Mark Bernstein

ABSTRACT I argue for a broader understanding of the morally considerable. I propose a neo‐Aristotelian account of individuals wherein some entities, often precluded from those deserving of moral consideration, are deemed proper subjects of such treatment. The criterion suggested is, roughly, that of self‐regulatory development, a teleological notion, that I argue should not be viewed as archaic and useless. Not only do many non‐human animals then become legitimate subjects of moral concern, but objects outside the animal kingdom, such as plants and trees, also are to be included in our ethical arena.

Some carnivores defend the position that the opportunistic consumption of meat is morally permissible even under the assumption that it is morally wrong to act in ways that ause unnecessary suffering to sentient beings. Ordering and consuming chicken once a week, they argue, will not increase the numbers of chickens suffering or slaughtered, since the system of purchasing and farming chickens is not sufficiently fine‐tuned to register differences at margin. We argue that, insensitivity of the market notwithstanding, consistent consequentialists are morally prohibited from each additional purchase and consumption of meat.

The world’s rapidly growing aging population will present physicians, including neurosurgeons, with a unique set of challenges in the ethical provision of personalized yet cost-effective care. The geriatric patient population is not a homogenous entity; instead, unique factors such as physiological and cognitive reserve, frailty, and socioeconomic background affect an older patient’s ability to tolerate neurosurgical afflictions and their treatments. As such, innovations in technology are needed to devise treatments with the geriatric patient in mind. More importantly, at the population and global levels, advancements in technology must be harnessed to ensure the equitable provision of neurosurgical care that respects physiological reserve while also employing technological tools to promote cognitive enhancement in this aging population. The growing field of geriatric neurosurgery is ultimately a dance between technology and ethics in ensuring optimal quality of life and end-of-life care.

The COVID-19 pandemic dramatically affected the provision of global neurosurgical care. Through the pandemic, neurosurgeons around the world were forced to adapt to changing operative capacity, stressors associated with redeployment, and uncertain working conditions. With extreme resource scarcity, there was an increased requirement to advocate for patients with neurosurgical emergencies. Triage and resource allocation emerged as a priority for hospital decision-makers around the world. We apply and synthesize several ethical frameworks to guide individuals through challenging resource allocation decisions associated with resource scarcity. We specifically discuss the accountability for reasonableness metaethical framework as well as a generalizable mechanism for policy implementation, data-driven reassessment, and iteration that allows decision-makers to continuously respond to dynamic pandemic conditions. Pandemic response initiatives and neurosurgical triage practices should be catered to health system microenvironments. Additionally, we explore the ethical and moral conflicts associated with redeployment and comment on the tension between provider obligations to safe working conditions and their simultaneous obligation to serving patients. Further ethical conceptual conflicts arise when deontological and utilitarian notions conflict one another. The following chapter emphasizes challenges associated with neurosurgical care during a pandemic and contextualizes these difficulties using the following core ethical principles: equality, equity, promotion of instrumental value, transparency, maximizing benefit, favoring those worst off, autonomy, relevance, appeals, and oversight. We emphasize the importance of forward planning during non-pandemic circumstances to create contingency schemas for future circumstances of resource scarcity.

Many neurosurgical conditions are incurable, leading to disability or severe symptoms, poor quality of life, and distress for patients and families. The field of neuropalliative care addresses palliative care needs of individuals living with neurological conditions. Neurosurgeons play an important role in neuropalliative care due to neurosurgeons’ understanding of natural history and treatment strategies of neurosurgical conditions, longitudinal patient-physician relationships formed in neurosurgery, and neurosurgeon responsibility for neurosurgical emergencies. Additionally, patients with neurosurgical conditions have unique palliative care needs given trajectories of neurosurgical diseases, prognostication, psychosocial factors, communication, and behavior. Palliative care improves outcomes among neurosurgical patients. Despite the importance of neuropalliative care, neurosurgeons often lack formal training in palliative care skills. Relevant skills include identifying patients requiring palliative care, assessing understanding of illness and preferences, educating patients, building trust, managing symptoms, addressing family and caregiver needs, discussing end-of-life care, and recognizing when to refer to specialists. The future of neuropalliative care involves increasing awareness of the importance of neuropalliative care, delineating priorities for neurosurgeons with regard to neuropalliative care, increasing emphasis on palliative care skills during training and practice, expanding research efforts, and adjusting reimbursement structures to incentivize the provision of neuropalliative care by neurosurgeons.

The vision of computers simulating human intelligence has materialized in the form of artificial intelligence (AI) and machine learning, which affects many aspects of modern healthcare. The past two decades have seen a 25-fold increase in the volume of literature about AI in medicine, underscoring its profound implications for the field. These applications leverage diverse model architectures, from neural networks to large language models, but their effectiveness and continued growth are contingent on availability of high-quality data. This raises important ethical questions regarding data ownership and stewardship in healthcare. The following chapter explores these ethical dilemmas from different stakeholder perspectives, including patients, healthcare providers, and technology companies. As each group’s needs may be distinct, guidelines should emphasize transparency and accountability to minimize the misuse of healthcare data. Data security is paramount to maintaining public trust in the confidentiality of their information and should be as important for the sustained growth of AI in medicine as profitability or scalability. To balance these considerations, regulatory bodies must enforce operating requirements through the collaboration of researchers, the private sector, and policymakers. The utility of cloud-based storage in accommodating the expanding volume of healthcare data is also discussed. The collection of this data has significant implications for patient autonomy and informed consent. Data ownership in the age of AI is a complex matter that must balance access to healthcare data with security and privacy such that informed consent and confidentiality are preserved. Guidelines must help stakeholders traverse this evolving landscape. While AI offers tremendous potential for innovation in medicine, it also must operate within and be accountable to an established set of ethical standards to preserve the trust implicit in the patient-physician relationship.

This work informs about major changes in health care systems at present and to come, and the ethical consequences. Rapid technological developments, especially in the fields of communication and virtual communication, artificial intelligence, implanted brain chips, augmented reality, in situ real-time pathological diagnosis of lesions during surgery, and others are challenging aspects of neurosciences in particular and medicine in general. Most of these modern technologies are available nowadays, just waiting to be tried and used. Ethicists (and neurosurgeons!) are facing unprecedented challenges as they have to be one step ahead in reading the future and predict what is coming and how the implementation of these technologies may affect patients’ safety, dignity, and autonomy. This book supports neurosurgeons and medical care providers to understand and implement the newly developed technologies, which will help advance medical care. Each chapter has been written by a world leader. Some of these authors are making the future and producing new advanced technologies. The authors discuss all the new innovations and the editors asked the authors to point out the ethical dilemmas if such technologies are implemented. The ethical questions are highlighted and suggestions are provided for solving such ethical problems to guarantee patient safety and dignity. According to the definition and principles of the Values-Based Medicine concept, the patient is the center of care, is the sole center of care. No compromising of patients’ well-being and safety can be allowed!

This article discusses ethical questions in neurosurgery as falling into two categories, namely those surrounding what neurosurgeons are currently doing, i.e. their current practices, and those surrounding what neurosurgeons will, theoretically, be capable of doing in the future, i.e. their future practices. It reveals the current and emerging applications of functional neurosurgery as well as the future controversies that will stem from them. It focuses on psychosurgery, enhancement and the brain–machine interface, in order to illustrate the pertinent ethical challenges and the role of the neurosurgeon in helping to address them. These three applications represent natural extensions of each other, as an exploration of the underlying mechanisms of psychopathology will ultimately provide insight into normal brain function. Concerns about the future of implantable technology, and the neurosurgeon's role in installing it, need to be addressed.

The decision to initiate invasive, first-in-human trials involving Parkinson’s disease presents a vexing ethical challenge. Such studies present significant surgical risks, and high degrees of uncertainty about intervention risks and biological effects. We argue that maintaining a favorable riskbenefit balance in such circumstances requires a higher than usual degree of confidence that protocols will lead to significant direct and/or social benefits. One critical way of promoting such confidence is through the application of stringent evidentiary standards for preclinical studies. We close with a series of recommendations for strengthening the internal and external validity of preclinical studies, reducing their tendency toward optimism and publication biases, and improving the knowledge base used to design and evaluate preclinical studies

Advances in neuromodulation and an improved understanding of the anatomy and circuitry of psychopathology have led to a resurgence of interest in surgery for psychiatric disease. Clinical trials exploring deep brain stimulation (DBS), a focally targeted, adjustable and reversible form of neurosurgery, are being developed to address the use of this technology in highly selected patient populations. Psychiatric patients deemed eligible for surgical intervention, such as DBS, typically meet stringent inclusion criteria, including demonstrated severity, chronicity and a failure of conventional therapy. Although a humanitarian device exemption by the US Food and Drug Administration exists for its use in obsessive-compulsive disorder, DBS remains a largely experimental treatment in the psychiatric context, with its use currently limited to clinical trials and investigative studies. The combination of a patient population at the limits of conventional therapy and a novel technology in a new indication poses interesting challenges to the informed consent process as it relates to clinical trial enrollment. These challenges can be divided into those that relate to the patient, their disease and the technology, with each illustrating how traditional conceptualisations of research consent may be inadequate in the surgical psychiatry context. With specific reference to risk analysis, patient autonomy, voluntariness and the duty of the clinician-researcher, this paper will discuss the unique challenges that clinical trials of surgery for refractory psychiatric disease present to the consent process. Recommendations are also made for an ethical approach to clinical trial consent acquisition in this unique patient population.

Received opinion attributes greater value to the lives of humans than to the lives of (nonhuman) animals. Arguably, this conviction allows the continuation of the institutions of factory farming, hunting, and animal experimentation. After all, if we believe that the value of animal lives is at least equal to the value of human lives, we would presumably be quick to renounce and abolish these activities. My aim is to show that we have no good reason to sustain our common belief in the hierarchy of value concerning animal lives.

In "Size Matters" in this issue, Joel MacClellan argues for three claims: according to utilitarianism, faced with a choice of eating large or small animals, we should eat the large; utilitarianism may ground obligations to eat meat; and we justifiably attract greater moral responsibility for the "direct" killing of our food animals than we do for "indirect" killing. MacClellan tends to underestimate the resources available even to hedonistic utilitarianism and oversimplifies the conditions in the food industry. His second claim has merit but is merely an instance of utilitarianism’s problem with providing a satisfying account of justice.

Virtually all persons—philosophers and laypersons alike—agree that, special circumstances aside, killing humans is more morally objectionable than killing animals. I argue for a radical inversion of this dogma: all else being equal, killing nonhuman animals is more morally objectionable than killing humans. We will discover that the dominant reason for the pervasive belief that killing humans is worse than killing animals—that the human kind of animal uniquely has the capacities for self-consciousness and self-reflection—can be implemented to demonstrate the very opposite conclusion.

One tolerably clear statement of Determinism has it that all events are caused. Expanded upon, this thesis has been taken as the claim that the existence of any event E1, has a set of events, E2 … En which antedate E1, and which are causally sufficient for the occurrence of E1. That is, given the occurrence of E2 … En, E1 is causally necessary. I would hardly wish to claim that this is the only plausible statement of the doctrine of Determinism; nonetheless it is a common one, and the one that I’ll use as definitive. Some have believed both that this premise is true and that it inevitably leads to a denial of free actions. While remaining neutral as to the merits of the Hard Determinist position, what I wish to show is that the consequences of the argumentation that has led them to such a position have been neither fully nor adequately understood.