Ethical physicians need to share their biases and prejudices and articulate alternatives and also be tolerant of the decisions of their patients and families.I believe that I am a moral, caring, dedicated doctor working with children and parents who are often faced with ethical problems of large and small dimensions. There is no question that these decisions should be ethical, but, in general, I find ethical theory of little day-to-day use. Indeed, even when an ethicist joins me in a discussion (...) of “What should I do?”, or more appropriately, “What should I advocate be done?”, I usually find their additions to the discussion wanting. Ethical theory gives guidance but does not seem to provide sufficient help in decisions for the individual case: What will be best for the infant with spina bifida while still in utero? Termination of the pregnancy? Birth and long-term care? What is best were that same child already born with a high paraplegia and hydrocephalus? What is best for the infant with a major malformation of the brain and uncontrollable seizures whose only hope for controlling the seizures is removal of half of the brain? What is best for the family in each of these situations and the many others I have encountered? What is best for society?I have been called a Hegelian pragmatist, although my knowledge of Hegel is minimal. I think that the term pragmatist is a badge of honour, because, on the front lines of clinical decision-making, I do not have the philosopher’s luxury of days or weeks for managing words. As a pragmatic doctor, I am forced to be a person of action or inaction. I must make a decision and advocate for the position I take.I am clearly a utilitarian, as I strive to produce the greatest good …. (shrink)

The current concepts of autonomy, surrogate autonomy and informed consent often lead to futile and expensive care at the ends of life. They may impinge on the dignity of the patient as well as subject society to unwarranted expense. In order to provide affordable healthcare for all, these concepts are in need of modification.