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Neurotrauma and the RUB: where tragedy meets ethics and science
  1. G R Gillett1,
  2. S Honeybul2,
  3. K M Ho3,
  4. C R P Lind2,4
  1. 1Dunedin Hospital and Otago Bioethics Centre, University of Otago, Dunedin, New Zealand
  2. 2Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia
  3. 3Department of Intensive Care Medicine and School of Population Health, University of Western Australia
  4. 4Centre for Neuromuscular and Neurological Disorders, University of Western Australia
  1. Correspondence to Professor Grant Gillett, Professor of Medical Ethics, Otago Bioethics Centre, University of Otago Medical School, 201 Great King St, Dunedin (PO Box 913), New Zealand; grant.gillett{at}


Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled; a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case.

  • Risk of unacceptable badness
  • decision making
  • outcomes
  • neurotrauma
  • quality/value of life/personhood
  • informed consent
  • allocation of health care resources
  • general

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  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Royal Perth Hospital Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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