Paternalist policies in public health often aim to improve people’s well-being by reducing their options, regulating smoking offering a prime example. The well-being challenge is to show that people really are better off for having their options reduced. The distribution challenge is to show how the policies are justified since they produce losers as well as winners. If we start from these challenges, we can understand the importance of the empirical evidence that a very high proportion of smokers regret smoking. (...) In short, it is important that they regret it and important that the proportion is so high. This paper explains how, philosophically, regret can relate to well-being and it considers some of the strengths and weakness in the empirical research that the explanation brings out. The regret case for regulating smoking is indeed strong, although not as strong as the empirical researchers think. It is much weaker for paternalistic intervention in other public health problems, such as obesity and binge drinking. (shrink)

In recent years, an old challenge to informed consent has been rediscovered: the challenge of ignorance. Several authors argue that due to the presence of irreducible ignorance in certain treatments, giving informed consent to these treatments is not possible. The present paper examines in what ways ignorance is believed to prevent informed consent and which treatments are affected by that. At this, it becomes clear that if the challenge of ignorance truly holds, it poses a major problem to informed consent. (...) The paper argues, however, that from both an empirical and a theoretical point of view, it is not convincing that ignorance prevents informed consent. Still, it seems important that the presence of irreducible ignorance is openly discussed during the informed consent process. (shrink)

Gender-affirming hormone therapy is increasingly available to support healthy development of transgender youth, but ethical concerns have been raised regarding fertility-related implications. In this article, I present data from an exploratory qualitative study of the decision-making experiences of trans youth, parents of trans youth, and healthcare providers serving trans youth related to fertility and family creation. I discuss how cisnormative and bionormative biases can impact care and contribute to ethically problematic narratives of regret. Finally, I offer recommendations to support ethically (...) sound, gender-affirmative fertility and family creation counseling with transgender youth. (shrink)

Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients’ capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient’s identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held by a higher level decision-maker, (...) such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth’s authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves. (shrink)

Jesper Ahlin Marceta published an article in this journal in which he formulated his “argument from testability”, stating that it is impossible, at least practically, to operationalize procedural authenticity. That is, using procedural accounts of authenticity, one cannot reliably differentiate between authentic and inauthentic desires. There are roughly two ways to respond to the argument from testability: top-down and bottom-up. Several authors have endeavored the top-down approach by trying to show that some conceptions of authenticity might be operationalizable after all. (...) At present, however, the bottom-up approach has not been put to the test. That is, no attempt has been made to use a currently existing assessment tool to guide the development of an account of authenticity. In this paper, I will investigate what it means to develop an account of authenticity bottom-up based on measures of concordance. More specifically, I will investigate the following three research questions. First, how do concordance and authenticity relate at a conceptual level? As crucial similarities exist between these concepts, concordance measures seem to offer a good starting point for the bottom-up approach. Second, how do judgements of concordance differ from judgements of authenticity? Both their scope and the way they are justified will turn out to be different. This suggests novel ways to react to Marceta’s argument from testability. Third, should we develop a theory of concordance? The positive answer to this question will point towards a central limitation of the bottom-up approach. (shrink)

An increasing number of bioethicists are raising concerns that young childless women requesting sterilisation as means of birth control are facing unfair obstacles. It is argued that these obstacles are inconsistent, paternalistic, that they reflect pronatalist bias and that men seem to face fewer obstacles. It is commonly recommended that physicians should change their approach to this type of patient. In contrast, I argue that physicians’ reluctance to eagerly follow an unusual request is understandable and that whatever obstacles result from (...) this reluctance serve as a useful filter for women who are not seriously committed to their expressed requests for sterilisation. As women already disproportionally bear the birth control burden, less resistance that men might be getting in terms of voluntary sterilisation works to women’s advantage, providing a much needed balance. Societal attitudes towards women and motherhood should not be confused with individual physicians’ reasonable reluctance to jump at a serious elective procedure at fairly mild expression of interest. (shrink)

BackgroundIn gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing (...) GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands.MethodsIn this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents’ explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged.ResultsRespondents’ ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC’s guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI.ConclusionsThis interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise. (shrink)