This article originally appeared in the National Post.
By Shawn Whatley, March 20, 2023
We’ve learned recently that transwomen may soon get womb transplants. Uterine transplantation is not new. Successful trials in non-trans women were reported five years ago, including live births. Given Canada’s no-questions-asked approach to gender-affirming care, medical leaders will probably support the transplants.
Also of note, the Special Joint Committee on Medical Assistance in Dying (MAID) recommended exploring extension of the eligibility criteria for mature minors. Days later, the Quebec government tabled Bill 11, which would allow advanced consent for MAID for those suffering from degenerative conditions such as Alzheimer’s.
Gender-affirming care and MAID came about by acts of will, not evidence. We decided they were good, then acted on our decision. Now we wait for evidence to support our choice.
Decisions without evidence are not new in medicine. Medicine grew through millennia of habits and expert opinions. In the 1980s, clinical epidemiologists at McMaster University pushed back. They demanded that medical decisions rely on reason and evidence, not just expert opinion or tradition. Gordon Guyott coined the term “evidence-based medicine” (EBM) in 1990. It became a world-wide movement and redefined what counts as knowledge in medicine.
But logic and evidence have limits. We cannot study parachutes by randomizing jumpers to go with or without a chute. Some decisions require common sense, standards of practice, and dare we say, tradition. Just because we can does not mean we should; logic and evidence cannot tell us either way.
Four decades of reducing medicine to EBM has left medicine without any other tools to weigh patient choice. We have only John Stuart Mill’s harm principle: patients should have whatever they want as long as it does not hurt anyone else. Choice must be affirmed.
Conservatives and classical liberals offer reasons why gender-affirming care or MAID for minors might be unwise. But reason was never at issue. For example, arguments about the lack of long-term studies for hormone therapy, the irreversible nature of treatment, or the fragile and changing nature of children’s development all presuppose that logic and evidence are the final arbiters.
What if future studies show testosterone treatment in girls is harmless? What if transmen show long-term happiness with top- and bottom-surgery? Will evidence of long-term safety prove the treatment was a good idea?
The crux is not the lack of evidence but the faith we put in evidence in the first place. Evidence will not win this debate. Gender-affirming care and MAID represent the latest apotheosis of life without limits. We feel squeamish to admit otherwise.
Freedom lovers feel loathe to question the limits of social choice. Limits should be learned in the family and have no place in public debate.
The left does not share the same compunction. It prefers values and morality over logic and evidence in public debates. The right recoils at overt moralizing. We must never turn politics into religion and thereby “immanentize the eschaton.”
I spoke with a fellow board member at the Canadian Medical Association shortly after the Supreme Court struck down the ban on euthanasia, in 2015. I said that making something legal does not make it right.
He said, “The Supreme Court has ruled otherwise.”
The courts define what is allowed, and what is allowed must be affirmed.
Conservatives and (especially) classical liberals need to get over their discomfort with talking about limits. Talking about morals and values is not the same as talking about religion — the left proves this every day in parliament.
Daniel Henninger, journalist, wrote a famous editorial called “No Guardrails” in the Wall Street Journal, 1993. He described how the death of self-restraint was undoing America. Rules that once governed behaviour had become devalued. He blamed “the intellectuals — university professors, politicians and journalistic commentators.” Henninger argued that we need guardrails to protect the weaker and more vulnerable people in society — those living at the margins.
In Canada, we have no guardrails in the gender and MAID debates. This needs to change. We should not be uncomfortable talking about selfishness, cruelty, or inhumane therapies. We should apply those labels to the issue in question. For example, it is cruel that poor people feel compelled to apply for MAID.
Whatever guardrails we choose, conservatives and classical liberals must shift. The debates about gender-affirming care and MAID are not about reason and evidence. If we, as a society, decide that all choices are good, no matter the outcome to the individual, then so be it. The course is set. We need the courage to say something now or watch as Canada becomes undone.
Shawn Whatley is a practicing physician in Mount Albert, Ont., and a fellow at the Macdonald-Laurier Institute. He is the author of When Politics Comes Before Patients: Why and How Canadian Medicare is Failing.