2. LITERATURE REVIEW
2.2 Feminist Critiques of Traditional Bioethics and the Principlist Approach to Autonomy .40
2.2.2 Feminist Critiques of Conventional Autonomy
2.2.2.4 Autonomy in context
reconciled in a relational and more context-embedded conception of autonomy. Similarly, Sherwin (1998b) distinguishes between the making of informed choices – agency – and being truly free from coercion in both the choices that are made and in the circumstances that structure that choice – autonomy. She proposes a relational reconceptualization of conventional notions of autonomy that can sufficiently absorb the complexity of making apparently un-coerced choices within a broader context of oppression. Towards this end, Macklin (1999 in Noring, 1999) proposes a relationships paradigm in ethics which is context-based, taking into account culture and gender, time and place, and emphasizing power, responsibilities, and historical
considerations. These alternatives offer particularly significant issues for consideration with respect to this study‟s contextual focus on research settings in developing countries.
In recent debates on the ethical requirements for conducting research in developing countries, the relationship between researchers and research participants is attracting greater attention. Benatar (2002) calls on researchers to recognize that they are, in most instances, from relatively
privileged backgrounds, while many research participants are among the poorest, most exploited, and oppressed populations. Following this, Benatar highlights the need to be sensitive to the fact that those who are disadvantaged or vulnerable are unlikely to view the world through the same lenses as researchers from first world, developed countries or to have had experiences that are even remotely synonymous with Westernized notions or ideals. Autonomy-based theories tend to ignore the fact that people are essentially products of their social history and current
environments. Such ontological neglect has the effect of protecting the privileges of powerful groups, and disempowering those who are exploited and oppressed (Sherwin, 1996).
Women may place higher value than men on the centrality of relationships in their lives. It is likely, too, that they also participate differently in those relationships. While men develop power- over and distance-between qualities of relationships, women work on promoting the values of care and mutual responsiveness within relationships (Friedman, 1998). The contrast between conventional notions of autonomy and feminist alternatives is clearly portrayed in the debate that was sparked by the announcement by a transplant team at the University of Chicago of its plans to transplant a hepatic lobe from a mother to her severely ill infant daughter. One opponent of the
“unethical” procedure expressed his reservations by arguing that, “simply put, how can a parent be expected to make an informed, rational, free choice when asked to consider donating an organ to his or her dying child?” (Colen, 1989 in Elliott 1999, p. 106). The reasoning behind this and other reservations was that the mother‟s emotional ties and moral commitment to her daughter
essentially made her decision “involuntary” and not truly autonomous. Feminist critics of principled autonomy would argue, along with Elliott, that
it is an odd notion of autonomy which would count emotional ties and moral
commitments as constraints on autonomy. The idea that a parent is coerced by her love for and moral obligations toward her child says something about the central place the ethic of autonomy (and the individualism that underscores that) holds in our culture (Elliott, 1999, p. 106).
In health care contexts, Dodds (2000) also shows how autonomy is frequently equated with informed consent and a person‟s exercise of “autonomy” is limited to choosing between the options with which she or he is presented. Similarly, Donchin (2000a) illustrates how, when the dominant, individualistic conception of autonomy is applied to ambiguous ethical cases such as physician-assisted suicide, it fails to reveal workable perspectives; perspectives that may only become clear when viewed through the lens of more relational conceptions of autonomy.
Adshead (2001) provides further grounds for revising traditional views of autonomy to account for the dependency that is part of the lives of men and women alike. Conceiving of autonomy as embedded in the gaps and connections between people in their relationships, Adshead argues, is consistent with “notions of best psychological health, where mutual interdependence is seen as being a goal of mature development, and detached isolation in terms of self, is seen as being potentially pathological” (Adshead, 2001, p. 143). The individualism inherent in conventional conceptions of autonomy has also been criticized for the increasing alienation in contemporary society, where individualism and egoism is replacing the sense of community and solidarity (Ter Meulen, 2001).
Many have argued that the social is essential for the realization of autonomy. Dworkin (1988) developed an account of autonomy with explicit attention to the values of human connection;
Feinberg‟s (1989) emphasis was on autonomy as self-legislation, self-reliance, self-possession, and yet still recognized that to be human is to be part of a community, where self-awareness comes from participating in existing social processes. However, these and other mainstream accounts of autonomy, while not entirely individualistic, are not considered sufficiently relational because they tend to regard social relationships as pre-requisites for, rather than an inherent part of, autonomy (Friedman, 1997). Accounts of autonomy should be cognizant of people‟s dependency, of their embeddedness in relationships, and of the relevance of both to ethical decision-making (Adshead, 2001).
Thus, feminism is not alone in its rejection of liberal individualism and of the prevailing
conception of autonomy that stands at the core of this theory (Fox & Swazey, 1984; Wolf, 1996).
The contribution that a feminist approach to (bio)ethics can make is a revision of theory and practice that will effectively reflect the social and the individual nature of human beings (Donchin & Purdy, 1999; Fishbane, 2001; Fricker & Hornsby 2000). One of the main charges that the feminist critique has directed at traditional interpretations of autonomy is that the notion of the self on which these interpretations are based is unacceptably individualistic. (See, for example, Code, 1991; Benhabib, 1992; Friedman, 2000b; Keller, 1985; Nedelsky, 1989;
Sherwin, 1992b). In formulating relational accounts of autonomy, therefore, feminists need to begin by building new models of selfhood in order to avoid the shortcomings of traditional approaches (Code et al., 1988; Cooke, 1999). To be an autonomous self, indeed, to “determine itself, a being must, at the very least, be a self” (Friedman, 2000b, p. 219). Herein lies the
apparent contradiction in feminist theory: the demand for respect for women‟s individual selfhood, and the rejection of assumptions about individual rights that suppress women‟s experiences and negate this respect (Nedelsky, 1989).
Based on the critique above, it is evident that some of the criticisms leveled against mainstream autonomy have to do with the masculine and individualistic bias in ethics in general and in the self conceptualizations that underlie autonomy in particular. Feminists have argued above that women value the connectedness to others that is neglected in the principle of autonomy as it is conceived and applied in bioethical practice. In the next section, the androcentric and
individualistic bias in contemporary ethics will be highlighted. The ethic of justice will be presented as a model of this individualistic ethics, and then contrasted with an ethic that
emphasizes relatedness. Care ethics is an alternative that has been developed in conjunction with feminist calls for a more relational autonomy that is closer, they argue, to women‟s experiences.
Care ethics has been put forward to counter the dominance of principles of rights, rationality and duty in the justice ethic that governs much of the guidance on resolving ethical dilemmas in, for example, human subjects research. The ethics of care will be described in more detail in the next section, and contrasted with the ethics of justice that has tended to dominate mainstream, male- oriented bioethics. More specifically, the development of the moral orientations – justice and care - that form the foundations of these ethical approaches will be explored.
2.3 Justice versus Care: An Ethic of Individualism versus an Ethic of Connectedness, Men