Within the world of medicine, there are many different ways to treat conditions, which are chosen based on many factors. For example, a fractured radius can be repaired through surgical intervention through an open reduction internal fixation, closed reduction, or just casting. The decisions are made based on the degree of severity or the overall probability of proper healing. Of course, the patients are provided with complete autonomy to make their treatment decision, but there are no other valuable ethical concerns.
Then there are treatments that yield large ethical concerns for the patients and their physicians. Arguably one of the most controversial arises when a patent presents with cerebral edema. There are multiple different types and causes but the main idea is the volume in the cranial cavity is fixed. It is estimated that the portions are 1400 mL of brain matter, 150 mL of blood, and 150 mL of cerebral spinal fluid (CSF) (Nehring et al., 2022). When these values fluctuate, pressure builds and brain matter gives in before the bone of the cranium. The most common form of edema is called vasogenic cerebral edema and occurs when the blood-brain barrier is disrupted. With the disruption, proteins and ions flow into the extracellular space. This flow changes the osmotic equilibrium and now allows for water to follow the solutes (Nehring et al., 2022). This becomes dangerous when this permeability change occurs in the white matter and damages nerve tracts.
The seemingly obvious treatment is to relieve the pressure by way of craniotomy. This procedure is performed using burr holes and connecting the burr holes to remove the skull flap if indicated (Fernandez-de Thomas and De Jesus, 2022). Statistics have recently shown that the procedure reduces the chance of death from 52% to 30%, but can increase the chance of causing a vegetative state by three times (Thompson, 2016). Ethically, this causes concern. The physician has to make a choice based on what will benefit the patient the most. In this case, one could argue, but it would probably be performing the procedure to reduce the chance of death. Then again, the physician has to understand non-malfeaseance and doing no harm to the patient. The decision is unclear... doing nothing risks death, but performing the surgery increases the chance of brain damage. The physician can control these probabilities by providing autonomy to the families and allowing them to make the decision they prefer.
Lastly, I didn’t tell you this before, but the 3x increase in causing a vegetative state is the difference between 2% and 6%. Knowing this information, do your answers to the ethics question change?
Fernández-de Thomas RJ, De Jesus O. Craniotomy. [Updated 2022 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Nehring SM, Tadi P, Tenny S. Cerebral Edema. [Updated 2022 Jul 31]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Thompson, Dennis. “This after Severe Head Injury Brings Mixed Results.” WebMD, WebMD, 8 Sept. 2016, https://www.webmd.com/brain/news/20160908/removing-part-of-skull-after-severe -head-injury-brings-mixed-results#1.
ReplyDeleteI think this is an interesting ethical conversation that can even be questioned further. For example, on top of the conversation about increasing chances of the vegetative state, the provider must likely have the conversation about what to do should this happen during surgery. Furthermore, should this surgery be an emergency, the surgeon likely doesn’t have much time to question these considerations, but rather do their best to mediate the situation to the best of their ability. Additionally, this conversation has likely changed over time as techniques related to neurosurgery changed.
Interestingly, as technology has advanced, so has the provider's ability to ‘control’ and/or prevent unwanted side effects related to somatosensation and motor control while conducting a neurosurgery. This particular advancement is the ability to monitor neurophysiological conditions intraoperatively, testing motor and somatosensation of structures related to the surgery in real-time while operating (Gonzalez et al., 2022). By testing somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs), surgeons were able to get these respective responses back to its baseline potential post-operatively over 90% of the time unless the preoperative diagnosis was trauma/infection (Gonzalez et al., 2022). Now, I am not sure how this technology could pertain specifically to a craniotomy. Should it be applicable, then the ethical question changes as one could be able to ‘test’ the patient while operating so as to decrease the risks leading to the vegetative state.
Gonzalez, A. A., Droker, B. S., Kim, E. S., & Parikh, P. (2022). Success Rate of Obtaining Baseline Somatosensory and Motor Evoked Potentials in 695 Consecutive Cranial and Spine Surgeries. Journal of Clinical Neurophysiology, 39(6), 513–518. https://doi.org/10.1097/WNP.0000000000000796