Governing Uncertainty: An Ethical Framework for Idiopathic Normal Pressure Hydrocephalus

AbstractIdiopathic normal pressure hydrocephalus presents distinctive ethical challenges, since its treatment requires lifelong device-based therapy in the setting of diagnostic and prognostic uncertainty. Although randomized controlled trials and pooled analyses demonstrate that cerebrospinal fluid shunting can substantially improve gait, and often continence and cognition, outcomes remain variable, and complications requiring revision occur in a significant minority of patients. These realities complicate informed consent, capacity assessment in cognitively vulnerable older adults, and just allocation of neurosurgical resources. Employing principlism, this article argues that clinical uncertainty should not preclude intervention but rather be governed through structured processes. These include a comprehensive consent framework incorporating surrogate decision-making when appropriate, an explicit discussion of shunt nonresponsiveness and revision probabilities, a transparent device selection policy, and guaranteed access to postoperative follow-up and programmable shunt adjustment. This article proposes a practical checklist for neurology and neurosurgery that balances beneficence with nonmaleficence, advances equity for geriatric populations, preserves the possibility of substantial functional recovery, and honors both patient autonomy and responsible resource stewardship.