Day: June 22, 2026

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.