Month: April 2019

Feminist Ethics in the Health Care of Women

Pat Anderson

DePaul University, School For New Learning

Major Piece of Work, Winter, 1993

Academic Mentor: Catherine Marienau

Professional Advisor: Ann Stanford

Introduction

Historically, the field of philosophy has been dominated by white males. If asked to name philosophers, the average person would probably name Aristotle, Plato or St. Thomas Aquinas. It’s doubtful many people would be able to name one female ethical theorist. The field of bio-medical ethics has experienced a similar history because most doctors have also been white males. As a result of this male dominance, theories about ethics and the practice of medicine have come from male perspectives; women’s perspectives, values, and life experiences have been left out.

Having spent twenty-six years in the medical profession in a traditional female role, that of a nurse’s aide, practical nurse and registered nurse, I know from first hand experience the negative effect that patriarchy has on patients. My biases and assumptions come from viewing patients contextually and emotionally, always keeping in mind the relationality that forms the core of their lives. I view patients from a mode of caring; doctors view patients in abstraction; they tend to use rationality in forming their professional ethics. My bias is that the patriarchal nature of medicine seeks to control women; I assume that this hurts women. I hope to learn if feminist ethicists share my assumptions and biases. Do they share my opinion that the vulnerability of patients (especially women) puts them in perfect position for the hierarchical medical institution to control them?

I will address the basic philosophical differences between feminist and traditional ethicists. I will then go on to discuss more specifically, the area of feminist ethics in the health care of women today. Some of the areas include, abortion, reproductive technology, pregnancy, menstruation, cosmetic surgery, research, cancer, and health care workers other than doctors.

I will use sources and personal experience to make the argument that the health care institution itself and the very field of medical ethics serves to maintain women’s oppression and devalued state in society. I plan to show that technology is being used to camouflage the fact that men are still using their power to control women’s bodies – things haven’t changed within patriarchy just because the science has become more sophisticated. The very mechanisms of oppression prevent women from seeing what is happening to them. Patriarchy is like a massive religious cult trapping all women whether they have had their consciousness raised or not.

I hope to illustrate that the manner in which women are oppressed by medicine is frighteningly not far removed from terrorism or brain washing. Yes, this is extreme – I mean it to be!

I hope to illustrate through an extensive review of the literature, and through my own practical experience that women’s oppression has been and still is being perpetuated by a bio-medical ethics that devalues women.

I hope to learn what women have to say about the field of medical ethics.

       -Do other feminists who have experienced health care differently than I perceive the system as I do?    

       -Do women offer viable solutions to today’s ethical dilemmas in the field of bioethics?

       -Could a combined perspective that would include feminist and “old school” ethical ideas be of use in a field like reproductive technology?

       -Could a combination of solutions actually approach justice?

       -What do male ethicists have to say about feminist ethics?

       -Would adding the feminist viewpoint change the relationship of the people involved in the biomedical environment? (doctors, nurses, patients, technicians and social workers).

       -Does the oppression of women affect feminist ethics? Are there male ethicists who are aware of and admit the oppression of women?

       -And what role do they see feminist ethics playing in bioethics today and in the future?

       -I will offer solutions posed by feminist ethicists and some of my own.  

Feminist Ethics in the Health Care of Women

Sexist Ethics

The very same hierarchical structures found in larger society organize the bioethics in health care. The primary concerns of medical ethics are issues that confront physicians. Doctors are in power so it’s their views that are usually adopted. Problems faced by nurses and other health care workers are frequently not dealt with at all. This suggests whose work is seen as important and worth studying. The complexities and tensions that exist among the care givers themselves are seen as irrelevant, thus ignoring the fact that their problems have an enormous effect on the quality of care given to patients (Sherwin 3).

Sexism and gender oppression can be so subtle and pervasive that without feminist inquiry they would be overlooked. Bioethics literature has not addressed the oppression of women, making that reason enough to peak feminist suspicions. Feminism should ask that bioethics include in its inquiries questions about whether their decisions affect women’s oppression in society (Sherwin 4). The medical field has been given the power of legitimacy because of it’s scientific knowledge and the power that it has over our health. The institution of medicine has been designed to reinforce sexism; sexism hurts women. We need to identify the connections between the practice of medicine and patriarchy.

“People’s lives can be poisoned by oppression as well as by toxins, and both elements merit consideration in moral evaluations of health care practices” (Sherwin 7).

“One of the central insights of feminist work is that the greatest danger of oppression lies where bias is so pervasive as to be invisible” (Sherwin 10).

Sherwin asserts that we need to questions assumptions we have held about health care (Sherwin 10).

Mendelsohn goes as far as saying that the religion of modern medicine is surrounded by a mystique that intimidates patients into accepting whatever the doctor says (Mendelsohn 4). He says that mortality rates show that when compared with a century ago, (excluding those saved by sanitation, nutrition and a few breakthroughs in epidemiology) Americans are not as healthy as 100 years ago, despite the wonders of technology and the religion of medicine (Mendelsohn 6).

Mendelsohn agrees with feminists that women certainly face sexist attitudes that can hurt them throughout society but,

       “the chauvinism of a physician or a surgeon, however, may condemn the same woman to a lifetime of dependence on drugs or cost her the life or health of her baby, to say nothing of the loss of her breasts, her uterus, her ovaries, and even her life” (Mendelsohn 28).

As far back as Hippocrates’s time, during the 5th and 4th centuries b.c., doctors thought a female’s reproductive system was the cause of women’s insanity and hysteria. As a result, for over two thousand years, women who were considered deviant, (who did not exhibit passivity and humility) were cured by hysterectomy. Ovariectomies discovered in 1809, were also used to cure insanity, psychological disorders and to keep women under the social control of men; female castration was thought to assure obedience from women. The medical profession used these justifications to remove ovaries until 1946 (Mendelsohn 30)!

G. J. Barker Benfield claimed, in his medical history book, The Horrors of the Half-Known Life, that the gynecological specialty was brought about to support retaliation against and for the control of women; doctors resented women’s entering the work force in the Industrial Revolution and the women’s movement associated with it. Doctors exploited their power as physicians and attempted to showed women who was boss by performing aggressive surgeries (such as ovariectomies and clitorectomies) (Mendelsohn 33).   

There are several main issues ethicists must address that are faced by women in the health care system; the unequal treatment of women, the roles of doctors and nurses and issues that relate to power struggles in relationships. Today’s medical ethics addresses emergency type issues and avoids everyday maintenance issues (Warren 32).

One issue, involves how ethical debates themselves take place and how ulterior motives effect what is believed and what is included in the arguments. Louder than the messages spoken with our lips may be what we select and what we neglect to chose to study – the games we play also sends a strong message (Warren 32).

Warren postulate that a sexist ethics would frame moral questions from a male perspective and use these male perspectives to formulate solutions. The moral dilemmas chosen would involve authority, status and power. For instance, who has the right to make a final decision about your health care, you or your physician? The solutions posed would ignore matters of vital importance to women and children. Warren uses an excellent example in that to save costs, patients are sent home sooner than before. When they get home a female family member will likely be involved in caring for the person; their unpaid labor is without social weight and is not valued (Warren 33).

Second a sexist ethics, would be hidden in a way to make it appear to be neutral. Ideal moral agents have been those who could use rationality or calculate the utility of a solution. In using these types of ethics people whose life experiences do not fit mainstream ideologies, like women, gays, lesbians or blacks are ignored. If we do not address their unique life experiences they will be made invisible even to themselves. By using universal perspectives, we are saying that all human beings are the same or generic. The fact that women’s bodies, emotions, and relationship are different than men are thus made irrelevant (Warren 33).

Third Warren says that a sexist ethics would frame debates in a manner that keeps women on the defensive; it would invite women into the framework, promising to address their problems – provided they don’t rock the patriarchal boat too much. Women are also on the defensive because one of the most popular debates lately has been abortion where women are pitted against a defenseless fetus (Warren 33-34). 

Warren suggests we look at inequalities, sexist occupational roles, personal issues, and relationship issues. She suggests we look at the inequalities toward women in health care and then seek solutions. She uses IVF (in vitro fertilization) as an example: the technology excludes women who are single or lesbians – you must seek to raise a child with a man to be considered for the technology (Warren 35-36).

Nurses have historically been delegated the passive female role; in these passive roles how do nurses resolve their ethical issues when the issues of the powerful doctors are the ones that are valued and taken up for ethical discussion? The training that doctors get is technical, not ethical and yet they have been given the authority in this field. Nurses are supposed to nurture, and rather than make decisions, they are supposed to follow doctor’s orders. These roles definitely follow gender edicts (Warren 36).

Medical ethics has not addressed stresses faced on the jobs of health care workers, despite higher than usual rates of alcohol and drug abuse among health care professionals. Divorce and suicide rates are also high. In addition to the personal being political, the personal is professional – what may be seen as personal may have a profound effect what happens on and off the job – for this reason it should be addressed by medical ethics (Warren 36-37). 

Oppression

“Marilyn Frye has defined oppression as an interlocking series of restrictions and barriers that reduce the options available to people on the basis of their membership in a group” (Sherwin 13).

These restrictions are insidious. The practices that make up the system of barriers appear harmless when looked at separately, but when looked at within a set of institutionalized norms, the patterns become clear. The ideologies that oppress are virulent because they are internalized by the oppressor AND the oppressed (Sherwin 14).

  Men

Unless men (and women) engage in demolishing patriarchal structures, they are complicit in maintaining them. Sexism gives men a choice of exercising their power. Those interested in real gender equality must do more than not using their choice – they should take active steps to get rid of the unjust power men hold merely by being male (Sherwin 25).

Jonathan Mann, of The Global AIDS Policy Coalition, served as a model of how men can help to stop the oppression of women. He appeared on “Good Morning America”, to discuss solutions to the problem of AIDS in Ugandan women. He sees the empowerment of women as a solution to the spread of AIDS among the women of Uganda. Mann says that if women were allowed to, get divorced,  own property, have rights, demand the use of protection from disease, refuse sex, or have a say in their lives, they might stand a chance to prevent themselves from contracting AIDS. He says that medical means are not the only ways to stop the spread of disease. Mann further stated that at the start of the AIDS crisis, 25% of the patients with AIDS were female, and now it is up to 40% (Mann 92).

“Although medical and surgical overkill are routinely inflicted on all Americans, its primary victims are women”  (Mendelsohn x). Mendelsohn wrote his book Male Practice to help women avoid the disastrous fate he knows many women have faced in the medical profession. He claims he purposefully used the male pronoun in the title because most doctors in the U.S. are men (Mendelsohn x). Mendelsohn is one of the few men who speak out clearly in support of women’s rights; he serves as an example as to how men can help overcome women’s oppression.   

Philosophical Ethics 

The study of philosophical ethics is concerned with value questions about human conduct; it studies the legitimacy of using categories like: good, bad, ought, should, right, wrong, obligation, responsibility, justice, injustice, praise or blame. Philosophical ethics seeks to specify appropriate grounds of justification for moral judgments. Most philosophers don’t prescribe commandments or suggest punishments from some high authority the way that churches do. Ethicists seek to make sense of underlying cultural values and types of considerations that determine the moral assessment of practices. Feminist ethics, however, considers oppression of women along with moral judgments (Sherwin 36).

Traditional Ethics

To distinguish traditional mainstream (malestream) ethics from feminist ethics we must compare and contrast their concepts (Sherwin 37).

Arthur Zucker lists in his preface the topics NOT included in his anthology, some of them are: nursing ethics, alternative concepts of medicine, and minorities in medicine. In the first paragraph he states that it’s not that he finds these topics unimportant, but he thinks that if a student comprehends the material he includes in his book, that the student will be able to think through other issues for her or himself with ease (Zucker ix). Yet if not introduced to taking oppression into account how can he know that students will be able to? The historical fact that women’s oppression has NOT been considered in traditional ethics illustrates the importance of his pointing it out. He acts as if he, as a teacher, has no power of influence over what his students think is important.

If Zucker gave a priority to the issues of the oppressed, he could give future students of ethics a sensitivity to oppression rather than not exposing students to oppression by excluding it from his anthology – NOT including oppression and other issues relating to women and minorities is a loud message about their value.

Zucker claims that the role of ethical theory is to identify relevant moral factors. By helping us to focus on specific aspects of a problem, theory gives us direction to sort things out (Zucker 10). By choosing not to include nursing, minorities and alternative health care options Zucker favors a discussion that would serve the status quo. If one does not factor in oppression as a relevant factor, how can moral agents say that they have looked all the moral

factors? Correcting the immoralities of women’s oppression is a morally relevant factor.

Zucker claims that theory provides us with a common vocabulary to the discuss the issues (Zucker 11). To a feminist, ethical discourse whose vocabulary is devoid of the word oppression is lacking a fundamental relevant factor. 

Zucker further states that the fact that theories are limited, allows for alternative interpretations, due to their complexities, theories impose artificial simplicity (Zucker 11). Feminists certainly see alternative interpretations in that they perceive that the traditional male devised theories serve to maintain a stratified social structure that keeps men at the top.

Deontologicalists

These theorists are involved in deciding which actions are required or prohibited as a matter of moral duty. Actions are deemed right or wrong because they are either required by moral laws or rules and are considered to be binding, independent of a person’s specific interests. The most influential deontologist was Immanuel Kant (1724-1804) whose theories, despite the fact that they were published over 200 years ago, are still used by some philosophers in 1992 (Sherwin 37).

Kant proposes we decide on the rightness of an action according to a logical principle. Moral duties are identified by rational, free persons using abstract reason; these duties must be above any personal considerations. This does NOT allow for specific facts in a situation. To Kant, the moral thing to do is to follow moral laws, not to try to attain the results we want. His theories require that we follow some actions despite the consequences (Sherwin 37).

Kant was critical of teleological theories (actions measured by their consequences) because one could not be sure of what the consequences of an act would be, so it left the morality questionable – they lacked universality. He thought that an ethical theory must tell us with certainty whether an action is right or wrong for all people in a given circumstance, even before they acted. Rightness or wrongness of an act depends on the motivation. For Kant it’s the quality of the will, not the quality of pleasure as a result of an act. Correct motivation depends upon reason (Zucker 4). Kant’s “categorical imperative” states,

“Act only according to that maxim whereby you can at the same time will that it should become a universal law”(Zucker 5).   

The idea of having to pass a “categorical imperative” test and having to think ahead so that you end up with a rule that applies to similar situations is ridiculous to me. Who decides what maxims are generalizable? An example of this type of maxim might be, all patients with cancer will receive chemotherapy, after all, the intention is good. 

These theories don’t fit women’s life experiences that are contextual in nature, which is opposite from the rational perspective that influenced the development of the categorical imperative. 

Kant assumed only men could be moral agents; they were able to ignore personal sentiments in making decisions. Feminists reject the very notion of a moral theory totally separated from sentiment (Sherwin 39).  

Teleological Consequentialism

The moral worth of an action is measured in terms of the worth of the consequences (Sherwin 39). (Which is quite different from deontologists who evaluate the correctness of an act by laws and rules they think must be followed, despite ignoring the contexts of specific situations).

These theorists say that the evaluation and decision regarding an actions rightness are based on whether the action maximizes the outcome when compared to alternatives (Sherwin 39). Using the example of all cancer patients receiving chemotherapy, we would be required to evaluate the consequences; consequences could be nausea, diarrhea, weight loss, extreme discomfort, depletion of infection fighting cellular function, multiple infections, longer life, cure, or death itself from the side effects. Who decides what is the prominent criteria to be used to evaluate these consequences?

Utilitarianism

In this theoretical framework, the consequences of ethical decisions are evaluated by accumulated effects on the welfare of persons. These theorists recommend not following rules if the outcomes are less than desirable, even if they appear rational in the abstract. Their analysis focuses on concrete or abstract experiences and denies that the feelings and attitudes of agents and those affected by the action should be considered. On an abstract plane rightness is calculated by the total amount of happiness and suffering created by an act without regard to whose happiness or suffering is involved; this theory is not concerned with merit or fairness. So, if a mother had to decide whether to help her children (2 of them) or her enemies (15 of them), she would simply have to go by the numbers to know which group will allow her to please the most people. This theory does not concern itself with WHO will be pleased, so a mother might be obligated to go against her family by following this theory. These theories demand impartiality of agents which many find repulsive (Sherwin 40).

The founder of utilitarianism, Jeremy Bentham (1748-1832), thought that we humans were subject to 2 masters: pain and pleasure; these powerful incentives control what we do. He coined the phrase, “principle of utility”, and wrote,   

       “By the principle of utility, is meant that principle which approves or disapproves of every action whatsoever, according to the tendency which it appears to have to augment or diminish the happiness of the party whose interest is in question” (Zucker 3).

He even developed a hedonistic calculus for moral agents to use to calculate the potential amount of pleasure and pain a specific action might take. Bentham’s theories did not address what to do if two actions yielded the same amounts of pleasure (Zucker 3).

(As a feminist, I know who would decide in a sexist, racist and classist society whose pleasure was of more value – rich, white men!)    

John Stuart Mill (1806-1873), claimed that a utilitarian needn’t use calculus to come to moral decisions. He thought that one could evaluate acts in advance and come up with guidelines and/or rules to speed things up. Mill thought that pleasure of the mind was of more value than the physical. If 2 acts yielded the same pleasure then “competent judges” were called who had experience with many pleasures to decide on the close calls (Zucker 3).

I can imagine that with this type of thinking the intellectuals could rationalize oppression quite well. If pleasures of the mind hold more value then they as intellectuals would be favored over the needs of the poor, women (who were certainly not seen as intellectuals in those days), blacks and Native Americans and others. They were free to sit in their ivory towers deciding on their own pleasures and ignore the oppressed people’s mere physical needs.

Both of the above theories require distancing one’s self from personal experiences. Kant is into universal laws, and consequentialists tell agents to weigh their own interests equal to everyone else, without moral evaluation of the interests themselves. Both theories deny weight to details of positions in dominance hierarchies. This type of abstract neutrality is objectionable to feminists, who look at the socio-political contexts of people in moral deliberations (Sherwin 41).       

W. D. Ross (1877-1971) attempted to combine Kantianism and utilitarianism. He identified “prima facia” duties and “actual duties”; prima facia duties are the ones that we see at first glance, ones that our reason sees as moral commands, that are self evident and obvious to rational persons. Our actual duties are not self evident, nor can they be logically obtained from prima facia duties; people with keen minds and moral sensibilities can differ on actual duties even if they agree on prima facia duties. Ross’s theories are weak in that he doesn’t tell us how to decide among the prima facia duties (Zucker 6,7,8).     

Ross says to measure the rational intuition of the “plain man”. He fails to take conflicting issues into account. Whose rational intuition is followed between the oppressor and the oppressed? These theories do not leave room to consider feminist concerns (Sherwin 38). Ross does not identify WHO is the “plain man”. 

Bernard Gert, a contemporary American philosopher, has also combined Kantianism and Utilitarianism. He sees morality as a public system applying to all rational people – the goal is to minimize evil. Gert claims that all rational persons would agree that certain things are evil: death, pain, disability, loss of pleasure, opportunity or freedom. He postulates 10 moral rules as the core of human moral experience that should never, without adequate reason, be violated:

“Do not kill. Do not cause pain. Do not disable. Do not deprive of freedom or opportunity. Do not deprive of pleasure. Do not deceive. Keep your promises. Do not cheat. Obey the law. Do your duty (in your job or your profession)” (Zucker 14).

Gert then goes on to identify questions to ask about the specific problem being addressed; the key terms in his analysis involve rationality, impartiality and irrationality. Zucker says that Gert’s moral theory addresses the type of problems encountered by health care professional and, “yields fresh insight about the moral experience of humankind” (Zucker 15).

Gert’s fundamental concept is rationality; in order to justify morality, the act must at the very least be rational because everything else depends upon rationality. Impartiality, he claims, is universally recognized as an essential part of morality. The rules of the game are known by all and all involved are required to act rationally. He discusses rationality as thus:

“A person with sufficient knowledge and intelligence to be a moral agent acts irrationally when he acts in a way that he knows, (justifiably believes) or should know, will significantly increase the probability that he will suffer death, pain, disability, loss of freedom or loss of pleasure, and he does not have an adequate reason for so acting. A reason is a conscious belief that one’s action will help anyone, not only oneself, avoid one of these evils, or gain some good, viz., ability, freedom, or pleasure, and this belief is not obviously inconsistent with what one knows” (Zucker 17).

As far as public rules, the following describes Gert’s description of a justified moral system:

“Everyone is always to obey the rule unless an impartial rational person can advocate that violating it be publicly allowed. Anyone who violates the rule when an impartial rational person cannot advocate that such a violation be publicly allowed may be punished” (Zucker 19).

Who are these impartial rational persons? Who decides who gets to make these decisions due to their status as being impartial and rational? Gert admits that impartial rational persons may disagree on the ranking of evils due to ideological differences, but does not offer solutions to these differences. Gert assumes that we have an egalitarian system. If Gert had come up with his moral system with the hierarchical nature of our world in mind his system would have to be vastly different. Under hierarchy in the medical field the doctors would be considered the impartial rational persons who are qualified to make judgments on how much suffering is morally allowable. In society at large, under hierarchy, those in power positions would be the ones making decisions about what’s evil and what is right. His ethics is dehumanizing to those without power who would be labeled partial and irrational; they would be viewed as needing those in power to “take care of” them.

Contractarianism/Social Contract Theory

Social contract theory is similar to the above three, but places objects in a social context. It makes the assumption that people are independent, self interested and view morality as though it were on a par with like trying to get cooperation among competitors. This theory appeals to a “social contract” or hypothetical agreement, the logical outcome of a reasonable negotiation with separate self-interested persons. These selves share a mutual gain – avoiding violence. Morality is a rational option to limit the dangers of life (Sherwin 41).

Only abstract features of significance to everyone have meaning in developing the contract. (no emotionality or contextual data). It does not address the morality of persons who do not meet ideal moral standards. Nor do they (the proponents of the specific theory) check out the moral relationship existing among people of unequal status. Details like whether or not someone is disabled, has talent or social status compromises the legitimacy of the contract (Sherwin 41).

Feminists say that these contracts developed under a “veil of ignorance” perpetrate oppressive practices. The theorists act as if traits like race and sex can be treated the same as eye color; they fail to identify mechanisms that maintain oppression (Sherwin 42).

Feminine Ethics

Sherwin discusses 2 distinct groups of concerns about traditional ethics:

       1.    “Feminine” ethics – how traditional approaches fail to address the moral experiences and intuitions of women (Sherwin 42).

Anti-women bias is seen in much of the traditional theoretical ethics work. As the leading moral theorists show, existing ethics proposals don’t get at their objective – impartial theories and most theories show gender bias and misogynist values; it is not insignificant that most moral theorists have historically been male (Sherwin 43). 

Aristotle’s theory of virtues is illustrative: men’s virtues were those needed for freedom and political life; women were those about obedience and silence. Only male virtues were the subject of philosophical interest or given value. Aristotle’s sphere of influence, which included most of our church fathers, lasted for centuries; his followers not only accepted his ideas about gender specific moral worth, but made them the centerpiece of a theology that has shaped Western values ever since (Sherwin 43).

Many of the historical moral theorists like, Thomas Aquinas, Jean-Jacques Rousseau, GWF Hegel, Friedreich Nietzsche, Jean-Paul Sartre, and Kant saw women quite differently from men. They thought that women were morally unfocused and not interested in the level of generality required for moral thought. To them it was obvious that men were naturally associated with reason. Women’s shortcomings justified excluding them from active participation in political life and for limiting their power and influence to the home. These theorists thought that the subordination of women was natural and saw in women a willingness to accept these facts passively. Sherwin quotes Rousseau who said bluntly that women were suited by nature, “… to please and to be subjected to man … Woman is made to put up even with injustice from him. You will never reduce young boys to the same condition, their inner feelings rise in revolt against injustice; nature has not fitted them to put up with it” (Sherwin 44).

Sherwin says that even the modern theorist, John Rawls (71), thought he could come up with an equitable theory without the special perspective of women. He suggested that “heads” of households could simply represent the whole family. He did not address the patriarchal societal tendency to allow men to disregard and regularly violate their wives and children. Neither did Rawls address the sexual division of labor (Sherwin 44).

Robert Nozick’s Anarchy, State and Utopia (74) and David Gauthier’s Morals By Agreement (86), illustrate that the presumption that philosophy can be gender-neutral perpetrates male privilege. Nozick and Gauthier assume women are moral agents, but the moral concerns examined are always most salient from a male point of view (Sherwin 44).

Sherwin relates complex ways in which the implications for women of traditional moral theory lead to “moral madness”. Traditional theories follow one or more patterns:

       “1.   They deny that women are capable of full moral reasoning;

        2.   They draw a distinction between public and private moral thought, restrict women to the domain of the private and then deny that the private domain constitutes moral thought;

        3.   They force women into a series of perverse moral double binds; 

        4.   They make invisible the domains wherein women’s moral decision-making is concentrated.” (Sherwin 44-45).

Freud thought women were incapable of justice because they were too personal and were unwilling to evaluate ethical claims using abstractions. Kohlberg deliberately excluded women from his study on the development of moral reasoning, as their inclusion would contaminate the data. He was actually acknowledging that women used different patterns to develop moral reasoning skills. Kohlberg was right in that when the tests he developed, using male norms, are applied to women, men score higher (Sherwin 45).

Women needn’t bother trying to convince men that their moral reasoning abilities are equal, but that the gender differences both deserve recognition as legitimate, important elements and need to be added to the public sphere of discourse (Sherwin 46).

A study showed that women focus on the details of relationships and are innovative in trying to find solutions to help all and avoid harm to anyone. Men tend to identify appropriate rules that govern the situation, select the solution most compatible with the dominant rule, even if someone’s interests may be sacrificed to justice. Gilligan named the way of women, as an ethics of responsibility of care and the men’s, as an ethics of justice. An ideal ethics would include both frames of reference. Gilligan asks that we expand moral considerations that consider feminine thinking to be relevant – not deficient (Sherwin 46).

Gilligan noticed problems interpreting women’s development and began to connect these problems to the fact that women have been historically excluded from theory building studies about the psychological development of morality (Gilligan 1). She found disparities between what women experienced and what the developmental charts said was supposed to happen at different points of development. It was previously judged that women’s not fitting in male designed stages was a problem with the women (Gilligan 2). Instead feminists argue that it’s a problem of not including women in developing the theories in the first place that is the real problem.

Gilligan attributed the different “voices” she heard from the women she studied to the different social context they lived in: social status, power differences, reproductive biological differences and the relations between the sexes themselves all worked to shape the different experiences men and women face in their moral development (Gilligan 25).

Gilligan discusses discoveries in social science where formerly considered “neutral” theories are now seen to reflect observational and evaluative biases. She notices how accustomed women have become to viewing the world through men’s eyes. The theories about moral development have adopted male life experience as scientific “norms”; society and women themselves have tried to fashion women out of male cloth. Freud built his theory of psychosexual development around the male child leading to his Oedipus Complex; in the 1920’s Freud tried to fit women into the male conceptions and then came to his famous “envy” conclusion that said women failed at this developmental stage (Gilligan 6,7). 

From the developmental differences Freud found in women he theorized, “for women the level of what is ethically normal is different from what it is in men,” he further concluded that women “show less sense of justice than men”, that they are less ready to submit to the great exigencies of life, that they are more often influenced in their judgments by feelings of affection or hostility” (Gilligan 7). Part of a boy’s developing a male identity involves separating from his mother; for girls their identity formation is intermingled with attachment to the mother. Thus, the male identity is threatened by intimacy, and the female identity threatened by separation. As a result, males have more trouble with relationships and females have more trouble with individuation. If these insights are put together with the psychological development markers made from studying men, it is clear to see why females are seen to “fail” because of their difficulty with separation (Gilligan 8,9).

Women find self definition within their relationships and judge themselves based on their ability to care. A woman’s place in a man’s life has been that of caretaker; male dominated theories of psychological development, have tended to minimize the value of women’s caring. When development scales get to stages of maturity and stress autonomy, women are seen as weak because of their continued concern for relationships (Gilligan 17).

Gilligan describes Kohlberg’s 6 stages of moral development; research which functioned on the assumption that females “didn’t exist”; he studied the moral development of 84 boys over a 20-year period. Despite the obvious exclusion of girls in his work he claims his stages are universal; it is rare however, that females ever reach his higher stages of development (Gilligan 19,20,21).

When the moral development of women is studied, problems derive from conflicting responsibilities, not competing rights; the resolution of these conflicts comes in contextual and narrative form, not from abstraction and formality. By adding a new dimension of interpreting girl’s thought, it becomes possible to perceive development that was not perceptible before. By doing so, one can consider differences with understanding rather than in terms of better or worse (Gilligan 19).

Erickson noted that women’s identity had as much to do with intimacy as with separation, but he did not incorporate his observation in his developmental chart (Gilligan 12,13).

Gilligan suggests the contrasting images of hierarchy in children’s moral development illustrate two views of morality that are complementary rather than oppositional or sequential. She admits that it goes against the bias of developmental theory that attempts to maintain the hierarchical system (Gilligan 173,174).

Miller calls for a new language in psychology that would separate the vocabulary of oppression and inequality from descriptions of caring and relationships, in addition to a call for social equality (Gilligan 48,49).

Noddings goes further than Gilligan and says caring is not only morally significant, but is the only legitimate moral consideration; the proper locus of ethical thought is the quality of relationships. She urges that we explore the mothering relationship as an alternative to the contractarian anonymous, isolated individual model (Sherwin 47).

Sherwin says that theories should involve models of human interaction paralleling the complexities involved in relationships and recognize the moral significance of actual ties that bind in relationships (Sherwin 49).

Feminist Ethics

Feminist ethics differs from feminine ethics in that it comes from the explicitly political perspective of feminism; the oppression of women is not morally and politically acceptable. It goes beyond women’s actual experience and moral practices, criticizing practices that form their oppression. Feminist ethics recognizes women’s moral perspective, the ethics of care, and seeks to expand our moral agenda to include caring. (Sherwin 49).

Sherwin warns that we must be careful with our caring philosophies because the very nurturing and caring we excel at are survival skills developed in an oppressed group that lives next to the oppressor. A potential danger of feminist ethics is that caring about others leads women to concentrate their energies on the needs of others – even to the point of protecting their oppressors (Sherwin 50).

A job for feminist ethics is to distinguish when care is appropriate and when it is best withheld. In feminist ethics, evaluating the moral value of specific acts and patterns of caring involves making political judgments (Sherwin 50).

We should guard against letting preferences, especially ones tied to feelings, be granted full range in ethical matters. Morality must respect sentiment, but not give it full moral authority. Feminist ethics involves a commitment to justice and to caring (Sherwin 52).

People don’t exist in abstraction, separate from social circumstances; moral directives to disregard the personal under a “veil of ignorance” are pernicious for political and ethical analysis. Feminist think that moral analysis needs to examine persons and their behavior in the context of political relations and experiences that are missing from most ethical debates (Sherwin 53). The goals of feminist ethicists are to include context, relationships, life experience and the oppression of women to ethical debates.

It is also important to distinguish liberal ethics from feminism. Communitarian theories are conservative, committed to protecting community values without evaluating their status in the hierarchies of oppression. They privilege the status quo; feminist ethics challenges it. The principle insight in feminist ethics is that oppression, however it is practiced, is morally wrong. Feminist ethics demands that the effects of any decision on women’s lives be a feature of moral discussion and decision making. Feminist ethics applies to political perspectives and how ethics must be revised to address the dominance and oppression affecting women. Feminist ethics has taken the lead in pursuing the analysis of all forms of oppression in its ethical analysis (Sherwin 54).

Feminism and Moral Relativism

Metaethics involves theorizing about the nature of ethics. Much of its work is abstract and uses technical language that is exclusionary and elitist. Few feminists have patience for intellectual puzzles that really have no practical relevance. Absolutist principles are often oppressive, and seem to undermine the strength of moral arguments against oppression (Sherwin 58-59).

Feminist Ambivalence About Relativism

Feminist ethics can’t go along with gender discrimination despite its overwhelming acceptance in our society. Moral relativism says moral judgments must be made by the existing norms of the community, but the whole of our community oppresses women (Sherwin 60).

Feminists do not only say that sexist practices are wrong for subjective reasons, they think they are wrong objectively also. Relativism is certainly not a theory that feminists can abide by. According to relativism, genital mutilation is ok in countries that accept its practice. A survey in 1983 in northern Sudan found 82% of women and 87.7% of men approved of the practice (Sherwin 62).

Relativism promotes authoritarianism in ethics. Our culture is structured on dominant relationships. Moral authority is claimed by the dominant group and is a part of the structure of oppression. Negative moral judgments toward women are very powerful because we were taught that part of our very femininity was to attempt moral approval – these authoritarian models maintain social order, (they maintain us in our places). Relativism is a way for ethics to legitimize the oppressive social organization (Sherwin 63).

Feminists are aware that the very same event can be seen quite differently i.e. the birth of a child, a miscarriage, or permanent sterilization, by different women depending on their vantage point and life situation. How someone perceives the world is not a given. Each person sees reality according to what the dominant forces in their world have taught them to see. That is until their consciousness is raised through political analysis; learning about alternative views can give someone other ways to perceive reality. We remain oppressed when we perceive only what the oppressors perceive, when we are held back by their values and categories (Sherwin 64).

To presume that it is a possible goal to come up with one moral theory or rule leads to domination by the people who are in power to enforce that view. Moral theory must retain the authority to assert moral judgments, while at the same time, allowing for the diversity among women’s perceptions of reality (Sherwin 65).

Sherwin discusses Trebilcot’s three principles in the context of women’s space:

       “I speak only for myself I do not try to get other wimmin to accept my beliefs in place of their own There is no “given””  (Sherwin 66).   

Even Treblicot says that these do not fit in a patriarchal milieu. This suggests that the application of relativism itself depends on the absence of patriarchy (Sherwin 66). In other words, if the entire community has an equal say in decision-making then relativism might work, but not in patriarchy.

Feminist Moral Relativism

To evaluate relativism, we must first know the context of the issue and the community in which we are talking, along with how the standard was reached, whose interests were served and what are the procedures for discussion and change. We cannot treat all communities the same; (what about a lesbian community) nor should we grant authority to all moral standards accepted in the community. Power relations shape the very values of the community and are interconnected within the political structures. So, we must pay attention to the existence of oppressive practices in a community (Sherwin 67).

A problem is that to many feminists the communities’ moral standards are not totally trustworthy so we need a much deeper measure than community agreement to find moral truth. How a community gets to moral decisions and the reasons for those decisions must be taken into account in evaluating them (Sherwin 67).

We cannot understand morality by reason alone, with each rational agent using reflection to come up with a moral law. We learn about moral standards by talking about them within our community and they can’t be worked out separate from their context. To be democratic about developing moral standards ALL in the community must partake in developing the standards – not just those with political power. If developed through oppressive forces it is not likely that safeguards will be in place to avoid further exploitation of the already oppressed (Sherwin 68-69). 

It is unlikely that one moral code would be adapted by all communities, hence absolutism is out of the question. Criteria are needed to limit the acceptable modes of moral standards in a community. From a feminist perspective, we must address whether or not oppressive circumstances limit input from some in the community and whether the compliance of the oppressed has been coerced or reflects real support (Sherwin 70).

The Advantage of Feminist Moral Relativism

Sherwin discusses Wong and his theory that relativism should allow for each side to have differing opinions as long as they can justify them and that each side should be tolerant of the other’s views and seek to coexist (Sherwin 70).

Sherwin thinks that testing the moral views of each side of an issue (like abortion) should not simply include their connection with a “well- established moral system”. Rather the justifiability of the side must be determined by the nature of its particular moral system; how did it evolve, whose interests are served, and most important whose interests are sacrificed? With abortion, conservatives base their argument on the life of the fetus. Their arguments are linked to a history of patriarchal control over women’s sexual and reproductive lives. They protect the life of the fetus while it is in the mother’s body; they do not illustrate concern for the millions of starving and abused children now living in the world. They do not campaign to get women the needed housing, child care, and educational services that many women need if they are to give birth to their fetuses instead of aborting them. Many antiabortionists are actually engaged in limiting these kind of supports (Sherwin 71). Their attitude is, you gave birth to them now you must take care of them. 

Among the staunchest antiabortion groups is the Catholic church, run undemocratically by celibate males. Women are not included on the decision making here. Almost every nation’s laws about abortion come from legislative bodies that are mostly male. Sherwin thinks Wong’s justification principle leaves out the history of oppression in favor of established traditions (Sherwin 72).

Until conservatives are willing to develop a moral policy on abortion in conjunction with all the women who will be affected by it, their position doesn’t constitute a moral position that we are obliged to respect. To use the example of genital mutilation, unless there is evidence to believe that women, free of patriarchal tyranny, would choose this practice we cannot see it as an acceptable local custom (Sherwin 74).

Feminist moral relativism is absolutist about the moral unacceptability of oppression, but is relativist on other moral matters (Sherwin 75).

Feminist Ethics of Health Care: Context’s Role

Sherwin discusses several theorists who agree that we must take into account, especially in matters of life and death, the context and the people in the situations involved and not just some abstract principles. The pursuit of universal, rather than contextual, ethics seems to restrict the very scope and analysis of ethics; broad principles are inadequate to apply to the complexities of bioethics and they obscure the most important facts about a situation. We must be precise about the term “context” because mainstream ethics does include context, but is not feminist in nature (Sherwin 76).

Sherwin calls the 1970’s the early days of medical ethics. At that time theorists tried to solve dilemmas using Kant, utilitarianism etc, and soon it became obvious that it wouldn’t work. She uses several examples of male theorists who agree that we must solve things on an individual case basis. She discusses Albert Jonsen and Stephen Toulmin’s book The Abuse of Casuistry 1988; they recommend an informal model of moral reasoning called, casuistry built around a, “recognition of significant particulars and informed prudence” (Sherwin 79).

Sherwin recommends using the concrete circumstances of actual cases and the specific maxims in front of the people involved. When one looks at ethics journals and articles about ethical issues today one can see that specific cases are used, not universal rules (Sherwin 80). I agree that the people involved should certainly be involved in ethical decisions concerning them. This goes along with my goal of having ethics be practical, not simply intellectual discourse, so that it cam meet the patient’s needs.

Theory-Based Alternatives

A basic assumption in medical ethics is that the health care providers are obligated to place priority on the welfare of their patients, even if greater utility could be gained by other means. Feminist ethics goes further and asks that we also consider things on the basis of the person’s place within hierarchical structures; special weight should be given to help undermine oppressive practices. Situation ethics is popular with health professionals because it’s user friendly. It directs agents to seek a loving and humane solution, but does not identify which solution is loving and humane (Sherwin 81).

Most medical ethicists and many feminist ethicists see a place for principles in ethics, but deny that principles alone are enough. Oppression is not a phenomenon that can be studied in the abstract; specific details about the form of oppression and the relevant features of the situation must be considered to make sense of the moral concerns involved (Sherwin 82).

Similarities: Feminist and Medical Ethics

Both feminist and medical ethicists are critical of traditional assumptions, made by mostly contractarians, that the role of ethics is to clarify the obligations that hold among persons viewed as pragmatically equal, independent, rational and autonomous (Sherwin 82).

Both agree with feminine ethics that we pay attention to interdependent, emotionally varied, unequal relationships that are our lives. Medical ethics does admit that the relationship between doctors and patients is far from equal, and the model of contracts negotiated by rational independent agents does not fit. The patient is dependent, vulnerable, and in a disadvantaged position due to illness (Sherwin 82-83).

Both evaluate behavior in terms of the effect on quality of relationships involved. Both agree that the establishment of trust is vital between physician and patient. Both use the considerations of caring, they call it beneficence, and assume it is owed to patients. Compassion is frequently claimed to be more important than honesty or justice in medical ethics. It may then appear that medical ethics is also feminist, but medical ethics fails to be committed to ending oppression the very core of feminist ethics (Sherwin 84).

Silence as Tolerance

Sherwin call physicians “the patriarchs of the body”. She asserts that current medical practice is a powerful institution that is involved in the oppression of women. It thrives on hierarchical power structures that themselves serve to maintain domination and subordination (Sherwin 84).

Feminist criticisms include: the institutional structures, authoritarian control, different treatment of male and female patients, doctors’ obsessive interest in women’s reproductive functions, their perpetration of sex-role stereotypes, reinforcing women’s subservience in the family. Medical researchers set their agendas with respect to women’s conditions according to male-defined interests in women. They authoritatively dictate patterns of normalcy in mental and physical health that serve the interests of men (Sherwin 85).

Women are discouraged from developing self-help behaviors that would give them power over their health. They are urged to measure their behavior with standards that most women can’t meet, so the women are blamed for overeating, smoking, not exercising enough, or for doing the above too much. Women are encouraged to be dependent on medical opinion rather than to listen to their intuitions about the welfare of their bodies and the people they care for. Men are in the positions of power in medical institutions, women are support staff and caretakers. Doctors decide if a woman’s request for an abortion is legitimate and when her reproductive organs become unnecessary and a threat to her well being. Doctors go along with advertiser’s design of the ideal woman and help us fit these expectations with plastic surgery and diet programs. With a male dominated legislature and legal system, doctors decide how much money to spend on life saving measures to a preemie infant, while funds are not available to protect millions of women and children from starvation (Sherwin 85).

Doctors medicate women with socially induced depression and anxiety which helps perpetrate oppression and deflects attention from the injustice of their situation. Having the authority to define normal and pathological and to coerce compliance to its norms, medicine strengthens gender roles and racial stereotypes thus reinforcing already existing power structures. Some offer advice that explains and excuses wife battering, incest and male sexual aggression and thus inhibits evaluation of these practices in moral and political terms (Sherwin 85).

Institutionalized medicine is accepted in society without question. Medical ethics has not addressed feminist issues and thus helps to legitimize the existing system. Lately medicine has incorporated ethics into their credentialing; they have a few questions on their exams and spend a few hours of their schedule in studying ethics. This is suspicious because it makes the public think that they are concerned with ethics and serves to further maintain the public’s trust. When abuses become public doctors renew their commitment to moral education; doctors are not required to soul search or to change their traditional ways (Sherwin 86). Doctors use ethics to inspire trust and thus maintain their public image of being the “kings of morality”.

Medical literature and conferences are concerned with establishing ethical rational for the practices already in place in health care. Criticism is reserved for new practices like fetal tissue research, paternalism because it goes against social norms and controversial issues like abortion. There is little evidence that medical ethics has addressed the oppression of women, people of color or the disabled (Sherwin 87).

Definition of Context

Sherwin asserts that most non-feminist ethicists examine medical practices separately (genetics, abortion) isolated from historical and political contexts that they occur in. When considered only abstractly, it is concluded that there are no violations of moral rules. They say the only moral dilemmas of each practice will be ones that concern specific cases. Then in a case study approach it is assumed all details can be clarified with a short description. Developing a context-specific approach to case analysis for an issue like surrogacy, often shapes the outcome of the analysis; it is easy to identify strong grounds in specific cases by illustrating an example that is benign and desirable – and vice versa (Sherwin 90).

From a feminist perspective we need to clarify the practice within the broader patterns of women’s subordination. We need to ask what affect will increase surrogacy have on the status of women’s oppression? (Sherwin 90).

Other Features of a Feminist Ethics of Health Care

Both medical and feminist ethics are concerned with quality and the nature of particular relationships, because both understand that rights and responsibilities depend on roles and relationships that exist among people with differing status and power. New models of interaction are needed to develop a system that is less hierarchical and less focused on power and control (Sherwin 92).

Feminist ethics will demonstrate that the role of the patient is feminine and thus requires submission to authority and being grateful for attention. Most women know they’re vulnerable to medicine’s power and laugh with suffering to avoid hostility and impatience and frequently apologize for needing attention. Feminism is invested in redefining feminine roles that will be great in health care too (Sherwin 92).

Medical practice perceives the body, under patriarchy, as feminine; medicine’s role is to explore, manipulate, and modify the body, the female body is particularly important. Sherwin relates from Body/Politics: Women and the Discourses of Science by Jacobus, Keller, and Shuttleworth, that there are significant political and moral questions about the relations between medicine and the female body. Discourses common to medicine and science reflect and support attitudes that reinforce patriarchy (Sherwin 93).

Many women find alternative practices in health care more empowering for them than traditional allopathic medicine (Sherwin 93).

The agenda of traditional bioethics has been concerned about the responsibilities of the health professional; feminist ethics reaches much farther and explores roles open to patients and non-professionals in seeking health and health policy (Sherwin 93).

Disability

We need a feminist theory of disability, which would show how disability is a socially construed response to a biological condition. Medicine has created arrangements and constructed attitudes that lead to the disabled feeling alienated from their bodies and frustrated by their socially supported sense of failure (Sherwin 90,91). 

Thirty million women in the U.S. have disabilities and are among the most frequent users of health care; the overlap of sexism combined with the discrimination against those with disabilities severely limits employment and education to these women. Even to obtain non-medical services (wheelchairs, transportation, Social Security benefits and personal care attendants) these women must obtain certification of need from a doctor, despite the fact that doctors have not been trained in or exposed to people with disabilities (Saxton 36).

Medical schools offer virtually no training in political or social problems posed by being disabled; nor do they learn about the further impacts of sexism, racism or homophobia on disabled women (Saxton 36).

The medical system lags in addressing the reproductive health needs of disabled women; there are myths that disabled women are not sexual beings let alone capable of motherhood. Most medial research in this regard has focused on male sexual function and reproductive abilities (Saxton 36).

Because women have not worked long enough in the Social Security System to qualify for Medicare, they must fight harder than men to obtain any benefits due to them. “Skimming”, a strategy to weed out patients who are a financial risk to insurance companies, hits women the hardest. Women with disabilities tend to be poor, unemployed, and unlikely to file lawsuits against abuses they face; they require pro bono legal services and societies encouragement to speak out (Saxton 36,37).

Feminists should certainly join with disabled women in their outrage that doctors are allowed to be seen as experts in matters they don’t even know about.

Abortion

Feminist ethics differs from what liberal arguments usually offer. Feminists evaluate abortion policy within a broader framework according to its place among social institutions that support the subordination of women. In contrast, non-feminists consider moral and legal permissibility of abortion in isolation. They ignore (and thereby obscure) relevant connections with other social practices, including the ongoing power struggles in the sexist society over the control of women and their reproduction. Feminists take into account actual concerns that particular women use in decision making on abortion. (i.e. the nature of her feelings about the fetus, relationship with partner, other kids she might have, various obligations to herself and others). In contrast, non-feminists, evaluate abortion decisions in the abstract (what sort of being the fetus is); from this perspective specific questions of context are irrelevant. In addition, non-feminists in support of choice, grounded in masculinist conceptions of freedom (privacy, individual choice, person’s property rights with own body) which don’t meet the needs, interests, and intuitions of many of the women concerned. Feminist see the moral issue involved differently. Non-feminists focus on morality and legality of doing abortions, feminists say that accessibility and delivery of services must be addressed (Sherwin 99-100).

Feminist ethics supports a model for the provision of services. We should develop an explicitly feminist morality regarding abortion that reflects deep appreciation for complexities of life, refusing to polarize and adopt simplistic formulas (Sherwin 100). 

Women and Abortion

The biggest difference with feminist perception on abortion is the attention it gives to the interests and experiences of women. We regard the effects on the lives of women individually with unwanted pregnancies and collectively as the main element in moral examination of abortion. It is considered self evident that the woman is subject of principle concern. Many non-feminists don’t see the pregnant woman as central and is thus rendered invisible; most of the attention has focused on the moral status of the fetus (Sherwin 100-101).

Due to recent threats regarding the loss of abortion rights women have developed self-help groups that get together to examine their breast and cervixes, explore home type remedies for infections and openly discuss sexuality and health. Although medically and legally controversial, some groups do menstrual extractions to remove the contents of the uterus either during menstruation or to remove a pregnancy, taking the power over their reproductivity out of legal or medical hands (Reinhard 94).

In 1971, The Federation of Feminist Women’s Health Centers, was started by Carol Downer. Downer used herself as a model to teach women how to examine their own cervixes. With this knowledge women could tell the medical establishment where to go – they could use knowledge to empower themselves (Reinhard 94).

In the United States the self-help groups stay underground to avoid the hostility directed against abortion clinics. Downer estimates that 20,000 menstrual extractions have been performed in other countries of the world over the last 20 years. The extractions are done in groups using a device called a Del-Em, put together with medical and household equipment; a flexible plastic tool, like a straw, is hooked up to a syringe with a one-way valve, after it’s placed in the uterus it can pump the uterine contents into a jar. These sterile procedures can be done within the first 8 weeks of pregnancy (Reinhard 94). 

Doctors warn these extractions can lead to infections and other complications. The California Food And Drug Administration says that the Del-Em is not legal, as all medical devices must be tested. Abortion must be done by a licensed physician by law, but it would be difficult to prove whether a woman was extracting menstrual blood or a pregnancy (Reinhard 94).

As a nurse, I know that any abortion can lead to an infection or other complication. Knowing too well how doctors break sterile technique and put patients at high risk for infection all the time, I would bet that women themselves, having more at risk – their own health and bodies, would be VERY cautious about sterile technique. (As if any woman couldn’t learn sterile technique). The question of legality is absurd because if it were not for the legal system’s nonsupport of women’s right to control their bodies, they wouldn’t have to take such desperate measures.

Feminists look at the role of abortion in women’s lives; the need can be intense, no matter how appalling or dangerous the conditions, women from diverse cultures and historical times have sought abortions. Antiabortion activists seem to accept the costs despite life threatening facts when abortion is legal; feminists value women, and judge the loss of women’s lives a matter of fundamental concern (Sherwin 101).

Feminists realize women get abortions for compelling, not frivolous reasons. Lack of access to abortion may mean that some women will be forced to remain in oppressed conditions. Only the woman is in position to weigh relevant facts. Feminists reject abstract rules to say when abortion is morally justified. A woman’s personal deliberations involve commitments to all concerned; there is no formula to evaluate all these complex concerns (Sherwin 101).

Women’s personal deliberations about abortion involve considerations that reflect their commitments to the needs and interests of all involved including themselves, the fetus, and other members of the family. No formula can balance all this. Feminists resist philosophers and moralists setting agendas for these considerations. Women must be acknowledged as their own moral agents. Even if a woman makes a mistake, no one else should be able to overrule or judge her decision (Sherwin 102).

Having a child affects major physical, psychological, social, and economic aspects of a woman’s life; she should have control over the timing, frequency and incidence as it involves most of what is valued in her life. It’s also linked to her sexuality. Her subordinate status often prevents women from refusing men’s sexual advances; if they cannot end unwanted access to their bodies, they then become even more vulnerable to these particular men due to greater financial need and less opportunities to earn money due to child care – she is forced into increased dependence – the cycle of oppression continues (Sherwin 103).

Non-feminists act as if women can simply avoid pregnancy by avoiding intercourse; these attitudes show little appreciation for the power of sexual politics in an oppressive culture. Patterns of male dominance frequently leave women with little control over their sex lives; they are victims of rape from husbands, boyfriends, bosses, friends, uncles, employers, customers, brothers, as well as strangers. Sexual coercion is often not seen as such, even by participants, but is the price of “good will”, popularity, economic survival, peace and simple acceptance. Women are frequently physically or psychologically threatened into intercourse; women are socialized to be compliant, sensitive to the feelings of others, scared of physical power; men are socialized to take advantage of opportunity to get sex and use it in obtaining dominance and power (Sherwin 103).

Women cannot rely on birth control; no form is fully safe and reliable. For most who want temporary protection the pill and the IUD are the most effective but carry significant health risks. Both additionally pose threats of involuntary sterilization (Sherwin 104).

Because only women experience the need for abortion, abortion policies affect them uniquely. It is vital to evaluate how the policies affect the oppression. Feminists see this as the principle consideration (Sherwin 105).

The Fetus

Contrasting with how feminists perceive moral acceptability, non-feminists judge abortion on the moral status of the fetus – whether or not the fetus lacks personhood. They argue about whether we give the fetus human status equal to ourselves. The woman on whom the fetus depends is seen as secondary; actual experience and responsibilities of real women are not seen as morally relevant (unless it can be PROVED she is “innocent” too, due to rape or incest). In some contexts, women are viewed as containers, mere mechanical life support system (Sherwin 105).

Antiabortionists say that the genetic make-up of fetus is determined at conception and genetic code is without question human. They show pictures of it, even call ultrasound an infant’s first picture. The fetus in its early stages is microscopic and indistinguishable from other species, lacks capacities that make life human and of value. They try to use sympathy to make the mother appear to be a killer, as if she’s involved in an adversarial relationship with fetus. Antiabortionists encourage people to identify with the unborn and not the woman whose life is at issue (Sherwin 106).

Arguments that focus on similarities with the fetus and infant fail to acknowledge that the fetus is wholly dependent; the newborn infant is independent in maintaining its own vital functions (despite needing care). Women who carry the fetus are seen as passive hosts whose only role is not to abort or harm the fetus (Sherwin 107).

Medicine supports these attitudes with rapidly expanding fetal medicine – they refer to the mother as a “maternal environment”. Fetal surgeons see the fetus as their patient, rather than the woman. They are ACTIVE agents in saving the fetus’s life (unlike the mom whose role is passive). In the medical model of pregnancy, the mother and the fetus are separate and in a conflict of interest. Increasingly women are described as irresponsible or hostile toward their fetus; out of concern for the fetus, doctors are seen as licensed to intervene and ensure women comply with their advice. Courts are called in to support doctors’ orders when moral pressures are not enough to assure cesarean sections and technologically monitored births. Some states are even beginning to imprison women for drug abuse or other socially unaccepted behaviors (Sherwin 107).

Physicians have joined antiabortionists in encouraging a cultural acceptance of the fetus as a unique individual separate from the mother, deserving their own distinct interests. Pregnant women are ignored or seen as deficient, so they can be coerced for the sake of their fetus. The interests of women are assumed to be the same as the fetus; a woman’s interests are seen as irrelevant, immoral, unimportant or unnatural. By focusing on the fetus as independent, it has led to denying women their role as independent moral agents in deciding what becomes of the fetus they are carrying. The moral question of the fetus’s status is quickly translated into a license to interfere with a woman’s reproductive freedom (Sherwin 107-108).

A Feminist View of the Fetus

In a feminist account, fetal development is seen in the context it occurs – in women’s bodies, rather than in the isolation of imagined abstraction. Their very existence is relationally defined, reflecting development in a particular woman’s body; that relationship gives those women reason to be concerned about them. Rather than seeing the fetus as an independent being, feminists suggest a more valuable understanding of pregnancy, “as a biological and social unit” (Sherwin 109).

The fetus is morally significant but its status is relational rather than absolute. Unlike us, fetuses don’t have independent existence. It is not sufficient to consider persons simply as Kantian atoms of rationality; persons are embodied, conscious beings with their own social history. Personhood is a social category, not an isolated state. Persons are members of a community, not undifferentiated conceptual entities (Sherwin 109).

No one other than the pregnant woman can do anything to support or harm a fetus without doing something to the woman who nurtures it. Because of this inexorable biological reality, responsibility and privilege of determining the fetuses specific social status and value must rest with the mother. The value the woman places on her fetus is the sort of value that attached to a budding human relationship (Sherwin 110).

Fetuses are not persons; they have no capacity for relationships; newborns are immediately persons because of their communication and response (Sherwin 111).

Abortion’s Politics

Sexual hierarchy must be taken into account with abortion. Most abortion opponents oppose sex outside of heterosexual marriage and support patriarchal patterns of dominance in these marriages. They say abortion allows women to get away with sex outside of marriage and supports a woman’s independence from men. The intensity of the antiabortion movement correlates with increasing strength of feminism. The original campaign against abortion can be traced to the middle of the 19th century – the time of the first significant feminist movement in the US. To both sides the emancipation of women is involved. More is involved than the life of the fetus (Sherwin 112-113). 

If we place abortion within the larger political framework, we see that most antiabortionists support conservatism that seeks to maintain dominance. Led by the Catholic church and other conservative institutions who not only endorse fetal rights, but male dominance in the church and home. Most abortion opponents also oppose birth control and all forms of sexuality other than monogamous reproductive sex; they also resist having women in leadership roles in their institutions. They also support economics that support the wealthier classes and ignore the needs of the oppressed and disadvantaged. Although they say they are committed to human life, many systematically work to dismantle social programs that give necessities to the poor (Sherwin 113).

To antiabortionists, abortion is not an isolated practice, their opposition centered on the social values that support the oppression of women. Most deny any legitimate grounds for abortion, other than to save the woman’s life – some, not even then. They think pregnancy can and should be endured; if the mother doesn’t want to care for the child, they assume adoption is easy (Sherwin 113).

This, in a world full of homeless babies and children desperately needing to be adopted: AIDS babies, handicapped, and minority babies. Even if you give birth to a healthy child and have people waiting to adopt, it is very difficult to give a baby up for adoption. An intense bond forms over the full-term pregnancy. Pregnancy is not just a 9-month commitment, it’s a lifetime responsibility which places a disproportionate responsibility on the woman. An ethics that cares about women would recognize that abortion can be their only recourse (Sherwin 114).

Expanding the Agenda

Feminists look at abortion in context of power and oppression, they look beyond moral or legal acceptability. Feminists say we must evaluate the morality of ensuring the safety of abortion. This includes removing class, racial, economic and geographical barriers to all women (Sherwin 114).

Feminism demands respect for women’s choices and moral agency. Many political campaigns for abortion rights make it a medical matter, not personal, suggesting that doctors can be trusted to make choices for women (Sherwin 114).

Antiabortion advocates have personalized their attacks and focused on harassing women with their protests as they enter and leave clinics. This is certainly not conducive to positive health care and is objectionable to the ethics of health care. Feminists need to develop an analysis of reproductive freedom to include sexual freedom as defined by women, not men; it would include a woman’s right to refuse sex. Freedom from oppression itself an element of reproductive freedom (Sherwin 115).

Feminists value fetuses that are wanted by the women who carry them and oppose practices that force women to have unwanted abortions. We must see that women get adequate support services to care for the children they would otherwise be forced to abort and with support would choose to carry (Sherwin 116).

Reproductive Technologies

Feminist writers take a broad perspective when looking at reproductive technologies; non-feminists take a narrow view. A definition of the new reproductive technologies: to facilitate conception or to control the quality of fetuses that are produced, including artificial insemination, ova and embryo donation, invitro fertilization (IVF), gamete intrafallopian transfer (GIFT), embryo freezing, prenatal screening, and sex preselection. Up coming technologies are embryo flushing for genetic inspection for transfer to another woman, genetic surgery, cloning, and ectogenesis (fetal development wholly in an artificial womb), racial eugenic planning, contractual pregnancy (surrogate mothering), almost all of this is done to women and their fetuses (Sherwin 118).

The basic concern according to Sherwin, about the new reproductive technologies is that they are being marketed and developed in ways that increase doctor’s control over women’s bodies (Sherwin 25 (Holmes & Purdy)).

Private & Public Interests

It is useful to remember that historically humans have wanted to control reproduction. Usually technological and reproductive choices are seen as private decisions; feminist think we should evaluate them within the broader domain of oppression. Must look at the political, social and economic effects along with the effect on the lives of those concerned (Sherwin 118).

Medicine is bent toward technology (technological favoritism) as medical education, public policy and the profit motive give technology as a measure of medical progress. Implementation decisions are usually left with those involved, despite societal effects (Sherwin 118).

There are patterns governing the use of technology. Initially innocent help for specific problems, end up nearly universal, coercive application to the public. (Electronic fetal monitors, ultrasound, prenatal screening and IVF). Private decision making is not sufficient because the broad effects go beyond specific users (Sherwin 119).

These technologies are likely to bring about profound cultural changes. With the increased possibility for intervention, there is a greater opportunity for those in power to control technology. Throughout history, those in positions of power and authority have sought to exercise it over the reproductive and sexual lives of those without power. (Plato saved for the philosopher-kings, the authority to arrange the reproductive pairing for all. The American South slave owners bred slaves like cattle) (Sherwin 120).

In this century, legislators and religious leaders have tried to restrict sex to married people, by proclaiming sex outside of marriage illicit. Women who engage in extramarital sex are whores and their offspring are labeled illegitimate (Sherwin 100).

Reproductive technologies can give people some control, but the actual control lies with someone else (Sherwin 120).

IVF in Bioethics Literature

Test-tube babies, circumvent rather than cure barriers to conception, usually caused by blocked fallopian tubes or low sperm counts (Sherwin 121).

Artificial hormones that stimulate egg production, often leading to dramatic emotional and physical changes. The released ova are harvested from the woman’s body by laparoscopic surgery. Semen is collected from the male. Washed ova and sperm are combined to promote fertilization. Newly fertilized eggs are transplanted into woman’s uterus. The woman’s blood and urine are monitored daily at 3-hour intervals. Women must undergo extremely uncomfortable ultrasounds to tell doctors when ovulation occurs. Some programs require the woman to remain immobile for 48 hours after the eggs are inserted and some require 24 hours in the head down position. Procedure may fail at any time and do most of the time. Most women endure the process several times and may be dropped from the program at any time. Many practitioners have attempted to obscure the fact that at best, only 10 to 15 % of the cases are selected as suitable (Sherwin 121).

The issues bioethicists have raised vary. Some religions, object to all reproductive technology as unnatural because it gets in the way of God’s plan (Sherwin 121).

Some worry that our humanness won’t survive the technology and that we will treat the artificially induced embryos as objects. Some fear we will not be able to trace the usual categories of parenthood and lineage and this will lead to our loosing aspects of our identity (Sherwin 122).

Those from secular tradition treat these issues as superstition with no clear sense of what’s natural and no sense that demands special moral status. All medical (and maybe all human) activity can be seen as an interference with nature, but don’t necessarily present grounds for avoiding such action (Sherwin 122).

Some theologians object to fertilization outside the body, without joining of human persons, as they say it takes away the value of the language of the bodies. Secular philosophers dismiss objections against asexual reproduction in a properly sanctified marriage. Nurturance of the child (which is the vital thing) does not depend upon the sexual act (Sherwin 122).

Sometimes IVF and artificial insemination are used to produce extra fertilized eggs whose moral status is questionable. Theologians worry that we can anticipate cloning which violates God’s plan. Theologians are concerned about cultural changes if reproduction is viewed as a scientific enterprise; they are concerned that we won’t foresee the future outcome and that we are on a slippery slope that will lead to more troubling practices (Sherwin 123).

Secularists see things differently; they think scientists are moral people and capable of evaluating each technology on its own merit. So, IVF must be judged on its own consequences and not with some future results that it may be linked to (Sherwin 123).

In order to obtain eggs, superovulation is chemically induced to produce multiple eggs. Collection of the eggs is difficult and the odds against conception are great. Several are obtained at once with the hope that if several are injected into the uterus, at least one will “take”. There are also some extras produced, we don’t have answers to what should be done with them? Should they be frozen or donated to other women who either can’t produce eggs or whose eggs are not genetically desirable? Should they be used for research or thrown away? (Sherwin 124).

What if 4 eggs injected actually implant? A woman’s body cannot deal with carrying this many fetuses. If you limit the number of available eggs collected you risk not having enough for fertilization (Sherwin 124).

Non-feminist theorists are concerned about safety in reproductive technology, usually that of the fetus. There is a higher rate of birth complications and defects with IVF, though most think it is safe enough. No mention is made of danger to the mother or of the similarities between clomid (artificial hormone that causes multiple ova release) and DES (the female hormone that caused cancer in the offspring of women who took it). There is no mention of other dangers such as the uncertainties about superovulation, ultrasound, general anesthesia for egg harvest and embryo transfer, very high rate of surgical births, and the emotional costs (Sherwin 125).

Most bioethicists focus on patient autonomy and individual rights and refer to IVF as a private matter. Conception is private so bioethicists think people who are infertile should not be denied parenthood if it is attainable. The desires and needs of individuals are used as the argument in favor of these technologies (Sherwin 125).

There is a question about distributing costs. IVF is very expensive (and profitable), costing several thousand per attempt. Since it is not usually covered by public or private insurance, it is only open to those with money (Sherwin 126).

The Feminist Perspective

Feminists call for looking at all the effects on the women involved before making bioethical evaluations. The way in which IVF is usually practiced it does not totally foster personal reproductive freedom. It is controlled by medical experts – not by the women who seek it. It is NOT made available to all women medically suitable, only to those judged worthy by the medical practitioners. There are many musts:

       -Be in a stable (preferably married) relationship with a male partner

       -Have “appropriate resources”, not only to pay for the  procedures, but to raise the potential child

       -Must demonstrate they “deserve” this support

       -None to: single women, lesbians, those not in the middle class or beyond, those with genetic handicap, or someone who is defined as deficient in mothering by the medical specialist. Because it is denied to single women, IVF can be accurately described as a technology for men who are judged worthy, despite the fact that it is carried out on their wife’s body. So, it ends up establishing super power to societies favored groups (Sherwin 127).

There is a clear pattern of ever-increasing medical control over our reproductive lives. (I recall worrying whether the doctor would LET me get my tubes tied. Who are they to tell me whether I want more children?) Canada and the US’s medical societies have removed midwives, thus eliminating women-controlled reproduction. Medically supervised pregnancies and hospital births are demanded of us all. Women who fail to comply may even be subject to criminal prosecution for endangering her fetus’s health. In the hospital setting, who controls the amount of technology to be used? They even get court orders for Cesarean sections if the woman doesn’t “consent” (Sherwin 127).

An interventionist medical approach alienates women from their reproductive experiences, treat women as passive bodies, focuses on the technology, and is more concerned with the product than with the process of reproduction. The more reproductive technology, the more power will be in the hands of the “experts” (Sherwin 128).

Informed consent is questionable because some technologies are presented as though they are proven treatments, when they are actually experimental. Often techniques are transferred from animal husbandry directly to women without clinical trials on primates. The mid-70’s was a time with many devastating experiences for women: thalidomide, DES, the Dalkon Shield, wide spread fetal x-rays, belated warnings about chemical contraceptives, and the latest – silicone breast implants. Bioethicists seem willing to rely on doctors’ assurances about product safety (Sherwin 129). Can we women?

Many IVF clinics are poor with record keeping and rarely offer full information about their low success rates. They encourage media exposure of the mom with a baby, but leave out the dangers involved for the woman and the high failure rate (Sherwin 129).

IVF in Context

Feminists look to see how reproductive technologies fit in maintaining women’s oppression. Since technology is not neutral, we must ask who controls it, who gains from it and how does it affect the oppression of women? (Sherwin 129).

IVF definitely serves the interests of the scientists who create and manipulate it. While obstetrical business falls, reproductive technology fills the void with prestige and high profit. The new technologies show that Ob-gyn doctors know more about pregnancy and women’s bodies than they do themselves.  

“it is NOT the concerns of people with fertility problems that matter most. Much higher priority is given to the concerns of those who invent, practice and promote the new technologies” (Sherwin 130).

Why do so many couples feel compelled and desperate to use these technologies? Some ethicists say it’s a basic instinct to want your own child and that it makes it ok ethically to use the technology. They don’t seem interested in the expectations placed on people to develop these desires. It may be a self-fulfilling prophecy that society tells them they must be desperate and the health professional assumes that they are. They seek “normalcy” and thus verify the professional’s assumptions. Feminist ethics looks at the social arrangements and values that drive people to take on the high risks of IVF and other technologies. Women are told that they are unfulfilled without motherhood (Sherwin 131).

Children also serve a symbolic function in that they hold together the institution of heterosexuality. We invest large sums of money in IVF to assure people their true genetic offspring, while leaving the needs of starving children unfulfilled (Sherwin 132).

Feminist must evaluate whether the technology reinforces social prejudices of oppression. Doctors use THEIR values (which reflect privilege) to determine who qualifies for the technology and who is sterilized. The black community has significantly higher infertility rates, but infertility programs are overwhelmingly directed at whites. Embryo transfers allow a dominant class couple to pay a poor woman of lower class to gestate their fetus, sparing the genetic parents the risks and inconveniences of pregnancy yet assuring the right genetic make-up of the child. Sex-selection allows for the social preference for males, more males means increased influence of male values (Sherwin 133). 

Most non-feminist bioethicists treat the reproductive technology like it was a consumer freedom to buy the technology. Rather than increasing a woman’s freedom from oppression the narrow concept of freedom of choice may help entrench the patriarchal idea of woman as child bearer (Sherwin 133).

To feminists, the main question is whether technology threatens to reinforce the lack of autonomy most women experience in our culture. Technology with the potential to further control women’s reproduction makes for a slippery slope (Sherwin 134). 

Mendelsohn included a quote by Gloria Steinem about the ability to learn the sex of a baby, “Given the increasing ability to predetermine a baby’s sex—plus the bias toward having more sons and the development of extrauterine birth—the worst of my fantasies passes through decades of decreasing female population, and ends in some zoo of the future with a dozen of us in cages beneath a sign: “Please don’t feed the women” (Mendelsohn 186, 187).

Raymond quoted scientist Erwin Chargaff about the new reproductive technologies, “the demand was less overwhelming than the desire of the scientists to test their new techniques. The experimental babies produced were more of a by-product” (Raymond 29). Raymond compares reproductive technologies in medicine to religious fundamentalism and explains that medical fundamentalism has two principles: The new reproductive dogma says that infertility is a disease that they have the cure for; the second is that anything that just might bring about a pregnancy is fair game to be tried on the desperate women (Raymond 29).

The technology however, does not cure infertility, it merely provides children to a very small number of the women. They don’t make it known that most of the technology is experimental, can be damaging to the women, and only sends 5-10% of the women home with babies. If the new reproductive technologies were viewed in the same light as other medical treatments, they would only be used for life threatening situations (Raymond 29).

A double standard is involved in the ideology of infertility; if it was the main concern, why not address the research to finding out how to prevent and cure the causes of infertility? Some of the causes are pollution, STD’s (sexually transmitted diseases), IUD’s (intrauterine devices), and PID (pelvic inflammatory disease). The U.S. National Center for Health Statistics (NCHS) and the U.S. Office of Technology Assessment (OTA) say the infertility occurrence is one in twelve couples; their studies do not show an increase in infertility from 1965 to 1982. The infertility experts claim the figure to be one in six or seven couples (Raymond 29).

The definition of infertility has gone from the inability to conceive after 5 years of unprotected sex to 1 year. (Now it can be called the inability to conceive quickly). The portrayal of infertility in the media is deceptive; a large percentage of the women who undergo IVF have had children in the past with a different partner, many go through it because of their spouse’s infertility, not their own, (estimates claim the percentage to be 25%). Many infertility experts never even test the husband’s sperm because they are reluctant to be tested (Raymond 29).

IVF once seen as a way out technology is now the most conservative when compared to what has grown from the initial getting the sperm and the egg together in a petri dish. Frozen embryos, embryo transfer from one woman to another, sex determination, and use in genetic experimentation and manipulation have surpassed IVF (Raymond 29,30).

Many of the women undergo IVF several times (some as many as 10); the average cost per cycle is $5,000. A large number of the IVF centers are for-profit as they are not federally funded, they must depend upon funds from universities, hospitals, drug companies, private organizations (often from venture capital) and patients. There is a real entrepreneurial spirit among infertility doctors. Doctors at the Northern Nevada Center say it will become a $6 billion a year business. Researchers showed in 1985 that half the clinics reporting success never actually had a live birth. Some claimed success by relating the number of implantations that never followed to a birth or used the number of women whose hormone levels became positive but did not necessarily mean they had an intact pregnancy. A congressional subcommittee reported in 1989 that the rate for taking home babies was 9%, but many of the clinics do not include live births in their numbers (Raymond 30).

The number of healthy babies born is another hidden statistic. There are reports citing increases in premature births, low birth weights, more birth defects, and four times higher mortality rates among IVF babies. (Raymond 30). We cannot afford to trust an industry that is using us as experimental victims and also making big profits for doing so. This is highly unethical behavior.    

Believe it or not the industry has used its very failures to justify developing more technologies. The problem of multiple fetuses caused by superovulation and multiple implantations has led to the need to justify aborting some of the fetuses, known as selective termination. It’s not just that it leads to some of the fetuses being discarded, but the procedure where doctors inject saline into the uterus to dispel some of the fetuses can cause bleeding, premature labor to the mother and loss of or damage to all the fetuses (Raymond 30). I would not at all be surprised if these same infertility experts were on conservative band wagons damning poor women for daring to seek abortions.

I agree with Raymond that IVF is being used as tool to perpetrate violence against women with society’s sanction in the name of medicine. Hyperstimulation of the ovaries and cysts frequently are the result of the superovulation required to obtain numerous ovum required to do IVF, to say nothing of the pain and trauma that are perceived as technical imperfections by the experts (Raymond 30).

An Australian female student observed a vaginal harvesting of eggs, done in full view of a medical school class. “At each follicle puncture he (the doctor) retracted the needle and then drove it in hard. The woman asked him to stop, because she was in great pain. But Dr. M. would have none of that…and so (more) follicles were punctured against her will…again each puncture unmistakably resembled a penetration” (Raymond 32).

Technical reproduction should not be included in the pro-choice platform because it doesn’t really promote women’s rights. Feminists have been accused of undermining reproductive rights, by being opposed to technology; the opposite is actually true. The new technologies favor the fetus’s and the potential father’s rights, but challenges the most basis rights of the mother. As technology takes the fetus from the mother’s body more and more so will it diminish the woman’s rights (Raymond 32).

Whose rights are valued in the case of India where 80,000 female fetuses were aborted within a five-year period ending in 1983 after undergoing amniocentesis to determine the sex of the child? (Raymond 32). Somehow, I know that the mothers are not willingly asking for the amniocentesis to avoid having daughters. The language used in the new reproductive technologies are illustrative of the desire to control and blame women when the product (a baby) is not forthcoming. The very term infertile gets public sympathy and support for technology. Doctors and medical researchers distance themselves from women when they say that they “harvest” eggs from the “uterine environment” or that the uterine environment was “hostile” when an IVF attempt did not implant – the person disappears. The hormones used to make a woman give out multiple ovums for IVF sometimes lead to implantation of quintuplets, doctors blame the woman and call what happened her having an atypical response or an inappropriate response to the drugs (hormones), rather than researching the drugs themselves. There is even a new technique that will “allow” a woman to be a “human incubator” for her own eggs (Rowland 38).

Some other language includes, “endocrinological environments”, “alternative reproductive vehicles”, “surrogate uteruses”, “in vitro ovary” and The American Fertility Society discussed women in an ethics report as “therapeutic modalities.” Terms used with surrogacy are: “host womb”, “gestational surrogate”, “gestational mother,” “host mother,” “agent of gestation,” “total surrogacy,” “partial surrogacy,” (as if a mother could do a half way job of carrying a pregnancy), this type of referencing takes away from the mother’s status in lieu of the genetic donor, the fetus is made somehow personal by referring to it as the “gestation of choice”. When women get used to being viewed as incubators they are dehumanized (Rowland 38,39,40).

A physician from Columbia University expressed irritation that medicine had to go along with a woman’s body rhythms, “It means you have to be available at the right time: you have to be a prisoner of that woman’s cervical mucous and her ovulation time” (Rowland 40). 

Medical texts describe the normal menopausal state of the ovaries as “unresponsive” or say that they have “regressed” or even “senile” (Rowland 38). I recently watched “Lifetime Medical Television” (a show for doctors only); I heard obstetricians talk about “controlling” the blood pressure despite the widespread non-compliance of the women. When asked how they decided whether or not to “control” a patient’s blood pressure at home or in the hospital, one doctor said, “when they are at home they can get up and walk around and do as they please, but in the hospital you have them as a “captive audience.” I heard them explain to one another how they decided when to “deliver” as if the mother had nothing to do with it. I HEARD them differently than before – I now realize they had been saying those type of things all along. We HEAR differently with our consciousness raised.

One last language tid-bit, the word obstetrician has its root in Latin and means, “to stand in the way”. (Rowland 41).  

Paternalism

There is much debate lately in non-feminist ethics about less paternalism in health care. Physicians have traditionally treated as they saw fit, patient consent was treated as a formality. There is pressure growing to halt this clash between autonomy and beneficence (Sherwin 137).

Traditional theorists assume patients are not always rational and don’t always act in their own best interests. They see autonomy as a concept built to establish self-rule within a conceptual framework structured around dominance relations (Sherwin 137).

Paternalism refers to the widespread practice in which doctors make decisions for patients, without their full understanding or consent. The basis of the decision is the patient’s best interest. Whether or not it brings about the best consequences is questionable because it is the physician’s perception of good, not the patients. It is an infringement on patient’s autonomy, usually thought justified only when the patient is incapable of making decisions. Feminism teaches us that we may be mistaken to assume a powerful, authoritarian father (like the role the doctor plays) will always act in the best interests of his wife and children. The power in this type or arrangement easily abused (Sherwin 139).

The fact that the patient is in need of care means he or she is vulnerable, weak, and frightened. Many doctors still believe it’s their privilege and responsibility to make decisions for patients; medical ethics decides what circumstances justify paternalism. Paternalism supporters claim: illness compromises reason, decisions can only be made by one with technical knowledge – the doctor, the patient’s belief in the doctor’s mystified power is vital, and must be done in a confident authoritative manner (Sherwin 140).

Patients & Reasoning

Women are patients far more often than men and are usually the ones who bring others to the doctor and are the ones to speak on their behalf. Women have heightened contacts with the medical institution; their oppressed status requires us to pay special attention to ways in which paternalism contributes to their disempowerment (Sherwin 141).

The status of a patient is feminine – they are expected to submit gracefully to the powerful rational authority. Paternalism mirrors and strengthens attitudes that support domination of what is perceived as female (Sherwin 141).     

“Reason” has been used as an ideological tool by those in power to serve political purposes. Changing normative concepts of reason play an integral part in politics of dominance. Reason has political power, it’s a mistake to accept unqualified appeals to the quality of someone’s reasoning ability without also assessing whose interests are being served. Because of the roles men and women play in health care, it’s important to reflect on ways in which gendered assumptions about reason have infected the norms of medical practice (Sherwin 141).

There certainly are some conditions that do cloud a patient’s reasoning ability: high fevers, serious accidents or neurological disorders. However, many interactions between women and doctors are not about illness; the medicalization of her normal reproductive cycle has been brought under medical control. Healthy women see doctors for contraceptives and for monitoring pregnancies. Even when women bring others to see physicians and are not themselves sick, they may still be dismissed as incapable of making decisions (Sherwin 142).

The fear of illness distorting reason, and increasing dependence is affected by the fear itself, and is sometimes magnified by the medical community itself. There are documented cases where doctors manipulated women into having hysterectomies by using the fear that “it” may return; “it” was the presence of pre-cancerous cells, NOT CANCER cells on a Pap smear. By mystifying and assuming its too complex doctors use medical information as a weapon that encourages dependency and fear. The power of the healer is maintained by fear rather than strength. If it is the case that fear really clouds reasoning ability, then open honest communication by the physician could do a lot to prevent fear that impedes reasoning (Sherwin 143).

How can we rely on the objective decisions from doctors when many hold stereotypes about women that they are irrational or stupid (especially minority women)? (Sherwin 143).

A second condition must be present for a doctor to make a decision for a patient, there must be a reasonable probability of harm. When patients truly are not able to make their own decisions, their needs can be addressed by someone who will be able to make decisions for them that go along with the patient’s values and interests. Doctors see themselves in this role as their scientific outlook makes them objective and knowledgeable. Feminists say scientific knowledge does not guarantee objectivity, nor is objectivity the big concern – Caring would be better. Most physicians are trained with an orientation to science over humanistic care, they may be especially bad in this role (Sherwin 144). 

Sherwin suggests we explore means of revising the patient-physician relationship to seek ways of empowering those who are not able to assert their own will (Sherwin 144).

Medicine & Science

The authoritarian medical model assumes that only doctors have skills and capacities to make decisions. Patients, and their guardians, are too uneducated, too emotionally distraught, or too stupid in the face of illness to make decisions. Other health professionals have only partial training, without complete training (and supervision) a little knowledge is thought to be dangerous (Sherwin 145).

The evolution of specialized fields has resulted in one doctor not being able to make decisions outside of his specialty. Doctors committed to technology, have learned to trust instruments rather than their own assessments or their patient’s reports. Labs take precedence over (patients) subjective symptoms. This type of environment is alienating and intimidates patients. Medicine has narrowed its focus to objectively measurable symptoms rather than a holistic look at a person. As a consequence, doctors don’t give TLC (tender loving care) (Sherwin 146).

TLC is viewed as feminine and has been devalued in health care. As a nurse who believes wholeheartedly in the actual healing power of TLC, I believe that without it there cannot be true healing. I HAVE included TLC while giving emergency care to patients experiencing a heart attack. The two concepts, healing via technical knowledge and caring enhance one another and give each other more power. The patient gains power within himself to aid healing when he is treated humanely; it boosts self his esteem and can lead to more positive thinking which is known to help us heal.    

Technical measures lend an aura of objective truth to the findings in medicine. This science supports doctors claims to dominance over health care workers and patients. It is unclear how much of their judgement rests on a scientific foundation. There is a great deal of intuitive reasoning and uncertainty involved in medical practice today, in addition to scientific facts. In claiming authority medicine presumes a degree of authority inappropriate to its level of knowledge (Sherwin 147).

Nurses certainly develop intuitive reasoning experientially, but it is not valued or taken seriously by physicians and some patients.

       Medical science is not infallible. The “scientific objectivity” of medicine tends only to observe what it looks for and what it expects to see. Many women have long complained of menstrual cramps, nausea in pregnancy, labor pain and infantile colic, these were declared psychological, and not organically possible because their existence was denied (Sherwin 147).

Mystifying, exclusionary language helps to defend its hierarchical structures and discourages challenges. Science accepts only a narrow sense of reason and knowledge, knowledge of personal experience is subjective, so it’s unreliable. Knowledge belonging to patients, who are mostly women, is discredited (Sherwin 147).

Science is far from objective. As an institution it reflects and supports interests and ideologies of dominant societal groups. It is NOT a neutral social instrument; it continues the oppression of women (Sherwin 148).  

Doctors cannot claim privilege in decision making because of scientific knowledge, it’s only one aspect of data required for decision making. The right treatment for a patient is not simply a scientific matter. Expertise in science makes doctors qualified to provide information to people trying to make health related decisions, but it does not license them to make their decision (Sherwin 148).

Paternalism & Trust?

The third argument is that a doctor’s authority is essential to healing. A patient’s belief in their doctor does seem to help them heal (Sherwin 148). I have seen that (and empirical studies have shown) that the placebo effect (a patient’s belief in a sugar pill will help him), is known to be powerful physically and psychologically.

This does not mean that the patient must be kept in the dark or that he should be kept dependent. Much evidence shows that patients who actively are involved in their care do much better (Sherwin 148-149).

Nursing’s goals are opposite from those of physicians – our goal is independence. Nurses goals are for patients to take care of themselves, to be in control with knowledge and confidence.

If patient’s having confidence in their healer is to work then the relationship must be based on trust. Faith that patients put in doctors to heal them should not come out of blind trust. Sherwin discusses a moral test for trust relationships: “they be able to survive awareness by each party to the relationship of what the other relies on in the first to ensure their continued trustworthiness or trustingness” (Sherwin 149).

Patients, especially female patients, have reason to be suspicious about the trust in their relationships with physicians. If patients sought to learn what their doctors rely on to ensure continued trust, it is unlikely that using the above definition a trust relationship would be sustained (Sherwin 149).

Women have different roles and experience with the health care system than men. Women are the major health care consumers and are a majority of the workers in heath care; men however, hold the positions of power. The model is based on a powerful paternalistic authoritarian directing subordinates in the treatment of (ideally) compliant, passive patients. These patterns of dominance mirror and reinforce social expectations of men as authorities and women as servants who follow through, but do not initiate treatment (Sherwin 149).

Gender imbalance in health care encourages doctors to accept the social attitudes about women and illness. In medical literature organic diseases have used male patients as their model and feminine models for mental diseases and with symptoms that cannot be answered organically. You can believe men’s symptoms of disease, but women are high strung. Ads for medications use men with pain relief and women with tranquilizers. Women are portrayed as weak and in need of calming. Gender is not the only stereotype used in dominance relations in medicine: race, class, ethnicity, sexual orientation, age and degrees of disability also affect whether or not the doctor accepts your report at face value (Sherwin 150).

Historically doctors have used whatever means was most salient at the time to ensure their monopoly over health care. Before the late 19th century physicians had to compete with other healers: wise women, midwives, quacks, sectarians and bonesetters. The 15th and 16th centuries illustrate the worst medical hostility that was combined with church-based misogyny. It fostered mass murders of alternative healers (mostly women) under the guise of witchcraft. During these times in history there was no interest in caring for women and children, they concentrated on middle-aged and elderly men. Their sought to maintain dominance by caring for those who were highly valued in society. The care of women was left to a widespread network of women’s culture (Sherwin 150). Interesting that we still have an underground network of women who educate each other about their health (see page 49).

In the latter half of the 19th century competition was fierce and doctors saw that a large market of their services was women; if they got this market, they had access to the other family members, so they focused on women, especially services involved in pregnancy and worked to get rid of access to other providers. They succeeded in getting a monopoly in health care and drove other health workers into subservient positions that required them to practice under the eyes of physicians. They lobbied for legislation to get control over women’s fertility and cut women off from abortion and contraceptive services. This control over women’s bodies improved their economic, social and political positions; the benefits to women are unclear (Sherwin 151).

By defining what is “normal” and healthy for women, doctors ensure women’s dependence. It continues today as evidenced by the new reproductive technologies. Today’s competition is severe among profit seeking hospitals. One of their strategies has been marketing to women with women’s health centers. Because women are the medical gatekeepers in most families, if an institution gets her loyalty, they will thus have access to the rest of her family – just like they did in the late 19th century (Sherwin 151). Being the subject of medical attention is not necessarily good for women. Dangerous and unneeded procedures have been carried out on women at terrifying rates. More surgical interventions in childbirth has led to increased mortality rates. There have been excessive numbers of surgeries on female organs. All women with breast cancer were subjected to radical mastectomies without scientific evidence that they were needed to increase survival (Sherwin 151).

A six-year study of communication patterns and structures of decision making between doctors and female patients, found that many more hysterectomies were recommended than were actually needed; this reflects an attitude that if reproduction capacity has ended, then the uterus is a dangerous organ and is best removed. A quote from a major gynecological text,

“Menstruation is a nuisance to most women and if this can be abolished without impairing ovarian function, it would probably be a blessing not only to the women but to her husband” (Sherwin 152).  There has not been a corresponding trend to remove cancerous testicles or prostate glands from men, as routine when reproduction is completed, despite their serious health threat (Sherwin 152). 

In mental illness, women are treated more aggressively and frequently than men. Behavior perceived as healthy for adults is seem as pathological for women. Psychiatrists have found a great deal of normal female behaviors, lesbianism, political resistance and not wanting children, as unhealthy. Women who seek support after sustaining injuries and psychological distress from battering, rape, sexual harassment, incest or racism are commonly treated with tranquilizers (or worse) to help them adjust to their situations. Women are twice as likely as men to be prescribed psychotropic drugs (Sherwin 152).

So, it is clear that when women seek treatment for conditions unique to women, they definitely risk harm instead of help. Paternalism encourages patients to trust and not question medical authority; it should not be accepted as common medical practice (Sherwin 153).     

Feminist Views

If particular situations are known to compromise one’s ability to reason doctors should seek to minimize these effects. They should help to mitigate the effects of diminished capacity by fostering a decision-making process sensitive to the patient’s overall interests. Medicine should be directed at maximizing a patient’s ability to make reasonable informed decisions. When paternalistic interventions are truly needed it should come from someone who can be counted on to give back authority to the patient as soon as possible – usually this person is not the doctor (Sherwin 154).

Physicians should earn trust – it should not be assumed. Trust is built through sharing information, particularly the medical knowledge that might bear on the patient’s expectations and deliberations. In the medical context, earning trust requires that the physician respect the decision-making authority of the PATIENT. An open health care process should include the patient in decision making and is more likely to get results that are in the best interest of the patient (Sherwin 154).

Most bioethicists recognize that doctors have technical knowledge essential to decision making, but they lack other kinds of knowledge needed to make decisions about a particular patient’s needs. They are not expert to the centrally relevant knowledge of each patient’s distress, values or coping strategies. Medical training does NOT provide them with knowledge about the social context in which the patient’s needs for health care arise (Sherwin 154).

Feminists and non-feminist colleagues in bioethics can agree and insist that physicians tell patients the information they need to make their own decisions. Most do not need technical terms or biochemical theories, they need to know what treatment is recommended and why, what their options are, and the consequences of each that are likely, what risks involved of treatment and of declining treatment that would likely be (Sherwin 155).

If physicians were to receive training in communication skills, they would be better equipped to give patients information and patients would have the information needed so that paternalism could be discarded. There is a danger however, that if doctors knew more about communication skills they would be even better at paternalism because it would aid them in manipulating patients and thus strengthen paternalism. Feminists demand an ideological change in doctor-patient relations. Physician’s knowledge is distorted by their own biased expectations and those of the scientists that they learn from (Sherwin 155).

Communication involves at least 2 parties. Ethicists should be concerned with the role of each participant when examining relationships between patients and doctors. Feminist ethics recommends that we not only advise physicians about how they should behave but also put priority on helping patients obtain information they need and to learn how to weigh and interpret the medical advice they receive (Sherwin 155).

This is what I want to help patients to do. I have called it helping them with their ethical needs. We have not used the term “ethical needs” but I am starting it because I see a need to help patients with taking control over their own “ethics of health care”. We have long used terms like social needs, sexual needs, biological needs, spiritual needs, why not ethical needs? Why not help patients say for themselves what their moral needs are? We may find, if we ask them, answers that could facilitate changing the system to meet their needs. They may tell us how we can meet their ethical needs.

In traditional approaches, when sources of potential physician biases are uncovered, the conclusion is to reject paternalism and go to autonomy. Many feminists are not comfortable with autonomy as an alternative. The concept of autonomy carries too many associations of isolation and independence to capture feminist conceptions of agency. In its place we could explore more of the relational concepts that different feminists have purposed, which might support the agency of patients without abandoning them to their rights (Sherwin 155-156). I agree with Sherwin that a feminist, relational, contextual, perspective that includes the patient’s voice would be helpful in empowering patients.

Sherwin discusses “autokoenony” which stands for “the self in the community”; it captures a sense of being free from dominance without suggesting self-domination. Autokoenony refers to: “a self who is both elemental and related, who has a sense of herself making choices within a context created by community”. (Sherwin 156).  An autokoenonous person interacts with others and makes decisions in consideration of her own place and of others in the community. In the medical setting it suggests an understanding that patients exist in a social world, where their ends and activities are defined in conjunction with others they trust. It’s a more realistic perspective of patients choosing in the company of others who help shape their lives. When patients are confronted with difficult decisions, physicians and patients might include others trusted by the patient to be included in the decision-making process. When patients are isolated, and have no others that they can trust, they could be helped to form relationships that could foster their decision making in an interactive way. Self help groups of patients with a common condition, for instance, usually provide patients with an opportunity to explore the complexities of their decisions in a nonhierarchical environment (Sherwin 156). The type of environment I have in mind.

The ethical question is not autonomy versus paternalism, it’s a question of how to strengthen the patient’s agency, how to help her make decisions that will serve her. It requires radical rethinking (just what I am in the process of doing) of the physician-patient relationship and development of improved patterns of communication and mutual respect (Sherwin 156).

Hopefully if patients can come to a place and talk, get information along with encouragement and support they will then go back to their physicians and demand control of their health care. We must demand respect from those in power – they will not GIVE it to us.

How about inventing a practice “amicalism”, built on a model of friendship? The intention would be to enlist friends or family in decision making, rather than treating medical choice like a contest between an isolated patient and a physician. When patients feel unable to make decisions on their own (or they are incompetent) they could be helped to communicate with others they trust – who have already demonstrated a commitment to them as individuals (Sherwin 157).  The health information centers could be a place where the whole family could come to talk about a health care decision.  

Research

Feminists are concerned about how the subject population is selected and what measures are used to obtain informed consent. In non-feminist bioethics, the ethical questions center on matters of participation and consent. Who can be asked to participate? What about subjects who cannot consent? What limits exist about the degree of risk they will be exposed to? What is legitimate research? What about the degree of spending (Sherwin 159)?

Feminist ask: How are topics chosen? Which issues are investigated and which ignored? Whose interests are served and whose are ignored? Who controls research conditions? Whom are researchers accountable to? Recognizing that patterns of oppression extend into medicine, feminists take a special interest in research done on women. Their study of women’s health care leads them to question what guidelines determine whether procedures are experimental or established. They recommend models of the subject-investigator relationship that differ from conceptions that govern most research practices (Sherwin 159).

Research & Oppression 

The central question is, what constraints should govern the use of human subjects. In double blind studies neither the investigator nor the subject knows whether the patient receives the treatment or the placebo. There is a risk that her condition could get worse either because she’s not getting the treatment or the treatment itself is dangerous. The general principle common to ethical debates is the subject must freely choose to participate. Women constitute a special consideration in research because women’s oppression consists in the subordination of women’s interests to those of others – be wary of any proposal to use women’s services for some greater social good. Women’s relatively powerless role in society and their disproportionate use of medical interactions makes them especially vulnerable. Researchers should be required to take special precautions against exploitation of women. We need ethical guidelines to govern women’s participation in medical research (Sherwin 161).  

Evidence reveals that we should be worried about research on women. Researchers have always been inclined to use as subjects those who are less valued in the society: prisoners, elderly, disabled, institutionalized, and the poor. Women, as an oppressed population, are considered expendable, making them candidates for risk exposure (Sherwin 161).

A former director of the public health department in Oak Park, IL, claimed that women were the best guinea pigs; they take the Pill with no questions asked, they pay for the right to take it and as experimental animals go, they are the only ones who feed themselves and clean up after themselves (Mendelsohn 35).

Patriarchy devalues women when they are no longer able to fulfill their childbearing role; women in post-operative surgical wards are vulnerable to multiple exploitation. Sherwin relates a case where researchers, in 1964, at a Jewish Chronic Disease Hospital, used 22 residents without their consent in a cancer study. They deliberately refrained from telling patients that they were being injected with cancer cells knowing no one would accept them – the patients were debilitated (600 others from prior trials had also been used) (Sherwin 162). Sherwin quoted Katz, “for two years we have been doing the tests routinely on all postoperative patients on our gynecological service” (Sherwin 163). These post-op patients were uninformed and non consenting. Bioethicists have debated research on prisoners and ill patients, but neglect to address what was routinely done to “healthy” gynecological patients (Sherwin 163).

Oppressed people are in coercive environments that leave them vulnerable to be exploited in research. Women should not be subjects of research that will not benefit women. If being female (black, disabled, poor) is not relevant to a study then don’t use them (Sherwin 165).

Women as Subjects

Most research that affects men and women is done on men; the results are then used as the norm. Expecting that women will respond differently than men, they leave women out to avoid “distorting” the data. We lack adequate information on how to treat women with heart disease or cancer. We understudy diseases affecting blacks, disabled, and Native Americans. It is of serious moral concern that doctors do not have information on diseases in these groups (Sherwin 166).

Data with research done on middle-aged white men is abundant in medical libraries. (Even research on rats excludes females). Where medicine like aspirin is concerned, physicians are left to make their best guess about whether it will help prevent coronary artery disease in women because no women were included in the studies. (Apparently the fact that heart disease is the number 1 killer of women means nothing) (Cotton 1049).

The same holds true for drugs like beta blockers and antidepressants. It holds true despite the fact that over the past 10 years much evidence has surfaced about the importance of how different drugs effect women, the elderly and racial minorities (Cotton 1049).

The National Institutes of Health (NIH), The Food And Drug Administration (FDA) and The Pharmaceutical Manufacturers Association claim that the issue is being looked into, however, no changes have been noted in research habits (Cotton 1049).

The Congressional Caucus on Women’s Issues has asked the General Accounting Office in Washington, DC., for proof that the NIH is including oppressed groups in their studies, as their policy dictates (Cotton 1049). 

A spokesman for the FDA says if rules are too strict they get in the way of research designs and it leads to drug companies dropping a study because it’s too expensive. He says rules to include the elderly are a waste of time because the drug companies know what they need to do, but they have no figures to illustrate that. A spokesman from the Pharmaceutical Manufacturers, Lionel Edwards MD, (chair of their Special Populations Committee) said that studies could be sub grouped to death and they would never get the new products out (Cotton 1049).

According to Michelle Harrison, MD, assistant professor of psychiatry at University of Pittsburgh, one thing that seems to get in the way of researchers using women is their menstrual cycles and pregnancy. We do however, USE these drugs on those with the confounding factors (Cotton 1049-1050).

Jean Hamilton, MD, Director of the Institute for Research on Women’s Health says that we frequently “stumble” onto information and that information is only the beginning of what we need to learn. Jerry Avorn, MD, a geriatrician and associate professor of social medicine at Harvard university Medical School says that the idea that white males present fewer confounding factors to researchers is made because white men run the country (Cotton 1050).

The common excuse for excluding women, teratogenic liability, can only be resolved through legislation. As more and more women are involved as researchers the menstrual cycle will cease to be a confounding problem (Cotton 1050).

Anne Willoughby, MD, MPH, chief of the pediatric, adolescent and maternal AIDS branch at the NIH’s, National Institute of Child Health and Human Development, says,

“We have to anticipate the barriers and address them aggressively up front”, (Cotton 1050) referring to the needs that must be addressed if we are going to use women in research. Needs like transportation and child care must be taken into consideration if women are to be involved in research (Cotton 1050).  

A New Zealand study in 1966, sought to prove the assumption that early signs of abnormal cell changes in cervix were unlikely to lead to cervical cancer. The researcher did not offer regular treatment to women diagnosed pre-cancerous; they were also denied relevant information about treatment options. No consent was obtained, but they were monitored and subjected to repeated invasive exams to establish “natural history of carcinoma in situ”. Over 20 years, 30 women died of cervical cancer and a variety of other health problems. The untreated had vastly higher rates of invasive cancer and death than those treated. Many in the medical community knew and disapproved of the study, but it wasn’t stopped until women mounted political pressure to force a public inquiry. Absence of political pressure in the medical community illustrates their willingness to tolerate needless death and suffering of women rather than restrict academic freedom of one of their own (Sherwin 166).

For decades radical amputation was the treatment for any evidence of cancer or even prospect of cancer in a woman’s reproductive organs. (Even if they only suspected it might develop). Only recently have studies been done to evaluate the effect of these “therapies” (Sherwin 166-167). 

Most medical research that has been done on women has centered on their reproductive functions – why? Much of the research done on oppressed groups seeks to find differences between oppressed groups and dominant ones, but little to meet the needs of the oppressed groups. By centering their efforts on having control of reproductive functions, researchers reflect a view of women defined in terms of their reproductive function. The research community and those who fund it thus perpetrate the oppression of women (Sherwin 167).

The earliest tests on the “Pill” were done on poor uneducated women in Puerto Rico and Mexico. Drug companies chose to avoid the limits of human-subject research in the West by going to underdeveloped nations (Sherwin 168).

Experimental treatments are monitored strictly, but established treatments are not. Patients think if they are not specifically asked to be involved in a research study that they are getting established treatment – this is often wrong. A fine, permeable line separates established from experimental in women’s health care (Sherwin 168).

Millions of women have used contraceptive devices and drugs they thought were tested and safe, but thorough testing had not been done on the Dalkon Shield. The Pill was marketed for 10 years before federal hearings on safety revealed risks and hazards of long-term use (Sherwin 169).

This failure to distinguish between research and therapy is found with infertility treatment too. Despite serious side effects and possible death adequate testing is overlooked before drugs are given as routine therapy. Fertility clinics all over the world are offering therapies that are expensive, dangerous, painful, traumatizing, even life threatening and for the most part unsuccessful; they experimented with techniques without saying they were researching them, thus leaving them not being subject to ethical scrutiny. Despite high failure rates with in vitro fertilization, it is seen as an established therapy. By tolerating the blurring of these boundary lines, they are limiting woman’s ability to make informed decisions about taking part in data collection for new means of controlling fertility (Sherwin 169).

Women’s need to control their fertility makes them especially vulnerable. The contraception and fertility industries are VERY profitable. Women’s powerless position in society makes it important that we guard against exploitation from pharmaceutical companies. Patients must be informed when we don’t know the long-term effects of drugs. The political implications of research should not be overlooked during ethical review (Sherwin 170).

Research & Organization

In research nature is objectified and scientific knowledge pursued so that it can be exploited and controlled. The knower is distinct from and dominant over what is known (Sherwin 170).

Feminists suggest a new scientific model – close the gap between the self and research object, by identifying with the biological material forming an emotional bond. To see what is missed by others using the standard scientific model, with distance between researcher and object. Get a feeling for the organism and learn to listen to the material – a model that connects the knower with the known (Sherwin 171).

Science projects an image of dispassionate objectivity and a search for truth. Science is an expensive, competitive institution; researchers do projects that they can obtain funding for. They need to attract grant money and get results and are inclined to shape research to objectives of funding sources. Projects are tied to interests of those with money and power to support the research. Much research is funded by the defense department with military interests. Much of the research in health care is funded by drug companies or the biotechnological industry. Even public money reflects the political clout of special interests. Despite knowledge that cancer prevention promises to save more lives than treatment, more money is spent on cure – it will bring more profit to industry and the latter threatens to reduce profits (Sherwin 171).

Biotechnology promises fame and prestige to doctors, scientists, and corporations involved and is a product for export. Sherwin says a doctor with a private in vitro facility in the U.S. could eventually generate 6 billion dollars a year (Sherwin 172)! This makes prevention of infertility unprofitable.

Western culture expects and celebrates technological solutions. Careers and institutional reputations are made on break throughs, and big profits go to innovators. Many forces lead to there being a market for high technology. There is little support for less dramatic, less-rewarding work with prevention and management of disease (Sherwin 172).

Medical research speaks of wars against cancer and heart disease, but they are not finding ways to avoid the battle. We hear of the demand for a cure for AIDS, but why not how to avoid or respond to the secondary infections that AIDS patients usually die from? Research for technology is readily funded and when successful, readily put into use. No where in the research phase do, they measure the implications for the new discoveries in the overall distribution of resources. We now have public hospitals with tons of technology, but having to close beds because they do not have money to pay their staff (Sherwin 172).

Technology is expensive and is available only in developed countries (and perhaps only to the wealthy). Western attention on technology has led to our abandoning responsibility for the health needs of under developed countries and the poor at home. Research leads to changes in health policy, there should be a way to review and anticipate the affects of it because once available it is irresistible (Sherwin 172).

The first large study on women with AIDS, by the government sponsored ACTG protocol 076, is to focus on pregnant women of color. African American and Latino women who have been affected the most by AIDS would like the right to decide for themselves whether or not to risk being in the study, but due to a federal requirement the fetuses FATHER must give approval for the woman to be part of the study. The National Institute of Allergy and Infectious Diseases claims that local boards can try to find loopholes, but that the 1975 rule is mandatory (Byron 95). Here the male government, the male father of the fetus and the male research establishment combine forces to maintain a women’s control over her own body.

Illness Labels

“one of the most characteristic and ubiquitous features of the world as experienced by oppressed people is the double bind—situations in which options are reduced to a very few and all of them expose one to penalty, censure or deprivation” (Sherwin 179). Medical authorities have created this for women by characterizing as pathological various bodily and mental states typical for women. Men have set the norms of health and illness and have given themselves control over their manipulation. Their viewing menstruation, pregnancy, menopause, body size, and feminine behavior as diseases is an integral part of women’s oppression. Defining ordinary female experiences as pathological justifies treating them. Their wide scale management is seen as beneficent (Sherwin 179).

Moral critiques of excessive medicalization do not imply that all menstruation, pregnancy etc are healthy, medical experts certainly do have therapies to help women (Sherwin 180).

History of Menstruation as Illness

As medicine grew in the mid-nineteenth century, gynecology evolved into a distinct specialty. The fashion at that time said that women were disabled during menstruation and the week before and recommended that they refrain from regular activities at these times. Scientific evidence claimed that the uterus competed with the brain for energy and blood, making it necessary for women to refrain from serious mental or intellectual work – it may harm them. By the end of the nineteenth century doctors led the crusade to get women out of the universities and the suffrage movement that brought them into politics (Sherwin 181). With the change in economic needs came a need for women to work, medical authorities revised their advice and said it was helpful for women to be very active during menstruation (Sherwin 182).

Premenstrual Syndrome

In 1931, Robert T. Frank is credited with labeling the week before menstruation as a sick time for women. He was concerned about a woman’s ability to work during this time and coined the term “premenstrual tension”. This was his way of saying just how pathological he saw this time of the month and wanted women to be excused from work during this time. This was convenient to the times in that women were supposed to be giving up their jobs to men because of the Depression and the war being over. World war II’s need for women in the work force miraculously brought another change in the prescription for premenstrual women when they again were needed in the work force (Sherwin 181).

Premenstrual Syndrome (PMS) was recently added to American Psychiatric Association’s official diagnostic list (Sherwin 180).

Katharina Dalton, a physician who saw herself as a sufferer from PMS, widely publicized the broad range of symptoms we now know as PMS. She claimed it to be a hormone deficiency and thought it should be treated by replacement. She said women can’t work properly at those times, were more accident prone, and are so crabby that they even make their husbands less efficient at these times. This was affecting our economy with the number of lost work days and it made PMS a “public” and a “private” threat (Sherwin 184).

There are at least 150 symptoms related to PMS without medical agreement on which should be included, about etiology or about treatment, yet it is seen as a real illness worthy of medical intervention. (The medical community does widely reject Dalton’s suggestion of hormone therapy) (Sherwin 184).

In the late 1970’s, coincidentally when feminism showed its face again, women went back to the work force en mass. Women are now demonstrating their abilities in fields previously thought of as only male allowing menstruation to be seen as a real liability for women. Doctors gladly offer evidence to maintain the claim that menstruation is an illness that gets in women’s way of their being able to compete. Males again use it as a weapon against us being equal (Sherwin 184).

Sherwin quotes Zita in her summarization of the medical perspective on PMS as a disease, “the codification of symptoms results in the morbidification of a sex difference which renders all women inherently disadvantaged in a man’s world”. (Sherwin 185). So, what ends up happening is that PMS functions politically in justifying and making sense of women’s economic and politically oppressed status (Sherwin 185).

PMS

Some women find positive validation with the labeling of PMS because in the past their symptoms had been trivialized. Many find relief offered in the women’s self-help press, others seek medical intervention. The fact that this labeling has helped some women is apparent, but feminists are ambivalent about it (Sherwin 197).

Some of the symptoms of PMS are behavioral. These behavioral symptoms don’t fit the norm of female passivity. They are less able to tolerate discipline, and monotony in their lives. They become irritable, depressed and angry at constraints in their lives. Perhaps these details in their lives that women hate are due to their subordinate status. Feminists would not see this anger as negative. PMS may be a social manifestation of rage about oppression (Sherwin 184).

Amenorrhea as Illness

Now that we know that we are diseased if we menstruate, we must also face the fact that if we don’t menstruate, we are also seen as “ill”. Some of the symptoms of PMS have been discovered in females too young or too old to menstruate and women who have had hysterectomies have had the worst symptoms. Some feminist theorists think that cyclicity itself is perceived as a problem in Western culture (Sherwin 185).  

Menstruation is seen as a problematic medical event. Sherwin discusses Martin who documented the ways that textbooks make negative references to menopause; the ovaries become “unresponsive” and start to “regress”. The hypothalamus gives inappropriate commands. Other words used in reference to female organs at this time of life are: faltering, withering and senile (Sherwin 185).

The World Health Organization recently defined menopause as an “estrogen deficiency disease” and thus requires major life changes for the woman. Many physicians prescribe hormone replacement. They claim that it will prevent osteoporosis, heart disease and the vaginal drying that occurs after menopause (Sherwin 186).

There are serious side effects involved with artificial hormone replacement. On Prime Time Live January 28, 1993, Diane Sawyer asked Bernadine Healy whether women should use hormone replacement after menopause. She said that we can’t tell whether they should or not, studies show that it will benefit their bones and heart, but there is worrisome information about them increasing a woman’s risk for cancer. She regrets and feels that it is unacceptable that we don’t have the answer for that. She said that we should and will do research on how to prevent heart and bone disease in women. The Women’s Health Initiative has appropriated $625,000 to study the effects of hormone replacement and vitamins on port-menopausal women (Healy, Prime Time Live).

I think that prevention is more cost effective economically, and in the emotional toll it takes on patients.

In a discussion of feminist ethics with Carol Krohm MD, she told me that what really infuriated her was she recently heard 2 male obstetrical\gynecological doctors talking about how they are going to start adding male hormones (androgens\testosterone) to female hormones given to post-menopausal women. They said there was a need to give it to them because of their complaints of decreased libido. Dr. Krohm said that she doesn’t believe that, she says the problem is probably the opposite – it’s the men who can’t get it up at that age who are the problem. She says if the women are not interested in sex after menopause it’s probably because they are so angry at having to put up with the men all those years (Krohm 92).

Mendelsohn says that women have been convinced that they need an annual Pap smear which he says is not necessary. The test results are frequently inaccurate and their main purpose is to keep gynecologists rich and busy. He says that if the results show the slightest change the women will be advised to have a hysterectomy. (In case there are any bad cells hanging around her uterus). While they’re in there they will also remove her tubes and ovaries, then she will need hormone replacement which will then possibly lead to her getting breast cancer. To say nothing of the pursuant sexual changes that may lead her to a psychiatrist. The surgeon who removes her breast will for sure not tell her that the hormones she took for 15 years and kept her gynecologist rich off her having to return for prescription renewals, caused her to get the breast cancer (Mendelsohn 3).      

Pregnancy as Illness

Women also stop menstruating with pregnancy; here is another women’s disease for medical science to oversee. Pregnancy is defined in medicine as a state requiring intense monitoring and almost constant preparation for radical intervention. Women are ordered to modify their lifestyle, report for regular checkups, be subject to potentially hazardous tests and above all else get themselves to the hospital before the birth so that doctors can control their birth. This encourages dependency on the medical system and gets in the way of women thinking for themselves how they want their pregnancies and birth to happen. If they even question not going along with the system they are seen as irresponsible (Sherwin 186).

The American College of Obstetrics and Gynecology says that they are to be credited with the decline in infant and maternal deaths during the last 100 years, but they leave out the fact that most of the decline happened at a time when babies were delivered at home without medical intrusion (Mendelsohn 6).

Two and a half million women in the United States had Dalkon Shields inserted between January 1971 and 1974, before they were taken off the market by The Food and Drug Administration. These intrauterine devices (IUD) had been used despite the fact they had not been tested properly and caused harmful side effects soon after they went on the market. Approximately 1,100,000 women have since had acute pelvic infections, 1/5 of them were left sterile, and seventeen have died from the Dalkon Shield. Physicians were not notified by A.H.Robins (the manufacturer) until September 1980 to remove the IUDs from any patients who still had them in (due to large amounts of publicity about the problem). This after $55 million had been paid out by their insurance company to cover damages from 600 court actions and 300 pending claims (Mendelsohn 35).

During the 1940’s and 1970’s DES (diethylstilbestrol, a synthetic female hormone) was used to prevent miscarriages. It was used without real knowledge of whether or not it actually prevented miscarriages or what the potential side effects might be. These facts did not get in the way of doctors prescribing the drug or the drug companies from marketing it (Mendelsohn 35,36).

After a while the University of Chicago did do research on DES using 2,000 healthy pregnant women who were told the drug was a vitamin; they were not told that they were being used like rats to test the drugs effectiveness. The researchers did learn what they wanted and that was that DES did not prevent miscarriages. The drug was still prescribed (Mendelsohn 36).

It only took until 1972 for the side effects to start showing up: breast cancer in the mothers who took it, vaginal cancer to their daughters and genital malformations in their sons. Most of the women who took DES from the experimenters were sought out to inform them of its dangers, but the medical system did not have a way to seek out and notify the children of all these women who were at risk. Mendelsohn feels that every doctor who gave out DES is morally obligated to alert their patients and children who are risk; he doubts that with the threat of law suits that many would do so (Mendelsohn 36).

I remember well an experience I had with DES. I worked as an LPN (licensed practical nurse) in the late 60’s in an obstetrical unit. I recall looking up the drug DES before giving it to a pregnant patient as the doctor prescribed. I had been severely warned against giving any medication to a pregnant woman, so since I had not even heard of the drug, I wanted to know what I was giving. I remember the absolute uproar it caused when I refused to give the pill because the Physician’s Desk Reference said it could cause fetal damage if given to pregnant women. I was the criminal at that time. I dared to question one of the “GOD Boys”. I dared to use my head and to care about and use the knowledge I had gained simply by taking the initiative to learn about the drug before giving it. Oh, I remember so well, I feel the same rage I did then, only now I like myself for what I did. Now I’m glad I got in so much trouble. I’m glad I had a big mouth. I actually used to feel that something was wrong with me that made me speak up about things like that.

A major turning point in childbirth control was when doctors placed women flat on their backs with their knees raised on a high table to give birth. What this did was disallow nature to assist the woman in giving birth; contractions combined with gravity were taken away in lieu of the doctor’s control and interventions. This simple position change made women actually NEED assistance to give birth. It has made giving birth very difficult, risky, painful and gave doctors rationales to AID women with their once natural process. (Anyone who has ever had to try to use a bedpan to have a bowel movement laying flat in bed will understand how unnatural this position is for evacuating from down below).

Studies had been done in the 1930’s that proved that intra-abdominal pressure was the strongest in the sitting position; there has never been a study to scientifically justify laying women down to give birth. It was done for the doctor’s convenience. The trauma created to the birth process by using this position makes birth a pathological event (she has to go against gravity and the upward curve of the pelvis) and gives obstetricians a reason to exist (Mendelsohn 152,153).

Mendelsohn says that the flat maternal position requires that an episiotomy be done, the need for surgery then justifies the need for the position to do the surgery easier. When mothers give birth in natural positions, the already remarkably flexible perineum becomes even more flexible with body changes that occurs during labor – women don’t need episiotomies! (This is when the vagina is cut before birth supposedly to prevent tearing.) (Mendelsohn 177).

Childers reported that it has recently been shown that episiotomies are not medically necessary, despite the fact that they are done on 70-80% of vaginal deliveries in this country! (Childers 92).

I have often wondered why nature would not have made it feasible for a woman’s body to let out a baby without a man cutting into her vaginal tissue. I wonder what the incidence of tears would be if they dared to allow nature to take its course. It seems similar to removing pre-cancerous organs or removing things to prevent cancer from coming at all or coming back.

Mendelsohn is my hero in speaking for the desperate need to develop a feminist ethics of health care. 

Pap Smears

Pap smears, believe it or not, have never been tested to see if they are effective or not. But that doesn’t stop physicians from using them to gain access to patients once a year. If you ask a doctor about the effectiveness of the test, they will tell you how the rate of cervical cancer is down – but the rates were down BEFORE Pap smears were around. A recent study, at Yale University Medical School, showed that Pap smears were inaccurate, had never been involved in trials and that there was no evidence that it had any effect on the death rate from cervical cancer (Mendelsohn 41,42).      

Mammograms

Mendelsohn relates a true story of a friend’s wife whose mammogram showed a tumor. A frozen section (fast) biopsy was done which came back positive; she had her breast removed. The post-operative pathology report (which is much more accurate, but takes a couple days) showed no evidence of cancer (Mendelsohn 43).

I am also aware of this happening to women. Women were asked to sign consents for mastectomies at the same time they signed for their biopsies. This is truly ridiculous because the very reason biopsies are done is to learn whether or not there is cancer. Frozen section biopsies (the ones done immediately after tissues removal) are known to be less reliable than full pathology reports. The fact that medicine did not mandate full pathology reports before doing procedures as devastating as mastectomies is an example of how medicine has devalued women – to put it mildly!

Necessary Drugs & Women?

In 1979 alone 160 million prescriptions for tranquilizers, sedatives and stimulants were written. (Only 10% of these were written by the specialists trained in their effects, psychiatrists). A federal report showed that 80% of amphetamines, 60% of mind-altering drugs and 71% of antidepressants were prescribed for women. Women with the same symptoms as men, were prescribed twice the amount of drugs as men (Mendelsohn 60).

Congresswoman Cardis Collins of Illinois is the head of the congressional task force on women and drugs. She says we are accustomed to thinking of drug abuse in terms of male heroin or cocaine addicts, but there are 2 million women addicted to prescription drugs. Doctors frequently tell male patient to use physical exercise to deal with their problems, a woman with the same symptoms is advised to take Valium. Roche Laboratories profits a half a million dollars a year in Valium. Valium leads to 50,000 emergency room visits a year, 90% of these visits are women (Mendelsohn 61).

I recall a patient I took care of in an intensive care unit who was there after a suicide attempt. She said it was her eighth attempt in the past 2 years. I reviewed all the medications she was prescribed by her psychiatrist and found 3 of them had side effects that led depressed patients to attempt suicide! I asked the patient if she was aware of the side effects of the medications she was taking. She said no, but showed no indication of “getting” what I was saying. She “got” it on an intellectual level, but could not see that her doctor might have had any responsibility in her frequents suicide attempts. She was being treated for depression. When she told me about her life, I thought it was horribly depressing as she was being abused by her ex-husband, her sons, and, in my opinion, her psychiatrist – she sure had reason to be depressed to me. When giving report to the next nurse I told her about the drugs and that I had been unable to get a hold of the doctor to notify him of the side effects that I had read about (I even wrote out the side effects and the page numbers in the drug book) this patient’s drugs. This nurse thought I was some kind of freak – we don’t tell doctors about side effects – they’re supposed to know – they’re the doctors – they prescribe them. Why was I as a nurse taught to NEVER give a drug unless I knew about it? Why was I taught that if I gave a drug that I knew would be harmful I should tell the doctor and refuse to give it? It just doesn’t seem to work that way in real practice.

Surgery

Doctors who are paid a salary do 50-100% less surgery than those whose income depends upon the number of procedures they perform. In 1980 Blue Cross and Blue Shield stopped paying for 28 procedures that they thought were not helpful to patients. In order to do these surgeries doctors would have to work hard to justify them to patients and interestingly a 75% drop occurred among these procedures (Mendelsohn 81).

Mendelsohn illustrates very well the risk we face under a surgeon’s knife. In 1974, 15,000 people died as a result of knives. Three thousand of them were murdered and 12,000 were from surgeons. At the time of Mendelsohn’s writing he predicted that if present rates continued, “one of every two women in the country will part with her uterus before she reaches the age of 65” (Mendelsohn 97).

Dr. Niles Newton, professor of psychiatry at Northwestern University did a study on the consequence of hysterectomy that may not be of much importance to male gynecologists, that is decreased libido. She found that 60% of women experienced suppression of their sex drive after removal of the uterus and ovaries. (Male gynecologists had told women it would enhance their sex life because they would not have to worry about pregnancy) (Mendelsohn 102).      

Breast Cancer

Dr. Halsted’s radical mastectomy was developed in 1882 when most breast cancers were not treated until very late stages. Studies have illustrated that 1/4 of all married women experience depression so severe that they contemplate suicide after mastectomy. Another 25% describe deteriorated sex lives. More than half have phantom breast pain (they feel pain in the breast that is gone). Psychologists who see these patients and have studied these patients blame the symptoms on lack of emotional support from doctors who did the operations and the husbands with whom they live (Mendelsohn 111,112).

It only took 90 years to have controlled studies done on alternative treatments. (Other studies had already shown that the Halsted did not have a better survival rate than less devastating treatments, but the Halsted was still used)! A 1970 study finally showed that 3 different treatments, Halsted radical, simple mastectomy and simple mastectomy with radiation were exactly the same in respect to reoccurrence of cancer (Mendelsohn 112).

The Pill & The IUD

The FDA approved the birth control Pill in 1960, but that approval was based on some despicable research. One hundred and thirty-two Puerto Rican woman took the Pill for a year or more, “five of them died during the study, and no effort was even made to find out why” (Mendelsohn 119)! This was some of the scientific evidence that the FDA used to approve the Pill, endangering 50 million women. Despite 20 years of use it has not been proved to be safe for women. In fact, 100 studies have linked the Pill with over fifty side effects. And yet, the FDA then said, “there is no conclusive scientific evidence that oral contraceptives are not safe for human use” (Mendelsohn 120).

For some women adverse effects show up right away, but for others they may not show up for 20 years. Some of the risks are: cancer of the cervix, uterus, breast and liver; In addition, the pill has been linked to heart attacks, strokes, diabetes, gall bladder problems, high blood pressure, depression, pulmonary embolism, vaginal infections, hair loss, growth of hair on the face, and diabetes. One also may learn that when one goes off the Pill and try to get pregnant, one is sterile. The side effects of women NOT using the Pill faced by the FDA and the drug manufacturers are LOST PROFITS; to them the end, population control, justifies the means (Mendelsohn 121).

Mendelsohn quoted Dr. J. Robert Willson, of the University of Michigan School of Medicine, at an International Conference held by the Population Council, they were discussing infections that IUD’s might cause: “perhaps the individual patient is expendable in the general scheme of things, particularly if the infection she acquires is sterilizing but not lethal” (Mendelsohn 126). What kind of medical ethics allows doctors to view their patients as expendable along the road to achieving social goals? (Mendelsohn 126,127).

Only 8.8% of female staff members of Planned Parenthood took the Pill compared to 70% of their clients; they knew about the harmful effects but their clients did not (Mendelsohn 129).

Eating Patterns as Illness

Our culture is fixated on the shape of women’s bodies; culture demands women to be attractive and or fat free. In addition to cultural pressure to be thin, women are also pressured by medicine telling them that it is unhealthy to be overweight. Ninety five percent of people in weight-reduction are women and 75% of American women perceive that they are over weight. Women are in addition, blamed for their lack of control in getting their weight down (Sherwin 188).

When women show that they cannot control their weight medical science is there to receive payment for stomach stapling, enforced dieting, mouth wiring, medications to decrease appetite, surgical removal of fat and even removing parts of their stomach or intestines (Sherwin 188).

Empirical evidence illustrates that weight charts telling women how much they should weigh according to their height are very low. They even show that women are healthier with a few extra pounds on them (10-15 pounds above charts). Research has not shown women to exhibit poor health with extra weight; research showing correlations between obesity, heart and diabetes were done with men and even more specifically showed the excess weight that caused harm was around the waist, not around the whole body, the way women carry excess weight (Sherwin 188).

The very advice given to women by medicine – to diet – can actually endanger their health. Dieting is rarely effective. Ninety five percent of dieters gain back the weight plus a few more pounds, and fluctuations in weight are harder on the body than a steady weight above the weight charts (Sherwin 188).

Medical science also labels a person “ill” if they don’t eat. Eating disorders such as anorexia nervosa and bulimia leave women easy prey to hospitalization and psychiatric treatment. They are an example of women taking cultural norms of what is required to be feminine to the ultimate. Whether you eat too much or too little you are subject to medicine’s interventions. Could it be that the norms for health could be off, and not women? If so, many women have eating problems then it may be cultural in origin and medical control may not be the best solution (Sherwin 189).

Cosmetic Surgery

Kathryn Morgan displayed a page of knives, scissors, needles, and sutures used in cosmetic surgery in her paper, “Women and The Knife: Cosmetic Surgery and the Colonization of Women’s Bodies”. She suggested that her readers look at them carefully, for a long time and to imagine them cutting into your skin (Morgan 26). I did.

As a nurse, my first glance simply revealed surgical instruments – no big deal. Then I looked at them with care for a long time, and imagined them being used on me, as Morgan suggested. I then looked at them as a feminist; I then saw them as mutilating, controlling devices used by patriarchy to manipulate women, to make women fit the image of beauty as defined by men, especially white men. (Not to mention the enormous profit they make from assisting us to look good for men).  This is another example of the medical system defining not only what is normal, or pathological, but outward appearance. What aspect of medical training certifies them to evaluate appearance?

One of the reasons Morgan gives for writing about the topic of cosmetic surgery is that she says it is or has been silenced in the fields of mainstream bioethics and virtually no discussion, feminist or otherwise, of the issues that may be present in this area. She thinks we, as feminists, need to ask, why women reduce themselves to potentialities (to fit the heterosexual image) as women. An enormous and growing demand exists for cosmetic surgery. Women are willing to sacrifice other parts of their lives for reconstructed bodies. Why, when the risks are so great? Risks such as: bleeding, infection, embolism, unsightly scar formation, skin loss, blindness, disability, pulmonary edema, facial nerve injury, and even death (Morgan 28).

As a feminist, and as a health professional, I feel that our silence makes us complicit in enlarging the scope of avenues to patriarchal power.  Women invest years of savings in the cosmetic surgery industry to “fix” natural flaws through dangerous and painful operations to make their bodies fit the norms of the fashion editors (Morgan 28).

Morgan also sees this topic as a part of the technologizing of women’s bodies in Western culture. We are seeing cosmetic surgery evolve to the point of being viewed as normal. This changing perception may lead to those who don’t “elect” cosmetic surgery will be seen as deviant (Morgan 28).

We are all witness to the controversy about silicone breast implants. Over one million women have had these implants. Two recent studies show that they block x-rays and cast a shadow over surrounding tissue, making mammograms very difficult to interpret. There also appears to be a higher incidence of cancer in those with implants (Morgan 29).

I personally knew a woman who had implants done, she was my next-door neighbor for many years. I had seriously wondered about her sanity in doing so because she chose to do it when her second child was 9 months old. I knew how challenging it was to change the diaper of and dress a 9-month-old. She was restricted from using her arms to lift or to do much of anything for 6-8 weeks after the surgery. (She did have her mother close by to assist). I remember telling her I could not understand her choice to have it done in the first place, but to have it done with her child that age I really didn’t understand. I told her I did however, realize that her reasons must be quite profound and vital to her very existence. Indeed, her decision came from her desperate desire to obtain her husband’s love. Despite my realizing that it must have been an act of desperation, I still needed to hear it from her. I still develop “wet” eyes when I think about what women will do to obtain acceptance and love.     

Morgan says she is shocked at the extent to which patients and cosmetic surgeons are committed to what she sees as “one of the deepest of original philosophical sins, the choice of the apparent over the real” (Morgan 28). Technologically created appearances become what is perceived as the real; youthfulness over the reality of age (Morgan 28).

In 1990, the most popular cosmetic surgery was liposuction; fat cells are vacuumed from beneath the skin never to return. At least 12 deaths have resulted from hemorrhages or embolisms. Sixty to seventy percent of cosmetic surgery patients are female (Morgan 29).

The relationship between the means and the ends are unilinear, but with the new technologies it has become circular; they present new possible ends. New objectives are added to the possibility of what one might desire. The role of technology has become transcendence, control, transformation, exploitation and destruction. The object of the technology is viewed as inferior; the higher purpose becomes to “fix” with the technology that justifies its existence (Morgan 30).

For most women, success is seen through interlocking patterns of compulsions: compulsory attractiveness, motherhood, and. Their attractiveness is determined my the tastes of men; a woman’s eroticism not dwelling on the penis is seen as either nonexistent, or pathological. Our reproductive services are to particular men or to male dominated institutions (Morgan 32). 

Most women in Western societies are socialized to accept the knives of technology. Those knives can be for healing purposes: saving the life of a baby from uterine distress, removing cancerous growths that threaten our breasts; they can straighten our spines, or can give function back to arthritic fingers. There are, however, other knives that perform episiotomies and other types of genital mutilation, cut into our bodies to remove ovaries and thus our “deviant tendencies”, some that amputate our breasts unnecessarily in the name of prophylaxis or simply in cases where less drastic measures would have sufficed, some get rid of our uteruses when we are beyond child bearing years or when we are of an undesirable color, and some knives that do unnecessary cesarean sections so the doctor can be on his way. Morgan admits to being afraid of the knives of plastic surgery, they manipulate our bodies to please the patriarchal, white supremacist culture (Morgan 32).

Isn’t it interesting that another word for cosmetic surgery is plastic surgery. The “plastic” certainly is more correctly descriptive to the images involved. Even the word augmentation is revealing.    

Women have historically been socialized to used their beauty as power. A quote from Mary Wollstonecraft (1792),

“Taught from infancy that beauty is a woman’s scepter, the mind shapes itself to the body and roaming round its gilt cage, only seeks to adorn its prison” (Morgan 34). Are women today making free choices to have cosmetic surgery or are they too simply adorning their prisons (Morgan 34).

The power that beauty yields is heterosexual affiliation not equally accessible to the who don’t fit the image of beauty patriarchy defines: the plain, ugly, old or unable to reproduce. The voices of women who seek cosmetic surgery are compelling. The youthful appearance they gain gives them a sense of identity that they did decide to acquire, to a certain extent. It enhances her status socially and economically, as it will better her potential for affiliation with heterosexual white men. Her pursuit of beauty brings her an approval that fits society’s values and thus increases her self esteem. The people she meets in the process of acquiring cosmetic surgery may treat her body in a caring way, this may be something lacking in her life. The accumulative results of the pursuit of beauty via transformation, are associated with self-fulfillment, self creation, self transcendence, and being cared for. While the power offered through acquiring beauty can boost a woman’s self image, it also gets her stuck in a mire of interrelated contradictions (Morgan 34,35).            

Some of the reasons women seek the expertise of plastic surgeons are to obtain glamorous breasts like the movie stars, to reduce their noses (often Jewish women), to Westernize eyes (Asian women), and to bleach dark skin. The results they hope to gain are more than just beauty; they are trying to mold themselves to fit to a white, Anglo-Saxon, Western image, to better function in a racist and anti-Semitic society. We might initially say that they have a choice, but actually they are seeking to conform. The appreciation women may gain from men in their newly acquired femininity is actually intrusive when it is obtained through incisions, sutures, staples and scars. Morgan identifies three paradoxes that choice involves:

       1. What simulates choice may actually be conformity at a deeper level (Morgan 35,36).

Who is really exercising the power involved in cosmetic surgery? The colonizing power comes from fathers, brothers, male friends and lovers and the cosmetic surgeons who offer their knives to fix a woman’s deformities. The power can even be present from within the woman herself, clothed in a diffuse manner. Women who are involved in self-surveillance behaviors like fixing their make-up all the time, or monitoring everything they eat, are maintaining obedience to the patriarchal powers that be (Morgan 37).

       2. The men in society that women transform themselves for are male-supremacist, heterosexist, ageist, ableist, racist, anti-Semitic and classist (Morgan 38).

       Health insurance policies do not cover elective cosmetic surgery, so women who want it must do so at significant cost financially and in terms of lengthy post-operative pain (Morgan 38).

       3. The technological imperative to be beautiful and the pathological inversion of what is normal convinces more women every day to have cosmetic surgery (Morgan 41).  

       Although admittedly not likely to ever be achieved, Morgan suggests that if women collectively chose to exercise their power, they could refuse cosmetic surgery and drastically affect the status of the market. This might also have the positive effect of leading surgeons back to healing again. Morgan suggests that we should not turn away from women who chose to have cosmetic surgery; this decision may be one of the only decision powers she may have in her life (Morgan 42).

Plastic surgeons rationalize that silicone breast implants are a matter of a woman’s free choice. We should think seriously about trusting companies that stand to profit $300 million dollars by going along with women’s “choices”. Anyone who listens to the afternoon news has probably heard that Dow Corning Wright was suppressing negative data about the silicone gel filled implants. Doctors don’t follow their patients to know about adverse effects and their medical society doesn’t demand a registry for patients to facilitate keeping tract of women and their adverse effects.

Applications of Concepts – Health & Illness

What medical science labels sick is taken as God’s solemn truth. The labeling of a condition to be a disease has enormous political and social implications. This is especially true with diseases associated with behavior judged socially unacceptable like alcoholism, drug addiction, mental illness and homosexuality (Sherwin 190).

Having a physical or mental disease can get in the way of obtaining equal opportunity. The way the definitions of health and illness are used shape social roles and set boundaries for medical authority; they also describe boundaries of those labeled as ill. If ill, you may be excused from some responsibility and get special treatment. Or they may be easy prey to stigmatization, paternalism and be judged unqualified for certain activities. Our society has given doctors a free hand in assigning powerful labels and the power to “fix” what they label as ill (Sherwin 190).

The medical model of health is tied in with value judgments. Sherwin quotes Englehart, in his book The Foundations of Bioethics,  “Medicine medicalizes reality. It creates a world. It translates sets of problems into its own terms. Medicine molds the ways in which the world of experience takes shape; its conditions reality for us” (Sherwin 191).

This reality is then reinforced by being considered socially acceptable; thus, the reality they create is socially dominating. The very defining of a problem as medical creates expectations and influences a person’s future – it changes our very social relations. Hidden policy and value judgments can also shape the “medical facts.” Doctors place far too much emphasis on laboratory theory and their clinical world of symptoms and not nearly enough on the expressed experiential data offered by patients about what they are experiencing (Sherwin 191).  

Feminist Views – The Health Illness Debate

Feminists fear medicine having authority in social and emotional spheres since their training does not give them expertise in these fields. Medical experts, coming from their homogenous class background, should not have authority to make decisions about lifestyle choices. Most feminists support a holistic attitude toward health; social ills are surely associated with poverty, oppression, ignorance and stress. Doctors, speaking from personal places that are not impoverished, non-oppressed, and certainly not ignorant should not be making judgments of those whose lives are affected by these social conditions. Medicine’s values and authority should not serve as filters for attempts to fulfill social needs (Sherwin 193).

Feminists think that decisions about what is illness as far as women’s health should be made among the women’s community, not within the very society that oppresses us. Medicine’s ascribing illnesses to oppressed groups may actually be a sign of or an effect of the group’s oppression; it may even serve to perpetuate their oppression. Labeling of illnesses of those within oppressed groups has enormous political ramifications. They may as a result face stigmatization, being seen as passive and thought of as less than competent (Sherwin 195).

The medicalization of menstruation, pregnancy, and menopause, assumes that these ordinary events in the lives of women are not valued – they have to be “fixed.” When body parts are labeled as diseased they become subject to the control of medicine; women themselves may thus feel an alienation from these body parts. Some important aspects of women’s oppression are the fact that their bodies are objectified and alienated in the process (Sherwin 196).

Medical objectification of our bodies in a sexist society reduces those bodies to sexual or reproductive functions under patriarchal rule (Sherwin 198-199).

Sherwin suggests that we only label the atypical menstrual changes that are harmful to women as diseased. To properly label what menstrual symptoms suggest disease we must first truly understand what is normal menstruation which has not been fully explored (Sherwin 199).

If we accept a medical model of PMS as a disease that affects 95% of women, we are accepting a sex difference that places us at a disadvantage societally. It serves to maintain our bodies under the authority of medicine (Sherwin 200).

We must keep in mind who gains from PMS being viewed as a disease; drug companies and medical specialists stand to profit, while we are subject to them and maintain our oppression (Sherwin 200).

The cyclic changes women experience must be perceived as normal; by rejecting the norm of PMS as a medical problem we gain some control over our bodies, lives, and the way society views us (Sherwin 200).

Illness and Oppression

A person’s health care needs usually vary inversely with their power and economic status. Poverty has a profound affect on a person’s health. One may not have adequate nutrition, shelter, clothes, heat, sanitary conditions, or clean water. Those living in poverty are also more likely to work at a job that presents health risks, are less likely to have health insurance and are more likely to suffer from a mental illness and be addicted to drugs or alcohol. Without money for health care one may let an illness go to an advanced stage, thus compromising recovery potential (Sherwin 222).

Those more likely to be poor are a societies oppressed segments: women, children and other minorities. Oppression itself causes illness due being exposed to high stress levels which leads to many serious illnesses. The very factors that cause a person to be oppressed societally also affect his/her treatment in the medical domain (Sherwin 222-223).

Serious or chronic illness may lead to poverty from fear and discrimination; the chronically ill then also face class oppression. Bioethicists have an enormous responsibility to address to connections of oppression and illness and to modify these connections. If ethicists don’t consider oppression’s role in destroying health they become complicit in maintaining the oppression (Sherwin 223).

Patients in Oppressed Groups

Women consume much more health care than men. (Seven times more according to Mendelsohn 1). Sherwin discusses a study that was presented to the American Medical Association which revealed gender disparities in clinical decision making. Despite the fact that women are likely to have more medical procedures done than men with the same symptoms, they have much less access to major interventions. Women are 30% less likely to get a kidney transplant; 50% as likely to receive tests for lung cancer; and only 10% as likely to receive cardiac catheterization than men. Other than the biological differences between the patients, nothing justifies the treatment imbalances other than gender bias. Cardiovascular disease is the leading cause of death in women in the U.S., but all the research has been done on men (Sherwin 223).

“If a man comes in with chest pain, we instantly worry about organic heart disease. A woman comes in with chest pain,  Hmm…Well, what is she upset about” (Healy, Prime Time Live)?  Heart disease kills 20% more women than men. One major prevention study not only didn’t include women, but it called the study “Mr. Fit”.  When researchers studied the effects of estrogen on preventing heart disease, it failed to show that estrogen would prevent heart disease, but the trouble was they did the study on MEN (Healy, Prime Time Live)!        

Another study found that when women were treated, they were subject to excessive testing, surgery and drugs. Most women seeking fertility control from professionals are placed on the birth control pill, interestingly, the majority of these health professionals or their spouses used barrier methods with less risks (Sherwin 224).

Doctors are educated to view women as anxious, deviant, unintelligent and not to take their complaints seriously. Research studies have shown doctors to be condescending to women, withhold information because they don’t think they can understand (Sherwin 224-225).

“the darker a woman’s skin and/or the lower her place on the economic scale, the poorer the care and efforts at explanation she received” (Sherwin 225).

The reasons for lack of safe, effective birth control, abortion and prenatal care are not just economic, but are even more political. Black women are four times more likely than whites to die in childbirth, three times more likely to have their newborns die, are twice as likely to die from hypertensive cardiovascular disease, have three times the rate of high blood pressure and lupus and are more likely to die of breast cancer even though they have lower incidence, are twelve times more likely to get AIDS and four times more likely to die of homicide (Sherwin 226). Many of the working poor do not qualify for Medicaid; even those who do qualify face doctors and hospitals who will refuse them. A 1985 study revealed that four out of ten obstetrical physicians refused to treat Medicaid patients (Sherwin 226).

Most affluent women will find nutritional guidance to assist them in loosing weight in their neighborhoods; few women on welfare have access to information on how to stretch their welfare dollars to get the most nutrition possible. When women are abused, they get patched up in an emergency room, and if a space is available may be referred to a shelter temporarily. There are not usually services available to assist the abuser in finding alternative methods of treating his spouse. Women then end up back with the abuser, showing up at the emergency room with more serious injuries, while their children are being given models of how people treat one another which they will then carry on to their own families (Sherwin 227).

Justice is often raised as a principle in bioethics literature; the main moral concern, however, is access. But even in Canada where universal health insurance exists, poor women still don’t have access because they lack money for transportation to get to the health facility. The fact is that some women are at risk for violence, developing addictions, and malnutrition and this affects their ability to care for their health needs. They are at risk because of our social system that allows one group to oppress others. Bioethics must address the needs of oppressed people (Sherwin 227-228).

Health Care’s Organization

The medical establishment is set up with the same stratification systems as society in general. So in addition to reflecting the same biases as society, the medical system also serves to maintain (Sherwin 228).

Women do most of the work in the medical system, but are not involved in policy making. They are the ones who provide home health, take care of their own families, (both of which are not for pay, so they go unrecorded and are not reflected in health care statistics), they have no authority, and the knowledge they acquire through experience is negated by those in the health care power structure (Sherwin 228).

Women do 80% of the work in health care institutions while men sit in the seats of power. Those in positions to set policy are overwhelmingly male: administrators, physicians and legislators. Most medical instructors, textbooks writers and hospitals directors are men. Women who do function in health care administration are middle managers where they do not have power over policy. Most research is controlled by men; research standards were set by privileged men to meet their requirements. They do not reflect ideas from female philosophers and scientists such as: adding space in a project’s design to measure participant control, decrease separation between subject and object, and resisting restrictive medicalized analysis (Sherwin 228-229).

The jobs with the lowest income and status in health care facilities are filled by working-class minorities: nurses’ aides, kitchen and cleaning staff etc. They have no voice in the system. There is certainly no research specifically to discover the needs of these minority women. Black women make up only 1% of the nation’s physicians. They have been kept out by hospitals refusing them internships or, if they did complete their training hospitals would refuse them admitting privileges (Sherwin 230).

Problems with sexism and racism have been made worse by oppressed groups being led to perceive that their interests were in conflict with one another, thus dividing them and decreasing their power potentialities. Sherwin sites Hine who showed that racial divisions have been in nursing since 1890, white nurses tried to keep black women out of the profession. Rather than joining with black nurses to counter racial prejudice, they feared for their own status and helped to sustain oppression on fellow women (Sherwin 230).

Not only are nurses oppressed by the predominantly male medical system, but they are also downright abused by the system. A survey conducted by The American Journal of Nursing revealed, far and wide, nurses are performing (mostly not even under physician supervision) exactly the same services for which doctors are billing patients, Medicare and insurance companies for. Researchers have suspected this for many years. The American Public Health Association says that physician payments have risen 17% per year, compared to 9% for other hospital costs and 4% in other parts of the economy. Congress is currently targeting physician payment reform (Griffith, Thomas and Griffith 22).

Carol Lockhart RN, Ph.D., is a member of the Physician Payment Review Commission, advised congress that we must address all health care providers. She encourages nurse to document their role in Medicare Part B, “We have little or no data showing how much of a particular service, now billed by a physician, is done by a nurse – or how many services are delivered by the nurse and billed under the physician’s name” (Griffith, Thomas & Griffith 24). The authors suspect that policy makers will be hesitant to include providers other than doctors because it would complicate things dramatically. They assert that the alternative is certainly not OK. They urge nurses not to allow policy makers to treat them as “invisible worker bees” of the health care system (Griffith, Thomas & Griffith 27).

Some of the services mentioned in the study were: giving intramuscular injections, starting intravenous infusions, giving blood transfusions, inserting urethral catheters, training in activities of daily living, interpreting an electrocardiogram, performing CPR, and suctioning of the upper airways (Griffith, Thomas & Griffith 27).

Having spent 26 years working hospitals, I know that doctors do not perform most of these procedures. (Just try to picture a doctor teaching a patient how to wash himself with a cast on). When a doctor does do one of these procedures it is in a teaching hospital, only so he can do it once or twice for the experience). I was appalled to learn that doctors billed for things like the above; I realize that I was so doing all of these procedures and that I had never thought about who got the money for them. It makes me wonder how much they charge for each of these and how wealthy I would probably be if Medicare reimbursed ME for each thing I did for a patient. Imagine also if listening, supportive touch, hugs, crying with families, and teaching patients to stay healthy were valued for their roles in healing.

The hierarchical system encourages competition rather than cooperation among social groups. It makes us all obedient to our superiors and hostile to those below ourselves; thus, all groups become complicit in maintaining the hierarchical structures. The health care system then reinforces the oppressive attitudes of the rest of society (Sherwin 231).

Effects on Health Care

It’s not only unjust to distribute health care with biases, but it also affects the quality of care. When most health care decisions are made by wealthy, white, well-educated males, it is obvious that they will make decisions that stem from their value systems which may be very different from those of the patients. It is also likely that their views of women, especially poor, uneducated minority women will be from a paternalistic vantage point. These physicians make decisions where cultural communication gaps exist – care suffers as a result (Sherwin 232).

Minorities and women frequently fill the health care institutions with dead-end, demoralizing jobs; they lack the power and influence to interject their cultural values into the system, as do the patients who are also frequently minority and female (Sherwin 233).

Researchers are inclined do study things that effect people in their world: heart disease, cancer and infertility. They are less inclined to be concerned about poverty, malnutrition or sickle cell anemia (effects mostly black in this country). What ends up happening is that those who need the system the most find the system foreign to them. Most family’s health needs are tended to by women who must try to operate in a male dominated system that is costly and hospital-based. They have to attempt finding their way around the system to obtain the right care, then they have to try to translate what they are told by the professionals and attempt to communicate their needs so that the professionals can understand it. Thus, the consumer and the providers must function across cultural and language barriers in times of illness, which are stressful enough (Sherwin 233).              

Child care and transportation are not included in health care resources, despite the fact that without them care will be almost impossible to obtain for many. White doctors and nurses are paternalistic in regard to minority patients; if they don’t follow “orders” they are treated with hostility and anger due to their noncompliance. It is frequently not considered that the patient may not have had the money for the medicine or the patient missed a scheduled exam because he feared loss of his job (Sherwin 233).

Chronic health problems that occur because of oppression itself do not receive proper care. Priorities for child and woman abuse are very low; the health care profession offers them drugs and lectures (Sherwin 233).

In order to obtain ongoing support survivors of sexual abuse, breast cancer patients and parents with chronically ill children must form groups to help themselves. I have run across more than one physician who became angry that I, as a nurse, informed their patients that there were cancer support groups available to them. They, male physicians, did not believe in “those groups.” How dare I offer something THEY did not approve of for THEIR patients. I know that they do not intend to offer their patients the intimate, ongoing, support and caring as the months go on. I know that they do not understand or sympathize with their patients’ losses, yet they try to “stand in the way” of their patients obtaining the help they need. (I would always call The Cancer Society from home, anonymously, for patients.)    

Ideological Influences: Gender, Race, & Class

The hierarchical health care system reflects society’s sexist, racist, and classist attitudes; it supports them and keeps them going as do all of our major institutions: the justice system, universities, the business world, and the world of civil service. Those in power are white males; they are supported by undervalued white professional women; mere physical work is done by minority unskilled labor. This stratified societal structure is of great moral concern (Sherwin 234).

Doctors have been justified in their dominance because the end – health, is of such high value that their means have been, by and large, acceptable. They “command” health care teams, “lead campaigns” against dangerous life-styles, and “battle” illnesses. They are allowed to give “orders” to nurses, physical therapists, other health care professionals and their patients; because of their expertise they rule all. White female nurses accept following doctors’ orders and thus serve as an example of how things should be done to minority nurses. These nurses in turn have authority over non-skilled hospital workers of color which perpetrates race oppression. So, the health care establishment serves as a perfect role model for how people keep stereotypes and oppression going (Sherwin 235).

It has been recognized for some time that stress is a major factor in illness. The standards used to evaluate levels of stress were developed from a male in authority perspective, the high-powered business executive. The image of stress found in an American study of stress at work found that it’s the lower level jobs were people have high work loads and no control over their work situations. It is poor women who have no control over their jobs and who must struggle to meet child care responsibilities who face the most stress – they receive little support societally nor any relief. Instead of being helped, they are judged when they develop poor coping mechanisms like alcohol abuse, smoking or the use of drugs. Traditional lists of stressful events included things like, being promoted at work, being drafted or having one’s wife start working. These lists do not include, being raped, having an abortion, loss of child care to a single working mother, working in a situation where you are being sexually harassed or having received an especially severe beating from your male partner (Sherwin 237).            

Those in power of health care resources cannot identify with these women and thus are not likely to be aware of their life stresses – so they receive no real help. Doctors use their power to reinforce negative attitudes about women; nineteenth century physicians had theories about women’s uteruses being in competition with their brains with the hopes of keeping them out of universities and “protecting” them from politics. Many doctors today promote estrogens in post-menopausal women, despite cancer risks, to help them avoid the undesirable effects of aging. Depending upon the current fashion, doctors have “helped” to maintain women’s feminine passive role with treatments like, genital surgery, psychosurgery, psychotherapy, hormone replacement, or tranquilizers. It has not been considered by the medical profession that perhaps changing the roles women have been relegated to might alleviate some of their life stress thus relieving physical complaints (Sherwin 237).

It is OK for women to develop illness as a response to overwhelming life stress because it fits the image of being passive, feminine and weak; it is NOT OK for women to question male authority by getting angry and rebelling. So, women unconsciously took the socially acceptable mode of stress relief – it is much less threatening.

The medical model has put its own knowledge at the top of the hierarchy and made other types of knowledge and experience subservient to that knowledge. This hierarchical structure is morally unacceptable simply because it is hurting people. It responds differently to different people’s needs; giving low quality and value to oppressed groups. Its structure supports oppression. It rationalizes that this hierarchy is essential to accomplish its ends; it tolerates unequal distribution of care, power and prevents equality (Sherwin 238).

Research Recommendations

Research is social and political and affects all of our lives. Unless there is more democratic representation among decision makers in research, the science will be a science that supports interests of the dominant groups in society. Scientists need to see their role in perpetuating existing power structures and increase the connection with subjects of their work; they must learn to see themselves as responsible to the people at large and not just to corporations and institutions that support them. It’s necessary to examine political and societal affects of research as well as its acceptance by subjects when evaluating its ethics. The dominant class controls research institutions and funding agencies, the values pursued reflect their class, gender and racial backgrounds which are powerful. Research pursued on women usually is chosen by privileged men (occasionally by women trained by such men). When research serves women’s interests it is because it coincides with those in control or because altruism was involved in a particular case. Or it may end up serving privileged women: white, middle class, educated and heterosexual (Sherwin 173).     

Research decisions should be public and should ensure accountability to the community affected. Oppressed groups should have a say in the goal setting and guides for research. Poor women and women of color will be harmed by fertility research on privileged women if the result is that eggs “harvested” from valued women, matured and fertilized in lab and transplanted into vulnerable women for gestation and delivery. These methods assure “proper” genetics without the risks and discomforts of pregnancy and birth for the “valued” women. (Sherwin 174-175).

Some feminists’ solutions to infertility are: research and treatment of sexually transmitted diseases (STD’S) and other causes of pelvic inflammatory disease which blocks tubes; a significant percent of female infertility is preventable. Prevention of involuntary sterilization. Direct attention to cause and cure of male infertility. Research into eliminating environmental and social factors that contribute to it (i.e. malnutrition). Pursuing techniques that will allow safe and reversible sterilization in men and women, and providing better fertility control (Sherwin 135).

Bernadine Healy said, on Prime Time Live, that the National Institutes of Health plans to use 625 million dollars through the Women’s Health Initiative to finally study the effects of hormone replacement and vitamin supplementation on postmenopausal women (Healy, Prime Time Live).

Solutions     

Sherwin cites Warren who suggests we must examine the fact that medical ethics requires an examination of the context of engaging in ethics itself. The context and methods of ethical analysis are themselves significant to the outcomes proposed. A “Sexist Ethics” is one in which men use their perspective to frame moral questions and propose solutions; its habit of cloaking itself in gender neutrality and selection of topics that ensure women are kept on the defensive by making matters of concern to them a constant subject of controversy. i.e. abortion, affirmative action (Sherwin 91).

Warren suggests three feminist themes that could direct the way medical ethics is discussed:

       1. DIVERSITY – Historically women’s theories and insights have been left out. After including women in ethical theories, we then must figure out how ethics can be inclusive to diversity. One way is to ask philosophical questions from varying vantage points rather than the traditional doctor-based ethics. Feminists could go beyond asking what a Hispanic woman from the barrio would need from ethics, by actually tagging along with a social worker to the barrio and ask women in the barrio what matters to them and what medical problems they face. Feminists question having universal theories fit multiplicity and suggest making room in the theory for particular others (Warren 40).  

       2. RELATIONSHIPS – How do people in academia relate to each other in ethical discussions? The motives and respect accorded to others in these discussions counts. When ulterior motives are involved, we are playing the ethics game. Winning the competitive argument does not lead to truth in solving ethical dilemmas. Feminists might do well to seek variations in the ethics game to find the moral benefits. Perhaps collective, anonymous authoring or using pseudonyms could be attempted. This could bypass reputation and stimulate concentration on the ideas. We could also appeal to the whole personality of the reader, not just his/her intellect. If we could inspire others to voice their ambivalence it could lead to self-knowledge and social harmony (Warren 41).   

       3. BASING THEORY ON ORDINARY EXPERIENCE – Feminist theories should not originate from ivory towers, but from real life experiences of real everyday people. Listening to ourselves would enhance trusting our own judgments, despite the fact that books may say something different. Doing so also challenges the experts. “If knowledge is power, ‘life precedes theory’ is social revolution” (Warren 42).

Warren suggests that in addition to questioning the power structure between doctors and patients, we should also question it between philosophers, students and ourselves (Warren 43).

Warren suggests ethicists might consider ways to resolve power conflicts, perhaps a sort of preventative ethics; rather than getting into who is in charge, the doctor or the patient, we could look to prevent the very power struggle itself. Medicine’s very educational set up and the organization of hospitals may be required. In addition, we might ask how health professionals can help to diminish the power disparities and enhance someone’s self worth. We might attempt to eliminate discrimination with a radical strategy: educate people to value themselves without it necessitating putting someone else down in the process. (Warren 38,39).

Warren also brings up an idea of feminists discussing relationship ethics. How can we train health care professionals to be sensitive, what should their work conditions be and how involved should they get with their patients? With the abortion debate we might add the relationship between the mother and child, not just whose rights are prominent (Warren 39). Warren suggests as a solution to the power struggles that we view the doctor as an educator rather than an authority figure. (Nurses traditionally have been delegated to do patient teaching simply due to their gender) (Warren 39).

“Teaching skills are hard won–requiring practice, experimentation, and sensitivity to audience. The medical model down-plays the difficulties of teaching well, tends to attribute failures of communication to patients and lets physicians who are poor teachers off the hook” (Warren 40).   

We should not keep trying to separate theory from nurturing. Nurturing needs to be valued monetarily and it should be incorporated into technical and theoretical education (Warren 36).

Sherwin suggests that the institution of medicine be transformed away from emergency treatments and concentrate on empowering people to help themselves stay healthy. She even suggests a nurse-patient model because nurses see their role as empowering and informing – not controlling. Nurses however, like mothers are limited by the fact that they themselves are oppressed (Sherwin 28, (Holmes & Purdy)).

The principle task is for feminists to develop a conceptual model to restrict the power involved in healing, by giving out specialized knowledge that will give people maximum control over their own health. To clarify how excessive dependence can be reduced, how caring can be offered without paternalism and how health care can become worthy of trust. The goal should be to spread information widely and foster self-help. Medical expertise should be seen as a social resource under the control of patients and those who care for them (Sherwin 28, (Holmes & Purdy)).

Instead of crisis management the main thrust should be – health empowerment. When counseling a family on saving a critically ill infant, one should keep in mind that, the mother will be the one doing the care, seldom with adequate support; not only should this lack of support should be included in the decision making process, but we should have supports available to make caring for the disabled child reasonable for the woman to do (Sherwin 94-95).

Patients don’t HAVE to all have the same condition to be able to help one another. Why couldn’t we have groups of patients who were in need of information come together; why couldn’t a patient with a terminal heart condition talk to a person with terminal cancer – they may indeed be able to give each other insight into how they can wrangle the system to get what they want in their medical care. How about a general information place for health care? A place that is non hierarchical, has no loyalties to doctors or hospitals, is just interested in helping patients to make their own informed decisions? That’s what I am envisioning myself doing. Why not be government subsidized? Could I be free with this type subsidy?

Feminists will press for change in status of women and children from breeder and possession, to valuing them. They will challenge the idea that having your wife produce a child with a man’s own genes is sufficient cause for their wives to undergo the physical and emotional assault IVF and genetic technology involve (Sherwin 135).

Conclusions

Doctors, because of their “power of legitimacy” in health care, could use their power to destroy patriarchal attitudes about women; they could dispel myths about racism, homophobia, and classism to begin to destroy oppression. Because the traditional medical model perpetuates oppression, we must develop different models in order to attain ethical acceptability (Sherwin 237-238).

A feminist ethics would expand health and the expertise involved with it. It would not dwell on the physiological, but would consider the social aspects of our lives that have profound effects on our health. It would bring the morality of oppression and its solutions into health care discourse. It would make clear that those in power are morally mandated to seek solutions to oppression. It would necessitate drastic changes in present health care policies. When oppression is considered in medical ethics, the authoritarian model in which the physician is the expert on all matters of health will shatter. A feminist ethics would recognize that experiential knowledge is vital to understanding how oppression effects health and how it can be reduced. Feminist ethics would require political along with moral understanding of health and health care (Sherwin 238-239).

A feminist model would produce social equality by empowering those who have been traditionally oppressed. It would limit the authoritarian scope of those who have gotten so used to being in control. The equalization of structures would foster higher standards of health and health care to those oppressed. It would hear those unheard voices and respond to their needs (Sherwin 239).

The medical model focuses on “cure” and that “curing” belongs to the providers. A feminist approach would ensure empowerment to the consumers of health care by giving them the information and the means to make life changes that would facilitate their health. The medical model is closed to alternative healing modes that increases the power of patients and diminishes medicine’s power over them. “A feminist model would be user-controlled and responsive to patient concerns” (Sherwin 239).

Such changes in our health care structures would direct our priorities to the necessities of healthy living and helping patients to obtain them, rather than waiting to address the damaging consequences. The democratization of the medical model may also lead to reduction in health care costs and be more effective at the same time. Most patients are much less interested (compared to providers) in crisis intervention and the use of high technology as solutions to their health care needs; most patients would prefer prevention (Sherwin 240).

Feminist ideals would seek to alleviate the maintenance of oppression in the health care system. It would attempt to provide fair distribution of health care resources and try to undermine the assumptions on which the rationale for oppression exists. Feminist alternatives are required for both ethics and health (Sherwin 240).

We must start with a democratization bioethics itself; medical ethics must recognize the value of incorporating diversity in its discourse and analysis. Bioethics is similar to other disciplines in that it is judged by the opinions of its participants. Let the moral analysis itself be moral by the inclusion of diverse voices and values in the attempt to develop solutions (Sherwin 240).    

It seems to me that, since women have bought into men’s moral theories it’s no wonder, they have been so guilt ridden when they somehow sense things are not right with the system, but feel, “who are they” to question the very core of things. Perhaps that’s why it has taken so long for women to evolve out of the guilt and accompanying loss of self esteem to even think about developing their own ethical theories that FIT in most people’s lives – not just those of women. Feminine ethics is involved in caring, but that was a way to deal with our oppressors – so we must use caution. Feminist ethicists ask when is caring ok and when is it best withheld?  Sherwin says we must consider justice AND caring (Sherwin 240).

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