Category: Ethics

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Surgical skill is not a virtue

J Neurosurg 145:281–283, 2026

This commentary examines the emotional and ethical burden neurosurgeons carry when surgical complications occur, using cerebral aneurysm surgery as a focal example to quantify lifetime risks and consequences. It contrasts the high technical demands and inevitable failures of neurosurgery with the personal toll of complications, including burnout, substance abuse, family strain, and elevated suicide rates.

The author argues for reframing surgical identity: technical skill is not a moral virtue. Emphasizing cultivated courage, relational commitment to patients, and character formation in training, the piece calls for open discussion of virtue ethics in surgical education to foster resilience and align clinical performance with the patient’s broader good.

Career complication burden A cerebrovascular neurosurgeon performing ~900 aneurysm surgeries can expect to cause roughly 27–60 strokes (3%–8% risk) and about 9 deaths (~1% mortality) over a career, excluding complications from other operations

Rupture vs treatment tradeoff Aneurysm rupture is catastrophic (30%–50% mortality; >30% long-term disability among survivors) yet rupture is rare, while preemptive surgery carries complication costs that patients and surgeons both bear

Hidden surgeon suffering Surgical successes are quickly forgotten, but complications can become lifelong, intrusive burdens that follow surgeons beyond work and create persistent regret

Downstream harms The cumulative burden is associated with high levels of physician burnout, family dysfunction/divorce, substance abuse, and elevated physician suicide rates; denial/avoidance can worsen relationships and invite legal risk

Skill-virtue confusion Training and professional culture can lead surgeons to treat technical skill as a moral virtue, so inevitable complications are experienced as failures of character rather than limits of medicine or circumstance

Key distinction Surgical skill is not a virtue; virtues are character dispositions aimed at human good, while skill is “technical goodness,” and medicine must be more than technique when technical answers fail

Relational triumph after technical failure A surgeon can fail technically yet “triumph relationally” by sustaining courage, honesty about what happened, and commitment to accompany patients and families through outcomes

Cultivating virtues for resilience Courage and character should be intentionally modeled and habituated in surgical training; separating skill failure from character failure supports resilience and continued service after complications

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Ethical aspects of waiting lists in neurosurgery

Acta Neurochirurgica (2026) 168:135

This narrative review examines the ethical implications of prolonged waiting lists for elective neurosurgery worldwide, using a four-principles bioethics framework (beneficence, nonmaleficence, autonomy, justice). It synthesizes literature, global examples, and case illustrations to show how extended delays can worsen outcomes, increase psychosocial burden, and mask hidden rationing.

The paper identifies systemic drivers of waiting lists—including resource limits, poor management, and policy choices—and argues for multifaceted solutions: transparent prioritization, improved referral and patient-flow systems, strengthened accountability across government, institutions, and clinicians, and better data collection to guide ethically grounded reforms.

Scope Long waiting times and large waiting lists for elective neurosurgery are a persistent global problem, intensified when outpatient and diagnostic delays are included.

Evidence gap Most available waiting-time evidence comes from high-volume non-neurosurgical procedures (e.g., cataract, hip/knee), with limited neurosurgery-specific research and few comprehensive multicenter/multinational datasets.

Clinical & psychosocial harm Delayed neurosurgical care is associated with uncertainty, dissatisfaction, pain/anxiety, severe depression risk, worse outcomes, higher costs, reduced quality of life, inequalities, and erosion of patient trust.

Bioethics—beneficence & nonmaleficence Extended waiting generally conflicts with doing good and avoiding harm by prolonging suffering and enabling deterioration, though limited exceptions exist where delaying surgery can prevent unnecessary procedures (e.g., some disc herniations with potential spontaneous recovery).

Bioethics—autonomy Long waits can undermine patient autonomy by preventing timely treatment aligned with patient wishes, limiting options as conditions evolve, and weakening informed consent when circumstances change between consent and surgery; lack of transparent queue/wait-time information is a key problem.

Bioethics—justice tension Under constrained access, distributive justice principles can conflict; long waiting lists can function as hidden rationing, with risks of unequal access tied to socioeconomic status, age, ethnicity, communication skills, gender, or geography.

Accountability Ethical responsibility for waiting lists spans government (macro resource commitments), hospital management (meso organization/capacity), and physicians (micro-level indications, prioritization, patient information/advocacy), though not equally.

Conclusion & direction Long waiting lists potentially violate three core biomedical principles (beneficence, nonmaleficence, autonomy) and challenge justice; addressing them requires better documentation plus multifaceted reforms beyond simply adding resources, emphasizing transparent prioritization and fair, ethical governance.

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Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living?

J Neurosurg 117:749–754, 2012

Although decompressive hemicraniectomy has been shown to reduce death and improve functional outcome following malignant middle cerebral artery territory infarction, there is ongoing debate as to whether surgery should be routinely performed, considering the very high rates of disability and functional dependence in survivors. Through a systematic review of the literature, the authors sought to determine the outcome from a patient’s perspective.

Methods. In September 2010, a MEDLINE search of the English-language literature was performed using various combinations of 12 key words. A total of 16 papers were reviewed and individual study data were extracted.

Results. There was significant variability in study design, patient eligibility criteria, timing of surgery, and methods of outcome assessment. There were 382 patients (59% male, 41% female) with a mean age of 50 years, 25% with dominant-hemisphere infarction. The mortality rate was 24% and the mean follow-up in survivors was 19 months (range 3–114 months). Of 156 survivors with available modified Rankin Scale (mRS) scores, 41% had favorable functional outcome (mRS Score ≤ 3), whereas 47% had moderately severe disability (mRS Score 4). Among 157 survivors with quality of life assessment, the mean overall reduction was 45%: 67% for physical aspect and 37% for psychosocial aspect. Of 114 screened survivors, depression affected 56% and was moderate or severe in 25%. Most patients and/or caregivers (77% of the 209 interviewed) were satisfied and would give consent again for the procedure.

Conclusions. Despite high rates of physical disability and depression, the vast majority of patients are satisfied with life and do not regret having undergone surgery.

 

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