Brains, Ethics, and Elective Surgeries: Emerging Ethics Consultation
Ford, Paul J., DeMarco, Joseph P., Ethics & Medicine
Increasingly health care teams seek clinical ethics advice related to patients being considered for elective neurosurgeries. Traditional clinical ethics consultations have focused on end-of-life decisions and/or hospitalized patients regarding decisions with considerable time sensitivity. Ethical deliberations about elective surgical procedures do not fit well into reactive clinical ethics consultation practices commonly employed for acute clinical ethics. The ethics consultant should be cognizant of the differences between these consultations and more traditional clinical ethics consultations. Performed carefully and reflectively, ethics consultations related to elective neurosurgeries can assist physician teams and patients navigate the particularly complex decision-making regarding neurosurgeries. We explore important similarities and differences between the two types of consultations and suggest how ethics consultants can be effective in the sphere of ethics consultation for elective neurosurgeries.
Key Words: Ethics Consultation, Surgery, Informed Consent, Neuroethics
Running Title: Elective Neurosurgery Ethics Consults
Leaps in knowledge within the neurosciences have translated to increasingly complex neurosurgical choices. Brain imaging technologies have improved in resolution and type. We can now better visualize abnormal formations as well as correlate functions with activations within the brain. On the interventional side, we are able to more precisely target sites within the brain for ablation or electrical stimulation. Rather than diminishing the difficulties in care, these new abilities and knowledge provide an increasing number of reasonable options that have differing types of benefits and harms. (Ford and Henderson 2005) Although, elective neurosurgery (ENS) interventions intend to improve quality of life, they also force patients and health care teams to make treatment decisions that balance categorically different benefits and harms. This generally occurs in the absence of an overriding concern for risk of immediate loss of life or function through inaction. A clinical ethics consultant may be helpful to both the patient and the medical team in complex cases regarding whether an ENS intervention should be offered/consented to. The ethics consultant should be cognizant of the differences between these consultations and more traditional clinical ethics consultations. This includes clearly understanding the limits of the ethics consultant's role.
Although traditional clinical ethics consultations have focused on end-of-life decisions and/or hospitalized patients, increasingly health care teams seek clinical ethics advice for patients being considered for ENS. (Ford and Kubu, 2006) These consultations have in common many of the features found in acute/emergent clinical ethics consultation. Yet, these consultations also vary somewhat from these common types of ethics work. We will briefly review the character of ethics consultation, elucidate unique aspects of clinical ethics consultation for ENS, provide a brief sample case, and conclude with suggestions for the use of ethics consultations for ENS.
Acute/Emergent Ethics Consultation
The most common type of ethics consultation, acute/emergent clinical ethics consultation,1 pertains to critically or terminally ill patients in a hospital setting.2 Clinical ethics consultants perform these with significant decision-making urgency because of the time sensitive nature of the particular situations. The reactive clinical ethics consultation model usually engages in "emergent" ethics consultations because of the limited time frame involved in decision-making. This includes acute illnesses as well as actual emergency medical care. Although clinical ethics consultations are almost always "elective" in the sense of not being required by law or custom, they are "acute" in the sense that they address medical emergencies or high acuity circumstances for which a time sensitive decision must be made. …