There has been a resurgence in the practice of psychosurgery in the last decade primarily for depression and obsessive compulsive disorder. This is due to the application of deep brain stimulation (which has largely replaced lesioning) and to a greater understanding of the imaging correlates of mental illness. Psychosurgery is expanding well beyond these indications. Many ethical challenges arise, including informed consent, establishing the efficacy of these procedures from the literature and in the design of new studies, the harm versus benefit ratio, and the role of institutional and governmental regulatory control over psychosurgery. Psychosurgery remains experimental or at least investigational and the ethical considerations should be of prime importance for any practitioner undertaking this surgery. We propose eighteen principles as a basis for a regulatory framework of psychosurgery. Neurosurgeons who perform psychosurgery have an immense responsibility to guard against a repeat of the failures of the past.