Moral distress in neurosurgical practice: a review

Moral distress, the psychological strain experienced when a clinician recognises the ethically preferable course of action but is constrained from pursuing it, and, more broadly, when the ethically preferable course of action is itself uncertain or contested, is increasingly recognised as a significant occupational hazard across healthcare. Neurosurgery, characterised by high-acuity decisions, prognostic uncertainty, and frequent end-of-life conflict, may represent a particularly high-risk specialty. We conducted a narrative review of the published literature on moral distress relevant to neurosurgical practice, drawing on the foundational conceptual literature, validated measurement instruments, two national surveys of moral distress among practicing neurosurgeons conducted in different healthcare systems, qualitative and ethics-focused literature involving neurosurgical trainees and decision-making, and closely related literature from surgery, critical care, and decompressive craniectomy decision-making. Nearly half of practicing neurosurgeons surveyed in the United States report significant moral distress within a given year, most commonly triggered by managing critically ill patients without a clear treatment plan, and most intensely triggered by family or institutional pressure to perform perceived futile surgery. A subsequent Danish national survey, using the same instrument but a different healthcare and legal context, found a substantially lower prevalence of clinically significant moral injury, indicating meaningful variation across healthcare systems. Moral distress is associated with burnout and has measurably contributed to neurosurgeons leaving or considering leaving clinical positions, and adjacent literature linking burnout to self-reported medical errors raises the plausible, though not yet directly tested, possibility that unaddressed moral distress carries downstream implications for patient safety. Decompressive craniectomy and other high-stakes, irreversible interventions in patients lacking decision-making capacity represent a recurring locus of ethical conflict. Emerging interventions, including moral distress consultation services (a distinct model descended from, but functionally different to, clinical ethics consultation), structured debriefing, peer-support rounds, and early palliative care integration, show promise but lack neurosurgery-specific evaluation. Moral distress represents an underappreciated threat to neurosurgical workforce wellbeing and, potentially, patient care quality and safety. Dedicated neurosurgery-specific research, validated measurement with full characterisation of relevant psychometric properties, and tailored mitigation strategies, including clearer delineation of when moral distress consultation versus clinical ethics consultation is indicated, are needed.