Paediatric emergency front-of-neck airway: issues of ethics, law, and philosophy.

Practitioners can face significant challenges when managing the airways of infants and neonates because of their unique anatomical and physiological features. The requirement for emergency airway management in this age group is rare. Details of emergency airway techniques in paediatric practice guidelines are missing or lack consensus, and it is known that outcomes for affected children can be poor. Ideally, these children should be managed by experienced paediatric airway practitioners working in a team. However, situations can arise where practitioners, unfamiliar and inexperienced with infants, find themselves in charge. So, what happens when such a practitioner encounters this life-or-death scenario and feels ill-equipped to act? The ethical and legal issues surrounding the management of this emergency are clearly defined, but they can be unknown or misunderstood by doctors. Compounding the extreme stress of the scenario is the moral and ethical dilemma of whether to act or not. The following discussion explores these issues and examines the philosophical and psychological perspectives.

Disagreement over vaccination programmes: deep or merely complex and why does it matter?

This paper argues that significant aspects of the vaccination debate are 'deep' in a sense described by Robert Fogelin and others. Some commentators have suggested that such disagreements warrant rather threatening responses. I argue that appreciating that a disagreement is deep might have positive implications, changing our moral assessment of individuals and their decisions, shedding light on the limits of the obligation to give and respond to arguments in cases of moral disagreement, and providing an incentive to seek alternative ways of going on in the face of intractable moral disagreement. Non-coercive, non-reasoned strategies have been used or recommended to increase vaccination rates. Such strategies look problematic when judged by the standards of ideal moral and rational argumentation, but more acceptable if seen as responses to deep disagreements.

Paternalism in practice: informing patients about expensive unsubsidised drugs.

Recent research conducted in Australia shows that many oncologists withhold information about expensive unfunded drugs in what the authors of the study suggest is unacceptable medical paternalism. Surprised by the Australian results, we ran a version of the study in New Zealand and received very different results. While the percentages of clinicians who would prescribe the drugs described in the scenarios were very similar (73-99% in New Zealand and 72-94% in Australia depending on the scenario) the percentage who would not discuss expensive unfunded drugs was substantially lower in New Zealand (6.4-11.1%) than it was in Australia (28-41%). This seems surprising given the substantial similarities between the two countries, and the extensive interaction between their medical professions. We use the contrast between the two studies to examine the generalisability of the Australian results, to identify influences on clinicians' decisions about what treatment information to give patients, and so the tendency towards medical paternalism and, more pragmatically, about how such decisions might be influenced.

Parental rights and medical decisions.

Most countries grant parents rebuttable legal rights to make treatment decisions on behalf of their young children, creating a presumption in favor of parental rights. This article identifies and provides a preliminary assessment of a perhaps surprising variety of arguments for the presumption in favor of this parental right. The arguments considered include those flowing from ideas that parents are motivated by their child's best interests; that they have privileged insight into their child's preferences and capacities; that parental support has clinical significance and may be contingent upon respect for the presumption; that parents and families typically bear the burden of treatment decisions; that parents' views often have a religious basis; that it would be improper to override parents' wishes other than in conditions of complete certainty; and that parents have 'natural authority' over their children. It is unlikely that this is an exhaustive list of the arguments that could be offered in favor of the presumption, and the treatment in the paper is brief. Nevertheless, it is hoped that enough is said to suggest that it is harder to defend the presumption than we might have supposed.

Scoliosis repair in a teenager with Duchenne's muscular dystrophy: who calls the shots?

In this exchange, a clinician (the first author) presents a case scenario for comment by an ethicist (the second author). The case concerns a 15-year-old boy with Duchenne's muscular dystrophy requested palliative surgical correction of a 60 degree thoraco-lumbar scoliosis. The surgical team were initially reluctant to offer surgery given their assessment of the perioperative and postoperative risks (anesthetic review suggested an 80% chance of surviving the surgery and 50% likelihood of returning home), but the operation proceeded. The case raises issues of the rights of patients to insist on nonfutile but high risk surgery, risk perception, resource allocation, autonomy, and the integrity of clinicians.

Mass immunisation programmes: some philosophical issues.

Most countries promote mass immunisation programmes. The varying policy details raise a raft of philosophical issues. I have two broad aims in this paper. First, I hope to begin to remedy a rather curious philosophical neglect of immunisation. With this in mind, I take a broad approach to the topic hoping to introduce rather than settle a range of philosophical issues. My second aim has two aspects: I argue that the states should have pro-immunisation policies, and I advance a view of the subsequent and more specific question as to which sorts of pro-immunisation policies they should prefer. I use the immunisation policies of the United States and New Zealand to frame my discussion of these substantive questions. Immunisation is effectively compulsory in the United States. New Zealand, by contrast, requires evidence not of immunisation but of immunisation status upon school enrolment: New Zealand's policy effectively makes immunisation choice compulsory. I argue that, as between the pro-immunisation policies of the United States and New Zealand, the latter should be preferred. Though the threshold question as to whether states should have pro-immunisation policies should be answered affirmatively, the move to compulsory immunisation cannot be justified.