Tag Archives: health and human rights

Viewpoint Therapy—Getting Identity Right

It was a bland, beige waiting room. John approached the receptionist’s desk. He felt awkward and uncomfortable—the awkwardness of a teenager doing something embarrassing while knowing that people were watching and judging. The waiting room was empty except for the receptionist and John’s mother, who had nudged him towards the desk while she took a seat.

I’m here to see Dr Childs he mumbled, fingering the cuff of his shirt. Sure hon, the receptionist smiled. You have a seat and she’ll be with your shortly.

He sat down next to his mother and thumbed nervously through a brochure he’d taken from the coffee table in the middle of the room—“Viewpoint Therapy – Helping Teens Explore Their Authentic Identity”. The pictures were soothing images of sunrises and beaches. On the third page was a head shot of Child’s. She had a slight smile and warm eyes. John’s mind flitted briefly to what the rest of her body might look like. A brief paragraph described Child’s approach to the healing journey: holistic, integrative, trauma-informed, grounded in mind–body connection, and authentic relationship building. Therapy was about creating a safe space for exploration. It was about meeting clients where they are, and about empowering growth through curiosity and compassion.

At the bottom of the back page in 4-point Helvetica was the disclaimer. None of our professionals are medically qualified. We engage in free speech at the rates displayed in our offices.

No one reads the fine print. John was no one.

Whether it was the pre-existing knot in his stomach or the gummy he’d had earlier, what John did read, he had to read twice. As his father liked to say, better informed but none the wiser. John definitely felt none the wiser.

One of the five doors coming off the waiting room opened and the full body version of the head shot appeared. John? Child’s inquired. John felt a slight twitch in his groin. His mother gave his shoulder a quick rub and a delicate push in Child’s direction. She smiled at Child’s who returned an acknowledging nod.

John and Childs had been dancing around for about thirty minutes. John had been fingering the shirt cuff on his right hand for almost the whole time. His head hung with embarrassment. It was only with occasional furtive looks he would see Child’s through his mop of brown hair.

The last thirty minutes had revealed John’s guilt and the shame. His almost constant thoughts about sex. His glances at girls breasts, necklines, buttocks, …. The slight (sometimes not so slight) tumescence. Oh My GOD—even now as he talked about it. The disgust with which he heard the girls whisper about it. Did you see….? Raucous giggles.

He loathed school.

His dad had seen him flipping through porn on his phone. His face flushed with the memory and with the memory of an almost instant desire to vomit.

And now he found himself in Child’s office.

Child’s knew she was at a difficult point in the therapeutic relationship. Teenagers are volatile. A soup of emotions and feelings. Sharp morals and jagged thinking.

Feelings of shame and disgust were normal, she said. In some ways they were appropriate. Looking at girls in class like that wasn’t right. Understandable? Maybe. Not here to judge. Here to help.

Now seemed to be the appropriate moment.

Your mom mentioned that you wanted to be gay. You want to escape that sense of shame and disgust about yourself. But you think of yourself as straight—a cis, hetero-normative cliche. You just can’t help but find girls attractive. It’s like that attraction is just a part of who you are. Something innate. It is so “you” that you cannot begin to imagine it being otherwise—and the shame and guilt.

John nodded. But you can’t just be gay, he said. I like being around other guys, but I’m just not attracted to them.

I think I can help you with that, Child’s said.

Six months later John was back in the same beige waiting room. Jessica—he now knew the receptionists name—waved him to take a seat.

John had lost weight. His clothes hung baggily. He glanced down and spotted the edge of a thin red wound near his left cuff. He pulled the sleeve down a little further.

Child’s appeared, smiled encouragingly and waved him into her office.

She looked winsomely disappointed. I’ll have to let your parents know, she explained. John was giving up on therapy. Giving up on himself.

Obviously any details were confidential, she reassured his slightly panicked look. But they do need to know you’ve decided to discontinue your healing. John could feel the sub-text: you’ll return to shameful, furtive looks at girl’s necklines. They’d never really gone away, John admitted to himself.

The process had started so well she reflected. Your faith … leaning on God. We had prayed together, here and then you with you family. There was such strength and hope. We had talked strategy. Then Luke had shown real interest when you had approached him. I thought you were making a real break through, then you pulled back. I think you used the word, “revolted” or was it “nauseous”?

Part of you obviously wanted to be gay. I could see it. Literally. You had it written on your forearms in hairline cuts. You thought I hadn’t noticed? Of course I had. It’s common. It was you rejecting the self attracted to girls—you were punishing it. If only….

I’m sorry we couldn’t complete your healing together, John. When you’re ready, my door is always open. I know that with faith and love you can do it.

Oral argument in the case of Chiles v. Salazar was heard by the US Supreme Court on 7 October 2025. The case was about the constitutionality of a Colorado law that prevented a therapist engaging in talk-based sexual-identity conversion therapy. Essentially, the argument was that banning the therapist (Chiles, a medically unqualified therapist) from engaging in talk therapy to convert a child from gay to straight sexual infringed the First Amendment—a denial of Chiles’s right to free speech. The argument hinged on the idea that therapeutic speech remains speech and thus, protected.

It was only Associate Justice Elena Kagan who inquired briefly about the protection offered by the First Amendment if the therapist was converting a child from straight to gay.

The problem with the free speech argument is that it gives cover to significant harm. Let me quote from a statement by an independent expert group published in the Journal of Forensic and Legal Medicine.

Conversion therapy is a set of practices that aim to change or alter an individual’s sexual orientation or gender identity. It is practiced in every region of the world by health professionals, religious practitioners, and community or family members often by or with the support of the state. Conversion therapy is performed despite evidence that it is ineffective and likely to cause individuals significant or severe physical and mental pain and suffering with long-term harmful effects.

That statement is about effectiveness, and the Supreme Court case is about the law.

The Court will rule in favour of Chiles. Talk-based therapy, they will say, is protected by the First Amendment. The court has often ruled that significant harm is protected by the law—see all the Second Amendment cases on the right to keep and bear arms. They would not, for a scintilla of a second, uphold Justice Kagan’s hypothetical. Conversion is only free speech in one direction and harm doesn’t matter.

The Hanging Garden of Human Rights

Human rights haven’t failed because they’re irrelevant. They’ve failed because they’re a hanging garden—detached from moral roots, stretched by competing claims, and hollowed out by politics. It’s time to reclaim the foundation.

In the late 1990s and early 2000s, health and human rights was emerging. But the field carried intellectual divisions. On one side were the public health practitioners—many without legal training—who used the language of “rights” as a cry for decency. Rights, for them, became a sharper way of saying “ought” or “should”—signalling fairness and ethical urgency.

To the lawyers, this was infuriating. When they spoke of rights, they weren’t talking about moral gestures. They were talking about the law—about using legal instruments to empower action. What do treaties require of duty bearers? How do we hold them to account? General Comment 14 wasn’t a metaphor. It was a legal tool—an authoritative interpretation of the right to health under international law.

While the lawyers stayed with “human rights,” others drifted towards a more explicit discussion of equity, fairness, and (natural) justice. The split revealed a foundational problem. Human rights—the narrower legal and procedural endeavour—had become crucially detached from the ethical instincts that once animated the field.

The narrowing of human rights to law provided rigour, but lost moral reach. And as states learned to ignore legal obligations with impunity, what remained was often hollow. Public health had a moral language without teeth. Law had a legal language with contradictions and a weak ethical foundation.

Today, the international human rights framework is fraying—and in danger of complete collapse. It’s not a failure of aspiration. It’s a failure of structure.

We appeal to fairness, but we disagree on what fairness means. We invoke rights, but the legal instruments offer an incoherent and contradictory account of what grounds them. And when rights collide—speech versus protection, work versus life—we have no principled way to resolve the conflict.

Too often, the international human rights framework is treated as if it’s free-floating. The rights are asserted without grounding, and negotiated without foundation. We’ve built a symbolic garden of human dignity, but it hangs untethered—detached from root and soil.

What we need, I contend, is a moral structure beneath the legal scaffolding. Something that explains not just what rights exist, but why they matter—even when they’re inconvenient, unpopular, or costly.

A Different Kind of Foundation

The traditional approach to grounding human rights is to seek a foundation in reason, drawing on various traditions of moral philosophy. Yet each of these traditions—necessarily, though often implicitly—relies on a set of foundational assumptions that themselves demand justification. For example, John Rawls, working within the liberal contractarian tradition, assumes that morality can be derived from radical impartiality (the “veil of ignorance”). John Stuart Mill and Jeremy Bentham, as utilitarians, treat utility—happiness—as the basis of moral judgment. Thomas Aquinas, the Catholic theologian rooted in natural law, posits God not merely as a theological claim but as a rational necessity. Immanuel Kant, the deontologist and perhaps the most rigorously reason-driven of all, grounds morality in the capacity for rational self-governance—the idea that to be moral is to act only on principles one could will as universal law.

Unfortunately, reasoning our way to good behaviour does not seem to have worked.

An Axiomatic Approach

An alternative approach is to work backwards. Rather than deducing rights from reason, we ask: what must be true for rights to make sense at all?

Three axioms emerge:

Inherent Dignity

Every human being possesses inherent dignity. It’s not something to be earned, granted, or achieved—it’s a moral condition intrinsic to personhood. Dignity doesn’t fluctuate with ability, social contribution, or behaviour. It’s not comparative. It doesn’t admit degrees. It is equal and inviolable.

Individual Welfare

Dignity, while inviolable, is not self-executing. The social and legal order must promote the material, psychological, and social welfare of individuals—so they can live, develop, and participate meaningfully. Without these conditions, dignity is betrayed in practice, even if affirmed in theory.

Constraint on Expendability

No one is expendable. Lives cannot be sacrificed for the convenience or benefit of others—except under conditions of compelling and justified moral necessity, subject to strict and transparent constraint. Where institutions permit suffering for efficiency, or render individuals invisible in pursuit of “greater goods,” moral collapse has already occurred.

These aren’t ideals. They are constraints. They don’t define utopia. They define a moral floor beneath which no system can fall and still claim legitimacy.

Axioms to Rights and Duties

From these axioms, rights and duties follow:

From dignity comes the right to recognition, and the duty to respect others as full moral equals.
From welfare comes the right to the conditions for flourishing, and a duty to assist when the need is real and the cost is bearable.
From non-expendability comes the right not to be sacrificed, and a duty of restraint—to avoid complicity in systems that treat people as disposable.

These are not grounded in legal agreement. They are grounded in the foundational, moral necessity.

Once one begins to play with this axiomatic approach, what fast becomes clear is that the state, as a moral agent, has been miscast in international law. The state is not a de facto rights-holder, nor is it a source for the rights of others. The state is a duty bearer—nothing more.

The state exists to protect dignity, promote welfare, and prevent expendability. When it fails to do this—systematically, persistently—its legitimacy erodes. Its existence is not self-justifying; i.e., the purpose fo the state is not to perpetuate its own existence. Its existence is contingent.

This flows from the axioms, and reframes the conversation: human beings do not have moral standing because the state recognises them. The state has standing only to the extent that it honours the people within its reach. This is not anti-state. But it is deeply sceptical of the idea that the state’s authority is morally primary. It isn’t. People are.

When Systems Fail

The axiomatic approach is pluralistic, but it is not permissive. Some systems are structurally incompatible with these axioms. For example, autocracies treat rights as contingent on loyalty or usefulness. Dissent is punished not because it is wrong, but because it defies power. Theocracies, in contrast, base human worth on belief and compliance to doctine. The person becomes secondary to divine law—as interpreted, of course, by the state. In both autocratic and theocratic systems, rights are conditional. Recognition is revocable. Worth is earned.

The axioms say otherwise. Dignity is inherent. Welfare is required. No one may be discarded.

It would be wrong to claim that the axioms are an expression of “Western values.” The expression of these kinds of ideas can be found across tradition in Asia, Africa, and the pre-colonial America. They are put forth as minimum moral thresholds. The test isn’t, thus, one of cultural conformity to some putative “Western” ideal. The test is whether the system respects the moral worth of the people within it.

Against Relativism. And Democracy.

Some people will simply not agree with the axioms. They will argue that certain groups—racial, ethnic, religious—are less than, sub-human. That outsiders are un-deserving. That dissenters are worthless. Life is to be instrumentalised for some other end.

Relativism, when pushed far enough, accommodates this. It permits anything, so long as it is “culturally accepted.”

The axioms say: no. Some practices are beyond justification.

Nor do the axioms necessarily support democracy. Majority rule is not a moral guarantee. A vote to discard a minority is still a failure. Democratic decisions must be constrained by moral principles.

Power alone is not a justification, whether the source of that power is autocratic, theocratic, or democratic. Justification is determined by what power does. Too often, might is blight.

Holding the Line

The axioms emerged from a simple realisation. Many communities, political parties, and even nations now openly argue that the value of other people’s lives lies only in how useful they are to the ambitions of those with power. The human rights framework is under siege—not just from external enemies, but from those who claim to defend it. You can see this everyday in the statements and actions of leaders (and wanna-be leaders) around the world. Western and Eastern Europe, the Middle East, Central, South and East Asia, Oceania and the Americas—everywhere leaders seek to treat some group as “other”. “Those people”—outsiders, the un-deserving—are no longer means to allowed to be the means to their own ends, they are the means to ours.

States invoke rights while violating them. Institutions look stable but are morally hollow.

The axioms of dignity, welfare, and non-expendability do not resolve every conflict. But they clarify the ground. They give us a framework to test law, policy, ideology—and to know when a system has failed, even if it looks orderly.

You can read the full account, with examples and theoretical detail, in the preprint on SocArXiv:

But the core is simple:

People matter. Their lives must be livable. And they cannot be discarded.

I am shocked these ideas are up for debate.

This blog was first published on 24 May 2025 and further edited on 7 June 2025

Would you give knee surgery to the FAT MAN?

I do understand your plight, Mr Smith. An arthritic knee can be extremely painful. And you say it’s so bad you can’t even walk from the living room to the kitchen. That’s actually very good news! Yes, yes … awful … but terribly good news. If you can’t walk to the kitchen, you can’t eat. If you can’t eat you’ll lose weight. And the faster you lose weight, the sooner we’ll schedule your knee surgery.

On 15 March 2017, Dr David Black, NHS England’s medical director for Yorkshire and the Humber, sent a letter of praise to the Rotherham Clinical Commissioning Group (RCCG). The RCCG had decided to restrict the access to smokers and “dangerously overweight patients” of hip and knee surgery. The letter was leaked, and it has triggered, according to the Guardian, “a storm of protest.”

The title of this blog is a play on David Edmond’s book, Would you kill the fat man, an exploration of moral philosophy and difficult choices about the valuation of human life. The RCCG’s decision intrigued me. It was essentially a decision about rationing a finite commodity — healthcare. In a world of plenty, rationing healthcare is a non-question. In the real world, however, in a world of shrinking healthcare budgets and a squeezed NHS, resources must be allocated in a way that means some people will receive less healthcare or no healthcare. Fairness requires that the rules of allocation are transparent and reasonable.

While you ponder, whether you would give knee surgery to the FAT MAN, I have a follow-up question. Would you want to see a doctor who would deny you knee surgery because of some characteristic of yours unrelated to whether you would benefit from knee surgery?

I am sorry Mrs Smith, today we decided not to offer clinical services to women, people under 5’7″, or carpenters. We need to cut the costs of our clinical services, and by excluding those groups, we can save an absolute bundle.

I have heard it said of the doctor, academic and human rights advocate, Paul Farmer, that he would regularly re-allocate hospital resources from Boston to his very needy patients in Haiti. He used to raid the drug stocks of a Boston hospital, stuff them in his suitcase and fly them back to his patients in Haiti. I have no idea if the story is true or not. It does mark, however, one of the great traditions of medicine. The role of a doctor is to advocate vigorously for the health (and often social) needs of the patient. The patient actually in front of them. The one in need. Because, if your doctor will not advocate for your health needs, who will? This is why all the great TV hospital dramas show a clash between the doctor and the hospital administrator. Administrators ration. Doctors treat. The doctor goes all out to save little Jenny, against all odds. The surly hospital administrator stands in front of the operating room, hand outstretched and declares (Pythonesque): “None shall pass.”

Under the current NHS system of clinical commissioning groups, there are family doctors who are simultaneously trying to make rational decisions about the allocation of limited resources to a population, and trying to be the best health advocates for the patient in front of them. That screams conflict of interest. If you live in the catchment area of the RCCG and want my advice, check out which doctors are part of the RCCG. If your doctor is one of them, change doctor immediately. Treating you, advocating for your health interests is what you need and should want. Unfortunately, if she is part of the RCCG when she is treating you, you are not her principal concern. Run(!) assuming of course that you don’t need knee surgery.

Should smokers and overweight people receive knee surgery? Let’s start with smokers. Why would you not want to treat a smoker? It is difficult to come up with arguments that are not so outrageous that they are embarrassing to make. But I won’t let personal embarrassment get in the way of stating the top two silly arguments that came to mind:

Smoking is a disgusting habit and anyone who smokes deserves all the pain they get?
Smokers won’t live as long as non-smokers, so the investment in surgery to reduce pain and improve mobility in smokers will not have the net benefits to society as the same investment in non-smokers.

The arguments for restricting the surgery to people who are not overweight are similarly cringe-worthy. There are also clinical reasons for prioritising the overweight. The load on joints resulting from increased weight creates greater wear-and-tear and, the broader inflammatory processes that obesity triggers also seem to increase the risks of osteoarthritis — affecting hands as well as knees. [See for example, here and here].

I can’t find the RCCG’s arguments for restricting access to knee surgery for smokers and people who are overweight, but prima facie it looks a lot like a variant of victim blaming.

Full disclosure. I am all for the rational allocation of resources. I think smoking is a disgusting habit. I am overweight and trying to do something about it. I also think that the arguments for resource allocation need to be more explicit about the social values upon which they are often implicitly based.