2. LITERATURE REVIEW
2.1 Conventional Approaches to Autonomy in Philosophy, Ethics and Bioethics
2.1.5 An Alternative Approach: Challenges from Virtue Ethics
How does (bioethics) reconcile the clearly immense differences in the social and personal realities of moral life with the need to apply a universal standard to those fragments of experience that can foster not only comparison and evaluation but also action?
(Kleinman, 1999, p. 70 in Hedgecoe, 2004, p. 126).
practice. Pellegrino acknowledges and addresses one of the main criticisms of virtue ethics – its circular logic. To break the cycle of defining virtue as “that which the virtuous person does and the virtuous person as one who acts virtuously…the concept of virtue must be defined in terms of some good, some telos, which the agent intends and acts to attain” (Pellegrino, 1995, p. 274).
Although virtue ethics also has its roots in early philosophical traditions – primarily in the works of Aristotle (384-322BC/1953) – its virtual absence in contemporary bioethical theory is partly a consequence of the culmination of the theories of Kant and Mill in moral philosophy
(Schneewind, 1997). One of the primary aims of virtue theorists, therefore, is to restore virtues to their rightful place in ethical theory and practice – a goal clearly articulated by virtue theorist Foot, who maintains that “a sound moral philosophy should start from a theory of virtues and vices” (Foot, 1978, p. xi). Others suggest that principlist ethics and virtue ethics are
complementary approaches that, if integrated, could provide a coherent framework for enhancing the ethical competence of health professionals, and for augmenting public trust in the character and actions of these professionals and their profession (Meara et al., 1996). However, one of weaknesses of the new virtue ethics is that it is under-developed in the contemporary literature as a result of its focus on criticizing the traditions to which it is opposed, rather than stating
positively and precisely what its own alternative is (Louden, 1997). This deficit notwithstanding, one of the most significant virtues of virtue ethics is that it shifts the focus from autonomy-based, contractual relationships to trust-based, covenantal ones (Pellegrino, 1995).
While principled ethics could be described as “obligatory,” virtue ethics encompass the “ideal” – one approach complements the other (Meara et al., 1996). Advocates of the virtue approach thus
acknowledge that it cannot operate as a stand alone normative ethic, but should be conceptually integrated with other ethical theories to offer comprehensive ethical guidance in the health professions. The value that virtue ethics brings to conventional theories like principlism is its foundation in community narratives – a contribution which, coupled with its focus on covenantal relationships, is particularly helpful in offering ethical guidance in multicultural settings (Meara et al., 1996).
The virtues of principlism are clarity, simplicity, and (to some extent), universality…But the vices of this approach are the converse of its virtues: neglect of emotional and
personal factors, oversimplification of the issues, and excessive claims to universality.
Virtue ethics offers a complementary approach, providing insights into moral character, offering a blend of reason and emotion, and paying attention to the context of decisions (Campbell, 2003, p. 292).
There is recourse, perhaps, in taking what is of value in the emphasis of virtue ethics – which, notably, is also essentially individualistic - on the virtuous clinician or researcher, and extending this to an emphasis instead on virtuous relationships. Intrinsic to health care ethics is Kant‟s philosophy that individuals are rational beings whose autonomous decisions should be treated as sovereign. However, Ter Meulen (2001) contends that less emphasis should be placed on
autonomy and more on moral virtues within relationships. As they are treated in ethical practice, says Ter Meulen, the relationships between patients and healthcare professionals, and between researchers and research participants, are predominantly contractual - defined in terms of rights and allowing no room for such virtues as solidarity and personal involvement. If, however, one shifts one‟s notions of personhood in bioethics from atomistic conceptions of persons to more relational constructs, then principles like autonomy become part of a wider morality of
relationship and care, where ethics of relationship and ethics of responsibility are better balanced and bioethical practice is better served by an integration of the two (Tauber, 2003).
In their discussions of the failure of autonomy as both a reality and an ideal, therefore, many theorists – virtue ethicists among them - appear to be moving in the direction of the feminist ethic of care, while not explicitly offering any of the clear alternatives to autonomy that many of the feminist approaches to ethics and bioethics seem equipped to offer. (See section three for a detailed discussion of ethic of care versus ethics of justice). From the above discussion, it is evident that the four principles approach is coming under increasingly critical scrutiny - from inside and out - and that this dominant theoretical framework could benefit from exploring alternative approaches such as feminist ethics, especially as it moves out beyond its Western borders and is applied in clinical research in developing countries, and to vulnerable populations within these contexts, where both the numbers and the marginalization of vulnerable persons increase proportionately. This requires more than simply presenting the alternatives, but also integrating them into the framework of bioethics (Crosthwaite, 1998) to produce viable
theoretical positions for exporting into the field, applying them in the contexts where they matter most.
The task for those who believe that autonomy is an important but not all-important response to the moral conundrums we face, is to show what we leave out when we frame our moral and social world in such constrained terms (Murray, 1994, p. 32).
This task has been taken up by feminist theorists who, in their efforts to reconceptualize the traditional concept of autonomy, are generating some of what is needed to fill in the gaps highlighted above.
2.1.6 Contextual Implications for Researchers
In South Africa, many persons, particularly women, may be prevented from making autonomous choices (in the traditional sense of autonomy) because of political, economic, social, emotional, and cultural constraints on their freedom (Jobson, 2005; Mills et al., 2006; Sideris, 2005;
Wassenaar et al., 2005). Women are more at risk for contracting HIV for several reasons – physiological factors, as well as other gendered, social norms and cultural practices. These include the accepted dominant role of the male in African cultures and the power of husbands over their wives in the marital relationship; attitudes that condone male promiscuity before and after marriage; and the belief that men should control the sexual encounter (Rakoczy, 2001;
Wingwood & Diclemente, 2000). These circumstances leave women with very little personal autonomy over their sexual relationships, where they cannot negotiate safe sex or fidelity (Leclerc-Madlala, 2000; Martin & Curtis, 2004; Memela, 2005), and over decisions concerning their own bodies. The explicit and implicit expectation within many cultures (in South Africa) is that women must be socially and economically dependent on men, establishing the ownership of women by men and further decreasing their freedom. The burden of impact of the HIV/AIDS epidemic also extends to those women who are not infected. Women are responsible for caring for the sick and dying, for orphans left behind – a burden often accompanied with the financial burden of these consequences. Indeed, it is the cycle of poverty that entrenches these norms and practices deeply within these communities.
Women‟s lower status, the poverty that they live in and with, and their economic
disenfranchisement, all have a major impact on their vulnerability to HIV/AIDS (Dunkle et al.,
2004; Kahn, 2001; Mills et al., 2006). Women living in these circumstances are thus disempowered on a number of levels. One of the goals of feminism in general and feminist (bio)ethics in particular, is to make the voices of these women heard. It is for these reasons and within this context that the present study contextualizes the re-conceptualization of women‟s autonomy within these daily lived experiences of the women who are most affected by the virus, and who are likely to be the target of much of the clinical research that is carried out in
developing countries such as South Africa. It is clear, then, that gender is a primary issue, and not one that should only be considered as an afterthought to the scientific concerns of such research.
Thus, while autonomy should not be abandoned, it is only part of the story, and needs to be modified to include (women‟s) “stories about how we are to live together, and how we are to make families and communities that support the growth of love, enduring loyalties and
compassion” (Murray, 1994, p. 33). The same argument applies to culture, and to the tendency to perceive one culture‟s worldview as superior to another. This is reflected in the domination of Western “independent” notions of self versus the interdependent views of personhood that are adopted in many non-Western cultures. In many developing countries, and in South Africa in particular, there are cultures with differing worldviews from those of the First World values of independence from which individualistic conceptions of autonomy arise. Thus, while feminist voices can help us to focus on women‟s unique experiences of agency, feminist (bio)ethics can also facilitate the adoption of a critical perspective when attempting to mould principles of autonomy in informed consent practices into more gender- and culture-sensitive conceptions.
The ethical issues associated with clinical research and especially with HIV/AIDS research, are as vast as they are complex. This, coupled with women‟s vulnerability, warrants special concern and challenges the adequacy of conventional informed consent procedures to the ethics of clinical vaccine trials (Mills et al., 2006; Wassenaar & Richter, 2000; Wassenaar et al., 2005). In these settings, ethical principles that are founded on (Western) concepts of abstract rationality, de-personalized obligation, procedural autonomy, and universality, may act to exploit, rather than exploit already disempowered women (Richter et al., 2000). “Trials, and in this instance, HIV vaccine trials, need to recognize that women‟s autonomy is historically compromised, requiring that a gender-sensitive ethics must be developed and actively applied” (Wassenaar &
Richter, 2000, p. 7). In contrast to conventional applications the principles and procedures of informed consent in clinical research, what may be needed to address the ethical complexities of such research in developing countries - and in South Africa in particular - is a feminist approach to bioethics, where the primacy of care, justice, and relatedness in women‟s experiences of their own agency is recognized and respected. Towards this end, this study attempts to supplement and integrate conventional approaches to the principle of autonomy in informed consent with conceptual equivalents from feminist ethics. Both feminist and African ethics emphasize dialogical morality and an ethic of care within a matrix of relatedness (Tangwa, 1996), making their primary focus the respect and preservation of interpersonal relationships (both in daily lived experiences of participants and of the research process itself), rather than abstracted notions of individual autonomy (Bowden, 1997).
This first section in this literature review has attempted to demonstrate the dominance of the principle of autonomy in conventional ethical approaches and, more particularly, in principlist
approaches to bioethics. It has highlighted some of the problems – conceptual and practical – with extensive, unconscious applications of autonomy as it is typically conceived. Virtue ethics has been presented as the beginnings of an alternative approach to autonomy that might rectify some of the shortcomings in conventional principles of autonomy, particularly as applied in informed consent contexts. In the next section, it will be shown how feminist ethics takes up some of the challenges posed by the virtue ethics approach. Building on the flaws of principled approaches to autonomy outlined in the section above, the feminist critique presented in the next section will highlight the gender bias in traditional bioethical principles. Following a brief
outline of feminist theory, the feminist critique of conventional autonomy will be discussed, with particular attention to the dangers of applying a principle of autonomy that is de-contextualized, de-gendered and detached in health care and health research contexts. In the sections that follow this feminist critique, reformulations of concepts that are inextricable from the theoretical project of reconceptualizing autonomy will be presented. The reconceptualization of autonomy to
include notions of relation and care will be explored further in the empirical chapters of this work, where the gendered association between the variables of autonomy and relation,
independent and interdependent selves, and justice and care moral orientations will be examined.