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“Girls Need to Dance”: How Jewish Women Navigated Twentieth Century Dance Halls
Full text linkThis paper dives into the vibrant world of early 20th-century dance halls, where Jewish immigrant women in New York City found freedom, excitement, and a chance to redefine their roles in a rapidly changing world. While reformers saw these dance halls as dangerous, immoral spaces, the women who flocked to them saw something entirely different: a place to explore romance, flirtation, and even sexual autonomy, all while challenging traditional gender norms. This paper explores how these women used dance halls to assert agency, challenge traditional matchmaking, and experiment with new forms of romantic and social relationships. Drawing on historical analyses by Kathy Peiss, Randy McBee, Sonia Gollance, and Mary Odem, as well as firsthand testimonies and period literature, the study examines the tension between perceived moral dangers and the lived experiences of Jewish women who found pleasure, independence, and self-determination in these spaces. Through commercial amusements like the dance hall, Jewish women navigated shifting cultural boundaries, formed homosocial bonds, and exercised the newfound ability to select their own partners, helping to shape evolving notions of gender, sexuality, and social identity within New York City’s immigrant communities
Juries Judging Science
Full text linkContemporary jury trials often include complex scientific evidence that can be challenging for lay jurors to understand and evaluate. This Article examines the capabilities of jurors to comprehend and apply scientific evidence in both criminal and civil trials. It begins by summarizing existing research on individual and collective jury decision-making competence, describing both the cognitive processes that jurors use to evaluate trial testimony and the contributions of group deliberation. The Article then explores the specific types of scientific evidence that are most challenging for jurors, including scientific research methods, statistical information, and probability estimates. It also examines the influence of factors such as the nature of the presentation of scientific evidence in court and jurors’ pre-existing attitudes toward science. Finally, the Article proposes reforms to jury trials and the presentation of expert scientific testimony. These include active jury reforms such as juror notetaking, question asking, and discussions during trial, improved methods for presenting scientific evidence, and the use of tutorials to enhance juror comprehension. By addressing the challenges jurors face, these reforms aim to improve the accuracy and fairness of jury decisions in cases with scientific evidence
Book Review of "Educating for the Anthropocene: Schooling and Activism in the Face of Slow Violence"
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Confronting the Gap between Classroom Ideals and the Reality of Clinical Culture: A Student’s Perspective : Teaching What Isn't Taught: Developing Moral Courage in the Face of Medicine's Hidden Curriculum
No full textPhoto by Hush Naidoo Jade Photography on Unsplash
Abstract
This pair of narratives engages with the moral and emotional tensions experienced by a medical student and a faculty physician in the context of a clinical encounter involving an incarcerated patient. The student narrative recounts the discomfort and internal conflict provoked by witnessing behavior she perceived as racially biased and dehumanizing, alongside her uncertainty about how—or whether—to speak up. The companion piece, written by her faculty mentor, reflects on this moment through the lens of the hidden curriculum, arguing that medical education too often neglects to cultivate the moral courage necessary for such moments. Together, these essays illuminate the silent lessons of professional socialization, the limits of formal ethics instruction, and the urgent need to teach advocacy and moral agency as core components of clinical training.
Essay 1 of 2: Confronting the Gap Between Classroom Ideals and the Reality of Clinical Culture: A Medical Student’s Perspective by Isabelle Band
Case
A surgical resident ushers me, a medical student on her first day of third-year clinical clerkships, into the trauma operating room (OR) and whispers, “Inmate from Rikers. Stabbed four times. They need a student to help them retract.” The patient is JA, a 31-year-old man with no past medical history presenting to the emergency department at a public hospital in New York City, after sustaining a penetrating stab wound to the abdomen with omental evisceration. After stabilization, he is rapidly transferred to the OR for exploratory laparotomy.
Three surgeons surround the operating table where the patient is intubated and his abdomen dissected and splayed open from sternum to pelvis. Despite my earnest attempts at suctioning, blood decorates the team’s blue gowns and seeps into their socks and shoes. As the surgeons systematically “run the bowel,” sliding their fingers along every centimeter of JA’s small intestine, the scrub technician leans towards the intern and asks, “What happened here?”
The intern chuckles, “inmate from Rikers. Another stabbing, by another inmate! It’s all in his chart.”
After the bowel injuries are repaired, the attending surgeon removes his gown and gestures to the senior resident, “you got the rest, right?”
She nods. The resident offers me the opportunity to staple closed the incision. It is my first day on the surgery clerkship. The resident models the first few staples, then I take her place and close the remaining length of the wound. The scar is long and crooked, with poorly aligned skin edges in several places. “Good enough,” the resident says. “He won’t care if this looks good.” I leave the OR feeling uncomfortable, but do not mention the experience to anyone.
I had many sessions on professionalism and humanism in medical school, but none prepared me for this moment. What made it so hard for me to speak up?
Commentary
My medical school curriculum dedicated one day per week, during the first and second year, to humanism in medicine. The sessions often focused on the provision of compassionate and equitable care for vulnerable patients, including but not limited to those who are temporarily unhoused, incarcerated, or undocumented. These sessions inspired us. Professors discussed the harms of using stigmatizing language in the electronic medical record and how to write about patients with sensitivity. A panel of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) patients shared experiences of discrimination in healthcare and advised students on providing sensitive and patient-centered care. Small groups of students regularly reflected on systemic racism in the American healthcare system and discussed principles of antiracist medical practice.
As I started my third year and entered the clinical arena for the first time, I anticipated that the real patients I met would be afforded the same painstaking care and thoughtfulness as the hypothetical patients we had discussed in the classroom. Unfortunately, I quickly learned that exalted classroom principles, like confidentiality, devolved precipitously in busy hospitals. I most often witnessed this as seemingly innocuous gossip about patients, which casually floated through hallways and work rooms. Trainees on the trauma service traded shocking patient stories like pieces of bubblegum. During rounds, a resident whispered, “She woke up to her husband standing over her bed ready to stab her with a kitchen knife.” While genuine empathy for patients was usually expressed, I wonder what purpose recounting these narratives served and what harms these casual disclosures produced. Did it allow for the collective reflection on tragic cases? Or did it nourish egos as if to say, this tragedy befell this patient, but I was there to sweep in and save them?
In the classroom, I had learned to avoid talking about patients in hallways and elevators, and to exclude stigmatizing, medically irrelevant descriptors (such as “inmate”) from the electronic medical record and even from discussions with team members. Why were these teachings so readily ignored on the trauma surgery service? Perhaps the team assumed the patient had forfeited confidentiality when JA was admitted to the hospital in an orange jumpsuit, accompanied by a prison guard. Or maybe the team felt a general sense of helplessness against deeply entrenched societal inequities, such as mass incarceration and systemic racism, that had already set JA at such a disadvantage. What additional harm could be borne by gossiping about the only black body in the room, that also happened to be the only one naked and anesthetized? Or by allowing an inexperienced student to fumble with a stapler on a gaping abdominal wound?
Another justification for shirking ethical principles on the floors was that residents, attendings, and other care team members often felt exhausted and overburdened by a broken system. Studies show that high levels of stress and burnout are associated with decreased empathy.[1] Residents worked 24-hour shifts every three days. Given the low volume of nursing staff, surgical residents were expected to wheel patients to the operating room, place IV’s and draw labs. Their exhaustion was compounded by the fact that most of their patients were among the city’s most vulnerable, including incarcerated persons like JA. Pathologies were more often more severe, and patients needed considerable support to ensure they could be safely discharged.
My understanding of this context contributed to my silence in this unsettling situation. If I had spoken up, would the team assume I was questioning their moral judgment or accusing them of providing substandard care and respond defensively? Would I appear idealistic and naive, implying that the team had the time to debrief every case or the capacity to provide culturally sensitive care to every patient on their busy service?
I am not proud to admit it, but I also worried about my rotation grade. I had learned that a key ingredient to a good grade on a clerkship is getting residents to like you, which requires being perceived as helpful but also having situational awareness (i.e., knowing when to be quiet and get out of the way). My experience of feeling silenced was not unique; a 2005 study found that third-year medical students frequently avoided speaking up about ethical conflicts for fear of reprisal.[2] A more recent paper noted that trainees and clinicians most commonly perform professional misdeeds when they are forced to make quick decisions in heightened emotional states, or when they face toxic work environments or hierarchical pressures.[3] This is the clinical reality I had to navigate, yet I was not prepared.
Moral courage is defined as doing the right thing, or not doing the wrong thing, despite the risk of consequences to oneself or other barriers including hierarchy.[4] Speaking up, when discussions about social justice and ethics are discouraged or even dangerous, requires tremendous moral courage. A study about moral courage among residents at Northeastern academic medical centers found that women are less likely than men to act on their moral beliefs, likely due to gender-based differences of empowerment among trainees. Other findings were that interns were less likely to exhibit moral courage versus residents.[5] Subconsciously, I think that being both a woman in a male dominated surgical service and a student at the bottom of the hierarchy, contributed to my silence. Ethicists have suggested that the development of moral courage should be a formal objective in medical education.[6] Teachings should not only focus on the development of moral reasoning and moral courage but should also attempt to explain why many “good” people sometimes don’t do the right thing.[7]
I wished that my pre-clinical years had better prepared me for what was a jarring transition from the controlled preclinical environment to the unpredictable clinical setting. Rather than questioning the team in real time or asking to debrief JA’s case, I chose to discuss the case months later with a thoughtful and trusted mentor, who highly values humanism in medicine, antiracism, and ethical practice. Those conversations inspired this reflection, which I hope will resonate with other trainees who have similarly been disappointed with their transition to clerkships and have struggled to find their voice in situations that felt wrong.
Essay 2 of 2: Teaching What Isn't Formally Taught: Moral Courage in the Face of Medicine's Hidden Curriculum by Krishna Chokshi
Ethics is a fundamental component of clinical practice, shaping physicians’ identities and guiding interactions with patients and colleagues. As educators, we aim to instill in learners the virtues of compassion, empathy, respect, and humility. Though we explicitly teach the attitudes, perspectives, and values of trustworthy and ethically minded physicians, we often fail to prepare them for the reality of clinical practice, where these ideals are eroded by competing demands and a medical culture that sometimes contradicts them. To navigate this dissonance, students must cultivate moral courage—the capacity to uphold ethical standards despite potential personal risk or discomfort—and learn from negative role models.
As preclinical students transition to clerkships, we must prepare them to confront scenarios where their values are challenged. Learners are usually indoctrinated into the realities of clinical practice through immersive experiences, often without formal guidance and support about how to navigate uncomfortable, unprofessional, or unethical behavior. Accepting this gap in education as a “reality” is morally injurious, especially as learners develop their professional identities during this critical phase. Both learners and seasoned clinicians need support as they grapple with the disconnect between aspirations and daily practice.
Studies highlight that many students witness or even participate in ethically troubling situations, such as violations of patient dignity or procedures performed without adequate consent. A 2015 study found that up to 60 percent of students were involved in situations where they felt they violated a patient’s dignity or participated in a procedure without the patient’s consent, at their instructor’s request.[8] Another study found that fewer than half of students feel empowered to speak up about unsafe or unethical behaviors, likely due to the hierarchical nature of clinical teams, fear of retribution, and self-doubt.[9] Over time, this environment may desensitize learners as they progress into residency.[10]
One student’s account of her first day in clerkships is a powerful testimony to how witnessing indignity burdens the conscience.[11] Negative attitudes towards patients, whether communicated through gossip or stigmatizing language, violate our basic duty of respect. The student experienced moral injury, which “results from traumatic ruptures between what people do and who they are.”[12] Burnout, emotional exhaustion, and loss of meaning in work often stem from feeling complicit in doing the wrong thing or constrained from doing what’s right. Our silence speaks volumes to the shameful aspects of medical culture we fail to challenge. Unfortunately, learning to be a doctor is intertwined with learning to ignore, accept, or feel defeated by the unethical behavior we normalize.
While what was said in the operating room was harmful, the student’s internal struggle about how to respond was likely more distressing. Fear of repercussions or not knowing what to say often silences students and clinicians alike. Our healthcare culture does not support such courage for learners, trainees, or even seasoned practitioners. In a large multicenter survey, nearly 30 percent of physicians were reluctant to question authority.[13] This silence not only fuels moral injury and burnout, but also compromises patient safety and care quality.
Amid a morally fraught clinical environment, ethics education has increasing importance. It should teach not only ethical principles but also the virtues of compassionate, trustworthy physicians.[14] In the student’s case here, ethical “rules” clearly indicate a violation of the patient’s privacy, but a virtue ethics approach highlights the clinical team’s failure to show care or respect. Their racist and callous words had a profound impact on the student, suggesting that her ethics education successfully imparted ethical sensitivity and self-awareness. The issue wasn’t insufficient humanistic education, but a lack of tools to cope with the disappointment of observing unethical behavior from her seniors.
Outside the formal curriculum, the informal curriculum (“how we do things here”) and the hidden curriculum (the tacit culture of values and norms they observe) may more strongly influence learners’ development in the clinical environment.[15] This “null curriculum,” that which is not formally taught, is influential. A 2016 medical school graduation questionnaire found that more than half of all students observed behaviors that contradicted what they had been taught about professionalism.[16] In this way, medical training may undermine empathy and ethical commitment, giving rise to moral distress.[17]
While negative role models contribute to the disconnect, contradictions between stated institutional values and actual practices deepen this tension. Learners often observe that though their academic institutions exalt health equity, they support several practices that contribute to health disparities, such as a two-tiered system, affording better services to patients with more socioeconomic privilege. The hidden curriculum is evident not only in clinical interactions but also in how academic healthcare institutions treat patient communities and uphold – or fail to uphold – their mission statements.
While negative role models are problematic, they offer critical learning opportunities. Witnessing unethical behavior helps students define their moral boundaries and deepen their commitment to ethical practice. These uncomfortable experiences clarify personal values and sharpen ethical convictions.
Still, ethics education often fails to equip students to act ethically under pressure. We teach students to identify ethical issues but not to navigate the emotional and professional complexities of acting on them. Embedding moral courage as an explicit competency is essential. We must expose the hidden curriculum to counteract its effects. Educators should encourage students to feel comfortable speaking up - that is, to develop moral courage, the ability to do the right thing or not do the wrong thing, even in the face of competing self-interests. In this example, the student’s role was to be a learner, not a “watchdog” of good behavior. Speaking up in the moment, as she reflected, may have been perceived as arrogance or self-righteous behavior. The student did nothing wrong by remaining silent, but she needed a space to reflect with trusted role models. The learning environment did not support her enough. Was she given the chance to explore what this experience meant for her professional identity?
Despite widespread ethics instruction, defining goals and measuring the impact of such education remains a challenge, resulting in heterogeneous approaches across academic institutions.[18] Most curricula emphasize ethical knowledge and frameworks. Instructors may present clinical cases for analysis, but it is harder to foster reflective practice and real-world application. Small group, case-based learning supports this reflection, and these spaces can also promote leadership skills and confidence, skills that are necessary for moral courage.
Investing in the moral courage of our students will improve the culture and moral habitability of our organizations for physicians, learners and staff, and the quality of healthcare for our patients. Moral courage involves calling out harmful behaviors in others and in ourselves and is essential for cultivating future physicians who advocate for their patients and a more just system. Not surprisingly, few students feel comfortable critiquing someone else’s behavior compared to rectifying their own.[19] Learning to provide respectful and constructive feedback, however, is a lifelong professional skill and critical to reforming our troubled healthcare system.
How can medical educators foster environments that build moral courage?
Acknowledge the Hidden Curriculum: Be transparent about ethical challenges students will face - pressures to conform, the normalization of unethical behavior – so students are prepared and can develop strategies to resist.
Structured Reflection: Reflection helps students process difficult clinical experiences and understand their ethical values. Use narratives, discussions, or writing prompts to deepen ethical insight.
Safe Spaces for Ethics Discussion: As students encounter more clinical situations, they need ongoing forums to explore ethical dilemmas. Role-playing, real-world case discussions, and debates in safe spaces without fear of judgment can foster readiness and courage.
Active Role Modeling and Mentorship: Educators should demonstrate moral courage and reflect openly on their own experiences with ethical challenges. When students see their mentors take a stand for what is right, they are more likely to emulate this behavior. Longitudinal mentorship helps guide students through identity formation and moral growth and allows students to seek guidance when faced with moral dilemmas.
Skill Development: Teach students how to speak up through structured training (i.e., role-playing or with standardized patients), just as communication skills are taught.
Anonymous Reporting Mechanisms: Minor transgressions often go unreported, yet they shape toxic culture. Involve students in designing transparent and effective reporting systems.
Our learners will inevitably encounter moments where they struggle to do the right thing – whether that requires calling out a colleague, advocating passionately for a patient, or confronting their own moral commitments. Just as we train our learners to communicate clinical information effectively and compassionately, we need to prepare them to not only identify ethical action, but to also consider what acting ethically requires of themselves. Empowering learners to take ethical action – not just recognize it – is transformative. The development of moral courage should be a core competency in ethics education. To achieve this, we must shift from asking “What is the right thing to do?” to “How will you do the right thing?”
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[1] Galit Neufeld-Kroszynski, Keren Michael, and Orit Karnieli-Miller, “Associations between Medical Students’ Stress, Academic Burnout and Moral Courage Efficacy,” BMC Psychology 12 (May 27, 2024): 296, https://doi.org/10.1186/s40359-024-01787-6.
[2] Catherine V. Caldicott and Kathy Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal: Lessons in Ethics from Third-Year Medical Students,” Academic Medicine: Journal of the Association of American Medical Colleges 80, no. 9 (September 2005): 866–73, https://doi.org/10.1097/00001888-200509000-00018.
[3] Catherine V. Caldicott, “Revisiting Moral Courage as an Educational Objective,” Academic Medicine: Journal of the Association of American Medical Colleges 98, no. 8 (August 1, 2023): 873–75, https://doi.org/10.1097/ACM.0000000000005239.
[4] Caldicott and Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal”; “Measuring Moral Choices by Physicians: Standing up for Patients,” American Medical Association, August 3, 2016, https://www.ama-assn.org/delivering-care/ethics/measuring-moral-choices-physicians-standing-patients.
[5] “Measuring Moral Choices by Physicians.”
[6] Caldicott and Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal.”
[7] Caldicott, “Revisiting Moral Courage as an Educational Objective.”
[8] Lynn V. Monrouxe et al., “Professionalism Dilemmas, Moral Distress and the Healthcare Student: Insights from Two Online UK-Wide Questionnaire Studies,” May 1, 2015, https://doi.org/10.1136/bmjopen-2014-007518.
[9] Neufeld-Kroszynski, Michael, and Karnieli-Miller, “Associations between Medical Students’ Stress, Academic Burnout and Moral Courage Efficacy.”
[10] Alastair V. Campbell, Jacqueline Chin, and Teck-Chuan Voo, “How Can We Know That Ethics Education Produces Ethical Doctors?,” Medical Teacher 29, no. 5 (January 1, 2007): 431–36, https://doi.org/10.1080/01421590701504077.
[11] Katharine R. Meacham, “Preventing Moral Injury in Medicine: Student Physician Stories of Moral Distress, Alienation, and Moral Imagination
Being Heard: Thinking through Radio with Palestine (October 2023–)
No full textWe describe Radio With Palestine (RWP), a project that broadcasts live sounds from demonstrations. Reflecting on RWP as ongoing work, we are thinking about rhythms, temporalities and resonant spaces of direct actions as manifestations of political urgencies and injustices. Ecological radio moves live sounds from place to place, colliding timeframes and moments of emergent struggles, creating a live archive that aims to amplify and document ephemeral situations, without turning them into spectacles or specimens.
During RWP, people attend actions in support of Palestine and run live audio streams. Using free streaming apps and DIY audio devices with omni-directional microphones, RWP enacts a form of flat listening against the grain of mainstream media. Events vary from minor acts of resistance at neighbourhood scale to large, conventionally under-reported protests.
By drawing attention to how (different) these situations sound, we can think about the ways direct actions work beyond each site, with its distinct architectures, tempos and acoustics. Being in and broadcasting streets full of dissonant sounds and voices, hearing ourselves back with lag, we sense both the possibilities and the limits of synchrony / solidarity.
Notes on Contributors
Soundcamp (Sasha Baraitser Smith, Mortimer Drew, Grant Smith) are an arts cooperative based at Stave Hill Ecological Park in Rotherhithe and Work Shop 1 in Loughborough Junction, with members in Glasgow, Berlin, Yorkshire, Crete and The Netherlands. We are interested in diy infrastructures that can move live sounds between places and situations, and give attention to less heard human and non-human communities. Our work appears as live transmissions, workshops, sound devices and events
Introducing Second Language Assessment
No full textPublished by Cambridge University Press in 2025, Introducing Second Language Assessment by Gary J. Ockey, Professor of Applied Linguistics at Iowa State University, is a recent addition to the field of second language (L2) assessment. The book is aimed at educators, researchers, and students who are interested in gaining a general understanding of how language assessment works in theory and practice
Autonomy on Trial: Trust, Capacity, and the Doctor-Patient Divide in US Bioethics and Law
Full text linkPhoto by CHUTTERSNAP on Unsplash
Abstract
This paper critically examines how US bioethics and health law conceptualize patient autonomy, contrasting the rights-based, individualistic model dominant in American legal doctrine with relational, duty-oriented frameworks found in parts of Asia and Europe. Analyzing landmark US cases—Cruzan v. Director, Missouri Dept. of Health, In re A.C., and Addington v. Texas—alongside bioethics scholarship, the paper highlights both the strengths and limitations of a legalistic approach to medical decision making. Drawing on comparative literature from India, China, Singapore, and several European nations, it explores how familial, cultural, and institutional norms shape the exercise of autonomy abroad. The paper argues that the American focus on individual consent and procedural safeguards can undermine trust in clinical relationships and neglect the social dimensions of care. It ultimately advocates for a more pluralistic model that integrates legal protections with relational ethics and calls for reforms to capacity standards, consent processes, and advance directives that respect cultural values while upholding patient rights.
Introduction
Patient autonomy has long been regarded as a cornerstone of US medical ethics. It is enshrined in law and policy as the basic right of individuals to make decisions about their own health care. In practice, however, legal cases and bioethics debates reveal tension between a formal, rights-based notion of autonomy and the relational values that many patients and cultures embrace. This paper examines how US law and policy interpret and enforce patient autonomy in contrast to relational approaches found in much of Asia and Europe. By analyzing landmark US court decisions and bioethics scholarship, this paper shows how American law practice often treats autonomy as an individualistic, legalistic matter that can sometimes undermine trust in the doctor-patient relationship. By comparison, many Asian and some European models emphasize duties, family involvement, and communal values in decision making. Critics argue that the American approach can reduce patients to processors of information rather than complex persons with relationships and values. In practice, a legalistic checklist for informed consent may prevail, sometimes at the expense of trust and empathy.
In sum, US bioethics and law emphasize individual choice, formal consent, and evidentiary standards. The prevailing model assumes an atomistic patient who holds rights (and responsibilities) to demand or refuse treatment, shielded by due process. This approach certainly protects autonomy on paper, but it may neglect the social and cultural dimensions of decision making. Some bioethicists caution that we must ask whether “moral claims that ought to be made into legal rights” are better served by courts or by ethical dialogue.[1] Before turning to alternative models, we should acknowledge both the value and limits of the current, rights-based framework. It clearly delineates patient entitlements and uses legal procedures to safeguard choices, but it may also narrow the focus to rules over relationships.
Autonomy in US Law and Bioethics
In US health law, patient autonomy is largely enforced through formal rules about informed consent and decision-making capacity. Under American jurisprudence, a competent adult generally has a constitutional right to refuse medical treatment.[2] For example, in In re A.C., a DC court emphatically held that even a pregnant woman has “the right to refuse medical treatment for herself and the fetus.”[3] If a patient is incapacitated, courts attempt to honor her wishes, for example, by substituted judgment or by appointing a surrogate decision maker in accordance with state law. They do not consistently defer to the state’s interest in preserving life. Similarly, Lane v. Candura affirmed that a competent elderly patient “has the right under the law to refuse to submit either to medical treatment or a surgical operation” — a decision that, though deemed unwise by her physicians, could not be overridden absent a finding of legal incompetence.[4] Notably, however, conflicts still arise. In 2025, for example, a hospital in Georgia kept a brain-dead pregnant woman on life support for months to allow her fetus to develop, citing a strict state fetal-protection law[5] – an outcome that shows the discrepancy between DC caselaw and the Georgia statute. [6] These cases illustrate an emphasis on informed consent: the patient’s decision (or presumed decision, if competent) must prevail unless clear evidence shows incapacity or a compelling state interest. Yet the Georgia case may indicate a trend toward failing to respect autonomy.
The US Supreme Court has reinforced respect for autonomy while also permitting robust state oversight in borderline cases. In Cruzan, the Court recognized a federal constitutional right to refuse unwanted life-sustaining treatment. However, it also held that states may require “clear and convincing” evidence of the patient’s wishes before allowing withdrawal of care. American law treats autonomy as a fundamental principle but subjects it to procedural safeguards. Likewise, in the involuntary commitment context, the Court balanced individual liberty against state interests by mandating a clear-and-convincing standard of proof for committing someone to a mental institution.[7] In Addington v. Texas, the Court insisted that due process requires more than a mere preponderance of evidence before depriving a person of liberty for psychiatric care, yet it declined to impose the criminal “beyond a reasonable doubt” standard. These rulings demonstrate that American law approaches life-and-death health care decisions as matters to be resolved through formal legal procedures, applying rules of evidence and capacity assessments. This legal framing ensures a degree of rigor and consistency in protecting patients’ rights, but it also reflects the tendency to translate deeply personal and complex medical dilemmas into technical legal questions. Importantly, the point is not to dispute the right to refuse treatment; rather, patients have the tool of resorting to courts and invoking legal procedures to ensure their ability to exercise their rights and to investigate limitations on them. Clinicians and hospital systems also look to courts to resolve issues. Some scholars suggest that other, less adversarial approaches might equally protect patient choice while better addressing the human and ethical dimensions.
Observers have described this legalistic phenomenon as the “language of the law” infiltrating bioethics. “Americans today truly do resolve political — and moral — questions into judicial questions,” [8] adopting trial-style reasoning and formal rights-talk even in intimate healthcare matters. One commentator warns that law’s technical discourse may be “inapt” for addressing ethical concerns, and that the legal process can distort the meaning of concepts like autonomy.[9] Similarly, an influential framework for assessing decision-making capacity analyzes ability in strictly cognitive terms. Capacity is defined as the ability to (a) understand information, (b) appreciate its significance for oneself, (c) reason about treatment options, and (d) communicate a choice. These four domains, drawn from case law and psychology, form the threshold for valid consent or refusal. In the US model, a patient lacking capacity cannot make certain binding decisions; instead, a surrogate decision maker, often a family member, or, in some cases, a state-appointed guardian steps in. This rights-based framework has virtues of clarity and fairness, but as critics note, translating every serious medical decision into a legal checklist can overlook the human context of care.
International and Relational Perspectives on Autonomy
Across Asia and Europe, many healthcare systems cast autonomy in a more relational or duty-embedded light. Cultural traditions, legal norms, and ethical theories in these contexts often emphasize family, community, and physician responsibilities rather than treating the patient as a solitary rights-bearer. One scholar observes that the very “principle of respect for autonomy” originated in Western bioethics and may not fit seamlessly into other cultures. Indeed, many critics view individual autonomy as “only applicable in the West,” contrasting it with the family- and community-oriented decision making typical in Eastern societies.[10] Informed consent itself is often seen as a Western import that requires cultural adaptation. One ethicist calls for “glocal” flexibility—an Aristotelian “Lesbian rule”—allowing bioethical principles to bend to local contexts. This perspective suggests that autonomy must be understood in light of social roles and trust networks, not assumed to be universal by US standards.
In India, for example, bioethicists tend to “reject the primacy of autonomy,” instead empowering courts to protect vulnerable patients even against the wishes of patients or families.[11] In practice, families and physicians often make decisions collectively, and courts may override refusals of treatment in the name of preserving life. Notably, one study suggests the Indian model does not necessarily reflect grassroots values but is partly a product of colonial legacy and legal conservatism., The author of that study critiques a competing bioethics in which courts and clinicians frame social vulnerability as mere “sociomoral underdevelopment,” cautioning that paternalism can masquerade as protection.[12]
Elsewhere in Asia, similar themes appear. In China, traditional Confucian ethics emphasize familial harmony and deference to authority. One survey of Chinese clinicians and ethicists reported widespread acceptance of “benevolent deception” — doctors withholding information from patients to avoid distress, with the family’s blessing.[13] Likewise, a case study involving a Russian émigré patient in a US hospital illustrates how families from some non-Western cultures may ask doctors not to disclose a cancer diagnosis. The authors of that study advise clinicians to elicit patients’ own values first: in the case described, the patient chose to limit her own informational autonomy. This approach respects autonomy in a broader sense—allowing patients to defer to family norms—but it may seem counterintuitive under a strict Western model. In East Asia generally, the doctor–patient relationship is often understood as a partnership involving the family; autonomy is exercised through dialogue and trust among all parties rather than in isolation.
Even in highly Westernized Asian settings, relational norms persist. In Singapore, even relational autonomy has limits under Confucian influence. A 2015 study found that Singaporean patients and families generally expect doctors to lead decisions, and there is little appetite for fully independent choice. Attempts simply to graft Western shared-decision models have fallen short. Researchers argue that given the emphasis on familial duty, a more “authoritative welfare-based” decision-making approach (akin to a best-interest standard) may better reflect local values. In practice, Singaporean hospitals often view care as a communal responsibility. Japan, though economically and institutionally similar to Western countries, shares many features with East Asian models of autonomy. Its legal framework upholds patient rights with important caveats. There is, for instance, no clear legal right in Japan to refuse life-sustaining treatment unless death is imminent. Courts have acknowledged a competent patient’s wish to refuse treatment on religious grounds (such as a Jehovah’s Witness’s refusal of blood transfusions) as a personal right that must be respected, yet in practice, hospitals typically require advance directives or agreements, and if a life-saving intervention is deemed absolutely necessary, they may proceed unless the patient arranges care elsewhere. In general, many Asian models integrate family consent as normative and expect physicians to occasionally act in a paternalistic manner. This can strengthen trust and preserve social harmony, though it may also sideline the patient’s explicit personal wishes.
European countries, while part of the broader Western bioethics tradition and recognizing informed consent and patient autonomy, still vary in how these principles are implemented. One analysis identifies at least three “voices” in Europe: (1) a deontological Southern model in which doctors are bound more by professional codes, and patient autonomy —while recognized— has often been secondary to physician judgement; (2) a liberal Western model (e.g. Germany, the Netherlands, the UK), resembling the Anglo-American approach, where patient refusal rights are strongly upheld and balanced with clinical judgement in cases of limited capacity; and (3) a Nordic welfare model, which prioritizes universal entitlements and assigns decision disputes to public bodies. For example, Southern European constitutions once obliged patients “to maximize his or her own health and to follow the doctor’s instructions,” whereas in Western Europe, patients retain the right to override medical opinion, and Scandinavian countries focus on broad social support rather than individual rights. Even within Europe, then, ideals of social solidarity influence the meaning of autonomy.
French medical ethics historically emphasized duty over rights—physicians had a legal obligation to treat and inform, but patients’ refusals were traditionally subject to scrutiny. French law once allowed doctors to determine medical futility without patient consent. After major public controversies (e.g. the Vincent Humbert case), France enshrined an explicit patient right to consent or refuse treatment in 2002 (the Loi Kouchner). Germany, too, blends individual rights with a strong welfare-state ethic: patients may refuse treatment, but there is also a cultural ideal of Dankbarkeit (“gratitude”) and high trust in physicians. In the Netherlands, patient autonomy is very robust — Dutch law and practice recognize advance directives and even permit physician-assisted dying — but the system also stresses open communication and mutual trust between doctors and patients. Overall, Europe tends toward a more communal approach in practice. As one analyst notes, even in the West, health care is seen as a social contract: medicine requires physicians to treat patients “with professional respect, delicacy and [ensuring they are] not marginalized.”[14] This ethic of solidarity and respect suggests that autonomy cannot be fully separated from trust and professional duty.
In summary, non-American contexts tend to view patient autonomy not as an absolute individual right enforceable by courts, but as one value among others within a web of relationships. Family members often have formal or informal roles in decision making. Physicians are expected to act paternalistically at times, motivated by beneficence and social norms, which can strengthen the patient’s trust but may also sideline the patient’s explicit will. These models aim to preserve dignity and communal harmony, sometimes at the expense of individual self-determination.
For example, the United Kingdom’s approach can be seen as intermediate. British law strongly protects an adult patient’s right to decide, yet courts will intervene in certain circumstances to serve a patient’s best interests—especially for children or incapacitated patients. High-profile UK cases show both sides of this coin. In the Charlie Gard[15] and Indi Gregory[16] controversies, judges upheld doctors’ recommendations to withdraw life-sustaining treatment from a critically ill infant despite the parents’ objections, emphasizing the child’s welfare over parental autonomy. Conversely, in the matter of Ashya King (2014), the High Court affirmed that parents could pursue an alternative cancer treatment abroad for their child, stressing that the state “has no business interfering” with parental decisions absent a risk of significant harm.[17] These examples demonstrate that while autonomy is respected in the UK, it is not unchecked — it is balanced against social welfare considerations.
Table: Comparison of Autonomy Frameworks
Critical Comparison of Frameworks
The US model has clear strengths. It highlights individual liberty as a central value, protecting patients (and physicians) from coercion or abuse. It treats all adult, competent patients as equally entitled to make decisions, regardless of age, background, or social context. This formal equality can empower marginalized individuals against domineering relatives or paternalistic doctors. Moreover, precise legal rules provide a clear framework for resolving disputes, allowing judges to interpret rights and duties. The American legal model offers clarity and strong safeguards for individual choice.
Nonetheless, this model has notable weaknesses. First, the legalistic approach can transform a moral dialogue into an adversarial process. Framing a medical decision as a legal battle may undermine the therapeutic relationship. While many patients experience clinicians as trusted partners, overly procedural interactions — particularly around consent and capacity — can make the encounter feel impersonal or even adversarial. For example, when a patient’s decision-making capacity becomes an issue, the standard criteria reduce the assessment to a checklist of cognitive abilities, which may ignore important personal factors like the patient’s trust in their doctor or their spiritual values. In sum, a rigid focus on procedures and evidence can strip away the empathetic, human element of clinical encounters.
Second, while meant to protect patients, high procedural and evidentiary standards can sometimes appear insensitive or even cruel. The insistence on “clear and convincing” proof of a patient’s wishes, though legally prudent, imposes a heavy burden on families already in crisis. In the Cruzan case, for example, Nancy Cruzan’s parents had to present formal evidence of their daughter’s desire to refuse life support despite their intimate knowledge of her beliefs. This protracted legal ordeal added to their suffering. Such strict requirements may inadvertently create a gap between what patients truly want and what the law will allow, delaying compassion and closure for families.
Third, an exclusive focus on individual rights can undercut communal support and narrow the physician’s role. When doctors are trained to prioritize autonomy above all, they might see themselves only as technical providers or expert witnesses, rather than as compassionate counselors or moral guides. Traditional notions of solidarity and a duty to care are sidelined. Some observers lament that an atomistic emphasis on choice can “abandon patients to their ‘rights’” meaning patients are left on their own to make harrowing decisions with minimal guidance or support.[29] In the US, there have been concerns about clinicians strictly following the letter of the law when seeking informed consent and thereby failing to engage with patients in a humane, relational manner.[30] The patient may technically have the right to choose, yet feel isolated or unsupported in exercising that right.
By contrast, duty-based and relational models emphasize trust, context, and mutual obligations. A key strength of these approaches is that they can foster a deeper sense of care. When families and doctors work together, patients often receive more comprehensive support and reassurance. The idea of doctors and nurses as moral guides rather than just service providers can build confidence. A truly patient-centered system means not simply upholding abstract rights but treating patients “with professional respect, delicacy and [ensuring they are] not marginalized.”[31] This ethos recognizes that many patients prefer to share decision making with trusted clinicians or family members. Indeed, when patients feel cared for by a trustworthy team, they may be more satisfied and less likely to resort to legal action. Relational models also better accommodate cultural diversity, as they allow for scenarios such as an Indonesian or Chinese patient’s preference not to be told bad news directly, or the South Korean deference to elders in family decisions, without reflexively labeling these choices as violations of autonomy. A collectivistic interpretation of autonomy can thus “maximize beneficence and trust within the patient–doctor relationship,” as one scholar suggests.[32] In public health crises or communal cultures, duty-based ethics may even help societies coordinate more effectively by stressing cooperation and communal well-being.
Yet duty-oriented models have downsides as well. Most notably, they risk paternalism and abuse. When the doctor’s or family’s duty is given primacy, patients may feel coerced or unheard. The acceptance of “benevolent deception” by some clinicians in East Asian contexts illustrates how easily trust can slide into withholding information: if doctors routinely decide not to tell patients the whole truth “for their own good,” who judges when that crosses the line into violating patient dignity? Similarly, requiring surrogate or family decision-making without clear patient input can lead to outcomes the patient herself would not have wanted, as one Indian ICU study showed.[33]
Relational models also tend to assume harmonious family dynamics; in reality, families can have internal conflicts or even financial interests that sway decisions. Critics point out that an overemphasis on community can end up suppressing individual autonomy in harmful ways.
Another challenge is inc
Is "Gender-Affirming Medical Care" Any of These? Defining Affirmation, Medicine, and Care in Context
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Abstract
This article examines the contested phrase “gender-affirming medical care,” now common in legislation, litigation, and clinical guidance. It analyzes the term’s three components — affirmation, medicine, and care — and asks what each requires in ordinary clinical practice, drawing on classical and contemporary philosophy-of-medicine frameworks. The article argues that the bundled expression often obscures more than it clarifies: “affirmation” is treated as will-realization rather than truth-recognition; “medical” is invoked where interventions compromise rather than restore bodily function; and “care” is reduced to consent-compliance rather than fiduciary beneficence. The analysis is conceptual, not prescriptive. Its aim is to disaggregate a rhetorically powerful composite into concrete clinical acts, monitoring obligations, and claimed benefits so that ethical and policy debates can proceed on clearer terms. By testing the phrase against its own parts, the article shows that it often fails to meet the minimal thresholds of each and calls for greater precision in medical language.
Introduction
Legislation, litigation, and professional guidelines increasingly turn on contested medical terminology, including what is commonly referred to as “gender-affirming medical care,” a term that now appears in state statutes, court opinions, and policy statements from leading medical associations. Yet it carries more than descriptive weight. The term embeds assumptions about truth, medicine, and beneficence that shape the debate from the start.[1] Before law and policy can meaningfully engage the merits of such interventions, the terminology itself warrants examination, both for its legal implications and for the persuasive force it carries in public debate. The point is underscored by United States v. Skrmetti (2025), in which the US Supreme Court addressed state restrictions on pediatric gender-transition interventions.[2] While this article does not engage the legal arguments of that case, the ruling illustrates how “gender-affirming medical care” (and similar formulations) has become pivotal not only in professional discourse but in constitutional adjudication.
Beyond its legal salience, this phrase now frames public and professional discussion of medical interventions. It is rhetorically potent: “affirming” suggests truthfulness, “medical” implies scientific legitimacy, and “care” evokes benevolence. Each term carries a weight of meaning that can, and should, be examined. This is not a mere semantic exercise; in bioethics, precise definitions are essential to consistent standards, equitable treatment, and informed policy. Without them, policy and clinical standards drift, at the patient’s expense.
The interventions covered by this expression range from puberty blockers and cross-sex hormones to surgeries that remove healthy organs or construct new anatomy.[3] Even their most indisputable consequences are often little known outside clinical circles. Long-term hormone therapy can impair fertility[4] and typically entails ongoing medical monitoring; after gonad removal, continued sex-steroid replacement is required indefinitely to avoid hypogonadism-related harms.[5] Surgeries are irreversible and permanently eliminate the capacities of the organs they remove.[6] In many cases, these interventions disable or alter normal bodily functions and commit the patient to long-term — often lifelong — medical follow-up.[7]
The analysis treats each element of the term to show that it falters under both widely used, practice-oriented accounts in the contemporary philosophy of medicine and the more comprehensive classical philosophical account of the person as an integrated unity of body and soul. While the clearest ethical concerns involve pediatric care (including questions of consent), the conceptual thresholds implied by the phrase are often unmet even for adults. The three components overlap in practice: affirmation, medicine, and care are not completely separate domains. However, this article approaches them singly, allowing each to be tested against its own criteria before considering their interrelation.
Is It “Gender-Affirming”?
To “affirm” something is to recognize and confirm it as true. In clinical settings, affirmation may take the form of reassurance, validation, or support, but the underlying structure is the same: affirmation aligns with reality, not against it. If a patient with severe protein-calorie malnutrition insists “I am overweight,” treatment that affirms the claim is not an act of truth-telling but of collusion in error.
In the classical philosophical-anthropological tradition, the human person is understood as an integrated psychophysical unity — often described in that tradition as a unity of body and soul — and sex is not an accessory but a fundamental determination of that unity. To affirm someone as the opposite sex is to deny this integral wholeness. Contemporary realist accounts also underscore this point,[8] arguing that gender is the lived form of a sexed body: the social reality of a body already determined as male or female, not a free-floating psychological construct detachable from the organism to which it belongs.[9]
One recent account observes that our modern technological imagination quietly shifts the meaning of affirmation itself. Once, to affirm was simply to take the world and the body as given. Now the given is treated as raw material for the will, to be reshaped until it matches desire.[10] By this logic, one affirms not by recognizing what is, but by bringing what is into conformity with what is wished. The word remains, but its meaning is inverted: what once denoted truth‑recognition now denotes will‑realization. This plays out in self-help and motivational literature.
Even bracketing these philosophical commitments, gender‑affirming falters under conceptually minimal analysis and ordinary clinical terms. Affirmation treats its object as true. In medicine, when a truth-apt clinical claim is at stake, warrant ordinarily rests on tests, examinations, and findings that stand apart from the patient’s own report. With gender identity, diagnostic standards rely on reported incongruence and associated distress over time rather than on objective tests or biomarkers.[11] Yet medicine cannot operate on self‑report alone when reality is disputed: “I have a fracture” begins, not ends, inquiry.
The same point becomes evident when we shift from words to procedures. Performing a vaginoplasty on a healthy male body does not make it more like a healthy female body, although postoperatively, the two will superficially share the absence of a penis and testes. Rather, this simply disables the male; it does not confer female-specific reproductive anatomy, physiology, or function.[12] The alteration is merely morphological. Such interventions are not only non-affirming but positively pathological on function-based accounts.
Counterarguments
Proponents may assert that the term affirmation reduces stigma and builds therapeutic alliance; respectful language matters. As noted above, however, in clinical practice, affirm ordinarily denotes truth-recognition rather than a presumption of correctness. Respect and alliance are compatible with assessment; they do not require presuming the truth of contested claims. If affirm is used only to describe an interpersonal demeanor, then it is distinct from the clinical question; by contrast, in policy and protocol contexts, gender-affirming often functions as an outcome-preferring label that tends to make identity-congruent interventions the default, although access is filtered by eligibility criteria.
Some have cited neurobiological studies to argue that transgender identity is grounded in biology, claiming that certain transgender individuals have brain structures more similar, on average, to the opposite sex.[13] Yet even setting aside the methodological limitations of such studies,[14] these findings concern group averages, not diagnostic markers. They are equally compatible with a simpler conclusion: male and female brains each span a range, and some individuals cluster toward one end without ceasing to be their biological sex. Because the distributions substantially overlap, average differences do not support individual-level classification or brains to be swapped across bodies; they only show that not all members of a sex are identical. Even if such correlations were consistent, they would not establish that gender can be defined apart from the sexed body.[15]
Another counterargument is that in contemporary usage, gender simply means identity, so to affirm gender is to affirm self-identification.[16] But that is a change in usage, not a refutation. If gender is defined to exclude the body, then of course affirmation need not track the body — but only by abandoning the term’s embodied referent. That shift is semantic, resolving the dispute by redefinition rather than by argument.
Is It “Medical”?
To call something medical is not merely to note that clinicians perform it or that it uses surgical or pharmaceutical techniques. In both classical and modern accounts, medicine is the art and science of restoring or preserving health. From Hippocrates to Aquinas[17] to contemporary philosophers of medicine, the practice is directed toward diagnosing, preventing, and treating disease or injury to maintain or restore proper bodily functioning. Even accounts that present themselves as value-neutral rest on some conception of health as an objective good to which interventions must be answerable.[18]
One influential biostatistical account defines health in terms of how well an organism’s parts function, relative to species-typical norms.[19] Disease, in this framework, is a measurable departure from those norms that lowers the odds of survival or reproduction. On this view, interventions that damage or remove organs in sound working order — such as sterilizing gonads or amputating breasts without pathological cause — produce disease.
In contrast, a widely discussed normativist account defines health as the ability to achieve one’s vital goals in standard circumstances.[20] A desire to occupy the social role of the opposite sex is intelligible as a psychological phenomenon. Lacking the bodily sex-specific characteristics of that role, however, does not constitute a pathology; nor does the normative account require medicine to pursue any self-reported goal that conflicts with actual capacities.[21]
Medicine rightly encompasses not only curative and preventive aims but also palliation and the relief of suffering. Analgesia, hospice care, and psychiatric interventions are part of medicine’s vocation, even when they do not restore lost functions. But even here, proportionality and evidentiary standards apply: the greater the irreversibility and loss of baseline functions, the stronger the justification required that benefits are durable and outweigh foreseeable harms.
Gender-transition procedures are generally not aimed at curing or preventing disease. They alter healthy bodies to fit a self‑reported identity, often by disabling or removing normally functioning organs. The resulting loss of fertility, sexual function, and other capacities is often integral to the desired phenotype, not an incidental side effect.[22] This differs from most accepted interventions, where impairment is an unfortunate trade-off for treating pathology. Given their aims and effects, whether such procedures can rightly be considered medicine in the ordinary sense is doubtful. Medicine typically resists altering or removing healthy organs in conditions such as body dysmorphic disorder or body integrity identity disorder, where the problem lies not in the organ but in perception or identification. The therapeutic aim is to address the discordance, not to make the body match the disordered image. This is not to equate gender dysphoria with either condition; the narrower point is that in all such cases the bodily structure is not diseased, and the mismatch lies between body and self‑concept. Historically, medicine has sought to resolve such mismatches by addressing the self‑concept, not by impairing healthy anatomy.
These philosophical concerns find a practical counterpart in recent independent evidence reviews. The UK’s National Institute for Health and Care Excellence (NICE) has examined puberty blockers and cross-sex hormones,[23] and the Cass Review, incorporating and extending those reviews, has independently evaluated gender identity services for children and young people.[24] All concluded that the research base for pediatric gender-transition interventions is of very low quality and insufficient to establish safety or long-term benefit.[25] Against that backdrop, a procedure does not become medical by virtue of who performs it or how skillfully; it becomes medical by what it aims at and what it accomplishes. Where the aim is not the restoration of healthy functioning, and the accomplishment is to compromise it, the description as medical does not hold, and the practices fall outside what medicine, in its ordinary sense, is understood to encompass.
Counterarguments
Some treat the recognition and endorsement of gender-affirming medical care terminology by professional associations as dispositive. Once major bodies use the label, the classification of the relevant interventions as medical is deemed settled. For advocates, such endorsements may appear to decisively buttress claims of safety and long-term benefit. But the value of such appeals to authority turns on independence, representativeness, and transparent methods; policy statements, often issued by small committees and subject to advocacy influence, falter under this standard. By conventional criteria, such statements are generally accorded less evidentiary weight than reviews that spell out how they searched, what they included, and how they judged the strength of evidence.[26] Policy statements can standardize vocabulary, but labels alone do not legitimize the term. Similarly, even where it exists, consensus may follow evidence but does not raise its quality.
Some will point to cosmetic surgery to show we accept non-restorative alterations as medicine. Yet cosmetic surgery already sits somewhat uneasily in the medical tent. Some of it is reconstructive, but much is ornamental, tolerated more as a cultural concession than as part of medicine’s central art. Yet cosmetic surgery does not ordinarily ablate sex-specific reproductive structures or impose lifelong medical dependence. Even when medicine sacrifices healthy tissue, the loss is accepted for the sake of preserving health. Gender-transition surgery is different: it effectively treats the sacrifice itself (fertility, sexual function, intact organs) as the remedy. Medicine can accept loss for health’s sake; it cannot redefine loss as a cure. If elective cosmetic surgery is near the border of medicine, transition procedures are well past it. In such cases, the Hippocratic imperative to avoid harm remains a vital ethical boundary that preserves the good of the whole human being in the integrity of body and person.[27] The point is not to withhold care, but to ensure that interventions genuinely promote patient health and well-being by standards that medicine applies to all patients, regardless of the condition.
Others may argue that experiencing one’s sexed body as incongruent can precipitate depression or anxiety, and that relieving suffering is a medical aim; they may contend that psychiatric diagnosis often relies in part on patient reporting. But diagnosis does not dictate proportional treatment. Self-reported distress can warrant psychosocial and psychiatric care. Supportive families, schools, and clinics may ease that distress. But that is distinct from the causal claim that transition-related interventions improve long-term, hard outcomes — and, absent strong evidence of durable benefit, such distress is a weak justification for irreversible procedures that disable healthy function absent strong evidence of durable benefit. Concerns about diagnostic expansion and medicalization only heighten the need not to let a label do the justificatory work.
Is It “Care”?
Even if gender-transition interventions could be classed as medical, a further question remains: do they meet the moral obligations that make medicine an act of care? Medicine, at its best, is not merely a technical service but a fiduciary relationship ordered toward the patient’s good. In clinical ethics, care implies technical competence, fidelity to the patient’s welfare, prudence amid uncertainty, and a commitment to avoid harm.
The duty of care[28] also includes proportionality: the scale and irreversibility of the intervention should bear a reasonable relationship to the certainty and magnitude of the expected benefit. When interventions remove healthy organs, impair fertility, or carry significant lifelong medical burdens, this proportionality threshold rises. In other domains of medicine, life-altering interventions with no return path are reserved for conditions that pose a clear and present danger to life or long-term health, anchored in strong evidence of benefit.[29] Under low-certainty evidence, best interests favor least-restrictive means first, with irreversible options reserved for clearer indications.
Within the classical tradition, care is a moral orientation toward the patient’s good, not merely the execution of a chosen procedure. Modern philosophy of medicine retains this orientation in, for example, an emphasis on beneficence within a covenantal relationship[30] and an account of medicine as a moral community.[31] Both approaches resist reducing care to technical provision or choice.
A further component of care is safeguarding against transient cultural pressures or institutional ideologies that may not align with patient welfare. The fiduciary role obliges clinicians to distinguish the patient’s interests from those of third parties and to resist conflating affirmation of a stated identity with the pursuit of the patient’s objective good. In gender-transition interventions, this includes recognizing that rapidly shifting cultural narratives, peer influence, or institutional commitments that do not necessarily track long-term clinical benefit may shape demand. Recent increases in referral rates and changing patient demographics in multiple countries underscore this.[32] Agreement with a self-description does not, by itself, justify irreversible alterations to intact anatomy.
To provide care is not merely to comply with a request or endorse a belief, but to act in ways proportioned to benefit over a life. Where evidence is weak, risks are high, and alternatives exist, proceeding is better described as service provision than as care in the richer ethical sense.
Counterarguments
Some argue care consists in respecting patient autonomy and that honoring requests is itself care. Informed consent is necessary but not sufficient; agreement alone does not make an act one of care. Valid consent requires understanding benefits and risks, key uncertainties, and available alternatives, including nonmedical options. In the context of gender-transition procedures, especially for minors, these conditions are often contested, and independent reviews have judged the evidence base low-certainty.[33] Where the evidentiary basis is uncertain, proceeding is not automatically an act of care simply because the patient or guardian agrees.
Reducing the essence of care to compliance with patient wishes treats care as though it were commerce, where the transaction is complete when the request is met, regardless of the long-term cost to the buyer. Autonomy, while essential, is not the sum of clinical ethics; it is bounded by non-maleficence, beneficence, and professional standards. Patients might request what is not in their interest, and clinicians have no ethical duty to comply simply because of a request. In fact, refusing foreseeably harmful interventions can be an exercise of respect for autonomy rightly understood — in fiduciary terms, the autonomy of the whole person over the course of a life, not the immediate choice of a moment. Respect for autonomy also includes protecting patients from choices that outstrip the evidence base for risks. This is neither refusal of care nor paternalism, but fidelity to the patient’s long-term good under uncertainty.
Others will appeal to measures of patient satisfaction, noting that some individuals report relief or happiness after intervention. Yet satisfaction is not identical to welfare; by itself, it cannot establish that the intervention was in the patient’s long-term interest. Patient-reported outcomes and lived experience are important for follow-up and for understanding subjective well-being, but they do not replace evidentiary or proportionality standards when risks are substantial or losses are nonrecoverable. In other domains of medicine, satisfaction is weighed against objective outcomes and foreseeable harms.
Conclusion
The label gender-affirming medical care subsumes three claims at once: that the interventions affirm what is true, are medical in aim and effect, and constitute care. Where those claims cannot be shown, the label obscures more than it clarifies and risks confusion in clinical decision-making.
Having tested the phrase by its own terms, the inconsistency that emerges is not merely semantic but practical. In medicine, language is part of practice. Terms shape what clinicians look for and how patients understand themselves. They also narrow which actions seem reasonable or obligatory. Bundling the three terms tends to insulate eac
Generating the Mapping Class Group: A Geometric, Algebraic, and Historical Survey
Full text linkThe aim of this thesis is to examine a problem that lies in the intersection of geometry, algebra, and the history of mathematics—the generation of the mapping class group. The group is a useful algebraic invariant of geometric surfaces. Given any surface, its mapping class group is the collections of distortions of the surface (smooth or topological) that preserve orientation, boundary points, and irregularities such as punctures or marked points. As Birman’s remarks imply, the study of the mapping class group draws together concepts from geometric and algebraic topology. To understand the algebraic structure of this group, we need to understand how distortions act on a surface up to isotopy. The ‘point pushing map’ and Birman exact sequence, which Birman proved in her doctoral dissertation in 1968, provides a case-in-point. Her work and subsequent research in this field relies on a combination of visual intuition and algebraic machinery—the relationship between which has long preoccupied the history of mathematics. This thesis will examine a specific aspect of this research—the generators of the mapping class group, i.e. the smallest set of distortions from which we can obtain the entire group. Our aim is to demonstrate that the mapping class group of a surface is generated by Dehn twists, which are a particular distortion obtained by cutting a surface about the neighborhood a curve, twisting the cut-out component in a full circle, and gluing the components back together again