Moti Gorin

The transgender child is a familiar and polarizing trope in the present century. Some, such as the writer J. K. Rowling, take transgender children to be cultural fictions: there are no trans kids, as there are no mermaids or leprechauns. Others, including prominent figures in pediatric gender medicine, hold that some children are transgender, just as some children have brown eyes or are naturally outgoing. The only difference is that transgender children require special support, unlike brown-eyed or outgoing children. Instruction manuals are needed, for instance Brill and Pepper’s The Transgender Child: A Handbook for Parents and Professionals. And when puberty commences, medical interventions may be recommended. A third view is that transgender children are examples of “making up people” in the sense of Ian Hacking’s eponymous 1986 essay: transgender children are brought into existence by a social process that involves (in part) naming or classifying children as transgender. This paper defends the third view: there are trans kids, but they are made, not discovered.

Simona Giordano1 raises objections to Recommendations 1, 2, 6 and 7 of the Cass review. While I do not have space to cover all of them, I will discuss some of Giordano’s major concerns, which I argue are unfounded or misguided. Giordano objects to recommendation 1 of the Cass review, which recommends that gender services maintain the same standards as any other service supporting patients with ‘complex presentations and/or additional risk factors.’2 Giordano claims this recommendation ‘seems to suggest that gender dysphoria in young people is inherently a complex situation and that all transgender and gender-diverse young people (TGDY) have complex presentations and/or additional risk factors.’ ‘Some might,’ Giordano writes, ‘and some might not’ (p1). But recommendation 1 was not made merely on the assumption that some patients might have complex presentations or additional risk factors. Rather, it responds to the uncontested finding that many youths presenting for gender services do, in fact, have complex presentations or additional risk factors. It is hard to see what could be objectionable about recommending that paediatric gender services maintain the same standards as those guiding any other service supporting a similarly vulnerable patient population, even if some patients are not especially complex or at additional risk. Recommendation 2 is that children and young people presenting for National Health Service (NHS) gender services be screened for neurodevelopmental conditions including autism and that they receive a mental health assessment. Giordano claims, ‘it is not clear what is the relevance of the assessment’ and that ‘there is no explicit discussion of why neurodiversity matters’ (p1). Giordano’s central worry here is that assessment and screening may lead to neurodiverse youth being prevented from accessing puberty blockers (PBs) and that such …

This letter responds to the Other Voices commentaries “Troubling Trends in Health Misinformation Related to Gender-Affirming Care,” by Stef M. Shuster and Meredithe McNamara; “Values and Evidence in Gender-Affirming Care,” by Os Keyes and Elizabeth Dietz; “Breaking Binaries: The Critical Need for Feminist Bioethics in Pediatric Gender-Affirming Care,” by Lisa Campo-Engelstein, Grayson Jackson, and Jacob Moses; and “Minors Lack the Autonomy to Consent to Gender-Affirming Care: Best Interests Must Be Primary,” by John C. Bester, in the May-June 2024 issue of the Hastings Center Report.

The “affirming” healthcare model for gender-distressed youth is endorsed by the medical establishment in the United States, but many European nations have retreated from it. This controversy would be expected to attract the interest of philosophers and bioethicists, with a diverse range of opinions appearing in academic articles. However, when philosophers and bioethicists have ventured into print, they have almost invariably endorsed the affirmative approach, which involves life-changing medical interventions on children with psychological problems. This is a sign that the process of academic research and writing is not functioning as it should. We recount the failure of philosophy and bioethics to address the issues raised by gender-affirming healthcare. We also offer an explanation of this failure, and in the final section make some recommendations for improving academic integrity.

The original “Dutch Protocol”—the treatment model comprised of puberty blockers, cross‐sex hormones, and surgery—was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions’ effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to significant international differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender‐affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's “embodiment goals.” In this article, I raise objections to autonomy‐based justifications for pediatric gender‐affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision‐making and, consequently, put patients at risk of medical harm.

Given the profound influence of social media and emerging evidence of its effects on human behavior and health, bioethicists have an important role to play in the development of professional standards of conduct for health professionals using social media and in the design of online systems themselves. In short, social media is a bioethics issue that has serious implications for medical practice, research, and public health. Here, we inventory several ethical issues across four areas at the intersection of social media and health: the impact of social networking sites on the doctor‐patient relationship, the development of e‐health platforms to deliver care, the use of online data and algorithms to inform health research, and the broader public health consequences of widespread social media use. In doing so, we review discussions of these topics and emphasize the need for bioethics to focus more deeply on the ways online technology platforms are designed and implemented. We argue that bioethicists should turn their attention to the ways in which consumer engagement, bias, and profit maximization shape online content and, consequently, human behavior and health. We also offer a set of recommendations and suggest future directions for addressing ethical challenges in these domains.

So-called “manipulation arguments” have played a significant role in recent debates between compatibilists and incompatibilists. Incompatibilists take such arguments to show that agents who lack ultimate control over their characters or actions are not free. Most compatibilists agree that manipulated agents are not free but think this is because certain of the agent’s psychological capacities have been compromised. Chandra Sekhar Sripada has conducted an interesting study in which he applies an array of statistical tools to subjects’ intuitive responses to a manipulation case, and he insists that the results of his study provide compelling evidence that people favor compatibilist views of freedom. I argue that because the case that forms the centerpiece of his study is relevantly different from the sort of cases incompatibilists have developed and because he fails to build deterministic conditions into this case, Sripada’s data cannot help settle the disagreement between compatibilists and incompatibilists

Imagine a drug—let's call it Curebitt—that is safe, cheap, and very effective: take a pill once a day and you will be healthier. Curebitt's taste is so unpleasant, so bitter, however, that a significant proportion of patients cannot bring themselves to ingest the pill regularly. Now suppose that after some time, another drug, Curesweet, hits the market. This drug is clinically equivalent to Curebitt and costs the same, but it is much more palatable, so adherence rates for it are significantly higher than for Curebitt. Should physicians continue prescribing Curebitt, now that Curesweet is available? No, prescribing the bitter pill puts patients at a greater risk of nonadherence and ultimately results in reduced clinical benefit for a significant proportion of patients, whereas prescribing Curesweet benefits more patients and increases the probability that any given patient's health will improve. The Curebitt versus Curesweet scenario draws our attention to how a physician can fail her patients by prescribing drugs with lower adherence rates when equivalent drugs with higher adherence rates are available. What does this fictional case tell us about the real world? A lot. We know that adherence rates vary with out‐of‐pocket costs. Name‐brand drugs carry higher out‐of‐pocket costs than their generic counterparts; as a result, when name‐brand drugs are prescribed rather than their generic counterparts, fewer patients receive health benefits. If prescribing Curebitt is unethical, then so is prescribing the name‐brand drug.

The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as “nudges.” Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations—for example, the tendency to choose the first option presented even when that option is not the best for them—thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients’ choices, the justification for doing so must appeal to an ethical and professional standard, not to patients’ preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar—the best-interest standard—offers a robust justification for the use of nudges.

Incentive programs have been criticized due to concerns that extrinsic rewards can ‘crowd out’ intrinsic motivation, and also that such programs might exert a corrupting influence on those receiving the incentive. Jonathan Wolff has argued that while these worries are in some instances well grounded, incentives can also operate by liberating people from social pressures that stand in the way of their intrinsic motivations. We further develop Wolff's insight by articulating a framework for assessing such incentives and discussing several areas of public health where incentives may play a positive role. In so doing, we describe the limitations of Wolff's thesis as well as the opportunities it presents. Finally, we suggest that there is an additional attractive feature of incentives that has been overlooked, which is their capacity to serve as ‘conversation makers’. By providing people an occasion to discuss reasons for and against various health behaviors, incentives have the potential not only to impact the health behavior of individuals but to affect cultural change at the population level

Utilitarian objections to the consumption of factory-farmed products center primarily on the harms such farms cause to animals. One problem with the utilitarian case against the consumption of factory-farmed products is that the system of production is so vast and complex that no typical, individual consumer can, through her consumer behavior, make any difference to the welfare of animals. I grant for the sake of argument that this causal inefficacy objection is sound and go on to argue that the utilitarian nevertheless has the resources to conclude that at least in some cases it is wrongful on utilitarian grounds for an individual to consume factory-farmed products. When a consumer who believes that factory farming is wrongful consumes the products of factory farms, she endorses wrongful practices, and by doing so she engages in a form of self-harm. Self harm, like harm to others, must be taken into consideration when a utilitarian agent deliberates about the permissibility of her proposed course of action. Therefore, the causal inefficacy objection, while powerful, is not decisive against utilitarian objections to consuming factory-farmed products.