In the case of Townsend v Epsom and St Helier University Hospitals NHS Trust, the Court of Appeal upheld the longstanding position that individual clinicians cannot be compelled to provide treatment that they consider clinically inappropriate, while holding that there is ‘no carve out for clinical decisions’ from the best interests framework for adults lacking mental capacity. Subsequent questions about who sets the treatment options; when and in what form there may be judicial scrutiny of their exclusion; and what follows if a court and clinicians disagree will be considered by the Supreme Court in January 2027. We argue that these questions are also pertinent to paediatric treatment disputes and warrant a consistent approach. Drawing on paediatric case law, we examine the boundaries of best interests decision-making to show that the breadth of best interests does not erase the different functions that contribute to a treatment decision. We invite the Supreme Court to recognise a distinct role for collective professional judgement in determining clinical appropriateness, while preserving the authority of the Court of Protection and Family Division of the High Court to scrutinise disputed exclusions. Judicial scrutiny should be proportionate to the nature of the dispute, protecting both patient welfare and professional integrity.
Professional autonomy is a foundational ethical principle in healthcare, underpinning healthcare professionals’ capacity to exercise independent clinical judgement in light of a patient's particular circumstances, preferences and needs. While ethical debate surrounding medical AI has focused extensively on safety, accuracy and bias, its implications for professional autonomy have received comparatively less attention, a notable omission given AI's growing role in shaping clinical decision-making. This article identifies three salient mechanisms through which AI integration may constrain professional autonomy: (1) algorithmic opacity and explainability, (2) automation bias and de-skilling and (3) institutional pressures. Whilst proposed safeguards such as explainable AI, professional training, system design and institutional governance represent important directions, they do not yet adequately protect professional autonomy. This article therefore calls for closer scrutiny of current approaches to AI integration and for governance frameworks that attend not only to the technical properties of AI systems, but to the organisational and institutional conditions in which they are deployed.
During the COVID-19 pandemic, England rationed access to critical care without any published national rule governing how that rationing would occur, allocating scarce intensive care resources through locally variable clinical discretion rather than any accessible framework. This article argues that governing acute scarcity in this way was normatively illegitimate, and that the illegitimacy cannot be cured by soft-law clinical guidance or retrospective judicial review. It defends three conditions: publicity, equal concern, and democratic accountability, grounded in Daniels and Sabin's accountability-for-reasonableness framework and shown to be immanent in existing public-law standards. Through the Thomson litigation and the human-rights reasoning in Tracey and Winspear , it demonstrates that the legal architecture for a binding framework existed and was not used: a governmental choice, not a necessity. It argues that soft law fails not because it is legally unaccountable but because ministerial answerability cannot substitute for deliberation at the point of criterion-setting. It defends primary legislation as the constitutionally appropriate form, specifies a duty-and-activation structure, and situates the argument in relation to the Covid-19 Inquiry Module 3 Recommendation 7.
Even when we agree on the appropriate ethical principle(s) for paediatric decision-making, parents can and do disagree with clinicians about how to interpret or apply these principles. How do we decide who is right when there is disagreement about what is ‘best’ for a child, or what constitutes significant harm? I believe we can answer these questions by shifting our gaze to the epistemic underpinnings of our moral judgments. In this paper I argue that the moral authority of both clinicians and parents is bound to their sphere of epistemic authority. When decisions turn on considerations outside of this sphere, their choices are constrained. First and foremost, knowledge(s) are shared in shared decision making. When knowledges are shared appropriately, and the epistemic authority of the parties involved is duly respected, the appropriate division of moral labour follows. These claims, if true, have a number of important implications the appreciation of which I believe to be useful for working through decisional conflicts in paediatric care.
Clinical ethics rightly emphasizes truthful disclosure, informed consent and respect for autonomy. Yet in serious illness care, patients and families often cognitively understand the information offered before they can morally inhabit it. This paper develops the concept of the moral timing of care: disciplined attention to when, how and within what symbolic world a clinical truth can be received without becoming abandonment, coercion or humiliation. It separates five ethically distinct temporal questions – when information is first disclosed, its pace, its staging, when a decision is asked for, and when intervention must occur – and positions the account against recent work on time and patient autonomy: where that literature shows patients preserving moral space through temporal self-management, this paper addresses the case in which acute biological urgency outpaces that capacity, so that creating a receptive space becomes the clinician's normative responsibility. Four anonymised vignettes from radiation oncology develop the argument: a Jehovah's Witness patient for whom blood was a spiritual threshold rather than a biological substance; a patient wounded by a well-intended but poorly timed truth; a family whose need for time collided with the urgency of anaplastic thyroid cancer; and adult children divided over their dying mother's treatment. Distinguishing chronological urgency from kairotic assimilation, the paper argues that ethical truth-telling requires more than accuracy: a receptive space in which truth can be borne, evaluated and transformed into a decision. Moral timing never justifies concealment or delay; it is a clinical virtue keeping clinicians truthful without violence, respectful without passivity.
