title: Priority setting in neurosurgery as exemplified by an everyday challenge.
abstract: BACKGROUND
  The allocation of limited healthcare resources poses a constant challenge for clinicians. One everyday example is the prioritization of elective neurosurgical operating room (OR) time in circumstances where cancellations may be encountered. The bioethical framework, Accountability for Reasonableness (A4R) may inform such decisions by establishing conditions that should be met for ethically-justifiable priority setting.
  
  
  OBJECTIVE
  Here, we describe our experience in implementing A4R to guide decisions regarding elective OR prioritization.
  
  
  METHODS
  The four primary expectations of the A4R process are: (1) relevance, namely achieved by support for the process and criteria for decisions amongst all stakeholders; (2) publicity, satisfied by the effective communication of the results of the deliberation; (3) challengeability through a fair appeals process; and (4) Oversight of the process to ensure that opportunities for its improvement are available.
  
  
  RESULTS
  A4R may be applied to inform OR time prioritization, with benefits to patients, surgeons and the institution itself. We discuss various case-, patient-, and surgeon-related factors that may be incorporated into the decision-making process. Furthermore, we explore challenges encountered in the implementation of this process, including the need for timely neurosurgical decision-making and the presence of hospital-based power imbalances.
  
  
  CONCLUSIONS
  The authors recommend the implementation of a fair, deliberative process to inform priority setting in neurosurgery, as demonstrated by the application of the A4R framework to allocate limited OR time.
authors.affiliation: Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada Department of Surgery, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
authors.forename: George M
authors.initials: GM
authors.lastname: Ibrahim
authors.forename: Michael
authors.initials: M
authors.lastname: Tymianski
authors.forename: Mark
authors.initials: M
authors.lastname: Bernstein
mesh_terms: D003657:Decision Making / Q000941:ethics*; D015276:Health Care Rationing / Q000941:ethics*; D006292:Health Priorities; D006801:Humans; D009493:Neurosurgery / Q000941:ethics*