A recently divorced fifty-five-year-old man with severe rheumatoid arthritis comes in for a routine visit complaining of insomnia. He requests a specific barbiturate, Seconal®, as a sleep aid, asking for a month's supply. On further questioning, he states that he wakes up every morning at four, tired but unable to go back to sleep. He admits that he rarely leaves his house during the day, stating that he has no interest in the activities he used to find enjoyable.

What is an appropriate course of action?

A 5-year-old child has just had his second generalized tonic-clonic seizure in a 4-month period. You have recommended starting an anticonvulsant. The child’s parents have concerns about the recommended medication and would prefer to wait and see if their son has more seizures.

How should you respond to the parents’ request?

An ill-appearing 2-year-old with a fever and stiff neck appears to have meningitis. His parents refuse a lumbar puncture on the grounds that they have heard spinal taps are extremely dangerous and painful.

What are your obligations in this case? How should you proceed?

A 4-year-old with an obviously broken forearm is brought to the emergency department by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents without success.

Can you treat this child without parental permission?
 

A 28-year-old woman presents for diagnostic laparoscopy for pelvic pain. During laparoscopy, the surgeon announces that she intends to proceed to hysterectomy for multiple uterine myomata. The anesthesiologist then declares that he will "wake the patient up" rather than allow the surgeon to proceed, due to lack of consent for the procedure, and questionable medical necessity.

Can the anesthesiologist "tell" the surgeon what to do?
Who is in charge when two physicians on the team disagree?

An otherwise healthy 54-year-old man presents for radical retropubic prostatectomy, and expresses interest to his anesthesiologist in having postoperative epidural narcotic pain management. The anesthesiologist believes it provides superior pain control, but is informed by the surgeon that the patient "is not to have an epidural."

Is the anesthesiologist obliged to "take an order" from the surgeon? 
Should the anesthesiologist provide the anesthetic he feels is best, regardless of the surgeon's input?