Clinical audits, observational studies and patient registries are essential for evaluating healthcare quality, identifying inequities and improving patient outcomes. New Zealand's ethics system plays an essential role in protecting participants and maintaining public trust and includes pathways for expedited review of low-risk research. However, New Zealand already has proportionate review mechanisms. The difficulty is that, in practice, studies requiring temporary access to identifiable information often receive the same level of scrutiny regardless of their actual participant risk, creating barriers that can prevent valuable studies from proceeding. The cost of these barriers is overlooked. When low-risk research is delayed or abandoned, opportunities to improve care are lost. Important questions affecting Māori and Pacific communities may remain unanswered, inequities may persist and New Zealand risks contributing less to international research efforts. The burden also falls on clinicians, particularly early-career doctors, who may become discouraged from undertaking research altogether. We argue that more consistent application of existing principles of proportionate review would maintain appropriate ethical oversight while supporting a health system that learns from everyday practice and continually improves care for all New Zealanders.

In this viewpoint, I examine evidential and ethical issues regarding the use of puberty blockers for adolescent gender dysphoria, and analyse whether informed consent is functionally equipped to provide a legal and ethical justification for their use under conditions of clinical uncertainty. My normative analysis uses Beauchamp and Childress' framework of respect for autonomy, beneficence, non maleficence and justice to examine the informed consent model in light of current evidence regarding benefits, risks, capacity and voluntariness. I identify five interacting factors that arguably undermine valid consent: diagnostic uncertainty and limited differential diagnosis; very low certainty evidence of benefit; uncertainty regarding potentially serious or irreversible harms; developmental limitations in decision making capacity; and compromised voluntariness due to social and emotional pressures. I argue that, taken together, these factors require an unusually strong conception of autonomy to over-ride beneficence and non maleficence in paediatric care. While informed consent remains necessary, I suggest that it is insufficient as the primary ethical or legal justification for adolescent puberty blocker treatment and that additional safeguards and justifications are required.