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Reworking Autonomy: Toward a Feminist Perspective

Published online by Cambridge University Press:  29 July 2009

Anne Donchin
Anne Donchin
Affiliation:
associate professor of philosophy at Indiana University, Indianapolis. She teaches and writes primarily in bioethics and feminist theory, preferably at their intersection
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Extract

The principled approach to theory building that has been a conspicuous mark of bioethical theory for the past generation has in recent years fallen under considerable critical scrutiny. Although some critics have confined themselves to reordering the dominant principles, others have rejected a principled approach entirely and turned to alternative paradigms. Prominent among critics are antiprin-ciplists, who want to jettison the principle-based approach altogether and adopt a casuistic (case-specific) model, and communitarians, who favor an eclectic model combining features of both the casuistic model and a modified principled approach. Particularly conspicuous in virtually all such critiques is their challenge to the preeminence of the principle of autonomy. Critical barbs have been aimed not only at theories favoring a hierarchical ordering of moral principles that give first place to autonomy, but also at those that include autonomy among a set of ostensibly coequal principles. Though these critics have performed a valued function by displacing bioethical principles from their Olympian perch beyond actual decision-making contexts, some version of the principle of autonomy may, nonetheless, be well worth defending but for very different reasons than those put forward by its supporters.

Type
Special Section: Beyond Autonomy
Information
Cambridge Quarterly of Healthcare Ethics , Volume 4 , Issue 1 , Winter 1995 , pp. 44 - 55
Copyright
Copyright © Cambridge University Press 1995

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References

1. Engelhardt, HT Jr. The Foundations of Bioethics. New York: Oxford University Press, 1986.Google Scholar This is the strategy employed by him in his book. Engelhardt locates himself within the mainstream of bioethicists in supporting the primacy of personal autonomy. He is also committed to advancing medical ethical theory by integrating the prevailing conception of autonomy into a more inclusive ethical framework.

2. Beauchamp, TL, Childress, JF. Principles of Biomedical Ethics. New York: Oxford University Press, 1994.Google Scholar This approach pervades the several editions of Beauchamp and Childress' work, including their most recent edition which acknowledges some of the criticisms I discuss here and briefly responds to critical objections. The authors include respect for autonomy among four moral principles including nonmaleficence, beneficence, and justice. Personal autonomy for them involves “personal rule of the self that is free from both controlling interferences by others and from personal limitations that prevent meaningful choice” (p. 121). They seek to cool objections to their formulation by giving respect for autonomy only prima facie standing. It can be overridden by competing moral considerations (p. 126).

3. Sherwin, S. No Longer Patient: Feminist Ethics and Health Care. Philadelphia: Temple University Press, 1992.Google Scholar Particularly noteworthy is this ground-breaking book. See also: Feminist and medical ethics: two different approaches to contextual ethics. In: Holmes, HB, Purdy, LM, eds. Feminist Perspectives in Medical Ethics, Bloomington and Indianapolis: Indiana University Press, 1992.Google Scholar Hers is the first full-scale treatment of biomedical ethics from a feminist perspective. In it Sherwin attempts to offer an eclectic feminist perspective that is agnostic to ongoing debates within feminist theory. Because her orientation is primarily pragmatic, her interest in theory is directed toward practice. Insofar as possible, I have tried to adhere to this policy in this paper. I depart from it only where I believe that theoretical disagreement has important implications for practice.

4. There is a growing literature addressing such discriminatory practices and the nonscientific assumptions underlying them. On the presumption that women are less competent than men to make their own decisions about life prolonging treatment, see: Miles, SH, August, A. Courts, gender, and the right to die. In: Law, Medicine and Health Care, 1990;8(2):85–93.CrossRefGoogle Scholar On the supposition that women's symptoms are more likely than men's to be attributable to psychiatric causes, see the report: The American Medical Association Council on Ethical and Judicial Affairs Gender disparities in clinical decision making. Journal of the American Medical Association 1991;266:559–62CrossRefGoogle Scholar and the sources cited there. Clinical judgments are also problematic insofar as they are based on research studies that have systematically excluded women. For a discussion of literature addressing this issue see: Ickovics, JR, Epel, ES. Women's health research: policy and practice. IRB 1993;15:4.CrossRefGoogle ScholarPubMed

5. The objections I raise here are taken from a number of writers not all of whom share the same perspective. I have in mind particularly Daniel Callahan whose article: Minimalist ethics. Hastings Center Report, 1981; 11(6)Google Scholar together with Leon Kass's Regarding the end of medicine and the pursuit of health. The Public Interest 1975;40Google Scholar initiated the ongoing debate. In that article and in many subsequent pieces Callahan has argued that a “minimalist ethic” has become the prevalent norm of bioethics. He argues for a reconsideration of other substantive values that stress communal cohesion and traditional continuities. Kass has also attempted to give shape to a version of a medical ethic that gives greater prominence to the authority of traditional institutions, weighing personal autonomy as a subordinate consideration.

6. Critics of Freudian views about women include Nancy Chodorow, Jean Baker Miller, and Lillian Rubin. The most widely known critic of Kohlberg's views is, of course, Carol Gilligan. In providing this terse summary I have disregarded some major differences among feminists, particularly regarding the sources of gender difference in shaping personal identity—whether gender specific identities are in some sense natural and inborn or are wholly dependent on historical and cultural conventions and circumstances.

7. I cite Beauchamp and Childress here since their view is so widely promulgated in bioethics courses and so influential in the bioethics literature. The criticisms I offer here are extendable to other theoretical accounts as well (Engelhardt and Norman Daniels, for instance).

8. See note 2. Beauchamp, Childress. 1994:124–5.Google Scholar

9. Within Engelhardt's bioethical theory, autonomy is inadequate to ground any substantive duties. It provides only as a minimal formal notion of morality that imposes on providers only a negative moral obligation to refrain from unauthorized actions involving others. To establish positive duties Engelhardt invokes a second principle grounded in autonomy, beneficence, which gives to moral life its content. Because he is persuaded that a secular pluralistic society can provide no general principle of beneficence to which all can appeal, rules of benevolence are necessarily particular, grounded in contracts among parties joined together in particular communities with distinctive views of the good life.

10. See note 2. Beauchamp, Childress. 1994:124.Google Scholar

11. Veatch's, article has been widely reprinted in bioethics texts. See, for instance, Ethical Issues in Modern Medicine, 3rd ed.Arras, J, Rhoden, N, eds. Mountain View, California: May field, 1989.Google Scholar

12. See note 3. Sherwin 1992. I am indebted to Susan Sherwin for this point although the use to which I put it is my own.

13. Response to Adrienne, Rich's eloquent work, Of Women Born, New York: Norton, 1976Google Scholar testifies to the widespread dissatisfaction of women with the medical options open to them.

14. For an intriguing account of the politics of breast cancer see Susan, Ferraro's article in The New York Times Magazine. 1993; 08 15.Google Scholar

15. Marilyn, Friedman develops this general critique in considerably greater detail in What are Friends For? Ithaca, New York: Cornell University Press, 1993.Google Scholar

16. Some qualifications need to be noted here. First, by the time prospective parents realize that they are unlikely to have a child without infertility intervention, their peak reproductive years have probably past. Adoption agency policies favor younger parents. So infertile people seeking adoption will need to explore other routes, “open” adoption or transracial or transcultural adoption. Because none of these options replicate the “natural-looking” family that many of those seeking fertility services desire, few are likely to explore these alternatives until all else has failed, some by virtue of their own preferences, others because of family and community pressures.

17. See note 3. Sherwin, . 1992:156, 257.Google Scholar

18. Lasker, J, Borg, S. In Search of Parenthood. Boston: Beacon Press, 1987 (particularly p. 145).Google Scholar

19. Fisher, S. The Patient's Best Interest: Women and the Politics of Medical Decisions. New Brunswick, New Jersey: Rutgers University Press, 1986.Google Scholar

20. Price, F. The management of uncertainty in obstetric practice: ultrasonography, in vitro fertilisation and embryo transfer, In: McNeil, M, Varcoe, I, Yearley, S, eds. The New Reproductive Technologies. London: Macmillan, 1990:142.Google Scholar

21. Morgan, R, Lee, D. Blackstone's Guide to the Human Fertilisation and Embryology Act 1990. London: Blackstone Press, 1991.Google Scholar

22. I have in mind, particularly, restrictions on women's reproductive freedom, such as forced caesar-eans, incarceration of pregnant women suspected of drug use, and denial of access to abortion services.

23. This taxonomy has a long ancestry that has been recaptured in some recent feminist discussions of autonomy. See, particularly, Thomas, Hill's discussion of it in Women and Moral Theory, Kittay, E, Meyers, D, eds. Totowa, New Jersey: Rowman and Littlefied, 1987Google Scholar and Lois, McNay's in her Foucault and Feminism, Boston: Northeastern University Press, 1992.Google Scholar

24. Hibbard, JH, Pope, CR. Another look at sex differences in the use of medical care: illness orientations and the type of morbidities for which services are used. Womens Health, 1986:11;21–36.CrossRefGoogle Scholar

25. I borrow this language from Seyla, Benhabib. Situating the Self. New York: Routledge, 1992:158–9.Google Scholar

26. A number of authors have considered the risks to women in giving themselves uncritically to the needs and preferences of significant others, both children and partners. For a superb analysis of these risks see Sandra, Bartky's Feeding egos and tending wounds in her collection of essays, Femininity and Domination. New York: Routledge, 1990.Google Scholar

27. Virginia Held offers this proposal in her Rights and Goods, New York: Free Press, 1984Google Scholar and elaborates on it in her recent book, Feminist Morality, Chicago: University of Chicago Press, 1993.Google Scholar Her perceptive insightful rethinking of the modern moral tradition in the light of contemporary women's experiences has contributed immeasurably to my own philosophical development.

28. Friedman, M. What are Friends For? Ithaca, New York: Cornell University Press, 1993Google Scholar and also her Autonomy in social context. In: Sterba, J, Creighton, P, eds. Freedom, Equality, and Social Change. Lewiston, New York: Edwin Mellen, 1989.Google Scholar See also: Raymond, J. A Passion for Friends. Boston: Beacon Press, 1986.Google Scholar

29. Meyers, D. Self, Society, and Personal Choice. New York: Columbia University Press, 1989,Google Scholar and her comment Personal autonomy or the deconstructed subject? A Reply to Hekman. Hypatia 1992;7(1).Google Scholar Although none of the thinkers I mention here address healthcare contexts directly, their views have much relevance for bioethical theory. I am much indebted to all of them for central insights that inform my own views here.

30. Burt, R. Taking Care of Strangers. New York: Free Press, 1979.Google Scholar