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No Longer Patient: Feminist Ethics and Health Care.

In these two volumes--one an attempt at a systematic monograph, the other a collection of essays (most of them previously published in Hypatia)--we have perhaps the first book-length approaches to a feminist medical ethics. If it seems a bit surprising that such volumes should not have appeared earlier, the contents of these two volumes is not terribly surprising. And that suggests that their concerns and perspectives have, in fact, already become a forceful presence through numerous articles.

Susan Sherwin's No Longer Patient is the more ambitious undertaking of the two. Its eleven chapters are divided into three parts: "Theoretical Beginning," "Traditional Problems in Health Care Ethics," and "Feminist Expansions of the Bioethics Landscape." Under these rubrics she (1) discusses a variety of conceptual issues (different forms of feminism, the relation of feminist theory to standard ethical theories, the problem of moral relativism); (2) discusses and attempts to offer a feminist perspective on four problems in medical ethics (abortion, new reproductive technologies, paternalism, and the conduct of research); and (3) seeks to broaden our vision of medical ethics by considering the intersections of gender, race, and class by criticizing views that make heterosexuality a norm, and by considering how feminist insight might illumine debates about the definitions of health and illness. The essays in Feminist Perspectives in Medical Ethics--somewhat wider ranging and inevitably less coherent as a whole--cover roughly similar ground. They also worry about the theoretical under-pinnings of feminist analysis, treat a range of particular moral problems (especially issues related to artificial reproduction and associated technologies), and seek an expansive understanding of medical ethics. The essays in the Holmes/Purdy volume have more bite and are likely to be of more interest to a reader already conversant with such questions. The Sherwin volume may prove more helpful to a reader for whom this is terra incognita; for the knowledgeable reader it may seem a little too general and often lacking an argument just where one might have hoped for it.

What makes an ethics, in particular a medical ethics, feminist? I am not sure the reader of these volumes will come away with a clear answer to that question. The answer might seem obvious. Such an ethics will, in the words of Laura Purdy, "[e]mphasize the importance of women and their interests." But if this is to be our starting point, we will be in danger of developing what Purdy says she does not want--"a 'special interest' ethics that can be ignored, relegated to the already large collection of theories among which people can arbitrarily pick and choose." If it doesn't speak to my condition, it will have no claim upon me. Indeed, such an ethics may seem to advocate special preference and injustice. Susan Sherwin's response to such criticism is to argue that an ethics of special preference is--for the time being--justified because of differences in "how women and men are situated in the existing patterns of oppression." That is, given a gravely sexist world, men are already the recipients of great privilege. An ethics that frankly seeks to foster the interests of women is a necessary antidote to the oppression masked by claims to treat people as individuals, and this antidote will continue to be necessary until "the forces of oppression ... are dismantled"--or, I fear, until the Kingdom comes. Virginia Warren, explaining in her essay in the Holmes/Purdy volume the need to make ethics less abstract, writes that she once found it helpful to ask herself: "If Gandhi were in my shoes (sandals, of course), how would he deal with the Dean of the Faculty on this matter?" What he probably would not have done is decided to put his ideals of fairness on hold until a world arrived in which they were perfectly exemplified. To be sure, a concern for fairness can and should be sensitive to relevant differences. Equal treatment is not the same as identical treatment--as parents who have several children quickly come to see. But this is not what Sherwin seems to have in mind in justifying special preference, for this kind of sensitive discrimination would still be needed even in a world free of the patterns of oppression to which she objects.

But, let us grant that the response has some force. Other questions remain. What if a sizable number of women do not believe that a feminist medical ethics is, in fact, emphasizing their interests--do not, for example, agree with Judith Lorber (in the Holmes/Purdy volume) that "a fertile woman undergoing IVF to try to have a baby with an infertile man," though she may think she is expressing her love for him, is more likely to be "making a partriarchal bargain--trying to maintain a relationship and have a child within the constraints of monogamy, the nuclear family structure, and the valorization of biological parenthood, especially for men?" Or what if large numbers of women do not, in fact, agree with Susan Sherwin that their heterosexual orientation may be less an expression of genuine preference and more a result of "the coercive demands of institutionalized heterosexuality?" The answer will have to be a theory of false consciousness, and Sherwin adopts precisely such and approach. Despite the feminist emphasis on the priority of women's personal experience, this turns out to be the experience only of a vanguard, which need "not accept that a woman's denial that she has experienced oppression refutes the reality of that oppression."

A different way to get at what makes a medical ethics feminist would be to focus on (allegedly) characteristically feminine modes of moral reasoning--most obviously in recent years, "caring." Thus, for example, in the Holmes/Purdy anthology Sara Fry argues that the foundation of nursing is caring (rather than autonomy, beneficence, etc.). She does not do this, however, without being subjected to some rigorous criticism in an accompanying response by Jeanine Boyer and James Nelson. Sherwin takes up this approach at several points and seems clearly ambivalent. She wants a feminist medical ethics to recognize the perspective of women, but she is reluctant to give support to the idea of "gender traits within a sexist culture." (Here again one might wish--indeed, I do wish--she were more willing to follow the truth of argument wherever it led her, with a certain confidence that the truth would not harm women.) The same ambivalence is evident in her discussion of moral relativism. She wants to criticize categorically some unjust actions and practices, even to offer cross-cultural criticisms. And she recognizes that the claim that oppressive practices are unjust will be difficult to ground in a relativist starting point. Yet, she fears adopting an "absolutist" stance in "a society structured by dominance relations." Only in a community "worthy of trust" would she be willing to reject the relativism that gives special place to women's interests. "Feminist moral relativism remains absolutist on the question of the moral wrong of oppression but is relativist on other moral matters." To any reader who is not already a true believer this must, however, sound more like a call for capitulation than moral conversation or argument.

Sherwin's own theoretical foundation, whatever its experiential roots, is not an emphasis on the importance of women and their interests. It is a rejection of oppression. "The principal insight of feminist ethics is that oppression, however it is practiced, is morally wrong." This starting point permits the expansion she attempts in part three of her work--an expansion which seeks to draw concern for race, class, and sexual orientation under the umbrella of a feminist approach to health care. In making this move, however, she makes a feminist medical ethics far more marginal than it need be since she, in effect, places beyond the pale of orthodoxy all who believe that the heterosexual bond is normative for human life. But more generally, it is not clear how she can share the concern of those who fear that expanded definitions of health will extend medical authority into too much of life while at the same time expanding the notion of "health needs" through an analysis focusing on gender, race, and class.

It is not possible within the scope of this review to take up in any detail the particular moral problems addressed in these two volumes. It is not surprising that many of them focus on human procreative potential, since that is clearly a point at which feminist concern and medical ethics are likely to interest. It is also a point at which--in discussion of new reproductive technologies and abortion, for example--there may be more than one feminist vision. Both Sherwin's monograph and most of the essays in the Holmes/Purdy anthology tend to view new reproductive technologies with suspicion and to assume that ready access to abortion is a feminist imperative. In this respect even both volumes taken together will not represent the full spectrum of feminist views. Another point at which feminist concerns and medical ethics are likely to interest is the issue of paternalism in health care. Sherwin devotes a chapter to the subject, and the several pieces in Holmes/Purdy on nursing ethics touch on related questions. Both volumes also pay some attention to medical experimentation, an area where feminist concerns are real, even if less immediately apparent. In neither volume are religious views represented, and, indeed, Sherwin seems tone deaf on the subject.

Read in tandem, these volumes suggest--at least to this reader--that feminist angles of vision are most likely to be illuminating when brought to bear on particular problems, but that claims to new theoretical advance in moral theory or to a feminist medical ethics that is theoretically innovative should be greeted with a good bit of caution.
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Author:Meilaender, Gilbert
Publication:The Hastings Center Report
Article Type:Book Review
Date:May 1, 1993
Previous Article:The Healer's Power.
Next Article:Feminist Perspectives in Medical Ethics.

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