Brian D. Earp

There is an ongoing public debate about sex, gender and identity that is often quite heated. This is an edited transcript of an informal lecture I recorded in 2019 to serve as a friendly guide to these complex issues. It represents my best attempt, not to score political points for any particular side, but to give an introductory map of the territory so that you can think for yourself, investigate further, and reach your own conclusions about such controversial questions as ‘What does mean to be a man or a woman?’

Much of modern ethics is built around the idea that we should respect one another’s autonomy. Here, “we” are typically imagined to be adult human beings of sound mind, where the soundness of our mind is measured against what we take to be the typical mental capacities of a neurodevelopmentally “normal” person—perhaps in their mid-thirties or forties. When deciding about what constitutes ethical sex, for example, our dominant models hold that ethical sex is whatever is consented to, while a lack of consent makes sex wrong.1 Consent, in turn, is analysed in terms of autonomous decision-making: a “yes” or “no” that reflects the free and informed will of our idealised, sound-minded adult. Whether such models provide adequate normative guidance for ethical, much less good, sex between neurotypical human adults is an open question.2 3 When it comes to the ethics of sexual activity between humans and non-humans—robots, say—or between humans who don’t fit the rational stereotype (such as older people with dementia or younger adolescents), we hardly know where to begin.4–7 It is therefore heartening to see a number of papers in this issue tackling the difficult question how to respectfully facilitate or respond to the needs, desires, and decisions of people with different kinds or degrees of autonomy.8 For example, Sumytra Menon and colleagues9 explicitly discuss the notion of “borderline capacity” and argue, in the medical domain, for shared and supportive decision-making practices to “foster the autonomy of patients with compromised mental capacity while being mindful of the need to safeguard their well-being.” (Could similar practices be applied to sexual decision-making?) Touching on a similar theme, Zahra Ladan 10 asks how we should conceive of liberty in the case of persons with certain inborn physical or mental limitations. Might it sometimes be necessary to …

We thank the commentators for their thoughtful responses to our article.1 Due to space constraints, we will confine our discussion to just three key issues. The first issue relates to the central ethical conundrum for clinicians working with young people like Phoenix: namely, how to respect, value and defer to a person’s own account of their identity and what is needed for their well-being, while staying open to the possibility that such an account may reflect a work in progress. This conundrum thus relates both to what will be beneficial for that person and what constitutes respecting their autonomy, and clinicians must dwell on these questions when deciding what forms of medical intervention to offer. D’Angelo,2 Lemma3 and Wren4 highlight the importance of considering Phoenix (or, indeed, any person pursuing gender-affirming interventions) as a ‘whole person in context’ (p5)2 prior to initiating treatment or care. In this way, they advocate for a process of ‘therapeutic exploration’ (p1),4 which includes taking sufficient time to explore Phoenix’s personhood with them so as to support them in achieving an ‘authentic self-discovery’ (p5).2 We agree with these authors that identity (including gender identity) development is a complex, life-long process that is influenced by biological, psychosocial and relational aspects, all of which may contribute to an individual’s desire to pursue gender-affirming interventions. To explore the various factors—both conscious and unconscious—that might be motivating Phoenix’s decision to pursue ongoing puberty suppression (OPS), D’Angelo,2 Lemma3 and Wren4 describe a comprehensive psychological approach to working with transgender (trans) and gender diverse (TGD) individuals and propose questions to guide such discussions. Consistent with this approach, we stipulated that Phoenix had undergone regular psychological counselling and that the psychologist had judged that ‘Phoenix’s distress is significant and enduring…not a symptom …

In this article, we analyse the novel case of Phoenix, a non-binary adult requesting ongoing puberty suppression to permanently prevent the development of secondary sex characteristics, as a way of affirming their gender identity. We argue that the aim of OPS is consistent with the proper goals of medicine to promote well-being, and therefore could ethically be offered to non-binary adults in principle; there are additional equity-based reasons to offer OPS to non-binary adults as a group; and the ethical defensibility of facilitating individual requests for OPS from non-binary adults also depends on other relevant considerations, including the balance of potential benefits over harms for that specific patient, and whether the patient’s request is substantially autonomous. Although the broadly principlist ethical approach we take can be used to analyse other cases of non-binary adults requesting OPS apart from the case we evaluate, we highlight that the outcome will necessarily depend on the individual’s context and values. However, such clinical provision of OPS should ideally be within the context of a properly designed research study with long-term follow-up and open publication of results.

The ‘born this way’ movement for sexual orientation minority rights is premised on the view that sexual orientation is something that can neither be chosen nor changed. Indeed, current sexual orientation change efforts appear to be both harmful and ineffective. But what if ‘high-tech conversion therapies’ are invented in the future that are effective at changing sexual orientation? The conceptual basis for the movement would collapse. In this chapter, we argue that the threat of HCT should be taken seriously, motivating a change in tactics for proponents of sexual orientation minority rights. We also discuss some of the practical-ethical and public-policy issues surrounding HCT, in case the technology is one day developed.

The articles in this issue explore a number of difficult choices in medical care and research. They investigate ethical complexity in a range of decisions faced by policymakers and clinicians, and offer new evidence or normative approaches for navigating this complexity. In this issue’s feature article, Ford and colleagues engage with an ethical challenge faced by policymakers in relation to health research: should free text data contained in medical records be shared for research purposes?1 While some types of data from electronic medical records are used widely in health research, privacy concerns have limited the use of free text data specifically. Ford and colleagues highlight the richness of the clinical information in free text and its centrality to some areas of healthcare such as mental health and primary care. In their view, while text analytic technology is developing rapidly, ‘policy makers routinely judge that the risk of re-identifying patients from text data is too high for these data uses’. Their citizens’ jury study in the UK found that participants were largely in favour of medical free text data being shared outside the NHS for research using an opt-out model: ‘the majority of jurors believed the benefits of sharing data for research outweighed the privacy risks’. In their commentary on this research, Largent and Morain raise some important issues about policymakers’ use of empirical findings …

If there is a single thread running through this issue of the journal, it may be the complex interplay between the individual and the system of which they are apart, highlighting a need for systems thinking in medical ethics and public health.1 2 Such thinking raises at least three sorts of questions in this context: normative questions about the locus of moral responsibility for change when a system is unjust; practical questions about how to change systems in a way that is morally appropriate without triggering unintended, potentially harmful side-effects; and epistemic questions about how to predict the multidimensional consequences of a proposed change or set of changes to an intricate social system such as healthcare.3 These questions crop up throughout the issue, as I will discuss, but my focus is the target article and linked commentaries on gender bias in the surgical profession. Hutchison conducted in-depth interviews with 46 Australian women surgeons and surgical trainees, taking care to avoid leading questions regarding gender bias or gendered mistreatment. Nevertheless, despite minimal prompting, at least four types of gender-related concerns were described by the surgeons,whether directly or indirectly: 1. structural bias in workplace factors, including insufficient parental leave for women, exclusion from men’s spaces where informal training may occur, and a dearth of senior female role models; 2. epistemic injustices including unfair doubting of women’s surgical competence or knowledge relative to men; 3. stereotyped expectations that women surgeons would or should shoulder the burden of medical carework, for example, by attending to patients’ emotional needs; and 4. objectification, both by colleagues and patients, including sexual innuendo, remarks about clothing, and even outright sexual assault. Each of these concerns is disturbing on its own, and yet they do not operate in isolation. Rather, they interact …

In this chapter, we introduce the notion of “moral neuroenhancement,” offering a novel definition as well as spelling out three conditions under which we expect that such neuroenhancement would be most likely to be permissible (or even desirable). Furthermore, we draw a distinction between first-order moral capacities, which we suggest are less promising targets for neurointervention, and second-order moral capacities, which we suggest are more promising. We conclude by discussing concerns that moral neuroenhancement might restrict freedom or otherwise “misfire,” and argue that these concerns are not as damning as they may seem at first.

What to do with the missing shade of blue (MSB)? Some have argued that Hume's famous thought experiment undermines his central doctrine – the ‘copy principle’ – such that he should have revised his whole theory in light of it. Others contend that the MSB is not a true or actual counterexample to the copy principle, but merely an apparent or conceivable one, so that he had no such obligation to revise. In this essay, I argue that even if the MSB is a true counterexample, Hume would not have been obligated to revise his theory, given methodological resources he makes available to himself elsewhere in his work and his overarching empiricist aims. And I offer a new suggestion for why he might have included and even highlighted the MSB in his writings despite its being so very vexing and peculiar.

Circumcision is often claimed to be simpler, safer and more cost-effective when performed in the neonatal period as opposed to later in life, with a greater benefit-to-risk ratio. In the first part of this paper, we critically examine the evidence base for these claims, and find that it is not as robust as is commonly assumed. In the second part, we demonstrate that, even if one simply grants these claims for the sake of argument, it still does not follow that neonatal circumcision is ethically permissible absent urgent medical necessity. Based on a careful consideration of the relevant evidence, arguments and counterarguments, we conclude that medically unnecessary penile circumcision—like other medically unnecessary genital procedures, such as ‘cosmetic’ labiaplasty—should not be performed on individuals who are too young (or otherwise unable) to provide meaningful consent to the procedure.

Background: Recent literature on addiction and judgments about the characteristics of agents has focused on the implications of adopting a ‘brain disease’ versus ‘moral weakness’ model of addiction. Typically, such judgments have to do with what capacities an agent has (e.g., the ability to abstain from substance use). Much less work, however, has been conducted on the relationship between addiction and judgments about an agent’s identity, including whether or to what extent an individual is seen as the same person after becoming addicted. Methods: We conducted a series of vignette-based experiments (total N = 3,620) to assess lay attitudes concerning addiction and identity persistence, systematically manipulating key characteristics of agents and their drug of addiction. Conclusions: In Study 1, we found that US participants judged an agent who became addicted to drugs as being closer to ‘a completely different person’ than ‘completely the same person’ as the agent who existed prior to the addiction. In Studies 2-6, we investigated the intuitive basis for this result, finding that lay judgments of altered identity as a consequence of drug use and addiction are driven primarily by perceived negative changes in the moral character of drug users, who are seen as having deviated from their good true selves.

For someone with an outsized influence on a field he helped to create, Dan Callahan was anything but overbearing. Physically compact, thin, and wiry in older age, he spoke at the rapid speed of his mind. Soon after I met him—when I was on the cusp of what would become a year‐long residency at The Hastings Center—I found myself seated in his decidedly quaint living room. Dan told a story that evening, one of many that has stuck in my head. It seemed to encapsulate his moral mindset and, in a way, his broader vision for bioethics. I am sure he has told the story many times to many people, but here it is as I recall it.

Davis called for “extreme caution” in the use of non-invasive brain stimulation to treat neurological disorders in children, due to gaps in scientific knowledge. We are sympathetic to his position. However, we must also address the ethical implications of applying this technology to minors. Compensatory trade-offs associated with NIBS present a challenge to its use in children, insofar as these trade-offs have the effect of limiting the child’s future options. The distinction between treatment and enhancement has some normative force here. As the intervention moves away from being a treatment toward being an enhancement—and thus toward a more uncertain weighing of the benefits, risks, and costs—considerations of the child’s best interests diminish, and the need to protect the child’s autonomy looms larger. NIBS for enhancement involving trade-offs should therefore be delayed, if possible, until the child reaches a state of maturity and can make an informed, personal decision. NIBS for treatment, by contrast, is permissible insofar as it can be shown to be at least as safe and effective as currently approved treatments, which are themselves justified on a best interests standard.

In September 2015 a well-publicised Campaign Against Sex Robots (CASR) was launched. Modelled on the longer-standing Campaign to Stop Killer Robots, the CASR opposes the development of sex robots on the grounds that the technology is being developed with a particular model of female-male relations (the prostitute-john model) in mind, and that this will prove harmful in various ways. In this chapter, we consider carefully the merits of campaigning against such a technology. We make three main arguments. First, we argue that the particular claims advanced by the CASR are unpersuasive, partly due to a lack of clarity about the campaign’s aims and partly due to substantive defects in the main ethical objections put forward by campaign’s founder(s). Second, broadening our inquiry beyond the arguments proferred by the campaign itself, we argue that it would be very difficult to endorse a general campaign against sex robots unless one embraced a highly conservative attitude towards the ethics of sex, which is likely to be unpalatable to those who are active in the campaign. In making this argument we draw upon lessons from the campaign against killer robots. Finally, we conclude by suggesting that although a generalised campaign against sex robots is unwarranted, there are legitimate concerns that one can raise about the development of sex robots.

The moral enhancement (or bioenhancement) debate seems stuck in a dilemma. On the one hand, the more radical proposals, while certainly novel and interesting, seem unlikely to be feasible in practice, or if technically feasible then most likely imprudent. But on the other hand, the more sensible proposals – sensible in the sense of being both practically achievable and more plausibly ethically justifiable – can be rather hard to distinguish from both traditional forms of moral enhancement, such as non-drug-mediated social or moral education, and non-moral forms of bioenhancement, such as smart-drug style cognitive enhancement. In this essay, I argue that bioethicists have paid insufficient attention to an alternative form of moral bioenhancement – or at least a likely candidate – that falls somewhere between these two extremes, namely the (appropriately qualified) use of certain psychedelic drugs.

Our understanding of the neurochemical bases of human love and attachment, as well as of the genetic, epigenetic, hormonal, and experiential factors that conspire to shape an individual's sexual orientation, is increasing exponentially. This research raises the vexing possibility that we may one day be equipped to modify such variables directly, allowing for the creation of “high-tech” conversion therapies or other suspect interventions. In this article, we discuss the ethics surrounding such a possibility, and call for the development of legal and procedural safeguards for protecting vulnerable children from the application of such technology. We also consider the more difficult case of voluntary, adult “conversion” and argue that in rare cases, such attempts might be permissible under strict conditions.

Male circumcision—partial or total removal of the penile prepuce—has been proposed as a public health measure in Sub-Saharan Africa, based on the results of three randomized control trials showing a relative risk reduction of approximately 60 per cent for voluntary, adult male circumcision against female-to-male human immunodeficiency virus transmission in that context. More recently, long-time advocates of infant male circumcision have argued that these findings justify involuntary circumcision of babies and children in dissimilar public health environments, such as the USA, Australasia and Europe. In this article, we take a close look at the necessary ethical and empirical steps that would be needed to bridge the gap between the African RCTs and responsible public health policy in developed countries. In the course of doing so, we discuss some of the main disagreements about the moral permissibility of performing a nontherapeutic surgery on a child to benefit potential future sexual partners of his. In this context, we raise concerns not only about weaknesses in the available evidence concerning such claims of benefit, but also about a child’s moral interest in future autonomy and the preservation of his bodily integrity. We conclude that circumcision of minors in developed countries on public health grounds is much harder to justify than proponents of the surgery suggest.

Recent research has relied on trolley-type sacrificial moral dilemmas to study utilitarian versus nonutili- tarian modes of moral decision-making. This research has generated important insights into people’s attitudes toward instrumental harm—that is, the sacrifice of an individual to save a greater number. But this approach also has serious limitations. Most notably, it ignores the positive, altruistic core of utilitarianism, which is characterized by impartial concern for the well-being of everyone, whether near or far. Here, we develop, refine, and validate a new scale—the Oxford Utilitarianism Scale—to dissociate individual differences in the ‘negative’ (permissive attitude toward instrumental harm) and ‘positive’ (impartial concern for the greater good) dimensions of utilitarian thinking as manifested in the general population. We show that these are two independent dimensions of proto-utilitarian tendencies in the lay population, each exhibiting a distinct psychological profile. Empathic concern, identification with the whole of humanity, and concern for future generations were positively associated with impartial beneficence but negatively associated with instrumental harm; and although instrumental harm was associated with subclinical psychopathy, impartial beneficence was associated with higher religiosity. Importantly, although these two dimensions were independent in the lay population, they were closely associated in a sample of moral philosophers. Acknowledging this dissociation between the instrumental harm and impartial beneficence components of utilitarian thinking in ordinary people can clarify existing debates about the nature of moral psychology and its relation to moral philosophy as well as generate fruitful avenues for further research.

In 2012, the politician Todd Akin caused a firestorm by suggesting, in the context of an argument about the moral permissibility of abortion, that some forms of rape were. This seemed to imply that other forms of rape must not be legitimate. In response, several commentators pointed out that rape is a and that there are. While the intention of these commentators was clear, I argue that they may have played into the very stereotype of rape endorsed by Akin. Such a response, I claim, actually obscures a range of sexual harms, including some that may not rise to the level of being a crime. I also offer some thoughts on the moral psychology behind anti-abortion arguments of the kind advanced by Akin

In English, as in many other languages, male-gendered pronouns are sometimes used to refer not only to men, but to individuals whose gender is unknown or unspecified, to human beings in general (as in ―mankind‖) and sometimes even to females (as when the casual ―Hey guys‖ is spoken to a group of women). These so-called he/man or masculine generics have come under fire in recent decades for being sexist, even archaic, and positively harmful to women and girls; and advocates of gender-neutral (or nonsexist) language have put forward serious efforts to discourage their use. Have they been successful, and to what extent? In this paper, I review some of the main arguments in favor of abolishing sexist male generics. I then present three studies tracking the use of he/man terminology in academic, popular, and personal discourse over the past several decades. I show that the use of these terms has fallen dramatically in recent years, while nonsexist alternatives have gradually taken their place. We may be paying witness to the early stages of the ultimate extinction of masculine generics.

Daniel Dennett (1996) has disputed David Chalmers' (1995) assertion that there is a "hard problem of consciousness" worth solving in the philosophy of mind. In this paper I defend Chalmers against Dennett on this point: I argue that there is a hard problem of consciousness, that it is distinct in kind from the so-called easy problems, and that it is vital for the sake of honest and productive research in the cognitive sciences to be clear about the difference. But I have my own rebuke for Chalmers on the point of explanation. Chalmers (1995, 1996) proposes to "solve" the hard problem of consciousness by positing qualia as fundamental features of the universe, alongside such ontological basics as mass and space-time. But this is an inadequate solution: to posit, I will urge, is not to explain. To bolster this view, I borrow from an account of explanation by which it must provide "epistemic satisfaction" to be considered successful (Rowlands, 2001; Campbell, 2009), and show that Chalmers' proposal fails on this account. I conclude that research in the science of consciousness cannot move forward without greater conceptual clarity in the field.

Ploug and Holm argue that polarisation in scientific communities can generate conflicts of interest for individual researchers. Their proposed solution to this problem is that authors should self-report whether they are polarised on conflict of interest disclosure forms. I argue that this is unlikely to work. This is because any author with the self-awareness and integrity to identify herself as polarised would be unlikely to conduct polarised research to begin with. Instead, I suggest that it is the role of (associate-level) editors of journals to detect and report on polarisation. One consequence of this view is that they need to be sufficiently familiar with the field of research they are evaluating to know whether polarisation is at stake.