Primum Non Nocere: Ethical Considerations of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) in Peritoneal Malignancies

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) offers survival benefit for select patients with peritoneal surface malignancies (PSMs), yet the ethical dimensions of patient selection, informed consent, and multidisciplinary care remain underexplored. In a field still evolving, where patients with comparable profiles may exhibit vastly different prognoses, a structured ethical framework can serve as a compass for surgical decision-making. METHODS: A narrative review of the literature examined the ethical considerations surrounding CRS/HIPEC for PSM. Topics include patient selection, the biological spectrum from indolent to aggressive disease, technical feasibility of complete cytoreduction, shared decision-making, surgical morbidity, palliative care integration, and special populations. RESULTS: The strength of evidence supporting CRS/HIPEC varies substantially by tumor biology, from near-curative outcomes in low-grade appendiceal neoplasms to marginal benefit in aggressive histologies such as sarcomatoid mesothelioma and signet ring cell carcinoma. When complete cytoreduction cannot be achieved, the procedure is unlikely to confer meaningful survival benefit and may cause significant harm. Traditional informed consent often omits the elements of informed decision-making; structured frameworks such as Best Case/Worst Case and REMAP (Reframe, Expect emotion, Map values, Align, Propose a plan) can bridge this gap. Decision regret data suggest that inadequate preoperative expectation setting contributes to patient dissatisfaction independent of surgical outcomes. Early palliative care and multidisciplinary collaboration improve prognostic understanding and alignment of treatment with patient goals. CONCLUSIONS: The ethical principles presented here are not rigid boundaries but flexible guides to help surgeons navigate clinical uncertainty. Although they focus on the surgical decision, they extend to every member of the multidisciplinary team caring for patients with PSM.