2. LITERATURE REVIEW
2.3 Justice versus Care: An Ethic of Individualism versus an Ethic of Connectedness, Men
2.3.1 The Problem with Conventional Ethics: Individualism and Androcentrism
2.3 Justice versus Care: An Ethic of Individualism versus an Ethic of Connectedness, Men
Bioethics is more than the sum of its collective medical and scientific parts; it uses biology and medicine as its metaphorical language and symbolic medium to deal with the beliefs, values, and norms that are basic to our society, its cultural tradition, and its collective conscience (Fox &
Swazey, 1984). Bioethics is a microcosm of ideological cross-currents within contemporary Western liberalist society (Jennings, 1998). As such, the values of individualism that Western society has consistently revered – individual rights, autonomy, self-determination and contractual relations - have also been accorded paramount status in the theories and practices of bioethics.
The importance that bioethics has placed on individualism has drawn it away from involvement in social problems, as the more socially-oriented values and ethical questions have generally been relegated to the perimeter of the bioethical framework (Fox, 1990). Rather than recognizing how social and cultural forces shape individuals from the inside and outside, bioethics tends to view these factors as external constraints that limit individuals and interfere with ethical deliberation. It was from this culture of liberal individualism that the principle of autonomy emerged, built on the atomistic conception of the self that Western individualism underscores.
Many have criticized the excessive focus in bioethics on individualism (Callahan, 1980, 1984;
Sullivan, 1982), while others have shown how the dominance of individualism has led to a preoccupation with autonomy in contemporary bioethics (Hoffmaster, 1992) – the “triumph of autonomy” (Wolpe, 1998, p. 48). Because the principle of autonomy is tied to its foundations in liberal philosophy, challenges to the current conception of autonomy constitute a challenge to the assumptions of individualism that define Western society (Graham, 2002).
Many have challenged the universal application of bioethical principles that are based as they are in a liberal individualist framework (Gordon & Paci, 1997; Jennings, 1998; Kuczewski &
McCruden, 2001). “The centrality of autonomy in bioethics is a reflection of the importance modern (Western) civilization has placed on the individual” (Dyer, 1997, p.172). As a result of its liberalist, individualistic underpinnings, Western philosophy has evolved into a culture preoccupied with the self – a self that is disembodied and disembedded and essentially reflects only aspects of the male experience (Benhabib, 1992; Cook, 1999; Schoeneman, 1994). Dyer (1997) argues that the bioethical principles of autonomy, beneficence, nonmaleficence and justice are grounded in assumptions about the relationship of members of society to one another.
Not only is the concept of autonomy inherently masculine it is also, by its association with individualism, inherently Western and a minority paradigm in relation to other societies and cultures throughout the world (Elliott, 2001). Similar concerns have been raised about informed consent, where respect for autonomy dominates, leading many to question the applicability of informed consent in societies that tend to emphasize relatedness rather than individualism (Alora
& Lumitao, 2001; Benatar, 2002; Christakis, 1992; Dooley, 2001; Gasa, 1999; Tauber, 2003).
Even in the West, there is no consensus on ethical principles (Snell, 2000), with arguments that the liberalism on which bioethics is based attempts to extend itself beyond reasonable limits and yet cannot accommodate conflicting interests (Schneider, 1998). And yet, “while there is some evidence emerging in the literature that a preoccupation with individualism, premised on the notion of a unique selfhood, is problematic, it remains, regrettably, at a superficial level” (Cook, 1999, p. 1295).
The almost exclusive focus on individualistic principles in contemporary Western bioethics has neglected what many believe to be central to ethical conduct – relationships between individuals.
The space that relationships are given in bioethics is primarily contractual. In reconceiving the principle of autonomy, the emphasis in autonomy should be shifted away from individuality and towards the social and relational nature of individuals, where the role of context is given
sufficient attention (Ter Meulen, 2001). Support for this view has arisen from concerns about the deficiency of applications of autonomy in the contexts of, for example, advance care planning (Ikonomidis & Singer, 1999) and clinical rehabilitation (Jennings, 1993). Operating in an era of scarce resources, rehabilitation‟s social and professional goals are ill-served by unrealistic and inappropriate notions of autonomy and independence, which produce conflict and frustration rather than the empowerment and respect that are necessary for transformative healing (Jennings, 1993). In many of these cases, bioethics has been criticized for failing to address the gap between theory and practice. In reality, morality and ethics exist in the intersubjective relations between people, where community meets individual and where it is possible to capture “both the value of communal life and the moral significance of the individual ethical voice” (Parker, 2001, p. 308).
Furthermore, despite the predominantly communal values held by traditional African and South African communities, Western, individualistic principles seem to be permeating these societies, as is especially evident in the way that research is being conducted in these communities.
Applying universal ethical guidelines and failing to recognize the importance of community may represent serious problems for the type of research increasingly being conducted in these contexts (cf., Crawley & Himmich, 2004; Diallo et al., 2005; IJsselmuiden & Faden, 1992;
Itzhaky & York, 2000; McCullough, 2002; Molyneux, Peshu & Marsh, 2005; Molyneux, Wassenaar, Peshu & Marsh, 2005; Mosavel, Simon, van Stade & Buchbinder, 2005; Quinn,
2004; Torres, 2000; Weijer & Emanuel, 2000; Weijer, 2002) – particularly regarding ethical concerns central to HIV vaccine trials in the African context, where ubuntu may represent the only appropriate response to the pandemic and the only hope of conducting ethical clinical trials.
Among the arguments against traditionally individualistic bioethics have been those that question the abstract, detached notion of the autonomous self – an ideal that privileges and universalizes that which is male, and removes the relational feminine self and qualities from the public ethical domain. As a result, bioethics has been criticized for its lack of attention to the role of situated context, of culture, of human emotions, of relationship, and of suffering, vulnerability, weakness, and compassion (Benhabib, 1992; Fry & Johnstone, 1994; Gaylin & Jennings, 2003; Thomasma, 1997). This tendency in bioethics to presume gender- and cultural-neutrality may be the basis of the rigid and arbitrary dichotomizing of the public and the private, reason and emotion, self and other, mind and body, culture and nature, the abstract and the concrete (Harding, 1987c). Most of what Western philosophy teaches and practices is “significantly flawed…and overwhelmingly male-dominated” and is especially harmful to women (Kourany, 1998, p. 3). The pervasiveness of this ethical androcentrism in practice is evident in, for example, societal notions that doctors - men - cure and nurses – women – care, which has historically perpetuated the perception that males practice medicine while females are assigned to the more feminine healing roles (Jecker &
Self, 1991), although this is no longer necessarily universally the case.
Masculinist approaches in ethics are widely applied, despite arguments indicating how this ethic is harmful in many situations where appropriate ethical recourse is already a contested area.
Parks (1999) shows how ethical androcentrism is manifest in traditional bioethics by considering
the case of maternal substance addiction to show how this ethic negatively affects the treatment of pregnant addicts. Situations such as this, when framed in a principlist framework, are treated as maternal-fetal conflicts. The mother and the unborn child are viewed as separate entities with conflicting rights and, in the case of maternal substance abuse, the rights of the fetus are given precedence over moral obligations owed to the pregnant woman. Feminist ethicists argue that a perinatal ethic based in general principles like autonomy and beneficence does not take gender into account, nor does it address the unique position of pregnant women (Harris, 2000), let alone pregnant addicts. Mahowald (1994) argues that unconscious application of allegedly gender- neutral ethics amounts, in many circumstances, to gender injustice. Because justice or equality is often construed as an ethical demand to treat all individuals in the same way, women are
traditionally treated no differently from men in areas where it is clearly neither possible nor ethical to do so. In reproductive genetics, infertility treatment, prenatal testing, and pregnancy termination, both male and female partners are considered essential to the reproductive process and, thus, modalities of testing, consenting, and counselling are discussed in the context of couples, despite the fact that none of these procedures requires participation or risk by the male partner (Mahowald, 1994). Women‟s reasons for making these decisions
tend to be based on the complex set of caring relationships that each women bears to others…Gender justice, implemented through support for the autonomy of those most affected by reproductive decisions, is a means, perhaps even an indispensable means, through which to realize an ethic based on caring (Mahowald, 1994, p. 74).