Daniel Mendelsohn, Nir Lipsman and Mark Bernstein
Advances in the neurosciences are stirring debate regarding the ethical issues surrounding novel neurosurgical interventions. The application of deep brain stimulation (DBS) for treating refractory psychiatric disease, for instance, has introduced the prospect of altering disorders of mind and behavior and the potential for neuroenhancement. The attitudes of current and future providers of this technology and their position regarding its possible future applications are unknown. The authors sought to gauge the opinions of neurosurgical staff and trainees toward various uses of neuromodulation technology including psychosurgery and neuroenhancement.
The authors conducted a qualitative study involving in-depth interviews with 47 neurosurgery staff, trainees, and other neuroclinicians at a quaternary care center.
Several general themes emerged from the interviews. These included universal support for psychosurgery given adequate informed consent and rigorous scientific methodology, as well as a relative consensus regarding the priority given to patient autonomy and the preservation of personal identity. Participants' attitudes toward the future use of DBS and other means of neuromodulation for cognitive enhancement and personality alteration revealed less agreement, although most participants felt that alteration of nonpathological traits is objectionable.
There is support in the neurosurgical community for the surgical management of refractory psychiatric disease. The use of neuromodulation for the alteration of nonpathological traits is morally and ethically dubious when it is out of sync with the values of society at large. Both DBS and neuromodulation will have far-reaching and profound public health implications.
Fred. L. Cohen, Daniel Mendelsohn and Mark Bernstein
The purpose of this case review was to identify and analyze existing wrong-site craniotomy (WSC) cases to determine the factors that contributed to the errors and to suggest preventative strategies for WSC. Wrong-site surgery (WSS) is a devastating surgical error that has gained increased public attention in recent years due to some high-profile cases. Despite the implementation of preventative methods such as preoperative checklists and surgical time-outs, WSS still occurs to this day. The clinical consequences of WSC are distinct compared with other types of WSS due to the unique function of the brain.
The authors searched medical, legal, and media databases and contacted state medical licensing boards to identify and gather information about WSC cases. The cases were reviewed and analyzed for factors that contributed to the errors.
Four major categories of contributing factors were found: 1) communication breakdown; 2) inadequate preoperative checks; 3) technical factors and imaging; and 4) human error. The WSC cases are used to illustrate how these types of factors can precipitate the surgical error. Clinical outcomes and disciplinary actions are summarized. Obtaining information about the cases discovered was very challenging, in part because WSS reporting is inadequate.
This case review demonstrates that a broad range of events and factors can cause human errors to breach patient safeguards and lead to a WSC; however, in essentially all cases the WSCs were preventable with strict adherence to comprehensive and thorough protocols.
Kathleen Joy Khu, Francesco Doglietto, Ivan Radovanovic, Faisal Taleb, Daniel Mendelsohn, Gelareh Zadeh and Mark Bernstein
Routine and nonselective use of awake and outpatient craniotomy for supratentorial tumors has been shown to be safe and effective from a medical standpoint. In this study the authors aim was to explore patients' perceptions about awake and outpatient craniotomy.
Qualitative research methodology was used. Two semistructured, open-ended interviews were conducted with 27 participants, who were ambulatory adult patients who underwent craniotomy for brain tumor excision between October 2008 and April 2009. The participants were each assigned to one of the following categories: 1) awake outpatient; 2) awake inpatient; 3) outpatient under general anesthesia; and 4) inpatient under general anesthesia. Interviews were audiotaped and transcribed, and the data were subjected to thematic analysis.
The following 6 overarching themes emerged from the data: 1) patients had a positive experience with awake craniotomy; 2) patient satisfaction with outpatient surgery was high; 3) patients understood the rationale behind awake surgery; 4) patients were surprised that brain surgery can be done on an outpatient basis; 5) trust in one's surgeon was important; and 6) patients were more concerned about the disease than the procedure.
The results reflected positively on the patients' awake and outpatient surgery experience, but there were some areas that require improvement, specifically perioperative pain control and postoperative care. These insights on patients' perspectives can lead to better delivery of care, and ultimately, improved health outcomes.