It is customary—albeit perhaps simplistic—to identify four ethical principles as the basis for good medical practice.1 These are beneficence, non-maleficence, respect for autonomy, and justice, primarily distributive justice. The challenge for the practising clinician is to determine a proper course of action when these principles conflict, particularly when the individual, social, or financial consequences of new and perhaps promising treatments are known incompletely. Decisions taken in good faith are now often subject to public comment or criticism, and the National Health Service and other legislation add further constraints by introducing new rights or prescriptive guidelines without necessarily identifying the resources to fulfil these obligations. Many of these concerns have been part and parcel of medical practice for centuries, but it is only recently that the aura of the always wise and caring practitioner has been challenged by an increasingly assertive and vociferous public, ready to seek legal redress for perceived or actual wrongs. There is, of course, no sound reason why judicial decisions are any more cogent on matters of ethical principle than those of the medical profession, but society has created a legal system to regulate the conduct of its members and empowers the judiciary to resolve conflict. Any consideration of the moral basis of medical practice must therefore also take account of judicial determination of those questions of principle which have reached the courts. Examples of ethical conflict spawned by lung disease are considered here in the light of decisions made by the English courts.

The surgical management of lung cancer is a good example of potential conflict between beneficence and non-maleficence. Surgery is painful and entails risk. Is this “maleficence” warranted by the anticipated “beneficence” of disease alleviated or even cured? The practitioner develops a trained enthusiasm to advocate treatment aimed at prolonging life but does …