,” in which we argued that both good and bad consequences could be expected to follow from love’s medicalization, depending on how the process unfolded. A flurry of commentaries followed; here we offer some preliminary thoughts in reply to the more substantial of the criticisms that were raised. We focus in particular on the nature of love itself as well as the role it plays (or should play) in our lives; we also touch on a number of practical issues concerning the likely effects of any plausible “real-life” love drugs and conclude with a call for careful regulation.