Ethical challenges with awake craniotomy for tumor.

BACKGROUND: Awake brain surgery is useful for the treatment of a number of conditions such as epilepsy and brain tumor, as well as in functional neurosurgery. Several studies have been published regarding clinical results and outcomes of patients who have undergone awake craniotomy but few have dealt with related ethical issues. OBJECTIVE: The authors undertake to explore broadly the ethical issues surrounding awake brain surgery for tumor resection to encourage further consideration and discussion. METHODS: Based on a review of the literature related to awake craniotomy and in part from the personal experience of the senior author, we conducted an assessment of the ethical issues associated with awake brain tumor surgery. RESULTS: The major ethical issues identified relate to: (1) lack of data; (2) utilization; (3) conflict of interest; (4) informed consent; (5) surgical innovation; and (6) surgical training. CONCLUSION: The authors respectfully suggest that the selection of patients for awake craniotomy needs to be monitored according to more consistent, objective standards in order to avoid conflicts of interest and potential harm to patients.

Decompressive craniectomy for diffuse cerebral swelling after trauma: long-term outcome and ethical considerations.

BACKGROUND: There is currently much interest in the use of decompressive for the management of diffuse cerebral swelling after trauma. Although the use of the procedure may improve survival, some of those survivors may be left severely disabled. The aim of this study was to see whether severe disability can be predicted and discuss the difficult ethical issue that this raises. METHODS: This was a retrospective cohort subgroup analysis of those patients with severe head injury in Western Australia between 2004 and 2008 who had had a decompressive craniectomy for intractably raised intracranial pressure despite maximal medical management. RESULTS: Among a total of 1,786 adult neurotrauma patients admitted between 2004 and 2008, 74 patients required a bifrontal decompressive craniectomy for intractably raised intracranial pressure. After the application of Corticosteroid Randomization After Significant Head Injury (CRASH) trial collaborators' prediction model, predicted and observed outcomes were compared. The mean timing and median timing of surgery were 42 hours and 30 hours after hospital admission, respectively. The timing of decompressive craniectomy was inversely correlated to the severity of the head injury (Spearman's correlation coefficient = -0.251, p = 0.031). At 18-month follow-up, 16 patients were deceased, 3 were in a persistent vegetative state, and 10 were severely disabled. In contrast to these unfavorable outcomes, 35 patients had a good outcome and 10 were moderately disabled at 18 months. The discrimination of the CRASH prediction model was excellent (area under receiver-operating characteristic curve, 0.905; 95% confidence interval, 0.829-0.982; p = 0.001). CONCLUSION: Our data provide some evidence that the CRASH prediction model may help clinicians and families to make informed decision about the benefits and risks of decompressive craniectomy for diffuse cerebral swelling.

Neurotrauma and the RUB: where tragedy meets ethics and science.

Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled; a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case.

Going against the grain: in praise of contrarian clinical ethics.

Contrarian ways of thinking are generally good for the intellectual life and clinical ethics is no exception. This essay introduces the papers in the 2003 issue on clinical ethics of the Journal of Medicine and Philosophy, each of which goes against the grain in interesting and important ways. Considerations of identity predominate, in discussions of cloning, separation of conjoined twins, and the coming into existence of human beings. Whether viewing organ donation as admirable sacrifice is an altogether good thing is considered, as is the justification of fetal craniotomy. Finally, there is a review essay about From Chance to Choice, an important new book for the philosophy and ethics of molecular medicine.

Two craniotomy arguments don't make it.

Craniotomy as a surgical procedure used in the delivery of a fetus is subject to various moral judgments, some positive and some negative. This article gives consideration to two arguments offered for the moral legitimacy of the craniotomy. Each argument is closely examined and each is found to be flawed and hence inconclusive.

The chapel and the operating room: the struggle of Roman Catholic clergy, physicians, and believers with the dilemmas of obstetric surgery, 1800-1900.

By 1800, the Roman Catholic Church and organized medicine faced the dilemma of how to resolve cases of obstructed births. American physicians usually practiced destructive operations, like craniotomy, in an attempt to save the lives of mothers. The church allowed such operations after the death of the infant. A new technique of surgery, the cesarean operation, offered hope that both patients would survive childbirth. Medical progress, and an emerging Catholic belief that the fetus was human, prompted Catholic physicians to advocate the new operation, and stirred a renewed debate among European theologians on the propriety of craniotomy. In America, the broad Christian tradition promoted by the Catholic Church began to inform medicine on the moral and ethical parameters of surgery. American physicians, for their part, engaged in their own debate on the propriety of the cesarean operation. This article, focusing on the cesarean debate, reveals the intersections of Catholicism and medical progress amid the growth of obstetric surgery from 1800 to 1900.