Fifteen Eighty Four

Within all fields of surgery, ethical issues are encountered on a daily basis however within the field of neurosurgery there are certain considerations that require specific consideration. In the first instance disease processes within the central nervous system can have an impact on cognitive function that may affect the function of consent. Secondly, there is the issue of neurocognitive disability and the possibility that neurosurgical intervention may leave a person with a level of neurological function that they might feel to be unacceptable. Finally, there is the concept of identity and the possibility that the person who survives surgical intervention may not have the same values as the person prior to surgical intervention and may feel that their outcome is acceptable.

The aim of this book was to provide an introduction to medical ethics and to provide a framework with which to analyse some of the key issues in that need to be considered specifically in neurosurgical practice. It has been divided into three sections, the first of which introduces core concepts such as the history of medical ethics, ethical models that can be used to examine clinical cases and the important ethical principles of consent and approaches to withholding and withdrawing medical care. There are also chapters on contemporary issues such as healthcare economics and the increasingly important impact of patient data collection, data ownership and issues around social media.

The second section of the book is very pathology and procedure specific. The aim of each chapter is not to exhaustively examine all aspects of neurosurgical management but rather to focus on key ethical issues within each subspecialty field. For example, within the field of traumatic brain injury the discussion focuses on the issue a of surgical intervention such as a decompressive craniectomy, that may convert death into survival with severe neurocognitive disability. Whilst many would regard this outcome as unacceptable it is important to recognise that people may learn to adapt to changing circumstances and learn live with their disability. Whilst this is by no means always the case, the concept of the “Disability Paradox” goes some way to explaining this observation and it is important that surgeons recognise this phenomenon in order to counsel surrogate decision makers and to avoid being overly nihilistic. Other chapters focus on issues such as changing outcome categories in clinical trials to achieve positive results (decompressive hemicraniectomy in ischaemic stroke) conflicts of interest (clipping versus coiling for aneurysmal subarachnoid haemorrhage) and the evolving concept of futility (paediatric neurosurgery). 

There are also chapters that explore the ethical issues in tumour surgery and spinal surgery, however, one of the standout contributions come from Paul Komesaroff and Jeffrey Rosenfeld who detail the rise and fall and the recent cautious resurgence of so called “Psychosurgery”. The development of this field of neurosurgery, with the introduction and subsequent acceptance of the of the frontal leucotomy has come to represent one of the key ethical lessons in clinical medicine and serves to act as a reminder for the need to continually scrutinise evidence and outcome especially when considering “new” or “emerging” scientific knowledge. Notwithstanding the importance of all aspects of ethics in neurosurgical practice, this chapter in itself, provides the reader with exceptional insight into the historical and contemporary the issues that need to be considered when practicing neurosurgery.

The final chapter looks at future developments and the first three chapters focus on innovation, stem cell therapy and machine brain interface. Within these rapidly developing fields one of the key ethical issues that require consideration is the need for a degree of regulation and governance that protects patients but does not overly suppress the ability to move forward. This regulation can occur at a governmental or institution level but must also occur at a personal level such that individuals can recognise the fine line that can exist between cautious innovation and unregulated experimentation.

The final two chapters explore issues regarding what may be considered self-promotion at the expense of potentially vulnerable patient groups. The chapter on international neurosurgery discusses the limitations of introducing a highly technical and resource dependent technology from high income countries into low income countries where the benefit may be limited and non sustainable. The final chapter explores similar issues when considering live broadcasts of neurosurgical procedure where there may be personal and institutional benefit for the surgeon, at the expense of a potential increased risk for the patient.

I hope the book provides educational benefit as well as general interest and it may well serve as a stimulus to further explore the field of bioethics which is an area of increasing importance.