Shared Decision-Making in the Operating Theatre

Some patients fade from memory with time. Others become part of who you are as a surgeon. This is one of those stories. More than two decades ago, while I was practising in Aberdeen, a 77-year-old gentleman was referred to me with a solitary 3 cm metastatic tumour in the left motor cortex. It was a small lesion, but it occupied one of the most unforgiving areas of the brain — where millimetres separate cure from lifelong disability. At first, I questioned whether an awake craniotomy was justified for such a small tumour. But after careful consideration, we decided it offered the safest chance of preserving his neurological function. The operation began routinely. He was asleep for the opening stages of the surgery and was gently awakened when we reached the critical phase. The theatre was quiet. Every member of the team knew we were entering the most delicate part of the operation. As I carefully began removing the tumour, he suddenly looked at me and said calmly, "Doctor... my right hand is becoming weak." Time seemed to stop. I immediately halted the operation. In that instant, I found myself facing one of the greatest dilemmas of my career. If I stopped, I would leave behind a metastatic tumour — the very reason he had entrusted me with his care. If I continued, I might remove the tumour completely, but at the cost of permanently weakening the hand that had served him for 77 years. No textbook prepares you for moments like these. Then I looked at him. He was awake. He understood. He was thinking clearly. And I realised something profoundly important. This was not my decision alone. I explained the situation honestly. There was no false reassurance, no attempt to influence him — only the truth. Then I asked, "What would you like me to do?" Without hesitation, he replied, "Doctor, remove the tumour." Those four words lifted an enormous burden. They did not make the operation easier, but they gave it clarity. Together, we made the decision. I completed the surgery. As expected, he woke with weakness in his right hand. The following morning, I went to see him, preparing myself for disappointment, regret, or even anger. Instead, he smiled. Then he said something I have never forgotten. "Doctor, thank you for letting me make that decision." He explained that throughout his illness, countless decisions had been made for him — by doctors, by hospitals, by circumstances beyond his control. But for the first time, someone had given him back ownership of his future. He had accepted the consequences because they were his consequences. That conversation changed me. It taught me that neurosurgery is not simply about removing tumours or mastering complex operations. It is about recognising that behind every MRI scan is a human being with values, hopes, fears, and the right to decide what matters most. Even today, whenever I face a difficult decision in the operating theatre, I remember that gentleman from Aberdeen. He came to me to have a tumour removed. Instead, he taught me one of the greatest lessons of my career: the finest surgeons do not simply operate on the brain — they honour the person who owns it.