Eight female nurses at a United Kingdom hospital are suing their employer for not assuring their psychological and physical safety. The nurses work in specialized areas that require their changing uniforms once daily. There is a trans-female nurse, similarly specialized, who changes with them. He wanders about the locker room in briefs or nude, the women report, ogling them as they exchange clothing. It has also been related that he continues to use his male name (Ian), and to exhibit masculine behaviors. Nonetheless, Ian claims to be trans-gendered, and according to regulation, that statement is sufficient for him to use the women’s locker room.

Two of the women are especially affected. One is Muslim, and his staring at her in her undergarments affronts her religious belief in modesty. She now changes in a small bathroom outside the locker room. Another nurse was sexually abused as a child, and Ian’s nude presence close to her causes flashbacks and crying, and she has retreated to a utility closet for her clothing changes.

Hospital administrators claim that they have not ignored the nurses’ predicament, but that they are incapable of aiding them as the regulation arises from the National Health Service (NHS), and that the hospital would be penalized if it barred Ian’s access to the locker room. It is not known if administrators prepared the parties for Ian’s entry or established any guidelines for his presence. Either action might have avoided the present conflict, and would have been within the regulation as written.

I found myself questioning whether Ian is trans-female or a male exploiting the regulation’s vagueness to indulge in underwear or voyeuristic fetish. The hospital cannot require Ian to establish his female bona fides, as despite his reportedly continuing masculine behaviors, there is no set of actions that define a trans-individual, and how he dresses and behaves within his domicile is unknown.

The situation is further complicated as the female nurses have threatened to resign. The U.K., like the U.S., has a staffing problem, especially among specialty nurses. The women will have little difficulty gaining employment at nearby hospitals, but their present facility will struggle to replace them. Consequently, the workload on the remaining unit staff will increase, and their morale will decrease, as will their trust in the administration. As has been demonstrated in other health care facilities, this will decrease staff retention and adherence to administrative dicta and eventually erode quality patient care and safety.

This raises an ethical conundrum that the NHS likely did not consider in establishing its equity rule for trans-gendered employees. The decree is not unique, but as written, it is sufficiently vague to potentially allow male abuse while negating female concerns. Whose rights take primacy; those of the female nurses, and secondarily those of other staff and potentially patients, or Ian’s? Is the principle of equity of greater value in this instance than the threats to the psychological and physical safety of the female nurses?

In an ideal world the hospital would create an environment salutary to both parties, but utopian circumstances rarely exist. Is Ian’s nude wandering and staring, if true, necessary to his changing uniform? Is it congruent with the behavior of the other personnel? If not, he should be counseled that his actions are generating discomfort and should be discontinued for a more harmonious environment. If Ian disagrees or does not comply, he should be offered the choice of changing behind a curtain or in a specified area from which he could only enter and exit the locker room. This would allow him use of the room, but also respect the concerns of the female employees.

If he refuses these options, the only remaining possibilities would be to create a changing space for trans-individuals, though this would violate the NHS dictum, or terminate Ian as uncooperative and unable to work with others. Losing a single nurse would create less disjunction in unit functioning than losing eight. To defend this action, keeping meticulous records of all meetings and correspondence would be essential.

Regardless of the option chosen, it would be disadvantageous. If Ian is terminated, he will immediately file an appeal with the NHS, and the appropriate labor board, civil rights, and LGBTQ+ organizations will champion his cause, and negative press will be generated. If the eight nurses are forced to resign, their union and/or professional organization will protest, Muslim and other religious rights groups will support them, as will organizations championing child sexual abuse victims, and again, the damaging press will be spawned, and resolution will be complicated and by politics and public pressure.

Nonetheless, if the needs of both parties cannot be totally met, and applying utilitarian ethics, Ian’s termination is most appropriate, as it would allow the maximal potential good for the greater number of people: employees and patients, as the hospital made good faith efforts to provide equitable solutions, but they were rejected. Nonetheless, this incident is only the tip of the iceberg, as an increasing number of cases of this nature will arise, and if equity is to be gained, the rights and concerns of all parties will need to be respected. Inevitably, this will require compromises that will be less than perfect for all involved.

M. Bennet Broner is a medical ethicist.