Governing Uncertainty: An Ethical Framework for Idiopathic Normal Pressure Hydrocephalus

Area of Science:

• Neurosurgery
• Medical Ethics
• Geriatric Medicine

Background:

• Idiopathic normal pressure hydrocephalus (iNPH) presents ethical dilemmas due to lifelong device-based therapy and diagnostic uncertainty.
• While cerebrospinal fluid (CSF) shunting improves gait, continence, and cognition in iNPH, outcomes are variable, with significant complication and revision rates.

Purpose of the Study:

• To address the ethical challenges in managing iNPH, particularly concerning informed consent, capacity assessment, and resource allocation.
• To propose a structured approach for clinical decision-making in iNPH that balances patient benefit with potential risks and resource stewardship.

Main Methods:

• Application of principlism (beneficence, nonmaleficence, autonomy, justice) to ethical considerations in iNPH treatment.
• Development of a practical checklist for neurologists and neurosurgeons managing iNPH patients.

Main Results:

• Clinical uncertainty in iNPH should not prevent intervention but requires structured governance.
• Proposed structured processes include comprehensive consent, discussion of shunt risks, transparent device selection, and guaranteed follow-up.

Conclusions:

• A structured approach, guided by ethical principles, can effectively manage iNPH treatment complexities.
• The proposed checklist aims to balance beneficence and nonmaleficence, promote equity, ensure functional recovery, and support patient autonomy and resource stewardship.