Tim Dare

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 Zealands 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.

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.

The counsel of rogues? : a defence of the standard conception of the lawyer's role

Contents: The standard conception of the lawyers role The critique of the standard conception The idea of role-obligation The standard conception and the role of law The standard conception and the client-professional relationship Virtue ethics, legal ethics, and Harper Lees To Kill a Mockingbird Detachment, distance and integrity Conclusion: a response to the critique Bibliography Index.

Mere-Zeal, Hyper-Zeal and the Ethical Obligations of Lawyers

According to the “standard conception of the lawyer’s role”, lawyers owe special duties to their clients that allow and perhaps even require conduct that would otherwise be morally impermissible. But ‘the standard conception’ has become an ironic epithet. If numbers count, the standard view now is that it cannot be right. The conception has passed from orthodoxy to fair game, replaced by a near consensus that it “must be abandoned, to be replaced by a conception that better allows the lawyer to bring his full moral sensibilities to play in his professional role”1 and that “[t]he lawyer’s role carries no moral privileges and immunities”.2 Much of the criticism of the standard conception is directed at the idea that it requires excessive and immoral advocacy on behalf of clients. “Every lawyer”, David Luban claims, “knows tricks of the trade that can be used to do opponents out of their legal deserts”.3 Critics of the standard conception claim that it not only allows, but also requires them to use such tricks if it is in their client’s interests to do so. But I do not think we should abandon the standard conception. This paper offers an alternative reading of the conception, proceeding from a functional analysis of law and drawing a distinction between “mere-zeal” and “hyper-zeal”, in an attempt to show both that the conception is essentially the right way to conceive of the ethical obligations of lawyers and how it is able to avoid the complaint that it requires excessive advocacy. In defense of a moderate version of the conception, I attempt to show that the conception requires and allows only mere and not hyper-zeal. I go on to argue that the distinction between these forms of zealous advocacy can be grounded in the current jurisdiction to prevent abuse of process, hoping to show both how the apparently fragile distinction can maintained, and to suggest—again contrary to critics—that the courts already possess the power and the apparatus, within the framework of the standard conception, to draw principled limits to legitimate advocacy. Legal Ethics, Volume 7, No.1

Addressing Child Maltreatment in New Zealand: Is Poverty Reduction Enough?

Jonathan Boston provides an insightful analysis of the emergence and persistence of child poverty in New Zealand (Boston, 2014, Educational Philosophy and Theory). His remarks on why child poverty matters are brief but, as he reports, “[t]here is a large and robust body of research on the harmful consequences of child poverty” (Boston 2014, pp. 10–11). One cost he does not explicitly mention is the increased risk of maltreatment faced by children living in poverty. Given the clear correlation between risk of abuse and poverty, Boston’s recommendations might be expected to go some way to addressing New Zealand’s appalling child maltreatment statistics. However, Boston himself identifies both fiscal and political barriers to the implementation of his proposed strategy. “Fundamentally”, he observes, “without adequate multi-party agreement, it will be hard to reduce child poverty on a durable basis” and “[c]urrently, such agreement is lacking” (Boston, 2014, p. 21). Even if we accept Boston’s strategies for child-poverty reduction, then, it is prudent to consider other responses to the consequences of child poverty. Significant and controversial aspects of New Zealand’s 2013 White Paper for Vulnerable Children can be read in this light, and one of them – the proposal to use predictive risk modeling (PRM) to identify children at risk of maltreatment – is the focus of this commentary.

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.

We need to confirm, not relearn old information

Clinical pharmacologists have contributed greatly to our understanding of drugs used in anesthesia and the perioperative period. Anesthesiologists, as practicing clinical pharmacologists, have readily adopted many of the techniques used by these scientists to further our specialty. Population pharmacokinetics and pharmacodynamics, modeling, and simulation are now common in our literature. This is particularly true for the intravenous anesthetic combination of propofol and remifentanil. We incorporate pharmacokinetic parameters (e.g., Marsh (1), Kataria (2), Paedfusor (3)) into our target controlled infusion pumps and make use of display screens to demonstrate drug concentration in the plasma and effect site for a typical child. Complex pharmacodynamic interactions between propofol and remifentanil are understood and used clinically (4). And yet, there still remains a divide between what the pharmacologists suggest based on science and what the clinician does, often based on empirical beliefs. We clinicians seem to believe that our field is special and sometimes separated from what the pharmacologist studies and reports. This is true even of common drugs such as acetaminophen (paracetamol); this analgesic/antipyretic has come under increased scrutiny since the introduction of the intravenous preparation. The basic pharmacokinetic parameters (clearance and volume of distribution) are unchanged no matter what formulation is used. The only parameters that might change are those describing enteral formulation absorption and bioavailability. The basic pharmacodynamic parameters (EC50, Emax) have been described in both children (5) and adults (6). Future studies should be planned to simply confirm what is known or explore differences in other populations, rather than re-learning what is known. This principle has been espoused for clinical drug development (7). Modeling and simulation are now integral parts of drug development (8), and yet we continue to design simple clinical studies without using this valuable resource. Adults and children are subjected to bloodletting for studies where the results could be predicted or where available knowledge could be used to improve study design or lessen patient numbers. Children are unnecessarily allocated to placebo groups in order to demonstrate drug effectiveness (9,10). Newly reported acetaminophen time-concentration profiles conform to known pharmacokinetic parameter estimates (11). Simulation will readily demonstrate that there will be differences in plasma concentrations in the immediate postoperative period between those given enteral and those given parental formulations, and yet there continue to be clinical studies demonstrating this (e.g., (12,13)). Although these studies may claim that ‘therapeutic plasma concentrations’ are achieved in the postoperative period, they often fail to recognize that it is the concentration in the effect site, rather than plasma that relates to analgesia (5). Plasma and effect site concentrations may be equivalent at steady state after regular dosing, but this is not so after a single dose. There is an equilibration delay between the central and effect compartments of 30–50 min (5,6). This delay has been demonstrated clinically in both children after inguinal hernia repair (14) and adults after third molar tooth surgery (15). Analgesic onset is more rapid after intravenous than after oral administration. These studies simply confirm what is already known. It is possible to use the different formulations to children’s benefit. Rectal absorption of acetaminophen is slow. Consequently, we might anticipate rectal administration to be associated with delayed onset of analgesia, but with an increased duration of effect. A simulation, based on known PK and PD, demonstrates this prolonged analgesic effect after a suppository in Figure 1. Analgesic duration in children 2–5 years presenting for adenotonsillectomy given either 15 mg kg 1 IV or 40 mg kg 1 PR intraoperatively have been compared in a clinical study (16). Kaplan–Meier survival curves show that the time to first analgesic request was longer in children receiving rectal acetaminophen (median 10 h, interquartile range 9–11 h) compared with those receiving intravenous acetaminophen (7.6–10 h). This prolonged duration of effect after rectal acetaminophen 40 or 60 mg kg 1 in day-case pediatric surgery has been demonstrated by others (17). However, those studies could have been undertaken with fewer pediatric patients by using those children to confirm known characteristics of formulation differences rather than using randomized controlled trials that require high patient numbers to generate the magic P < 0.05 (18). The potential usefulness of the learning versus confirming principle is highlighted by investigations into the analgesic effectiveness of acetaminophen after cleft palate surgery. Acetaminophen is a mild analgesic with efficacy (Emax) of 5.2/10 (visual analogue scale 0–10). A concentration in the effect site compartment of 10 mg L 1 is associated with pain reduction in 2.6/10 in both neonates and children (5,19). If pain is scored at 6/ 10 after surgery, then this effect site concentration of

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.

Authorship wanting: dead or alive.

Dead poets are venerated; not so the occasional author of a scientific article who did not live to see submission of his or her work. The current issue of Pediatric Anesthesia includes a retrospective report that was planned and performed circa 1995–2002 by a single investigator (1). The work was completed by his colleagues after his demise. Despite this individual researcher’s large contribution to the work, he was not granted authorship, only an acknowledgment. Should he have been granted authorship? The International Committee of Medical Journal Editors (ICMJE) has developed criteria to differentiate authors from other contributors for a scientific paper. Four criteria are suggested for authorship (http:// www.icmje.org/recommendations/browse/roles-andresponsibilities/defining-the-role-of-authors-and-contributors.html):

Ethics and the law: an introduction

‘Legal ethics’ is a broad church, embracing the legal regulation of lawyers as well as the empirical, historical, sociological and – since the mid-1970s – philosophical study of legal practice. Ethics and the Law is the first book-length introduction to this last, philosophical, thread. Brad Wendel is a singularly appropriate author for such an introduction. He is a lawyer and a philosopher, a leading contributor to contemporary philosophical legal ethics, and he writes clearly and engagingly. Ethics and the Law is divided into two parts. The first part introduces a range of philosophical issues raised by the ethical analysis of legal practice; the idea of role differentiation; reflective equilibrium and the form of common justifications of legal practice; the justification of the legal system itself, particularly the adversary system; connections between leading positions in the philosophy of law and legal ethics; questions about the relationship between citizens and government and the notions of obligation and obedience; and the challenge of unjust laws. The second part is motivated by appreciation that the role of lawyer is not monolithic: there are many ‘law jobs’ – lawyers work as criminal defenders, as prosecutors, within civil litigation, as in-house or company counsel, representing clients in courts or as adviser or counsel in matters never likely to be independently examined, and so on. These roles raise distinct ethical issues that are identified and discussed in chapters dedicated to each of the selected law jobs. This is for the most part a very good introduction. The book displays its author’s mastery of an impressive range of material. It includes engaging and deeply troubling cases, such as the one it starts with, in which client confidentiality leads lawyers to sit on a confession that might have spared an innocent man 25 years in prison, gives a sense how justification might proceed in applied ethics, and in legal ethics in particular, and draws connections between legal ethics and broader philosophical issues. The chapters on the multiple roles of lawyers in the second part are both nuanced treatments in their own right and an important reminder of the need for proper regard to the detail of particular roles within law. Too many write as though all lawyers work in court, or deep in the shadow of litigation. Wendel’s introduction is a reminder that that is not so, and why it matters. Inevitably, there are quibbles. The authors of introductory texts tread a fine line when drawing connections between their topics and broader issues: the connections can enrich new readers’ understanding of the core topic, or puzzle and confuse. Mainly, I think Wendel gets it right but occasionally he delivers a perfectly good introduction to some aspect of social or moral philosophy without making its connections to legal ethics very clear. Chapter 4, on the philosophy of law, is a useful primer on legal positivism and natural law theory, for instance (though the omission of legal realism at this point is curious, since the view has been an influential foil in legal ethics), but the discussion turns to legal ethics only very late in the piece. Chapter 5 introduces a range of views about