Commentary by bioethics professionals, who will be publishing in Pediatrics, appeared in The Conversation regarding the recent criticisms of a study of hormone blockers used to treat gender dysphoric children. The article is called “Puberty-blocking drugs: the difficulties of conducting ethical research” and it addresses the ethical dilemmas around randomized trials and treating people with gender dysphoria.
Some commentators on the UK trial have claimed that the study was flawed because it lacked a control group. But would it have been ethical to perform a controlled trial? To our knowledge, all of the previous studies of puberty blocking in adolescents have had a similar observational design (that is, no comparison group that is not treated). Potentially, this is based on either ethical or practical grounds. The ethical argument is that it would be wrong to withhold treatment from distressed adolescents who may benefit from delaying or halting the physical changes of puberty.
These ethical concerns about control groups was expressed by Kristina Olson, head psychologist researcher on the Trans Youth Project. She repeated an opinion many affirmative model advocates (and others) have about using control groups for gender dysphoria treatment. There are ethical concerns in using control groups on human subjects in general.
Some scientific caveats, none of these involve random assignment. I think every single person involved in this debate agrees that the scientific claim that we really want to randomly assign people would be the most unethical behavior ever. So, we are not going to say you get hormones and you don’t. No one’s ever going to do that.
Due to the possible dangers of hormone blockers, and that the psychological impacts can’t be determined without a control group, they lay out a case for more accurate studies.
In a forthcoming commentary in the journal Pediatrics, we also set out an ethical argument in favour of controlled trials of puberty suppression. We argue that one of the goals of medical ethics is to promote well-being. But in gender dysphoria it is uncertain whether puberty suppression achieves this goal. The drugs have potentially serious physical side effects. The nature and extent of the psychological benefits are unclear and may differ from person to person. It remains uncertain whether they are in the overall best interests of the adolescent.
They address the fact that a strict randomized trial may not be the best option as it forecloses treatment options for a youth who may be very distressed.
If puberty suppression is to be used with uncertain consequences, it is imperative that we study the effects as systematically as possible. Where a controlled trial is impractical, this might be through an observational design.
They discuss the difference between adults and cognitively immature minors who can’t truly consent to the harsh realities of what medical treatment does to the body.
Medical professionals also have an ethical obligation to promote the well-being of patients, and they also have an obligation to promote their autonomy. In the case of adult patients (with capacity), the right thing to do, in the face of uncertainty about the patient’s best interests, is usually to respect their wishes.
But autonomy is more complicated in the case of young adolescents. Adolescents have varying degrees of cognitive development, which is relevant to their capacity to make decisions. Autonomy is not merely desiring something, it is genuinely and accurately understanding oneself and the options available, and vividly imagining the consequences of all feasible courses of action. How much does an adolescent understand themselves, and how well have they understood and reflected on the consequences of their choices? Clearly, there are some situations where it would be a mistake to automatically comply with an adolescent’s expressed wishes.
Topic 17: Moral Dilemmas, on the GHQ site, has a table that contains the pro and con arguments for socially and medically transitioning minors.
Wilkinson, D., Savulescu, J. (2019, July 25). Puberty-blocking drugs: the difficulties of conducting ethical research. The Conversation. Retrieved from https://theconversation.com/puberty-blocking-drugs-the-difficulties-of-conducting-ethical-research-120906?utm_source=twitter&utm_medium=twitterbutton
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