Dear Editor,

In the sacred space of the operating room, neurosurgeons navigate a profound philosophical paradox that has challenged military strategists for millennia: How do we earnestly prepare for war while sincerely pursuing peace? The ancient Roman adage, “Si vis pacem, para bellum” (“If you want peace, prepare for war”), finds an eerily apt application in the nuanced practice of neurosurgery. As we meticulously plan for catastrophic complications we hope never to encounter, we embody this paradoxical wisdom every time we approach the human brain.

THE HISTORICAL CONNECTION

The history of medicine, particularly neurosurgery, is inextricably linked with warfare. As Hippocrates emphasized, “War is the only appropriate school for surgeons.”[ 3 ] Indeed, many advances in neurosurgical technique emerged from battlefield necessity. From early trepanation descriptions in Egyptian papyri to modern evacuation protocols, the crucible of war has forged many of our most valuable clinical tools.[ 3 , 4 ] World War I introduced concepts of early operation for trauma and forward-operating hospitals, while World War II advanced medical evacuation and resuscitation strategies.[ 4 ]

This historical connection presents us with our first paradox: our healing art was refined through human conflict. The battlefield surgeon’s pragmatic utilitarianism – making difficult choices under constraints to maximize overall benefit – mirrors our own decision-making when complications arise.[ 2 ] In war zones, this “surgical utilitarianism” reflects “the pragmatic choices surgeons make when faced with challenging circumstances.”[ 2 ]

THE PHILOSOPHICAL TENSION

Can we truly prepare for catastrophic complications while simultaneously working to ensure they never occur? Unlike military strategists, we prepare not to ensure victory over an adversary, but to protect the vulnerable neural tissue we have been entrusted to heal. Our “war planning” manifests as exhaustive anatomical knowledge, meticulous procedural simulation, and contemplation of escape routes from potential disasters. This preparation is not motivated by aggression but by profound reverence for what is at stake.

War, like a surgical complication, represents a “cataclysmic” affliction that “befalls some portion of humanity” and serves no greater purpose.[ 5 ] It brings destruction and loss, with a “total effect (that) is certainly negative.”[ 5 ] Similarly, intraoperative complications – vessel avulsion, neural injury, and uncontrolled swelling – are catastrophes that we strive to avoid while paradoxically rehearsing our response to them daily.

Yet preparing for complications alone is insufficient. The true mastery of neurosurgery lies in prevention – creating conditions where complications never materialize. Here, the war analogy evolves: our greatest success is not in winning battles against complications but in preventing these conflicts entirely. We painstakingly analyze preoperative imaging, optimize patient physiology, and refine technical approaches precisely to avoid entering the battlefield of crisis management.

THE NEUROSURGEON’S COGNITIVE DUALITY

This duality creates a cognitive dissonance that every experienced neurosurgeon recognizes. We must hold two contradictory mindsets: vigilant preparation for disaster and serene confidence in our ability to avoid it. We meticulously map collateral circulation while believing we won’t compromise any vessels. We prepare for massive hemorrhage while expecting pristine hemostasis. We rehearse responses to brain swelling while anticipating normal intracranial pressure.

This is not cognitive inconsistency but rather a sophisticated reconciliation of opposites that defines surgical wisdom. The neurosurgeon embodies both the war strategist and the peace negotiator, often simultaneously. In conflict zones, surgeons must be “trained and confident to venture into any injured territory regardless of any level of difficulty,” while maintaining the clarity to perform “the right surgical task.”[ 2 ]

EMBRACING THE PARADOX

I propose that this paradox – preparing for war while pursuing peace – is not merely an incidental aspect of neurosurgical practice but its defining philosophical core. The capacity to maintain both mindsets simultaneously represents the highest achievement of surgical maturity. The novice surgeon either fails to prepare adequately for complications or becomes so fixated on potential disasters that technical execution suffers. The master neurosurgeon achieves cognitive integration of these opposing forces, much as a skilled martial artist prepares thoroughly for conflict while seeking harmony.

Perhaps this is why neurosurgery remains as much philosophical practice as technical endeavor. Each operation is an exercise in navigating contradiction – disturbing the sacrosanct, wounding to heal. We operate in the narrow space between hubris and humility, between aggressive intervention and cautious restraint.

As we advance into an era of increasingly complex interventions, this philosophical tension will only intensify. Technological innovations may reduce certain complications but will inevitably introduce others. Our challenge remains constant: to prepare thoroughly for battles we hope never to fight. In embracing rather than resolving this paradox, we find our distinctive contribution to medicine – a discipline that, like war and peace themselves, helps “regulate high-quality structure and manifestations” of human potential.[ 1 ]

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

Patient’s consent is not required as there are no patients in this study.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The author confirms that they have used artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript including spelling and grammar.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Bazaluk O. The philosophy of war and peace. Philosophy Cosmol. 2016. 17: 12-25

2. Ferreira C, Correia M. Surgical frontiers in war zones: Perspectives and challenges of a humanitarian surgeon. BMC Surg. 2024. 24: 192

3. Ha Y. War, peace, and neurospine. Neurospine. 2018. 15: 433-4

4. Rainone GJ, Zelmanovich R, Laurent D, Lucke-Wold B. How war has shaped neurosurgery. World Neurosurg. 2023. 93: 823-8

5. Rodehau-Noack J. War as disease: Biomedical metaphors in prevention discourse. J Eur Stud. 2021. 51: 356-73