Management of hydrocephalus in patients with leptomeningeal metastases: an ethical approach to decision-making.

PURPOSE: Leptomeningeal metastases (LM) are a rare, but often debilitating complication of advanced cancer that can severely impact a patient's quality-of-life. LM can result in hydrocephalus (HC) and lead to a range of neurologic sequelae, including weakness, headaches, and altered mental status. Given that patients with LM generally have quite poor prognoses, the decision of how to manage this HC remains unclear and is not only a medical, but also an ethical one. METHODS: We first provide a brief overview of management options for hydrocephalus secondary to LM. We then apply general ethical principles to decision making in LM-associated hydrocephalus that can help guide physicians and patients. RESULTS: Management options for LM-associated hydrocephalus include shunt placement, repeated lumbar punctures, intraventricular reservoir placement, endoscopic third ventriculostomy, or pain management alone without intervention. While these options may offer symptomatic relief in the short-term, each is also associated with risks to the patient. Moreover, data on survival and quality-of-life following intervention is sparse. We propose that the pros and cons of each option should be evaluated not only from a clinical standpoint, but also within a larger framework that incorporates ethical principles and individual patient values. CONCLUSIONS: The decision of how to manage LM-associated hydrocephalus is complex and requires close collaboration amongst the physician, patient, and/or patient's family/friends/community leaders. Ultimately, the decision should be rooted in the patients' values and should aim to optimize a patient's quality-of-life.

Innovation in neurosurgery: less than IDEAL? A systematic review.

BACKGROUND: Surgical innovation is different from the introduction of novel pharmaceuticals. To help address this, in 2009 the IDEAL Collaboration (Idea, Development, Exploration, Assessment, Long-term follow-up) introduced the five-stage framework for surgical innovation. To evaluate the framework feasibility for novel neurosurgical procedure introduction, two innovative surgical procedures were examined: the endoscopic endonasal approach for skull base meningiomas (EEMS) and the WovenEndobridge (WEB device) for endovascular treatment of intracranial aneurysms. METHODS: The published literature on EEMS and WEB devices was systematically reviewed. Identified studies were classified according to the IDEAL framework stage. Next, studies were evaluated for possible categorization according to the IDEAL framework. RESULTS: Five hundred seventy-six papers describing EEMS were identified of which 26 papers were included. No prospective studies were identified, and no studies reported on ethical approval or patient informed consent for the innovative procedure. Therefore, no clinical studies could be categorized according to the IDEAL Framework. For WEB devices, 6229 articles were screened of which 21 were included. In contrast to EEMS, two studies were categorized as 2a and two as 2b. CONCLUSION: The results of this systematic review demonstrate that both EEMS and WEB devices were not introduced according to the (later developed in the case of EEMS) IDEAL framework. Elements of the framework such as informed consent, ethical approval, and rigorous outcomes reporting are important and could serve to improve the quality of neurosurgical research. Alternative study designs and the use of big data could be useful modifications of the IDEAL framework for innovation in neurosurgery.

Separation of Craniopagus Twins.

Separation of craniopagus twins is fraught by ethical issues. The surgery is high risk and may involve the sacrifice of one twin. We review surgical successes in separation of craniopagus twins and consider ethical and legal concepts affecting the decision to undertake such procedures. Our discussion considers how Gillett's potentiality principle and the concept of moral permissibility may be used to arrive at fair and realistic decisions.

Primo non nocere or maximum survival in grade 2 gliomas? A medical ethical question.

BACKGROUND: Maximum safe resection is the "gold standard" in surgical treatment of grade 2 gliomas (G2Gs), aiming to achieve maximal survival benefit with minimal risk of functional deficit. OBJECTIVE: To investigate the attitude of patients and experts towards more extensive surgery with a trade-off between neurological function and survival time. METHODS: Eight patients and seven experts participated in semi-structured focus group interviews. RESULTS: Both patients and experts accepted the premise of balancing neurological function versus longevity. Some patients would accept an increased risk of permanent neurological deficits in order to obtain a chance of increased survival. There was a significant variance in what constituted "quality of life" both between patients and for the individual patient over time. CONCLUSIONS: In important life-changing decisions there is no "one size fits all". We find that it is ethically acceptable to offer more extensive surgery than is possible within the concept of maximal safe surgery as a treatment option, when balancing the principles of beneficence, non-maleficience, autonomy and justice supports the decision. At the same time it must be remembered that even when the patients have made a well-informed decision, some will regret it. In that situation it will be our job as healthcare professionals to support them and help carry some of this burden.

Are patients open to elective re-sampling of their glioblastoma? A new way of assessing treatment innovations.

BACKGROUND: This is a qualitative study designed to examine patient acceptability of re-sampling surgery for glioblastoma multiforme (GBM) electively post-therapy or at asymptomatic relapse. METHODS: Thirty patients were selected using the convenience sampling method and interviewed. Patients were presented with hypothetical scenarios including a scenario in which the surgery was offered to them routinely and a scenario in which the surgery was in a clinical trial. RESULTS: The results of the study suggest that about two thirds of the patients offered the surgery on a routine basis would be interested, and half of the patients would agree to the surgery as part of a clinical trial. Several overarching themes emerged, some of which include: patients expressed ethical concerns about offering financial incentives or compensation to the patients or surgeons involved in the study; patients were concerned about appropriate communication and full disclosure about the procedures involved, the legalities of tumor ownership and the use of the tumor post-surgery; patients may feel alone or vulnerable when they are approached about the surgery; patients and their families expressed immense trust in their surgeon and indicated that this trust is a major determinant of their agreeing to surgery. CONCLUSION: The overall positive response to re-sampling surgery suggests that this procedure, if designed with all the ethical concerns attended to, would be welcomed by most patients. This approach of asking patients beforehand if a treatment innovation is acceptable would appear to be more practical and ethically desirable than previous practice.

Medical Ethics and Artificial Intelligence in Neurosurgery-How Should We Prepare?

BACKGROUND: The development of artificial intelligence (AI) raises ethical concerns about its side effects on the attitudes and behaviors of clinicians and medical practitioners. The authors aim to understand the medical ethics of AI-based chatbots and to suggest coping strategies for an emerging landscape of increased access and potential ambiguity using AI. METHODS: This study examines the medical ethics of AI-based chatbots (Chat generative pretrained transformer [GPT], Bing Chat, and Google's Bard) using multiple-choice questions. ChatGPT and Bard correctly answered all questions (5/5), while Bing Chat correctly answered only 3 of 5 questions. ChatGPT explained answers simply. Bing Chat explained answers with references, and Bard provided additional explanations with details. RESULTS: AI has the potential to revolutionize medical fields by improving diagnosis accuracy, surgical planning, and treatment outcomes. By analyzing large amounts of data, AI can identify patterns and make predictions, aiding neurosurgeons in making informed decisions for increased patient wellbeing. As AI usage increases, the number of cases involving AI-entrusted judgments will rise, leading to the gradual emergence of ethical issues across interdisciplinary fields. The medical field will be no exception. CONCLUSIONS: This study suggests the need for safety measures to regulate medical ethics in the context of advancing AI. A system should be developed to verify and predict pertinent issues.

Ethical Incorporation of Artificial Intelligence into Neurosurgery: A Generative Pretrained Transformer Chatbot-Based, Human-Modified Approach.

INTRODUCTION: Artificial intelligence (AI) has become increasingly used in neurosurgery. Generative pretrained transformers (GPTs) have been of particular interest. However, ethical concerns regarding the incorporation of AI into the field remain underexplored. We delineate key ethical considerations using a novel GPT-based, human-modified approach, synthesize the most common considerations, and present an ethical framework for the involvement of AI in neurosurgery. METHODS: GPT-4, ChatGPT, Bing Chat/Copilot, You, Perplexity.ai, and Google Bard were queried with the prompt "How can artificial intelligence be ethically incorporated into neurosurgery?". Then, a layered GPT-based thematic analysis was performed. The authors synthesized the results into considerations for the ethical incorporation of AI into neurosurgery. Separate Pareto analyses with 20% threshold and 10% threshold were conducted to determine salient themes. The authors refined these salient themes. RESULTS: Twelve key ethical considerations focusing on stakeholders, clinical implementation, and governance were identified. Refinement of the Pareto analysis of the top 20% most salient themes in the aggregated GPT outputs yielded 10 key considerations. Additionally, from the top 10% most salient themes, 5 considerations were retrieved. An ethical framework for the use of AI in neurosurgery was developed. CONCLUSIONS: It is critical to address the ethical considerations associated with the use of AI in neurosurgery. The framework described in this manuscript may facilitate the integration of AI into neurosurgery, benefitting both patients and neurosurgeons alike. We urge neurosurgeons to use AI only for validated purposes and caution against automatic adoption of its outputs without neurosurgeon interpretation.

Ethical considerations in targeted paediatric neurosurgery missions.

Within the context of global health development approaches, surgical missions to provide care for underserved populations remain the least studied interventions with regard to their methodology. Because of the unique logistical needs of delivering operative care, surgical missions are often described solely in terms of cases performed, with a paucity of discourse on medical ethics. Within surgery, subspecialties that serve patients on a non-elective basis should, it could be argued, create mission strategies that involve a didactic approach and the propagation of sustainable surgical care. The ethical considerations have yet to be described for paediatric neurosurgical outreach missions. We present here the perspectives of neurosurgeons who have participated in surgical outreach missions in Central America, South America, Eastern Europe and sub-Saharan Africa from the vantage point of both the visiting mission team and the host team that accommodates the mission efforts.

Surrogates and extra-familial interests.

A case is presented in which the therapeutic interests of the patient conflict with the safety of a community, and in which the surrogate decision maker has very limited knowledge of or concern for the patient's preferences. The substituted judgment and best interest (or rational patient) standards for surrogate decision making are problematic in this case. It is argued that the interests of even those outside the family ought to be taken seriously when making decisions about such cases, and it is proposed that clinical ethics committees could play a new role here. This case also illustrates the difficulties of making decisions regarding the treatment of a very unlikable patient.

Conflicts of interest in deep brain stimulation research and the ethics of transparency.

In this article we will draw on experiences from our own research on deep brain stimulation of the central thalamus in the minimally conscious state. We describe ethical challenges faced in clinical research involving medical devices and offer several cautionary notes about its funding and the interplay of market forces and scientific inquiry and suggest some reforms.

Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review.

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.

Launching invasive, first-in-human trials against Parkinson's disease: ethical considerations.

The decision to initiate invasive, first-in-human trials involving Parkinson's disease presents a vexing ethical challenge. Such studies present significant surgical risks, and high degrees of uncertainty about intervention risks and biological effects. We argue that maintaining a favorable risk-benefit balance in such circumstances requires a higher than usual degree of confidence that protocols will lead to significant direct and/or social benefits. One critical way of promoting such confidence is through the application of stringent evidentiary standards for preclinical studies. We close with a series of recommendations for strengthening the internal and external validity of preclinical studies, reducing their tendency toward optimism and publication biases, and improving the knowledge base used to design and evaluate preclinical studies.

Intracranial tumor surgery in patients >70 years of age: is clinical practice worthwhile or futile?

OBJECTIVES: To study survival and functional outcome after intracranial tumor surgery in elderly patients. MATERIALS AND METHODS: This is a retrospective study of 289 consecutive patients of age > or =70 years, who underwent primary surgery (resection or biopsy) in the time period 2003-2007 for an intracranial tumor (87 astrocytomas, 79 meningiomas, 62 brain metastases, 33 pituitary adenomas and 28 other tumors). RESULTS: The surgical mortality was 2.8%. Overall survival at 6 months, 1, 2 and 5 years was 73%, 57%, 46% and 38% respectively. Histology, pre-operative Eastern Cooperative Oncology Group (ECOG) performance score and resection, as opposed to biopsy, were significantly associated with survival. Gender, age and American Association of Anaesthetists (ASA) score were not significantly related to survival. One-year survival after surgery for astrocytoma, meningioma, brain metastases and pituitary adenoma were 24%, 94%, 31% and 96% respectively. More than 85% of the patients who were alive 6 months after surgery had a stable or improved ECOG score compared with their pre-operative score. CONCLUSIONS: Surgery for intracranial tumors in selected elderly patients is worthwhile, not futile. Age alone should not be used as a selection criterion for treatment.

Autonomy and authenticity of enhanced personality traits.

There is concern that the use of neuroenhancements to alter character traits undermines consumer's authenticity. But the meaning, scope and value of authenticity remain vague. However, the majority of contemporary autonomy accounts ground individual autonomy on a notion of authenticity. So if neuroenhancements diminish an agent's authenticity, they may undermine his autonomy. This paper clarifies the relation between autonomy, authenticity and possible threats by neuroenhancements. We present six neuroenhancement scenarios and analyse how autonomy accounts evaluate them. Some cases are considered differently by criminal courts; we demonstrate where academic autonomy theories and legal reasoning diverge and ascertain whether courts should reconsider their concept of autonomy. We argue that authenticity is not an appropriate condition for autonomy and that new enhancement technologies pose no unique threats to personal autonomy.

Personal identity, enhancement and neurosurgery: a qualitative study in applied neuroethics.

Recent developments in the field of neurosurgery, specifically those dealing with the modification of mood and affect as part of psychiatric disease, have led some researchers to discuss the ethical implications of surgery to alter personality and personal identity. As knowledge and technology advance, discussions of surgery to alter undesirable traits, or possibly the enhancement of normal traits, will play an increasingly larger role in the ethical literature. So far, identity and enhancement have yet to be explored in a neurosurgical context, despite the fact that 1) neurological disease and treatment both potentially alter identity, and 2) that neurosurgeons will likely be the purveyors of future enhancement implantable technology. Here, we use interviews with neurosurgical patients to shed light on the ethical issues and challenges that surround identity and enhancement in neurosurgery. The results provide insight into how patients approach their identity prior to potentially identity-altering procedures and what future ethical challenges lay ahead for clinicians and researchers in the field of neurotherapeutics.

Vulnerable brains: research ethics and neurosurgical patients.

Seven specific challenges in patient vulnerability related to neurosurgical advancement highlight needed augmentations for standards in innovation and research that do not unduly inhibit access to potential therapies while assuring just treatment of patients.

Amygdaloid neurosurgery for aggressive behaviour, Sydney, 1967-1977: societal, scientific, ethical and other factors.

OBJECTIVES: In 1967, despite escalating international hostility towards psychosurgery, a program of amygdaloid neurosurgery for the reduction of aggressive and self-harming behaviour commenced in Sydney. In this paper, the second of two articles on the Amygdaloid Neurosurgery Project (ANP), we analyse the relative contributions of seven nominated societal, ethical and other factors to the genesis and demise of the ANP, and consider implications of the history of the ANP for the future of neurosurgery for psychiatric disorders (NPD) in New South Wales (NSW) and elsewhere. CONCLUSIONS: Leadership and the availability of resources were crucial factors in the genesis of the project. Its scientific foundations were doubtful in 1967, and remain so in 2009. Ethical issues became the focus of hostile media and Government attention in 1977 and precipitated the project's demise. Lessons derived from an historical analysis of the ANP should assist the medical profession develop appropriate approaches to recent advances in NPD, including deep brain stimulation, new ablative procedures and stem cell implantation.