Values-based medicine

Values-based medicine (VsBM) is an ethical concept, and bioethical framework has been developed to ensure that medical ethics and values are implemented, pervasive, and powerful parameters influencing decisions about health, clinical practice, teaching, medical industry, career development, malpractice, and research. Neurosurgeons tend to adopt ethics according to their own values and to what they see and learn from teachers. Neurosurgeons, in general, are aware about ethical codes and the patient's rights. However, the philosophy, concept, and principles of medical ethics are rarely included in the training programs or in training courses. The impact of implementing, observing the medical ethics and the patients' value and culture on the course, and outcome of patients' management should not underestimate. The main principles of medical ethics are autonomy, beneficence, nonmaleficence, justice, dignity, and honesty, which should be strictly observed in every step of medical practice, research, teaching, and publication. Evidence-based medicine has been popularized in the last 40-50 years in order to raise up the standard of medical practice. Medical ethics and values have been associated with the medical practice for thousands of years since patients felt a need for treatment. There is no conflict between evidence-based medicine and values-based medicine, as a medical practice should always be performed within a frame of ethics and respect for patients' values. Observing the principles of values-based medicine became very relevant as multicultural societies are dominant in some countries and hospitals in different corners of the world ¹⁾.

1. 🔹 Strengths of the Article Timely ethical emphasis: The article addresses a crucial gap in surgical practice — the marginalization of formal bioethical training in neurosurgical education. This is particularly relevant in high-stakes, high-stress disciplines such as neurosurgery.

Reinforces core principles: By reaffirming foundational ethical tenets (autonomy, beneficence, nonmaleficence, justice, dignity, honesty), the authors underline the moral obligations that should guide all aspects of neurosurgical activity.

Calls attention to multiculturalism: The mention of culturally diverse societies and the importance of incorporating patient values into decision-making is highly relevant to global neurosurgical practice.

2. 🔸 Conceptual and Structural Weaknesses Lack of operational clarity: The article defines VsBM in vague, conceptual terms without providing concrete mechanisms for its implementation in daily clinical decision-making. How VsBM complements or modifies existing protocols is not explored in depth.

No empirical evidence: Despite highlighting the supposed impact of values on outcomes, the article fails to present data, case studies, or empirical research demonstrating how VsBM tangibly alters patient care or improves neurosurgical results.

Overgeneralization: The claim that neurosurgeons are “generally aware” of ethical codes is not supported with data. Additionally, stating that ethics is rarely included in training programs is anecdotal and could vary widely across countries and institutions.

Redundancy and circularity: The paper repeatedly states that ethics is important but does not delve into how specific ethical dilemmas manifest in neurosurgery (e.g., in end-of-life decisions, surgical futility, or informed consent under pressure).

Failure to address tensions with Evidence-Based Medicine (EBM): While claiming no conflict between EBM and VsBM, the article avoids engaging with the real-world friction between standardized protocols (EBM) and patient-specific values (VsBM), particularly in neurosurgical triage or resource-limited contexts.

3. 🧠 Relevance to Neurosurgery Clinical depth is lacking: The article does not provide neurosurgery-specific scenarios or ethical case vignettes, missing an opportunity to ground theory in practice.

Ethical urgency understated: Fields like neuro-oncology, pediatric neurosurgery, or trauma involve ethical dilemmas daily. VsBM is most needed where uncertainty, long-term disability, or survival with poor quality of life are frequent — this is not explored.

No integration with professional standards: Organizations like the WFNS or AANS have ethical guidelines. How VsBM aligns or contrasts with these is not discussed.

4. ✅ Recommendations for Improvement Include neurosurgical case studies or dilemmas illustrating VsBM in action.

Provide data or a model curriculum integrating VsBM into neurosurgical training.

Critically analyze real vs. ideal alignment between EBM and VsBM in high-stakes decisions.

Propose institutional frameworks for ethical auditing or values-based discussion during morbidity & mortality sessions or surgical planning.

5. 🧾 Conclusion The article raises an important ethical concern: the underrepresentation of formal ethical reasoning in neurosurgical education and decision-making. However, its lack of specificity, data, and operational guidance makes it more of a philosophical essay than a practical contribution to the field. For VsBM to be impactful in neurosurgery, it needs to move beyond slogans and integrate with real-world dilemmas, training pathways, and institutional policies.