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Position statements
Surg Neurol 1991;36:3
3
Position Statements
Testimony
in P r o f e s s i o n a l L i a b i l i t y Cases
The American legal system requires expert testimony for both plaintiff and defendant. The committee believes it is of central importance that such testimony be truly expert and as impartial as possible. The committee proposes the following guidelines for expert witnesses: 1. "Expert" testimony should reflect not only the opinions of the individual but also honestly describe where such opinions vary from common practice. The expert should not present his or her own views as the only correct ones if they differ from what might be done by other neurosurgeons. 2. An expert should be a surgeon who is still engaged in the active practice of surgery or can demonstrate enough familiarity with present practices to warrant designation as an expert. 3. The neurosurgeon should champion what he/she believes to be the truth, not the cause of one party or the other. 4. The neurosurgeon should not accept a contingency fee as an expert witness. Treatment
of Children with Severe
Congenital Malformations The birth of a child with severe congenital abnormality such as a myelomeningocele presents both parents and physicians with difficult decisions which are made more difficult by the uncertainty of prognosis. Although it is unlikely that a consensus could always be achieved as to which children should be treated, agreement can be reached about some o f the basic ethical principles related to decision making. The primary responsibility of the neurosurgeon according to the recently formulated Code of Ethics of the AANS is to "provide the best care for the patient that available resources and circumstances provide." When confronted with a problem for which he/she is unfamiliar, the neurosurgeon is obligated to use consultants and other health care providers with recognized records o f excellence as a source of information concerning current therapies and prognoses. The neurosurgeon is specifically cautioned against using "quality of life" criteria in his or her determination o f treatability. He/she should render an opinion as to Published 1991 by Elsevier Science Publishing Co., Inc.
the feasibility of surgery and the prognosis, if known, for future cognitive and physical outcome. The patient's parents or other surrogate decision maker should then attempt to arrive at a decision which would represent the child's best interest. Institutional committees may sometimes help in this decision-making process but must be considered to have only a consultative role.
The Withdrawal
o f M e d i c a l Treatment
Neurosurgery finds itself at the center of social change with regard to the deliberate withdrawal o f support systems from patients who are terminally ill. The following recommendations are presented for consideration in these matters: 1. It is of central importance to have as much certainty in the diagnosis of both terminal illness and irreversible coma as possible. Consultation should be obtained where appropriate and whatever confirmatory tests are necessary to establish the diagnosis should be performed. 2. If the patient is competent, his or her wishes should be honored. If the neurological surgeon cannot in good faith do this, the appropriate course is to find another neurological surgeon to assume the patient's care. 3. If the patient is incompetent, major consideration should be given to what the patient would have wanted or if that cannot be ascertained, to what the patient's surrogate would have wanted. If the patient's wishes cannot be ascertained, the guiding principle should be what the neurological surgeon feels is best for the patient. 4. The actual decision making is best done by the patient's family or surrogate in concert with the neurological surgeon. If there is an institutional group for helping to make such decisions it can be used. 5. "The withdrawal of care" in terminally ill or permanently comatose patient~ can be used to mean many courses of action. There are situations where institution's legal counsel should be consulted before any definitive action is taken. The decision-making process, however, should remain between the neurological surgeon and family. 0090-3019/91/$0.00
3
Position Statements
Testimony
in P r o f e s s i o n a l L i a b i l i t y Cases
The American legal system requires expert testimony for both plaintiff and defendant. The committee believes it is of central importance that such testimony be truly expert and as impartial as possible. The committee proposes the following guidelines for expert witnesses: 1. "Expert" testimony should reflect not only the opinions of the individual but also honestly describe where such opinions vary from common practice. The expert should not present his or her own views as the only correct ones if they differ from what might be done by other neurosurgeons. 2. An expert should be a surgeon who is still engaged in the active practice of surgery or can demonstrate enough familiarity with present practices to warrant designation as an expert. 3. The neurosurgeon should champion what he/she believes to be the truth, not the cause of one party or the other. 4. The neurosurgeon should not accept a contingency fee as an expert witness. Treatment
of Children with Severe
Congenital Malformations The birth of a child with severe congenital abnormality such as a myelomeningocele presents both parents and physicians with difficult decisions which are made more difficult by the uncertainty of prognosis. Although it is unlikely that a consensus could always be achieved as to which children should be treated, agreement can be reached about some o f the basic ethical principles related to decision making. The primary responsibility of the neurosurgeon according to the recently formulated Code of Ethics of the AANS is to "provide the best care for the patient that available resources and circumstances provide." When confronted with a problem for which he/she is unfamiliar, the neurosurgeon is obligated to use consultants and other health care providers with recognized records o f excellence as a source of information concerning current therapies and prognoses. The neurosurgeon is specifically cautioned against using "quality of life" criteria in his or her determination o f treatability. He/she should render an opinion as to Published 1991 by Elsevier Science Publishing Co., Inc.
the feasibility of surgery and the prognosis, if known, for future cognitive and physical outcome. The patient's parents or other surrogate decision maker should then attempt to arrive at a decision which would represent the child's best interest. Institutional committees may sometimes help in this decision-making process but must be considered to have only a consultative role.
The Withdrawal
o f M e d i c a l Treatment
Neurosurgery finds itself at the center of social change with regard to the deliberate withdrawal o f support systems from patients who are terminally ill. The following recommendations are presented for consideration in these matters: 1. It is of central importance to have as much certainty in the diagnosis of both terminal illness and irreversible coma as possible. Consultation should be obtained where appropriate and whatever confirmatory tests are necessary to establish the diagnosis should be performed. 2. If the patient is competent, his or her wishes should be honored. If the neurological surgeon cannot in good faith do this, the appropriate course is to find another neurological surgeon to assume the patient's care. 3. If the patient is incompetent, major consideration should be given to what the patient would have wanted or if that cannot be ascertained, to what the patient's surrogate would have wanted. If the patient's wishes cannot be ascertained, the guiding principle should be what the neurological surgeon feels is best for the patient. 4. The actual decision making is best done by the patient's family or surrogate in concert with the neurological surgeon. If there is an institutional group for helping to make such decisions it can be used. 5. "The withdrawal of care" in terminally ill or permanently comatose patient~ can be used to mean many courses of action. There are situations where institution's legal counsel should be consulted before any definitive action is taken. The decision-making process, however, should remain between the neurological surgeon and family. 0090-3019/91/$0.00