Abstraction

The first concern that these feminist bioethicists raised was that of abstraction, and the view that ethical decision-making was achieved by adhering to universal or impartial rules, principles, or norms. Wolf and Tong were not alone in highlighting this issue: Helen Holmes, for instance, argued that abstraction led to gaps in bioethics; Margrit Shildrick pointed to the trend of universality in poststructuralist and postmodern theory; and John Arras discussed the importance of cases and narratives in bioethics.^{Footnote 7,Footnote 8,Footnote 9} In Wolf’s anthology, Susan Sherwin worried that patients were regarded with interchangeable sameness, and Mary Mahowald, that particular standpoints were being ignored.^{Footnote 10,Footnote 11} Others in the collection also touched on the issue: Dorothy Roberts noted that the discipline assumed a generic physician and patient, served by generic ethical principles; Rebecca Dresser, that it opted for generality over particularity; Janet Farrell Smith, that the physician regarded the patient as a generalized other and abided by norms predetermined by rational abstract deduction; and Hilde and James Lindemann Nelson, that such generality did not allow for acute perception.^{Footnote 12,Footnote 13,Footnote 14,Footnote 15} Taken together, the worry about abstraction in bioethics was significant.

The principlist method, which was prevalent in bioethics at the time, provides clear evidence of this inclination to abstraction and mirrors the approach of much post-Enlightenment moral philosophy (notably deontological and utilitarian thought).^{Footnote 16} The common feature here is an appeal to abstract rules or calculations to do ethics. In this regard, bioethics tends to be deductivist or top-down in approach.^{Footnote 17,Footnote 18} The effort is in seeking out the right sort of universal principles to adopt, but, when this is achieved, all that remains is to apply that rule in each instance.^{Footnote 19} There has been much critique of this view, including from inductivists, who prefer a bottom-up model.^{Footnote 20,Footnote 21} Some principlists too have expressed concern over a purely deductivist account, claiming that the principles were never intended to be so framed.^{Footnote 22}

The feminist critique joins its voice to these concerns, proposing that abstraction obscures factors that are relevant to moral judgment. Wolf, for instance, argues, “Universal moral rules or principles posited for the abstract, generic person erase that person’s gender (not to mention race, class, and other characteristics).”^{Footnote 23} She goes on to contend, “It is only when a situation is appreciated in its particulars that the full moral problem and plausible tools for its resolution appear.”^{Footnote 24} Similarly, Tong argues that truth and knowledge are not views from nowhere but are situated and partial.^{Footnote 25} She submits, “What I see is a function of who I am—a white, middle-class, well-educated, post-menopausal, Catholic, heterosexual, married academic and mother of two boys.”^{Footnote 26} Such features, feminists argue, are fundamental to accurate moral reasoning and should not be abstracted away. These, for instance, may affect a patient’s medical experiences or a doctor’s perception of a problem. Avoiding such detail (as the general approach does) suggests a reduced understanding or less appropriate solution in bioethics. This was an important element of the feminist critique.

Individualism

The second concern that feminist bioethicists raised was about over-individualism. Again, others—such as Renee Fox and Judith Swazey, Hyakudi Sakamoto, and Sherwin—also broached this issue.^{Footnote 27,Footnote 28,Footnote 29,Footnote 30} In Wolf’s collection too it was a recurring theme: Laura Purdy implied that taking the individual to be isolated from her context was a non-feminist approach to health; Farrell Smith expressed worries that decision-making in medicine was understood to be one person reflecting alone; Adrienne Asch and Gail Geller highlighted problems with the assumed autonomous, self-focused individual in genetics; and the Lindemann Nelsons argued that theories of justice for distributing healthcare viewed the individual in an atomistic way.^{Footnote 31,Footnote 32,Footnote 33,Footnote 34} Taken together, these works make clear that individualism was a common concern of feminism at the time.

This propensity for individualism emerged post-Nuremberg, with a growing emphasis on autonomy, and developed most rapidly in the United States, such that a liberal commitment to individual rights and freedoms became part of its fabric.^{Footnote 35} Autonomy, perhaps understandably given its historical origins, came to take precedence over the other principles,^{Footnote 36} promoting the individual’s capacity to choose and rejecting paternalism.

Though the desire to safeguard the individual is clearly well motivated and although various feminists hold differing ontologies, many feminist bioethicists were concerned with the type of agent and autonomy that emerged. They broadly critiqued the overly detached and self-sufficient construction of the individual, claiming that this was an unrealistic picture.^{Footnote 37,Footnote 38} Wolf, for example, argues, “Bioethics has embraced a liberal individualism with more vigor than it has embraced anything else,” and points out that this is unsettling because it depicts “the moral community as a set of atomistic and self-serving individuals.”^{Footnote 39} Consequently the default agent of bioethics is detached and self-regarding. Likewise, Tong contends, “Lurking within the deep structure of traditional ethics (and, I would add, traditional bioethics) is a creature known as the autonomous self, generally pictured as a biological male, intent on maximising his self-interest.”^{Footnote 40} Such a “self is entirely separable from others” and excessively self-focussed.^{Footnote 41} Further, the concept of autonomy itself has become intertwined with this kind of self, and “there has been a gradual alignment of autonomy with individualism.”^{Footnote 42} Autonomy has become synonymous with substantive detachment and independence. Both the agent and autonomy, then, are criticized for being highly individualistic notions. Although some feminist bioethicists wish to retain understandings of autonomy—as we shall discuss—concern about individualism was a primary theme of the critique.

Power

The third feminist concern that Wolf and Tong discussed was about privilege and power. This thread ran through most, if not all, of the chapters in Wolf’s anthology: Sherwin bemoaned the lack of focus on the oppressive aspects of the medical structure; Mahowald argued that women were subjugated in the medical establishment; Roberts emphasized the racial and social inequalities in the doctor-patient relationship; Dresser highlighted women’s frustration with the attitudes of medical professionals; Purdy drew attention to underlying biases in the judgment of women’s bodies; Farrell Smith noted the commanding nature of doctors’ speech; Vanessa Merton argued that women were unfairly excluded from research; Ruth Faden, Nancy Kass, and Deven McGraw contended that women’s healthcare needs often went unnoticed; and the Lindemann Nelsons noted the white, middle-class, male bias in healthcare distribution.^{Footnote 43,Footnote 44,Footnote 45,Footnote 46,Footnote 47,Footnote 48,Footnote 49,Footnote 50,Footnote 51}

The establishment—doctors, researchers, clergy, review boards, professional societies, and governmental bodies, for instance, all of whom are authority figures or institutions—have traditionally driven and shaped the agenda in bioethics.^{Footnote 52} The discipline, that is, has typically focused on issues raised by experts: “concerns presented not by patients and families but by professionals.”^{Footnote 53}

Feminists have been critical of this establishment-led approach, not because such groups do not raise significant ethical questions but because this perspective has obscured the power dynamics involved. The worry, as Wolf argues, is that in attending to the concerns of the establishment, “bioethics has stopped asking the big questions; instead of debating whether a technology . . . should be used at all, we end up debating merely how it should be used.”^{Footnote 54} As such, “bioethics may have lost its critical capacity” by becoming part of the problem, not only by failing to champion the kinds of issues that affect laypersons but, more importantly, by sidestepping harder discussions of structural change.^{Footnote 55} To address this, Tong contends that feminist bioethicists ask the “so called woman question” to uncover ways in which women, as a marginalized group, are systematically underserved in bioethics.^{Footnote 56} They ask, for example, why women’s specific health concerns are not taken seriously and explore the latent, perhaps even blatant, gender biases of those who diagnose them. Likewise, they question why authorities medicalize reproduction by focusing on discrete stages or components, thereby disengaging from the overall process, and how the social institution of motherhood silences women’s conflicted lived experiences.^{Footnote 57,Footnote 58} Such examples suggest that there are power imbalances within bioethics that are often unrecognized and seldom resisted or challenged. The feminist critique, then, is that bioethics regulates the present system but fails to tackle its wider flaws. It serves the interests of those in power because it responds to their concerns, while it fails to protect the most vulnerable because it stops short of the more pressing task of structural critique.

In Sum

These three criticisms provide a taste of some of the problems identified by feminist bioethics almost two decades ago. For those making them, these critiques were often seen as revolutionary, in that they demanded a wholesale overhaul or “reconstruction” of many of the underlying ideas in bioethics.^{Footnote 59} Although such radical change has not (yet) happened, some of these critiques have influenced the theory and practice of mainstream bioethics, though perhaps not quite in the way, or to the extent, these theorists hoped, as we shall see.

The Relational Self

First, we consider the feminist claim that the self should be regarded as social. Drawing on advances in feminist ethics more broadly, many feminist bioethicists have placed greater significance on our connectedness and have argued for relational selves.^{Footnote 60}

In so doing, such bioethicists have directly challenged some of the gold standards of bioethics. Though important, practices like consent and confidentiality, for example, have been critiqued for being individualistic concepts, and so too has the principle of autonomy.^{Footnote 61} Rather than autonomy (Greek for “self” and “rule”), which is associated with separate and independent selves, feminist bioethicists, building on the work of feminist philosophers, have promoted “autokoenomy” (Greek for “self” and “community”), which recognizes selves in perpetual relation to others.^{Footnote 62,Footnote 63,Footnote 64}

Many contemporary bioethicists have adopted such approaches. Indeed, the language of a relational self and autokoenomy is explicit in several recent works: for instance, in discussions of intergenerational interdependence and justice;^{Footnote 65,Footnote 66} vulnerability in research,^{Footnote 67} disability,^{Footnote 68} and bio-ethics;^{Footnote 69} and constrained agency in psychiatry.^{Footnote 70,Footnote 71} In all these areas, the relational model recognizes—as the norm—the patient’s interconnections with others: that patients are rarely in the position of the highly rational decision-maker, that single treatment decisions cannot be isolated from the patient’s life and context, and that patients are seldom fully autonomous or not autonomous.

In such ways, the relational self and autokoenomy have been developed and applied extensively, if not always dominantly, in key bioethics debates. They can be seen as attempts to address the problem of individualism, and also of abstraction, in bioethics as identified by earlier feminist scholars.

Particularity

A second area in which feminist critiques have had some effect is in particularity. Feminists have advocated seeking detail and actual experience by, for example, recognizing context-specific vulnerability,^{Footnote 72,Footnote 73} discerning differences in situations, and advocating circumstance-appropriate protections.^{Footnote 74}

Perhaps the clearest evidence of the move to particularity can be seen in nursing ethics.^{Footnote 75,Footnote 76} Rather than the general patient, it is the particular patient, in all her specificity, that is the focus. Achieving this shift in emphasis is difficult work: it requires being receptive to the patient’s unique and holistic physical, psychological, and emotional needs, and it necessitates that the patient receive care appropriately too.^{Footnote 77} These insights are already part of nursing ethics to some degree, but, as the spate of recent high-profile scandals shows,^{Footnote 78} there is some way to go yet in turning feminist bioethics theory into practice. Still, the hope is that, where concrete detail, good judgment, and compassion are valued, care is likely to be better practiced, and as such nursing ethics can be regarded as a particular embodiment of the concerns of feminist bioethicists to reject abstraction. There is, however, as we explore in the final section, some tension between this type of particularism and decisive feminist intervention in debates.

Justice

The third response is justice. Feminist bioethics, as Tong argues, attempts to grapple with issues of justice that arise in the microcosmic (the ethics of care) and the macrocosmic (the ethics of power).^{Footnote 79} It recognizes that there are likely to be all sorts of power imbalances: for example, between a particular man and woman and in a context of wider gender-subordinating norms, respectively. Activities in bioethics cannot be divorced from these structural frameworks of power.

Examples of uncovering and addressing injustice can be identified in some recent literature. There has been work on using reproductive technology to help women made infertile by inadequate sexual health provision,^{Footnote 80} efforts to champion abortion rights when such rights are in danger of being surreptitiously overridden,^{Footnote 81} explorations into medicalization,^{Footnote 82,Footnote 83} discussions on mental health prejudice within the medical system,^{Footnote 84,Footnote 85} and calls to consider the absolutely, not just relatively, vulnerable.^{Footnote 86,Footnote 87}

This trend is also evident in the field of public health ethics, in which the focus is less on fixing the health of individuals and more on securing the health of the collective.^{Footnote 88} This includes proactively preventing or mitigating the threat of infectious diseases, promoting healthy lifestyles in populations, and protecting the health of the most marginalized groups.^{Footnote 89,Footnote 90} It illustrates the connectedness and vulnerability not just of persons but of the human species and highlights systemic problems that impede healthy societies across the globe. This approach, then, has links with the ethos of feminist bioethics as interested in structural injustice wherever it occurs. However, a population focus also stands somewhat in tension with the rejection of abstraction, because the emphasis is on the general public rather than particular relationships.

In Sum

Taken together, whether directly or indirectly, advances in these three areas—developing the relational self and relational autonomy, focusing on particularity, and insisting that context and structure are relevant to justice—take seriously the feminist critique of bioethics. In various ways, these shifts interconnect: regarding persons as relational suggests understanding the social conditions in which relationships are immersed, and discerning particularity implies looking at the specific detail of the relationship, while human vulnerability indicates our interdependencies and fragility in light of oppressive systems and structures. They also potentially conflict: too much particularity can obscure matters of justice and can collapse back into individualism. Balancing these insights is an ongoing concern for feminist bioethicists.