First Opinion is STAT’s platform for interesting, illuminating, and provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers, and others.
To encourage robust, good-faith discussion about issues raised in First Opinion essays, STAT publishes selected Letters to the Editor received in response to them. You can submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.
The story
“7 pediatric bioethicists: Proposed ban on Medicaid funding for hospitals providing gender-affirming care for minors is deeply unethical,” by Ian D. Wolfe, Rafael Escandon, Meredithe McNamara, Sabrina Derrington, Emily Berkman, Amy Caruso Brown, and Alyssa Burgart
The response
As co-authors of the Health and Human Services Pediatric Gender Dysphoria Review, we read with interest Wolfe et al.’s critique of the review. Unfortunately, Wolfe et al. misunderstand evidence-based medicine principles. Surprisingly, given that most of the authors have received some formal training in bioethics, they also seriously misunderstand medical ethics.
To begin with a point of agreement, we are heartened to see Wolfe et al. acknowledge the uncertain evidence, because much of their prior work has confidently extolled benefits of medical and/or surgical interventions. (One author has previously suggested that critics of the evidence base are propagating “scientific disinformation.”) However, Wolfe et al. falsely claim that the review ignores studies reporting benefit, that it considers “common sense” to be “enough to prove harm,” and that the Review “minimizes” patient-reported outcomes. In fact, Chapter 7 assesses known and plausible harms by incorporating evidence from biology, physiology, pharmacology, and the science of human sexual development, and patient-reported outcomes (e.g., depression severity) are reported in many if not most of the studies incorporated in the review’s evidence synthesis.
Wolfe et al. claim that “peer-reviewed scholarship has identified significant scientific and methodological flaws in [the review],” but that “analysis of its poor ethical reasoning remains urgently needed.” On the first claim, the two papers that supposedly “identified significant scientific and methodological flaws in the report” did no such thing. In our detailed response to these papers we anticipated that they would end up “uncritically cited” as evidence “that the Review has been ‘debunked,’” and indeed this is exactly what Wolfe et al. have done. But expert methodologists and physician researchers unaffiliated with this field found the review to be scientifically and methodologically sound.
Wolfe et al.’s “expert ethical analysis” begins by alleging that the review “fails to appropriately apply a basic bioethical assessment of proportionality by ignoring or minimizing the serious harms of withholding gender-affirming care.” However, Wolfe et al. do not cite any evidence of these harms, and since systematic reviews show no reliable evidence of benefit of providing these interventions to youth, one cannot assert that there are harms of delaying them until adulthood.
Next, Wolfe et al. claim the review “appears to adopt the precautionary principle, insisting regulators protect against any potential risks before the public can access novel therapies.” This is false. The review takes no regulatory position and clearly explains that in medicine precautionary considerations caution against serious risks, not “any potential risks.”
Wolfe et al. also claim that “an unbiased bioethical analysis does not pose the question of whether gender-affirming care for youth should exist, but to whom, when and how it should be provided.” However, the general principle is plainly false. If a colleague proposed treating minors’ poison ivy rashes with amputation of the affected limb, would Wolfe et al. maintain that an unbiased bioethical analysis should ask not “whether limb amputation for poison ivy rash should exist, but to whom, when and how it should be provided”?
In the last part of their ethical analysis, Wolfe et al. claim that “the best interest standard … says that clinicians and parents should work together on behalf of the child to make decisions grounded in the child’s overall best interests, not just the child’s physical or medical well-being.”
But their own supporting reference contradicts this, stating that clinicians and parents should “protect and promote the health interests of their child” (italics added) — and in any case, there is no evidence that medical transition promotes minors’ overall best interests, either. Their reference (an article co-authored by Johan Bester, a clinician-bioethicist who favorably reviewed the review’s ethics chapter) also states that the fiduciary relationship between clinician and patient “requires clinicians to demarcate the range of clinical options available to protect and promote their patients’ health interests.” That is, clinicians have a duty to restrict the range of clinical options, because medical interventions with unfavorable risk/benefit profiles can set back patients’ health interests rather than protecting or promoting them. The review’s ethical analysis draws upon and reinforces this obvious point.
Finally, Wolfe et al. irresponsibly assert that “more transgender and non-binary minors will suffer and die if these recommendations are enacted” (italics added) citing a paper studying the impact of “anti-transgender laws” on suicidality. (Presumably Wolfe et al. are referencing proposed Medicaid/Medicare rules; the review itself makes no policy recommendations.) The cited paper is an analysis of cross-sectional non-probability online surveys that does not examine suicide; also, of the 48 laws studied, only seven restricted medical/surgical interventions. To date, one study has examined completed suicide rates in this population and found no evidence that pediatric medical transition reduces suicide. Similar scare tactics were employed by activists in the U.K. and were found to be empirically unsupported. Clinicians must stop misleading patients and families with scientifically unfounded claims regarding suicide. As Dr. Bester put it, “The phrase ‘You can either have a dead daughter or a live son’ should live in infamy in the annals of medical ethics in perpetuity. It is dishonest, untrue, coercive, and undermines sound medical decision-making for vulnerable minors.”
— Moti Gorin, Kathleen McDeavitt, Alex Byrne, and Zhenya Abbruzzese, co-authors of “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices”
The story
“The food nationalism of the new dietary guidelines,” by Vishal Khetpal
The response
Dr. Khetpal rightly highlights the dietary guidelines’ dismissal of the health equity working group’s recommendations, and the limitations of culturally narrow promotional materials. Our disagreement, however, turns on a more basic question from information diffusion theory: how to achieve high homology between messenger and audience when attention itself is scarce.
The guidelines’ upstream decision to limit cultural framing reflects a downstream reality. Consumers have severely limited subjective bandwidth for nutritional guidance. People decide what to buy in seconds. Inferentially, in those scarce moments, every visual element competes for the same cognitive capacity.
When attention is this constrained, dedicating visual bandwidth to representational cues necessarily displaces something else. If what is displaced is clarity about nutrient density, information that directly affects diabetes and cardiovascular disease, those trade-offs matter. Dr. Khetpal advocates for high homology by cultural mirroring. It is reasonable to argue that limited attention makes such mirroring more important. But in a two-second fixation window, specific cultural markers can act less as bridges than as filters, engaging some viewers while excluding others.
A practical alternative is high homology through cultural neutrality. Direct schematic images grounded in universal metabolic principles (e.g. glucose response, nutrient density, protein quality) function well across cultures because they describe how bodies work, not how people identify. A nutrient-density biological framework is inherently agnostic. Goat, fish, legumes, ghee, olive oil, biryani, jollof rice, or plantains can all fit.
Health equity and cultural representation definitely matter. But effective health communication begins with shared biological constraints and good science. Cultural neutrality, grounded in universal metabolic reality, may be the most equitable way to use the few seconds of consumer attention we are actually permitted.
— Bruce Tizes, M.D., J.D., M.P.H.
The story
“TrumpRx has a fundamental flaw,” by Sean D. Sullivan and Ryan N. Hansen
The response
My wife and I are doing IVF. One cycle of meds costs approximately $19,000, and between two insurers we only had $10,000 in lifetime coverage. Under this plan, a $900 IVF injection is reduced by up to 85%. That’s a real win. It gives people a choice: Use insurance or cash-pay at a deeply discounted rate.
— Jesse Edwards
The story
“We helped create Medicare Advantage. Here’s how to fix it,” by Donna Shalala and Tommy G. Thompson
Outstanding and very well-crafted article. The landscape is such, unfortunately, that we see where seniors are being devalued more and more each and every day. MA plans are truly coverage that is needed and in a majority of cases more desirable than traditionally limited Medicare. Let’s continue the fight and the push at all levels to espouse the true benefit and value of these plans.
— Kenneth Carruthers, Evicore by Evernorth, a Cigna company
The response
“We helped create Medicare Advantage. Here’s how to fix it” negligently “protects” the overpayments that subsidize more benefits and higher sales commissions to agents. The authors hail an overpayment that is only 14% (and down from 20% the prior year). These overpayments fund the supplemental benefits and low cost sharing. Unfortunately, the authors display a negligence, ignoring the 50% of Medicare beneficiaries enrolled in original Medicare and the original purpose of Medicare Advantage to compete with original Medicare on a level playing field. This negligence fails to perform the duties owed to all Medicare beneficiaries and this purpose — not just those in the overpaid private plans.
Democrats have forgotten original Medicare. More than half of today’s Medicare beneficiaries are enrolled in original Medicare and are satisfied. Original Medicare enrollees comprise a large majority — over 50% — in each of 47 states. These enrollees are ignored in favor of overpaying Medicare Advantage plans. Instead of a level playing field, Medicare Advantage has been given a financial advantage.
Originally, the Medicare Advantage program had been expected to reduce Medicare spending and payments were set at 95% of original Medicare. The government now overpays Medicare Advantage plans — over $106 billion between 2010 and 2019. The excess government payments to Medicare Advantage plans are used to provide extra benefits that original Medicare beneficiaries do not have. Originally these extra benefits were to be paid for out of the managed care savings alone. Original Medicare beneficiaries must pay for extra benefits out of their own pocket.
Negligent Republicans have forgotten the idea of “competition.” Medicare Advantage was intended to compete on a level playing field with original Medicare. Using managed care Medicare Advantage would improve health and lower costs and add some extra benefits to be a better value when compared to original Medicare. Market-based efficiency and competition are traded away for private plan “largesse.” Total Medicare payments to Medicare Advantage (including rebates for extra benefits) are estimated at 104% of original Medicare spending. This amounts to hundreds of billions in extra spending above original Medicare. The extra spending is “government excess” at the expense of taxpayers and original Medicare enrollees.
The excess payments to Medicare Advantage plans are used to provide extra benefits that original Medicare beneficiaries do not have. Originally these extra benefits were to be paid for out of the managed care savings alone. Be fair to all Medicare beneficiaries!
— William Schiffbauer, Schiffbauer Law Office