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
2.2.2.1 Principled autonomy and (the neglect of) gender
There is considerable variation in how autonomy has been defined from study to study
(Steinberg & Silverberg, 1986), which may account for the discrepancies in investigations into gender differences in autonomy. While some studies have suggested that men and women do not differ significantly in their experience of autonomy (Anderson, Worthington, Anderson &
Jennings, 1994; McChrystal, 1994), others have found evidence in support of the theories that women value relatedness over autonomy (Jordan, 1984 in McChrystal, 1994; Surrey, 1991) and, as such, exhibit significant differences compared to men in terms of their experience of
autonomy (Bekker, 1993; Miller, 1986, 1990). It has been argued that the duality in Western thought perpetuates the perceived differences between men and women, thereby downplaying differences within groups (beta bias) and overestimating differences between them (alpha bias) (Hare-Mustin & Marecek, 1986, 1987, 1988; Stewart & McDermott, 2004), which has led in turn to a number of studies which have focused on the diversity within groups (Ewing, 1990; Killen, 1997; Mines, 1988; Sinha & Tripathi, 1994; Turiel & Wainryb, 1994).
However, in response to findings that have found a greater desire for autonomy in women than in men (Fleming, 2005; Lamborn & Steinberg, 1993), feminists are among those who point to the role of context in determining these results. While some have suggested that the women‟s
movement and changing gender roles in society have contributed to the greater value that women appear to place on autonomy (Anderson et al., 1994; Eagly & Mladinic, 1989; Eagly, Mladinic &
Otto, 1991; Gerson, 2002; Labott, Martin, Eason & Berkey, 1991), others have argued that societal pressure places women in a conflicted position, forcing them to deny their gendered tendency toward relatedness by exhibiting greater levels of autonomy (Catina, Boyadjieva &
Bergner, 1996; Layton, 2004). This has generally been defined as a negative experience for women (Lamborn & Steinberg, 1993) and may account for other instances of psychological effects on women, such as the development of eating disorders (Mensinger, 2005; Steiner-Adair, 1990). It also draws attention to the importance of sociocultural context in shaping autonomy, which has been the focus of a number of studies (Catina et al., 1996; Collins, 1990; Henderson, 1997; Joseph, 1991; Ma & Schoeneman, 1997).
While bioethics has concentrated its focus on issues of patient and participant autonomy, and power imbalances between health professionals and their clients, researchers and their research participants, it has paid scant attention to the impact of gender on these issues (Crosthwaite, 1998). In addition, there is still a widely held belief that bioethics is cognizant of the gendered particularities of its subject matter and of its own theoretical underpinnings. Feminist charges against the concept of autonomy include arguments that
it is inherently masculinist, that it is inextricably bound up with masculine character ideals, with assumptions about selfhood and agency that are metaphysically,
epistemologically, and ethically problematic from a feminist perspective, and with political traditions that historically have been hostile to women‟s interests and freedom (Mackenzie & Stoljar, 2000, p. 3).
Donchin (2001) points out that the very valorization of autonomy as a norm in bioethics is problematic. Standard conceptions of autonomy in ethical approaches pit interpersonal
connection against autonomy as mutually exclusive ways of relating which, combined with the contractarian model and focus on individual decision-making, presents images of “bleak
dystopian scenarios” that block out alternative ways of reconciling theory and practice (Donchin, 2001, p. 375).
Shildrick (1997) has challenged the dominance of autonomy in bioethical theory and practice on the grounds that autonomy has been constructed as the exclusive privilege of a male subject.
Friedman (1997) points to the role that popular culture and gender stereotyping have played in reinforcing the association of autonomy with men, rather than women. This, combined with the establishment of autonomy as an ethical ideal, implies that, compared to men, women are somehow deficient human beings. Others have also drawn attention to this pathologizing of women and minorities who do not match or aspire to the separation and independence of the idealized autonomous self (Fishbane, 2001). This “attenuation of the human in „man‟ is a source of sickness, both cultural and individual” (Rawlinson, 2001, p. 405), such that the silence on gender in contemporary bioethics renders the „other‟ gender – that is, women – invisible.
Wolf (1996) points out that many of the quandaries that bioethics confronts – from genetic screening and reproductive technologies to the HIV epidemic and allocation of health resources – have profound implications for women. And yet, bioethics has paid little attention to gender in its ethical considerations. Gender has also played a large but unexamined role in research
settings, too, according to Wolf. In the selection of research subjects, for example, there has been little analysis of gender equity which, in turn, underplays the systematic exclusion of women – particularly women of childbearing age – from AIDS research protocols that may be the only means of access to a promising drug – not to mention the release of these drugs without adequate testing of safety and efficacy in women. Wolf also argued that bioethics tends to be a
conversation among experts about patients‟ and research subjects‟ rights – conversations in which patients and research participants tend to be the objects of concern rather than full members of the ethical conversation.
Feminist ethics pay careful attention to context, to the social, to the unique particularities of individuals and of every moral problem, and to the power imbalances that are played out in bioethical theory and practice.
It follows that one of its tasks is to challenge medicine‟s androcentrism – its standing assumption that men are the norm for human beings – and to call attention to the ways in which this assumption marks women as either unimportant or pathological (Lindemann Nelson, 2000, p. 493).
Little (1999) emphasizes the androcentrism inherent in society, and in theories and practices that grow out of this society, not least of which is bioethical theory – the effect is that what is
presented as normal for all humans is actually the norm for a small, privileged group of men, when these are in fact gendered concepts. Rawlinson (2001, p. 45), too, contests the “masculine marking of its supposedly generic human subject” and shows how this has been harmful to women, rendering them invisible and silent. As a result of feminism‟s attention to gender, key concepts such as respect for autonomy are afforded richer understanding as their meaning is extended beyond models of values that are exclusive to a privileged group of men (Lindemann Nelson, 2000).