In two preceding posts the students in my Medical
Ethics course learned that, because of hormonal imbalances early in the
development of a fetus, a child can be born with genitals that do not match its
actual sex—that is, its sex as determined in totality by its genes,
chromosomes, hormones, incipient general anatomy, and psyche.
That explained why the child in their case
study, a girl from India, grew breasts and started menstruating at age 14 even
though she had a penis and had been raised as a boy.
The parents insisted the doctors in New York perform
immediate, radical, and clandestine "corrective" surgery, including
removal of the girl's ovaries and mammary glands.
They wanted the doctors to restore their
"son" to them. And they wanted the child never to know she was their
daughter.
As a practical matter, sex alignment surgery is
not an off the shelf procedure that can be cobbled together on a quick trip to
New York. But that day the students were focused solely on the medical
ethics of the case.
They had to tackle this question: What is the correct ethical choice for the doctors to make in the case, and why is it correct?
Opinions don't count
The students were not invited to give their personal
opinions. They had to declare, then explain in the language of medical ethics, the
answer that would be marked correct when they took the U.S. Medical Licensing
Exam.
More than passing a test was at stake. Later,
when they were practicing physicians, that same answer would bind medical
licensing review boards.
Here are three possibilities:
(a) The doctors should
respect the cultural values of the foreign parents and perform the surgery. The
parents have full authority to make medical decisions for their minor child.
(b) The doctors should
propose instead to perform corrective surgery to match the girl's genitals with
her actual sex. That would involve removing the penis and replacing it with a
surgically constructed vagina.
(c) The doctors should advise the parents to
delay any irreversible action until tests confirm the true sex of the child;
until the medical options have been determined; and until the child is
sufficiently knowledgeable to participate in the decision.
Which action is ethically correct?
Choice (a) is incorrect.
Doctors should of course respect other peoples'
cultures. But they have no obligation to deliver medical treatment that violates
their own cultural and ethical values.
And while parents are empowered to make medical
decisions on behalf of their minor children (under 18), they are not allowed to
make bad medical decision for their
kids. If, for instance, doctors agree a child needs recognized medical care,
and the parents refuse, they can be charged with child neglect.
Choice (b) is incorrect.
Doctors can refuse to perform medical care that
violates their own values. However, they are not allowed to proactively impose
their values on others. They should present the medical alternatives and explain
the risks and benefits of each. The patient or surrogate decides.
(Note. Not that long ago some physicians,
though acting with good intentions, routinely followed an unethical practice in
the delivery room. When a child was born with non-standard genitals, they tried
to “correct the defect” with immediate surgery, even sometimes without
consulting the parents. Better protocols are in force today.)
Beneficence and Autonomy
The ethically correct choice is described in (c).
Doctors are required above all to provide beneficent care. At this point in the
girl’s life, either choice—surgically making her into a him, or him into a her—would seriously harm the patient. Neither choice would render the
girl any medical benefit.
After beneficence, patient autonomy is the second foundation of medical ethics. The
parents were asking the doctors to violate the child's autonomy as an individual. The doctors must
avoid the same error. The decision will affect her life profoundly. Ultimately
the choice should be hers.
NEXT POST:
Waves Don't Quit
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