Originally a comment by The Whimster Gap on When in doubt, do the dangerous thing.
It might be worth stepping back a bit to understand what’s going on here. There’s obviously the stuff about particular medical practitioners being signed up to a particularly weird and inexplicably popular ideology religion, but that’s not the whole story.
No: we have to go back a few decades, to when Tom Beauchamp and James Childress published a book called The Principles of Biomedical Ethics: a book that has gone through several editions since, and been tremendously influential around the world. It’s the standard textbook for a lot of clinical ethics teaching. B&C’s basic position is this: that there are four basic principles to any recognisable moral system: respect for autonomy, beneficence, non-maleficence, and justice. These four principles may manifest in any number of ways, and there may be ongoing disagreement about which is the more important and about how to apply them; but they’re there all the same. And from that, we can derive some claims about how to understand the nature of dilemmas in medical practice, and maybe hope to come up with a solution.
I’m not persuaded by their position, but it’s not completely without merit when its kept in its proper place. The real problem is the way it’s been taken up by medical schools. What was a hypothesis about moral reasoning became a dogma – “Principlism”, sometimes known as the Georgetown Mantra (because B&C were associated with Georgetown University). I’ve lost count of the number of clinicians and ethics teachers in med schools I’ve come across who think that moral reasoning is simply a matter of saying something about each of the principles in turn. On the other hand, they’re medics: maybe we shouldn’t worry too much if their attentions lie with medicine. They’re at least thinking about conduct.
However, this gets compounded by a dogma that it’s respect for autonomy that’s primus inter pares. At the most basic, this means that a patient gets to refuse even simple and life-saving treatment. And maybe if you think that people should be able to make their own damn fool decisions, that’s fine. But the dogma has also taken on another form, which is that respect for autonomy is not simply about taking patient autonomy seriously, and thereby giving patients the final say about accepting treatment – but that respect for autonomy means taking requests for treatment just as seriously as refusals.
This is plainly asymmetric, though. It’s one thing to sigh and discharge a patient who’s refusing antibiotics to treat an infection; it’s quite another to take seriously a request for antibiotics from a patient for whom antibiotics would do nothing.
Still: the (understandably) naïve way in which clinical ethics is taught to clinicians means that a lot of them end up thinking that a patient request that φ is not just a reason to φ, but that it is a powerful and perhaps overriding reason to φ, irrespective of clinical judgement.
OK: now let’s go back to the clinic, with a couple of scenarios.
In the first, a child has (let’s say) a deformed limb, and major surgery is suggested. The child is mature. In this kind of case, it is possible that his or her opinion on whether to accept the surgery would be taken seriously, and may be definitive. If the child is sufficiently mature, the reasons for the decision are irrelevant.
In the second, a comparably mature child decides that they’re in the wrong body, or that they have a gender-spirit that is not so closely aligned with their body that their body determines it, but is closely-enough aligned with the body that the body has to be altered. And the doctor thinks, “Well, a child mature enough to refuse surgery and to have that treated as compelling is surely mature enough to request an intervention and to have that treated as compelling.”
Medicine here becomes a service industry, based on a naïve understanding not just of the importance of respect for patient autonomy, but of what respect for patient autonomy is to begin with.
Maybe being signed up to genderwibble greases the wheels; but I suspect that there’s a lot of medics who’d be sympathetic to the request not because they are so signed up, or even because they’ve even thought about it in any depth, but simply because they think that that’s what respect for patient autonomy requires.
