Some days are better than others

When I started in philosophy, I did so because of my interest in psychology and the mind. I had just finished an Honours BSc in biological psychology and wanted to pursue the theoretical aspects of mind and those theories we had that related mind to brain. The clinical aspects of psychology interested me at one time, but I was never very tempted to become a clinician. I was more interested in the theory. During my graduate degrees, I took some courses in applied ethics and bioethics. These were courses I took because of general philosophical interest; I thought I should get as well rounded an education as I could. These were much different courses than what I had been used to in philosophy. They were about understanding real moral problems in real people's lives. I developed bioethics as an area of competence. As it has turned out, I teach a great deal: primarily, problems of philosophy, logic, applied ethics, and bioethics. I try to strike a balance between theory and application in these courses; bioethics is the most lively of these courses and these students learn how to think. I am pretty sure that it is not because of me, but because these students, nursing and paramedic students, grapple with the material honestly and deeply. In my view, these students leave with the beginnings of the life long endeavour to be virtuous care-givers. The four primary principles of biomedical ethics that have been considered the most important for quite some time are beneficence, nonmaleficence, justice, and autonomy: more simply: heal the sick, do no harm, distribute medical services as needed, and respect the person of the patient. However, I have argued in class that beneficence is better understood as two principles; positive beneficence and utility. The principle of positive beneficence asks that moral agents provide benefit, while the principle of utility requires that moral agents weigh benefits and deficits to produce the best result. The question I ask is whether the directive to 'heal the sick' really fulfils the principle of positive beneficence. I mean, is healing all that a physician can do in order to provide the benefit that the principle requires? Justice requires that needed medical services are provided as best they can, given the resources available. This is the source of some of my frustrations over the last few days. You see, the Alberta government introduced their 2009-10 budget on 7 April 2009. Among the various announcements, Alberta Health and Wellness is to de-list gender re-assignment surgeries and the $200/yr benefit for chiropractic services. The savings from the gender reassignment surgery (GRS) de-listing will amount to about $700,000/yr. The chiropractic subsidisation will save approximately $53 million/yr.  To put this into perspective, the entire Alberta budget is to be $36.4 billion. While totals expressed in hundreds of thousands of dollars, the chiropractic subsidy represented 0.14% of the total budget while the GRS program represented 0.0019%. If we compare the government budget is comparable to a household budget (I do not subscribe to this comparison), given the Canadian median household income (2007) of $53,634, then the funding of the chiropractic subsidy is analogous (if we assume that all of this will be spent) to a household spending $75/yr; a Combo meal at Wendy's every month. The GRS program analogously costs about $1/yr; any household could find this amount in the cushions of the couch and in the dryer. Seeing these amounts in context, it is hard to see the gravity that Minster of Health and Wellness seems to express when he says "unless we get a handle on expenditures, we won’t have a publicly funded health care system" (FFWD).  The savings of these two cuts is vanishingly small, but it could still be argued that somehow they are legitimate cuts, not because of the economic savings, but because the government shouldn't be funding them anyway. It was suggested that chiropractic shouldn't be funded on the grounds that, among other things, it is 'unscientific'. This is a claim that I have agreed with, with varying strength, depending on what one means by 'chiropractic' for a number of years. The wikipedia discussion on chiropractic  follows closely the contours of the debate as I understand it. To be fair, I tend to think that those chiropractors who think that subluxations are simply mistaken and should not be funded. Those who think they are doing much the same thing as a physical therapist should be funded. Simplistic, yes. However, there is real scientific discussion over 'subluxation' driven chiropractic; that it compromises the health of patients. Please note that the biomedical principle at work here is nonmaleficence.  The cuts to gender reassignment surgeries have been lauded for a number of reasons including the procedure is 'cosmetic' and thus 'elective', the procedure is 'a choice' --- a mere desire to be of the other sex --- and thus elective, the procedure is not even medically necessary; that those suffering from gender identity disorder (GID) should be treated by psychotherapy and drugs.  It is important to see that these arguments are neither economic nor medical; they are political. Even the 'GRS is unnecessary surgery' is a political rather than medical argument. The contours of the argument are more or less that GID is surgical mutilation being delivered to serve a delusion that the patient is of the opposite sex. Please note that the characterisation of GRS as mutilation depends upon the claim that those with GID are under a delusion: that they are members of the opposite sex. The term 'delusion' clearly implies a break from reality; a delusion is something like 'a persistent false psychotic belief regarding the self or persons or objects outside the self that is maintained despite indisputable evidence to the contrary' (Miriam-Webster). Well, what does 'psychotic' mean? It pertains to a fundamental derangement of the mind (as in schizophrenia) characterized by defective or lost contact with reality especially as evidenced by delusions, hallucinations, and disorganized speech and behaviour. Our last question, really, is how do people who are diagnosed with GID actually see themselves (in other words, what is the diagnostic criterion with respect to this)? We'll have to consult the diagnostic criteria here: 

• Strong and persistent cross-gender identification

• Persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender-role of that sex

• The diagnosis is not made if the individual has a concurrent physical intersex condition

• Clinically significant distress or impairment in social, occupational, or other important areas of functioning.

So, intersex patients are excluded. So, how to we characterise this? GID patients have a strong and persistent cross-gender identification which is accompanied by persistent discomfort/sense of inappropriateness of current gender-role which results in clinically significant distress or impairment of functioning. I think that only with a rather jaundiced eye could one see this criterion as 'wanting to be a member of the other sex'. Insisting on 'objective' criteria for diagnosing psychiatric disorders would require tossing out practically all conditions relying primarily on symptoms: I am thinking of anxiety disorders here. Our next question is whether this strong and persistent cross-gender identification counts as a delusion. Well, recall, a delusion is a persistent false psychotic belief regarding the self or persons or objects outside the self that is maintained despite  indisputable evidence to the contrary. I suppose we could say to a male to female transsexual, someone who has a strong and persistent cross-gender identification, 'you have a penis right there. Do you still think you are female?' Of course, this is ludicrous for this is not what 'cross-gender identification' means. If we did have someone who insisted that they had no penis despite the fact that there was one right there, we would be excused for leaning towards saying that the patient was under the effects of a delusion. However, this does not exemplify how transsexuals express this cross-gender identification. Adult transsexuals tend to say things like 'I was supposed to be a girl,' 'woman trapped in man's body,' and 'male body, female brain.' You'll note here that all of these phrases, either implicitly or explicitly, that the embodied sex is male, but there is something wrong, something that is incongruent. More of these sorts of biographies can be found in all sorts of personal accounts such as Jamison Green, "Becoming a Visible Man," Pamela Hayes, "The Other Women: A Story about Three Transsexuals," Christine Jorgensen: "A Personal Autobiography, Jan Morris, "Conundrum," Aaron Raz Link & Hilda Raz, "What Becomes You," and Lannie Rose, "Lannie!: My Journey from Man to Woman." So much for the 'delusion' objection; transsexuals feel a profound and clinically significant and impairing dissonance in their gender identity. They don't just 'wish' to have the genitals of the other sex. Nor do they actually think they are physically the other gender. To insist that, in spite of all of this, transsexuals are delusional is to be in the grip of an ideology and as such not really contributing to understanding whether GRS should be funded or performed. The other claim, that GRS is somehow mutilation, presumes that the surgery has no therapeutic effect or that there are other treatments which are as or more effective as surgery in alleviating the profound and clinically significant and impairing dissonance. let's take a quick look at that possibility. A review of all of the research into transsexualism and the attempts to use psychotherapy and drug therapy is far to ambitious for this venue. I suggest a Google Scholar search for many of the raw studies. I offer one of the conclusions from an influential survey: "the observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option" (Transsexualism: A review of etiology, diagnosis and treatment). This is not to argue that GRS is some sort of magic treatment. The kind of GID which needs to be treated by GRS is the most severe kind and psychotherapy might still be required to allow the patient to thrive in the new gender-role. It is the fact that for the most severe GID cases, only GRS significant alleviation of the symptoms of severe GID.  I think that the argument that somehow GRS is not an appropriate therapy for severe GID is unreasonable to pursue. The medical sciences are in their relative infancy and new medical, psychiatric, and surgical techniques are being developed all the time. Our understanding of the aetiology of conditions changes over time and thus, sometimes, our treatments change. At this point, this is where we are with respect to the treatment of severe GID. All of these things having been said, why are some days better than others? Because in my reading of the many, many comments to stories about the de-listing of GRS in Alberta, I found exceptionally little strong argumentation, indifferent attitudes, condescension, ignorance of the goals and methods of medicine and surgery, and a general predilection in imposing personally held views without much in the way of being open to being wrong. I fear that public discourse in this country is becoming a mere shouting match. It seems to me that the basic principles of proper argumentation are being ignored in favour of techniques which give the appearance of 'winning'; techniques which serve to back an opponent into either simply disengaging (usually from frustration) or being unable to respond. Of course, neither of these events indicate anything about the goodness of the position held to have 'won.' However, it is become more and more apparent to me that this event—having the last word or leaving opponents without a response—is serving an epistemological function: people are using it as an indication of truth! I cannot express my sadness. How we have gotten here is beyond me; I am sure there are sociologists and anthropologists who have hypotheses on the subject. All I can do is take my very small number of students I get each year and teach them not only how to argue, but how to sift through the mess that is our public dialogue and come up with defensible answers. This experience has convinced me that I need to ensure that my students can do these things rather than trust that they can based only on their performance on theoretical tests and papers. They need to develop wisdom as well as knowledge. That is a much more difficult result to achieve.