Ethical issues in neurosurgery – A scoping review from the EANS Ethico-legal committee

Background: Ethical considerations are integral to neurosurgical decision-making, yet emerging technologies, demographic shifts, and global crises continuously introduce new challenges. Key ethical concerns include patient autonomy, prioritization, the value of life, research ethics, and personality-altering procedures. Despite their importance, formal ethics training for neurosurgical residents is often lacking, and guideline application remains inconsistent. This scoping review summarizes current literature on ethical issues in neurosurgery, identifies key topics and assessment methods, and highlights research priorities to enhance ethical awareness. Methods: A systematic literature search was conducted in Medline, Embase, and Web of Science using the search strategy (Ethic∗[Title]) AND (neurosurg∗[Title]). The search, performed on October 8, 2024, yielded 334 records (1985–2024). After removing duplicates and screening, 13 studies met inclusion criteria. Two independent reviewers selected original research in English or German addressing ethical neurosurgical issues, excluding opinion pieces, reviews, and case reports. Extracted data included study characteristics, country, year, topic, design, and key findings. Results: From a neurosurgical perspective, six ethical subcategories emerged: decision-making (31 %), pediatric neurosurgery (23 %), neurosurgery in developing countries (15 %), artificial intelligence (15 %), functional neurosurgery (8 %), and patient care (8 %). From a classical ethical standpoint, seven studies (53.8 %) focused on psychosocial ethical issues, four (30.7 %) examined normative ethical questions, and two (15.4 %) addressed aspects of professional ethics. All studies employed a qualitative research design. Most studies (77 %) used questionnaires or structured interviews for data collection. Findings revealed regional differences in ethical decision-making, increasing reliance on hospital ethics committees, resource-related dilemmas in low-income countries, and emerging AI-related concerns. Despite growing interest, structured assessment methods and standardized ethics education remain limited. Conclusions: Ethical challenges in neurosurgery, as explored through the lenses of indirect sources (published literature), are diverse and shaped by technological advancements and sociopolitical factors. AI-related ethics and crisis-driven dilemmas, such as those arising from wars and pandemics, are gaining attention. However, research methodologies remain inconsistent, limiting data comparability. Future studies should focus on enhancing ethics training and developing standardized frameworks for ethical analysis improving neurosurgical ethical decision-making.