Table 3 Excerpts from critical appraisal, summary report, and ongoing reflection stages of analysis

All excerpts mentioned pertain to the same publication. We followed the same process for other publications

Does the author articulate an ethical argument developed through an analytic process?

Answer: Yes. Normative claims are grounded in appeals to ethical principle(s): principle of subsidiarity

Analysis step 1: Summary (Excerpt only)

This is an article directed at a clinical audience. The article opens with an introduction, proceeds to define the principle of subsidiarity and its subprinciples, reviews its application to gender-affirming care in paediatric practice and finally sets out the ethical consideration of minimal autonomy for allocating decisional authority to youth who lack full capacity to consent. The publication also discusses how to better support the decision-making of youth who lack full capacity to consent

The author breaks down the principle of subsidiarity into three subprinciples (page 2):

The default subprinciple – “Patients should hold decisional authority by default.”

The necessity subprinciple – “Higher level decision-makers should only hold decisional authority if all lower-level decision-makers clearly lack the capacity to make a decision consistent with the patient’s best interests, even with support.”

The superiority subprinciple – “Higher level decision-makers should only hold decisional authority if they are clearly better positioned to make a decision consistent with the patient’s best interests than all lower-level decision-makers.”

Minimal autonomy as adapted by the author in the context of gender-affirming care (page 3):

“(1) the patient is guided by their gender subjectivity and other values, cares, and commitments; (2) they act based on reasons prescribed by their gender subjectivity, values, cares, and commitments; (3) they are open to seeing reasons to the contrary.”

Analysis step 2: Higher-order summary (Excerpt only)

a) Parents nor courts are clearly not better positioned to make decisions consistent with youths’ best interests, even when they lack capacity because:

1. Youth have minimal autonomy

In the case of gender-affirming care, only patients have an intimate understanding of their own gender subjectivity

Gender identity is very personal

They are able to reflect their choices and see options contrary to their choices

They seek care because of their lived experiences

2. Difficult to prove minors seek care against their best interest

3. Parents nor courts have direct access to the youth’s psychological experience of gender

To make decisions in their best interest, one needs to understand the youth’s values to make decisions

b) Youth should have the authority to make decisions once the intervention is offered

c) Parents should support decision-making

d) Lens of subsidiarity provides a framework for allocating decisional authority for youths and adults who lack full capacity to consent due to age, maturity or disability

Analysis step 3: Interpretative analysis

Young people are likely to make decisions based on their interest, but how can it be ascertained if they are indeed making the ‘best’ decision since young people may be influenced by extrinsic factors such as peers or the internet. Additionally, certain treatments may impact fertility, prompting young people to weigh the prospect of sacrificing it without having experienced parenthood. Furthermore, the author does not offer a clear definition of commitment. This omission is significant because if commitment entails a lifelong requirement for screening or medication adherence, there is a risk that some young people might discontinue treatment prematurely for various reasons. Such interruptions can pose significant problems. This publication contradicts many others that explore the pros and cons of such treatments. The publication could benefit from more empirical evidence supporting the arguments. It feels like the author strongly supports transgender youth making their own decisions. We think this viewpoint might also be influenced by the author’s personal biases