We have all likely encountered the case of a patient stricken by severe acute neurologic injury (SANI) for which the neurosurgical team’s emergency department consultation note reads: "no indication for surgical intervention given gravity of prognosis; continue with medical management." Afterward, the patient is admitted to the neurocritical care unit (NCCU), undergoing central line placement, exposure to potentially harmful and escalating medical therapies to treat intracranial hypertension, additional diagnostic tests, and sometimes even cardiopulmonary resuscitation (CPR), despite an unchanged prognosis.

This scenario raises a fundamental question of practical bedside ethics: Why might a neurosurgeon choose to withhold surgery on the grounds of a bleak prognosis, while it is uncommon for the intensive care team to do the same with seemingly equally invasive, life-sustaining therapies?

This paradox in care decisions reflects a deep-seated ethical tension within neurocritical care, centered around the balance of beneficence and autonomy. Beneficence—acting in the patient’s best interest—may shift the clinical team away from performing procedures with heightened risk where the potential benefits are unknown and considered to be small. Conversely, autonomy—upholding the patient’s or family’s right to make informed choices—might prompt clinicians to proceed with aggressive interventions, deferring a final prognosis until more information has become available. Balancing these two principles appears to be in the eyes of the decider.

When it comes to cases of SANI and the decision to operate, a surgeon may assess the situation as making an error of omission vs. an error of commission. If they deem death to be inevitable, taking the patient to the OR will not benefit the patient and leaves open the possibility that death occurs due to, or through, their own action. Death in the case of not pursuing operative management is, of course, due to the initial injury. Interestingly, it seems that decisions to pursue mechanical ventilation or CPR in this same scenario reverses the weight of the error: not to perform the intervention will certainly lead to death, while its implementation may, temporarily, prevent it.

One reason for the divergence in decision-making may be the difference in our proximity to each intervention. As intensivists we recognize the violation of the person with intubation, ventilation, chest compressions, and other interventions, but rarely are we physically present for every breath of the ventilator or pushing on the chest for each compression. Meanwhile, to “cut” might be assessed as the most intimate of interventions as the surgeon’s hand stays with and completes each step after the decision has been made to go to the operating theater.

Might it be the finality of the intervention? Once an operation has begun it is rarely stopped and certainly never at the behest of the person or family. Quite different is the feeling with interventions such as mechanical ventilation, dialysis, or CPR. Each might be compassionately removed after thoughtful inquiry and alignment of care goals that cannot always be known in the first moments of a patient’s SANI.

Certainly training, experience, and bias are part of the calculus when balancing risks and benefits of our interventions. Recalling cases that have gone to the OR in similar circumstances, only to transition goals of care the following day after the shock of the initial tragedy has settled, may sway a surgeon. Similarly, seeing a patient walk into clinic after spending months in acute care facilities might push the intensivist to try just one bolus of 23% hypertonic saline. We can all agree that our ability to prognosticate in the first hours after an injury is weak at best.

One final difference that may create the seeming discrepancy in care paradigms is the culture of medicine and the public. Both medical team members and the patients and families alike commonly accept that surgery may not be an option for a particular injury based on the surgeon’s consultation. The same does not apply to most medical interventions and the dark side of “do everything.” We offer surgery to patients and their families but we ask them to opt out of medical interventions like ventilation and CPR.

These discrepancies highlight an ethical inconsistency that can be challenging for both providers and families to navigate. Families may struggle to understand why surgery was declined due to poor prognosis, yet other invasive treatments that might only delay an inevitable outcome are pursued. For the healthcare team, this may create moral distress, as members question the ethical rationale behind prolonging care with interventions they believe may not ultimately benefit the patient.

To address this challenge, shared decision-making has become an essential framework. This approach involves transparent discussions with the patient’s family, exploring their values, expectations, and understanding of the prognosis. By facilitating open conversations about both the benefits and limitations of intensive therapies and surgical intervention, neurocritical care teams can help families make informed decisions that reflect their loved one’s values. Our efforts to encourage a shared path of decision-making fosters collaboration and may reduce the inconsistency between surgical and critical care decisions, as it brings these perspectives into alignment and balances the goals of beneficence and autonomy.