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Moral philosophers offer competing criteria for ethical decision-making. But how are our decisions made on the ground, in real-life cases, where they really matter? Are they products of ‘really valid’ philosophical justifications, or are they made rather under circumstances that have nothing to do with the ‘real validity’ of the justifications we give them.

Claiming to have deduced its practices from pure philosophical principles, notably ‘respect for autonomy’ and ‘justice’, medicine and the entire health care system uphold the former option. That said, a brief sociological analysis of human research ethics, the euthanasia debate, and the discourse on allocation of scarce resources within the NHS leads to some counter-intuitive, and at any rate disturbing, conclusions.

Dr Miran Epstein is Senior Lecturer in Medical Ethics and Law at Barts and The London School of Medicine (Queen Mary University of London) and is a trained medical doctor. His prolific writing on the subject unflinchingly confronts the most difficult problems in medical ethics today. He offers an insider’s view of how ethical decisions are made, what the vested interests are and how we might hope to do better.