Toward a Standard of Medical Care: Why Medical Professionals Can Refuse to Prescribe Puberty Blockers

Abstract

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria.

KEYWORDS:

• Medical refusals
• Decision theory
• Health
• Puberty blockers
• Standard of care

Acknowledgements

I am grateful to Paul Hruz, Daniel Rodger, Michal Pruski, Paul Weirich, Philip Robbins, Dennis Valez, two anonymous referees, as well as audiences at the Inaugural Conference for Christian Bioethicists and the annual meeting of the Association for Practical and Professional Ethics for helpful comments and conversation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 For different interpretations of ‘interest’ in this context, see: Kulesa (2022).

2 These authors also present arguments against conscientious objection based on its idiosyncratic nature (Savulescu 2006; Schuklenk 2015), the unprovability of religious claims (ibid.; Schuklenk and Smalling 2017), and possible negative outcomes of denying services (ibid). Yet, all of these other arguments seem contingent on the success of the argument I have reconstructed here since, if it is not essential to the medical profession to provide legal services in the patient’s interest, then none of these other arguments carry weight. I focus on this argument since it is most central to their position.

3 Savulescu, Schuklenk, and Smalling also seem at points to implicitly assume as a further condition that a practice must be standard medical care (e.g., these services are ‘part and parcel of modern medical practice’ Schuklenk (2015)). As the next section points out, the most obvious reading of this condition would be the legal reading, where some service is a standard of care if another (minimally) competent physician would provide that service under similar circumstances. Making this implicit condition explicit will not change the above verdict concerning their view since some (minimally) competent physicians would prescribe puberty blockers in similar situations.

4 Thus, in what follows, it should be understood that the proposed condition of an increase in well-being must be jointly sufficient with the earlier definition to be considered a standard of medical care.

5 For the purposes of this paper, one can understand well-being according to any of the major three classes of theories of well-being: hedonistic theories, desire-satisfaction theories, or objective list theories.

6 Savulescu (2001) makes a similar claim about reproductive care.

7 The ‘does not detract from proper functioning’ should be understood as all-things-considered proper functioning. Clearly, chemotherapy detracts from proper functioning but, all-things-considered, the goal of chemotherapy is to eventually restore proper functioning.

8 A reviewer helpfully has noted that my proposal entails that some controversial practices do not count as standards of medical care. Some practices which would not be considered standard medical care, given this proposal, include elective abortions, infanticide, physician assisted suicide, euthanasia, torture, and female genital mutilation. On the other hand, this means that any practice which does not detract from the patient’s proper functioning is eligible to be considered (but not necessarily) a standard of medical care, such as aborting a fetus to save the mother’s life. This condition will be relevant for conscientious objection since, if we only protect refusals of procedures which violate a standard of medical care, then practices which prevent, reduce the severity of, or mitigate the bad effects of pathologies, will not be open to conscientious objection. For other cases of (sometimes) protected conscientious objections that this proposal would affect, see Rich (2015).

9 This claim places my view close that of Card (2017) and Eberl (2019), but differs in at least one crucial aspect: my position focuses on the reasonability of medical refusals based on the likelihood that a practice is conducive to proper functioning.

10 I only intend this expected medical utility calculation to compare procedures where at least one of them seems to induce a dysfunction. This is because the paper is not making a claim about deciding between two procedures where neither procedure induces a dysfunction (as both may turn out to be a standard of medical care). Nonetheless, medical professionals ought to consider comparing services which induce dysfunctions because standards of medical care are only required not to detract from all-things-considered proper functioning.

11 This is just an example of how similar quality of research could be determined, even though randomized control trials are impossible to study the efficacy of PBs on psychological well-being.

12 This places my view close to conscientious objection based on an internal morality of medicine (Pellegrino 2001; Hershenov 2020, 2021). One way my account differs from, or advances the claims of, such views is the emphasis on rational decision making.

13 I’m grateful to an anonymous review for pointing me to this comprehensive overview in Biggs (2022).

14 It’s also not clear to what extent children are able to consent to a medical intervention which has potentially far reaching and long-lasting effects (see: Latham 2022).

15 Contrary to de Vries et al (2014), Chew et al (2018) found that ‘the effects of GnRHas on anger and anxiety remain unclear with conflicting results’ (ibid). Another study found that prescribing GnRH analogues lowered the probability that individuals would entertain suicidal thoughts (Turban et al. 2020). Other studies conclude that global functioning increases for those who undergo treatment with GnRH analogues (Costa et al. 2015). However, this recent research is problematic. Biggs (2020) argues that Turban et al (2020), without any measures of psychological problems prior to the study, cannot establish any causal connection between puberty blockers and reduction in suicidal thoughts. Second, Costa et al (2015) finds no statistically significant evidence that prescribing this therapy actually does increase global functioning (Biggs 2019).

16 I’m grateful to Paul Hruz for conversation on this point.

17 Notice, given my account, it does not follow from a clinician’s being rational when she does not prescribe PBs that another clinician is irrational if she does prescribe such therapy. Given RANGE and the inconclusiveness of studies to date, another clinician may perfectly well assign a higher probability value to PBs alleviating dysphoria. She may cite those studies that suggest PBs are conducive to well-functioning. Thus, given RANGE and some relevant data suggesting that PBs contribute to well-functioning, a clinician can be rational when she does prescribe PBs. The flexibility provided by my account, I believe, effectively captures a range of actions clinicians can pursue in an area of medicine where results are still inconclusive or conflicting.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Ryan Kulesa

Ryan Kulesa is currently a PhD student in the philosophy department at the University of Missouri. His research interests include bioethics, metaphysics, and philosophy of religion.