In 1947, the Nuremburg trial established that patients must consent to procedures being performed on their person and established autonomy as one of the major pillars of contemporary medical bioethics (Shuster 1998). Autonomy refers to the right of a capable individual to make decisions regarding their care free of coercion or influence. The concept of autonomy is essential to the practice of medicine and the conduct of surgical procedures.

A traditional view of autonomy holds that capable individuals should be informed of all options, alternatives, and perceived benefits and risks, thereby allowing them to reach informed decisions regarding their personal care. Practically speaking, this discussion is affected by cultural, social, and personal considerations. For instance, some patients do not wish to be informed of material risks associated with a given neurosurgical procedure.

A “relational” view of autonomy has been proposed, whereby the treating surgeon must acknowledge and take into consideration the patient’s internal moderating factors that affect his/her autonomy (Sherwin 1988). While a capable patient has the right to make decisions regarding his/her personal care, various moderating variables may affect this decision. For instance, numerous factors may be involved in a patient’s reluctance to include trainees in their medical care. Preoperative stress about the surgical procedure may make the patient hesitant about the involvement of less experienced individuals, previous encounters with medical errors may render the patient more suspicious of medical systems, or the patient may originate from a country or region with a strict hierarchical health-care system where being treated exclusively by a senior surgeon is highly desirable. Alternatively, a lack of knowledge about the integral role of trainees in the daily operation of hospitals may result in a belief that their presence is superfluous or that they are only there to learn, rather than contribute to the patient’s care.

Indeed, many of these factors are related to socioeconomic, cultural, and geographic factors beyond the information received by the patient, irrespective of how adequate or comprehensive. A patient from a rural setting, for example, may have had less exposure to trainees and may be unfamiliar with their role in clinical care. Attitudes toward trainees may also differ by culture and age. The level of knowledge of resident involvement in clinical care is low among patients in general to start with (Knifed et al. 2008a). Interestingly, residents themselves have also reported feeling as though patients were rarely well informed about their roles (Knifed et al. 2010). The partnership between the neurosurgeon and the patient may therefore have a role in affecting the individual patient’s autonomous decision to have trainees involved in his/her care. Information presented to patients regarding the involvement of trainees in their care should be placed within the individual patient’s contextual and relational understanding.

Although the concept of truth-telling has evolved over the last several decades, it is a self-evident statement that patients deserve to be told the truth. Deception, however, often occurs in clinical settings, although the vast majority of deceptive acts are not self-serving (Everett et al. 2011; Yu and Bernstein 2011). For example, a substantial proportion of medical residents were found to be willing to deceive insurance companies for additional patient benefits (Everett et al. 2011). Germane to the current discussion, it has been previously found that surgeons do not often voluntarily inform patients about the involvement of residents in their operation (Knifed et al. 2008b).

Truth-telling is a bidirectional process aimed at empowering patients to navigate their illness. The evolution of truth-telling is perhaps most apparent in the field of neuro-oncology. Whereas in 1961, most physicians did not reveal a cancer diagnosis to patients (Oken 1961); by 1979, only 2 % reported that they would withhold such information (Novack et al. 1979). Patients are also increasingly empowered to play an active role in directing their medical treatment. The globalization of information and greater awareness of the organization and hierarchical structure of hospital-based medicine, via the internet, or even medical dramas on television, have provided patients with greater insight into the involvement of trainees in routine care. Greater dissemination of information has also empowered patients to critically appraise all aspects of their care, including the involvement of trainees.

The question remains to what extent disclosure of trainees’ roles to patients is important, as it has been previously deemed inconsequential by treating physicians. A qualitative study of patients undergoing brain tumor surgery demonstrated that patients generally prefer to know exactly what the physician knows, even if it may be seemingly inconsequential to their care (Yu and Bernstein 2011). As a component of truth-telling, it should be explained to patients that trainees play an important role in their surgical and postsurgical care. Their involvement throughout the patient’s illness should be emphasized to facilitate the strengthening of the therapeutic resident-patient relationship. This is particularly relevant as it has been previously shown that patients consider direct communication with the surgeon postoperatively as very important (Rozmovits et al. 2010) and patients are likely to frequently encounter trainees in their postoperative care.

One uncompromising feature of health-care systems is to deliver the highest quality care. Certainly, the foremost concern for patients is their underlying diagnosis and its safe treatment. Conflicts may arise between patients and trainees if the former view the latter as a threat to their safety. Patients who hold such views are, however, a small minority. Studies have consistently shown that patients generally view the care provided by trainees favorably (Resnick et al. 2008; Stewart et al. 2011). In fact, patients often perceive trainees as reliable sources of information and have problematic relationships with residents if they are perceived as inaccessible or lacking communication skills (Boutin-Foster and Charlson 2001; Ruiz-Moral et al. 2006).