Help! I think I’m a Deontologist

Why I am categorically opposed to the Puberty Blockers Trial

I learned a new word the other day: ‘deontology’, or ‘deontological ethics’. I came across it in Ian Hacking’s excellent book, Rewriting the Soul – Multiple Personality and the Sciences of Memory. Fans of philosophy are probably already familiar with the term, but it was pleasingly new to me. It has helped me make sense of some of my thoughts about the PATHWAYS puberty blocker trial, which we learned this week will begin recruitment in August.

Hacking defines deontological ethics in opposition to ‘utilitarian’ or ‘consequentialist ethics’ in a chapter of his book about child abuse. In his own words:

Consequentialism assesses whether an act is good or bad in terms of its consequences. Deontology urges that there may be categorical imperatives to do, or refrain from, certain acts, regardless of their consequences.

I’m sure most of us instinctively feel that we are deontologists when it comes to a primal wrong like child abuse. As Hacking puts it, child abuse is an “absolute evil”. We don’t need to provide cast-iron evidence of negative consequences in order to assert that it is always, without exception, wrong to abuse a child.

Nonetheless, what Hacking skilfully demonstrates is how highly we prize consequentialist arguments, and how often we default to a consequentialist position, almost without realising we’re doing so. He questions the research claiming to show that childhood trauma inevitably leads to mental health problems, psychosocial difficulties, and poor life outcomes, in paragraphs that make for distinctly uncomfortable reading. Conceding the consequentialist argument and allowing that child abuse may have fewer negative consequences than is generally supposed feels disturbingly close to conceding the moral argument altogether. As I am sure Hacking intended, I found myself anxiously wondering what my opposition really consisted of, if there was no evidence of harm.

But, from the deontological perspective that Hacking adopts, ‘bad results’ are irrelevant to deciding whether child abuse should be unequivocally opposed. In fact, he argues that the search for ‘bad results’ with which to pad out a dodgy consequentialist argument may even be a distraction from what really matters:

Many child abuse activists who ought (in my opinion) to be deontologists, attending to the absolute evil of child abuse, are in practice consequentialists, trying to discover bad results of such acts.

I have spent two years making consequentialist arguments against the PATHWAYS puberty blocker trial. I’ve articulated the ‘bad results’ of puberty blockers so many times and in so many different ways that I could recite them in my sleep: osteoporosis, cognitive impairment, sexual dysfunction, infertility, worsening mental health, ‘locking in’ an identity that is transient for most young people…We have yet to pin down the precise incidence and magnitude of these harms, but they are consistently evidenced in the research we already have.

Like so many others, I have endlessly recited these harms in reports, briefings, podcasts, open letters, and articles. I even helped author Genspect’s Memorandum of Understanding on Protecting Puberty. I’ve debunked the asinine claims made by supporters of the trial about things like suicide and precocious puberty, and I have always tried to keep detransitioners front and centre in my advocacy. Their devastating experiences of regret and remorse represent, in my view, the most damning proof of all that medically transitioning minors can have dreadful consequences.

The evidence of ‘bad results’ from pediatric medical transition is mounting day by day, and it seems to me that on any fair assessment, we have won the consequentialist arguments. This is a failed medical intervention, as my Genspect colleague Dr Stella O’Malley has repeatedly said. Yet we have still been unable to prevent the puberty blocker trial from going ahead.

Partly this is because there is just enough ambiguity in the existing evidence base to allow supporters of the trial to adopt a consequentialist position of their own. In their view, it is not prescribing puberty blockers that leads to negative consequences, and they cling to this conviction with just as much fervour as we, their opponents cling to our own. Combine this with the fact that the authorities responsible for the trial have flatly refused to engage with the substantive arguments of their critics, and you can see how we have arrived at our present unedifying state of consequentialist deadlock.

Are critics of the puberty blocker trial at risk of making the mistake identified by Hacking, of clinging too tightly to the consequentialist position for fear that conceding it might tacitly legitimise the very thing we are trying to oppose? Something that has been much on my mind is what the trial is likely to find should it go ahead. It will not run for long enough to detect the most pernicious harms of puberty blockade, including detransition and regret.

As Helen Joyce, Director of Sex Matters, has pointed out, the trial has effectively been designed to test whether children who really, really want something are happy when they get it and sad when they don’t. When it turns out (shockingly) that they are, tedious consequentialist arguments about the weighting of harms and perceived benefits will have to be had all over again. In many ways, it feels as though we have reached the limits of what evidence-based medicine can actually achieve as a decision making framework.

I am not suggesting that we abandon consequentialist reasoning altogether. It is right and good that health professionals and medical researchers, like my colleagues at the Clinical Advisory Network on Sex and Gender (CAN-SG), should continue to document the harms associated with paediatric gender medicine. Politicians and journalists who speak out against the trial must be well-briefed and conversant with the technical issues in order to go toe-to-toe with its supporters. What Hacking has made me wonder is whether we have underestimated the broader popular force and impact of pure deontological opposition. I tried to articulate this in a social media post about the Data Linkage Study earlier this week:

I am begging critics of the puberty blocker trial to stop getting lost in the weeds, arguing about research ethics, Gillick competence, informed consent, fertility preservation, and the like. The NHS’s refusal to complete the Data Linkage Study (DLS) before proceeding with a new trial is the ONLY argument worth making on this issue…The fact that the NHS is getting ready to run a live experiment on vulnerable children before it has even established the fate of those it has already experimented on is utterly damning…Critics of the trial must stop fighting on their opponents’ turf by quibbling over technical details. We need to relentlessly force the DLS onto the agenda and expose the shameful hypocrisy of the NHS.

I was trying to say that we should have the confidence to move away from the consequentialist discourse we are presently mired in. Completing the DLS should be a categorical imperative of the kind that Hacking locates at the centre of deontological ethics. It is irrelevant whether the puberty blocker trial is, technically speaking, a ‘good’ trial. There can be no excuse for proceeding with it before the DLS is completed. Exhausting every means of finding out what has happened to the generation of children already subject to experimental puberty blocking treatment is, in a very straightforward and commonsense way, simply the right thing to do.

I think we should probably be careful about how many deontological beliefs we acquire. If all your ethical commitments are founded on ‘categorical imperatives’ for which you require no objective proof, then you are likely to end up just as intolerant and close-minded as the worst kind of trans activist. Even so, sometimes we have to be fearless about letting the consequentialist argument go and trusting that the deontological alternative is strong enough to stand on its own. You don’t need a medical degree to know that it’s wrong to do the puberty blocker trial without doing the DLS first. It’s just common sense. Given that the authorities responsible for the trial are committed to ignoring the consequentialist arguments, I think it’s time to rally massive public opposition to the trial around that very simple fact.

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