Raising the ethical standards in neurosurgery

Abstract

The historically aware neurosurgeon cannot but be astounded by the remarkable progress of the specialty since the early 1900s. Around that time, the neurologist David Ferrier described neurosurgery as ‘a sort of polite way of committing suicide’ [1]. Today, spectacular neuroimaging techniques, neuroanaesthesia, neurostimulation and brain-computer interfaces, the prospect of neural transplantation using stem cells, and advances in operating microscopes, surgical instruments and technique are only some of the developments that reflect the evolution of the specialty. Progress in medicine, however, often presents new ethical challenges, and neurosurgery is no exception. Our ability to manipulate and interfere with the brain, and the implications of such an ability on personal identity, consciousness and wellbeing, have raised such an array of ethical issues that a new branch of bioethics has emerged to address them: neuroethics [4, 9]. While we can open the closed box of the skull with greater ease and safety than ever before, it is not infrequent for neurosurgeons to approach an operation, be it an awkwardly placed petroclival meningioma, a large infiltrating highgrade glioma or an unpredictable cerebral aneurysm, knowing that there is a chance that their patients may die or be so cognitively impaired as a result of the operation or its complications that they may no longer be able to make decisions. The invasiveness of many intracranial operations and the risks of neurological deficit distinguish neurosurgery from other specialties. It seems sensible, given these features, that neurosurgeons not only inform patients of the possible outcomes of high-risk operations, but also offer competent patients the possibility to discuss what they would like to happen if they lose the ability to make decisions (“some patients in your situation have views on what they would want if their condition deteriorates after the operation. The chances of this happening are low, but some patients appreciate the opportunity to make plans. Do you have any views on this?”) [3]. Depending on the patient’s answer, the surgeon could mention the possibility of creating a Durable Power of Attorney (or, in the UK, a Lasting Power of Attorney), which would allow patients to appoint a person (or several persons) to make decisions on their behalf if unable to do so themselves. Alternatively, patients may want to make an advance directive (formally called an ‘advance decision’ in the UK), specifying what treatment they would not want to receive in the future. If the patient has preferences but does not wish to record them in such a formal manner, the surgeon can document them in the notes. This will provide some indication of the patient’s views and wishes that may be of future use. It is important to raise the subject in this preoperative encounter (rather than wait to see how the situation evolves) for it may be the last time the surgeon sees the patient when he or she still has capacity. If patients accept the offer to have this discussion (and doubtless some patients would rather not), it will allow clinicians to continue respecting their autonomy when they D. K. Sokol (*) Lecturer in Medical Ethics and Law, St George’s, University of London, Cranmer Terrace, London SW17 0RE, United Kingdom e-mail: daniel.sokol@talk21.com