In all fields of clinical medicine, there is an increasing awareness that outcome must be assessed in terms of quality of life and cost effectiveness, rather than merely length of survival. This is especially the case when considering decompressive craniectomy for severe traumatic brain injury. The procedure itself is technically straightforward and involves temporarily removing a large section of the skull vault in order to provide extra space into which the injured brain can expand. A number of studies have demonstrated (...) many patients going on to make a good long-term functional recovery, however, this is not always the case and a significant number survive but are left with severe neurocognitive impairment. Unfortunately, many of these patients are young adults who were previously fit and well and are, therefore, likely to spend many years in a condition that they may feel to be unacceptable, and this raises a number of ethical issues regarding consent and resource allocation. In an attempt to address these issues, we have used the analytical framework proposed by Jonsen, that requires systematic consideration of medical indications, patient preferences, quality of life and contextual features. (shrink)

The field of modern day bioethics is relatively young and continues to constantly evolve in parallel with the ever increasingly complex nature of contemporary medical practice. These advances present clinicians with an array of therapeutic options that would have not seemed possible only a generation ago. Given these medical advances and the expansion of the academic and medicolegal field of bioethics, one would have thought that clinical decision making would have become easier. However paradoxically this has not proved to be (...) the case. Each advance may provide an answer to a particular clinical question which is almost immediately replaced by a whole new set of ethical problems that require consideration. (shrink)