Ethical Challenges with Awake Craniotomy for Tumor

Abstract

78The frequency and indications for use of modern awake craniotomy are increasing. 1 The first "contemporary" application was for the treatment of epilepsy in the early 17th century. 2,3 It was followed by resection of tumors from eloquent brain regions, [1][2][3][4][5][6] and then to routine, nonselective tumor resection regardless of the involvement of eloquent cortex. 1,7 Faster resumption of normal activity by the patient and more efficient use of medical resources has led to its performance with less regard to tumor location, and even on an outpatient basis in some neurosurgeons' practices. 8-10 Awake brain surgery is also used for neuromodulation in the treatment of idiopathic Parkinsonism, essential tremor, dystonia and chronic pain, 11,12 and has been experimentally applied in a number of nonmovement disorders such as depression, obsessive compulsive disorder, Tourette's disorder, Alzheimer disease, chemical addiction and obesity. 12 We explore some of the factors that influence whether to recommend awake brain surgery to tumor ABSTRACT: Background: Awake brain surgery is useful for the treatment of a number of conditions such as epilepsy and brain tumor, as well as in functional neurosurgery. Several studies have been published regarding clinical results and outcomes of patients who have undergone awake craniotomy but few have dealt with related ethical issues. Objective: The authors undertake to explore broadly the ethical issues surrounding awake brain surgery for tumor resection to encourage further consideration and discussion. Methods: Based on a review of the literature related to awake craniotomy and in part from the personal experience of the senior author, we conducted an assessment of the ethical issues associated with awake brain tumor surgery. Results: The major ethical issues identified relate to: (1) lack of data; (2) utilization; (3) conflict of interest; (4) informed consent; (5) surgical innovation; and (6) surgical training. Conclusion: The authors respectfully suggest that the selection of patients for awake craniotomy needs to be monitored according to more consistent, objective standards in order to avoid conflicts of interest and potential harm to patients.RÉSUMÉ: Défis éthiques concernant la craniotomie en état vigile pour traiter une tumeur. Contexte : La chirurgie du cerveau en état de vigile est utile pour traiter certaines pathologies telles l'épilepsie et les tumeurs cérébrales ainsi qu'en neurochirurgie fonctionnelle. Plusieurs études ont été publiées sur les résultats cliniques et l'issue chez des patients qui ont subi une craniotomie en état vigile, mais peu d'études ont traité des aspects éthiques. Objectif : Les auteurs ont exploré d'une façon large les questions éthiques entourant la chirurgie en état vigile effectuée pour l'ablation de tumeurs dans le but de favoriser un examen plus approfondi du sujet et de susciter la discussion. Méthode : Nous avons procédé à une évaluation des questions éthiques associées à la chirurgie en état vigile pour l'ablation d'une tumeur c...

Intraoperative Monitoring

“…In addition, awake craniotomy for interactive testing is arduous for patients, impossible for children and emotionally fragile or cognitively challenged for adults, and raises ethical concerns (Ford et al, 2007;Kirsch and Bernstein, 2012); today, its main indication is for language mapping. In addition, awake craniotomy for interactive testing is arduous for patients, impossible for children and emotionally fragile or cognitively challenged for adults, and raises ethical concerns (Ford et al, 2007;Kirsch and Bernstein, 2012); today, its main indication is for language mapping.…”

Awake craniotomy for brain tumor: indications, technique and benefits

“…In the experience of the senior author and according to publications of other authors, patients' satisfaction with the procedure is high [103]. However, those surgeons who are convinced of the benefits of awake craniotomy must not blindly recommend it to every patient and must be aware of potential abuses of any procedure due to the asymmetry of power between the surgeon and his/her patient [104].…”

Is outpatient brain tumor surgery feasible in India?

“…[13][14][15]17,26] Nonetheless, in an evidence-based medical culture, the lack of data does raise questions regarding the ethics of advocating the use of outpatient brain tumor surgery, and hence, it is not possible to provide entirely unbiased recommendations to patients. [43] However, there are recent data that suggest that cancer patients may live longer if they undergo surgery avoiding the use of volatile agents (i.e., general anesthesia). [44] Another important ethical issue is whether neurosurgeons under or over select patients for awake brain surgery based on personal preference.…”