Reconsidering the ethics of provocation techniques for Psychogenic Non-Epileptic Attacks and proposed ethical guidelines for use

•With the rapidly changing context of the patient-healthcare relationship, a reconsideration of the ethics of PNEA provocation in needed.•With over one-fourth of epilepsy monitoring units not utilizing PNEA provocation techniques (most of which citing ethical concern), others without protocols, and most not obtaining patient consent, a reconsideration of the utilization of these methods is both necessary and timely given new research on the topic.•Given new cultural emphasis on patient consent and psycho-socio-economic wellness, the topic of ethics of PNEA provocation techniques is pertinent to any epilepsy specialist’s practice. Patients with psychogenic non-epileptic attacks (PNEA) are subject to considerable direct and indirect comorbid psycho-socio-economic impact from their condition. Fortunately, diagnosis and treatment of PNEA has shown to be both medically effective and cost-efficient, ultimately improving PNEA symptoms, mental health, quality of life, and healthcare resource utilization. Though provocation techniques for PNEA have proven highly effective in diagnosing and providing expedited treatment to these patients, they have recently begun to fall out of favor due to ethical concerns about their use. Today, over one-fourth of epilepsy monitoring units do not utilize PNEA provocation techniques in those suspected of the condition. Of the monitoring units that do, less than 10% have an established protocol, and only 20% reported patient consent. The ethics and implications of the methods of diagnosing PNEA have been debated for decades. Specifically, the ethicality of attempting to provoke PNEA episodes using the proven effective methods of suggestion, nocebo, and other techniques have often left clinicians and medical ethicists offering opposing views. Here we review the personal and societal costs of PNEA, the efficacy of these provocation techniques, and the ethical considerations regarding their use, with specific emphasis on the importance of how these techniques are described to patients, as to both ensure informed consent and removed deception. Additionally, addressing these concerns, we propose ethical guidelines for the use of provocation techniques for the diagnosis of PNEA, concluding that such techniques can be ethically applied when certain conditions are met.