Psychiatric neurosurgery is experiencing a revival. Beside deep brain stimulation (DBS), several ablative procedures are currently in use, namely stereotactic radiofrequency ablation, Gamma Knife radiosurgery and magnetic resonance-guided focused ultrasound (MRgFUS). Each approach has a different profile of advantages and disadvantages. To date, the superiority of one particular approach in terms of efficacy, efficiency, risks, adverse effects, costs, and patient acceptance could not be proven. Therefore, a clear recommendation for a specific therapeutic approach is not possible at present. Many ethicists, psychiatrists, psychotherapists, and laypeople are skeptical about psychiatric neurosurgery. Psychiatric neurosurgery, especially the ablative procedures are regarded as a successor of lobotomy. Particularly, there are concerns about personality changes through psychiatric neurosurgery. Further concerns relate to the lack of evidence for the safety and efficacy of psychiatric neurosurgery. A comprehensive and differentiated ethical analysis of the different psychiatric neurosurgery approaches has to be based on an evidence-based analysis of the benefits and risks of the different approaches rather than on outdated prejudices or ideology. The preliminary evidence for the efficacy of psychiatric neurosurgery and the urgent need for effective therapies for treatment-refractory psychiatric disorders justify further research in psychiatric neurosurgery. However, neither the high mortality rates of severe psychiatric disorders nor their socioeconomic burden can justify therapeutic adventurism. Since psychiatric neurosurgery has the potential to modify some personality traits and the behaviour of patients, these interventions must meet the highest ethical and scientific standards.