Wolf may have chosen this selves. I3 Dresser identifies three themes from that move- strategy, however, because of page limitations and the ment-discontentment with contemporary health care, breadtli of topics she included. Purdy makes clear, however, that ommend age limits on health care access without consider- her definition does not include social infirmities, because ing that most elderly are women;9 death and dying issues their inclusion in a definition of health medicalizestoo much that ignore gender ramifications;10and definitions of health of life and makes physicians experts in matters that are that emphasize the absence of infirmities rather than the better dealt with through public debates that tap the knowl- state of positive weIl-being.
Both articles are full of information with attention to voices of disempowered groups, more about how women have been excluded from research and participatory democracy, and a demedicalization of aspects the harmful effects of that exclusion. For example, the re- noncompartmentalized interest in outcomes, not services. Because feminist bioethical literature is so diverse tuses take priority over the health of already living women. The subordination of the health interests of live women to unborn fetuses in research protocols for drug testing is further exposed by Faden, Kass, and McGraw, who show References that almost all the studies of women and H N were de- 1.
See, for example, KH. Rothenberg and E. Thomson, voted to issues of vertical transmission-primarily to fe- eds. Rothman, The Tentative Pregnancy: Prena- to the health of the infected women. This article examines tal Diagnosis and the Future of Motherhood New York: Viking, the painful history of the inordinately slow response of ; G. Stanworth, ed. Callahan, ed. HarvardUniversity Press, ; I?
Boling, ed. Though women der: Westview Press, ; R. Arditti et al. Holmes, ed. Holmes et al. Chadwick, ed. Sen and R. Snow, eds. Spallone and D. Steinberg, eds. York: Pergamon, Actually, Westview Press, ; M. Holmes and L. Purdy, eds. Asch and G. Sherwin, No Longer Patient: Feminist 9. Nelson and J. Dula and S. Goering, eds. White, ed. Todd,lnti- See, for example, D. See S. Bioethics: Beyond Purdy, supra note 11,at To assume, as does Wolf, that actively aiding versus passively withdrawing inevitably robs one of such dignity is to beg the question.
Likewise, Wolf seems to assume that a prescriptive model like amicalism obviates the need for PSA. She asserts without defense that "if a friend were to tell me that she wished to kill herself, I would not be lauded for giving her the tools" Wolf , What does it mean for a principle like "amicalism" that she takes that statement as given whereas I am able to imagine circumstances in which such "lauding" is appropriate? Can friends reasonably disagree about a course of treatment?
And isn't there a difference between knowing what a person would want in a certain set of circumstances and justifying acting on the knowledge? If there is a difference, then what criteria distinguish "amicalism" from what the law has termed "substituted judgment," where one determines as closely as possible the patient's wishes and acts on them? How is it different from a "best interests" standard, which clearly might conflict with substituted judgment? The normative stance I have ascribed to Wolf is nowhere more evident than in her discussion of the use of pain medication for the suffering and the ill.
In that context, she invokes Double Effect Doctrine DED --grounded in a now-seldom-invoked distinction between knowledge and intention and between active killing and passive letting die--to justify "giving pain relief and palliative care in doses that risk inducing respiratory depression and thereby hastening death" , Wolf urges better physician training in pain management, an uncontroversial recommendation 13 easily supported by PAS advocates; I would argue, however, that such recommendations do not get to the core of the issue. Setting aside the question whether all pain can be palliated one of Kevorkian's patients was a physician, himself an expert on pain therapies , Wolf's strategy wrongly presumes that pain is the only legitimate?
From the claim that most if not all pain is treatable, Wolf concludes that few patients would request euthanasia. But must untreatable pain be the only permissible reason for suicide? In the Netherlands, for example, pain is cited only as the second most common reason for people's requests for euthanasia, the most common being "dignity.
Further, patients in pain may prefer to die rather than to be "sedate[d] [in]to unconscious" Wolf , Thus, even with more training for physicians on appropriate end-of-life care, insurance payments tied to certain procedures, modifications in anti-addiction laws, incentives for hospice care, and so forth, some reasonable patients may prefer death. Nelson and Nelson insist that a theory of justice and resource allocation that does not incorporate gender is inevitably flawed, and they highlight as a case in point arguments about age-based rationing that ignore gender.
Given that women live longer than men, an age-based facially neutral rationing policy will disadvantage women. We can see the centrality of this concern with respect to euthanasia as well. But this transformed vision does not necessarily lead to the conclusions Wolf draws. For example, while it is true that women live longer than men, it is also true that women are the primary caretakers in families, both at beginning and end of life.
Wolf's emphasis here on the woman as patient mirrors feminist treatments of this and related subjects; the single-minded attention to woman-as-patient obscures the multiple positions and contexts in which women exist. What about women as the primary caretakers for the sick and the dying, including men? For example, when Wolf insists on context, she asks about the "family, social, economic, and medical supports she is or is not getting" , ; italics added. She does so to point to a failing in rights approaches that ignore such questions.
But note how here she assumes a female patient and a failed system of personal and social networks. Setting aside the improbability that such failures are true in each and every case of a request for euthanasia, isn't it women in formal and informal networks who will most likely bear the burden of care for such patients? If that is the case at least some of the time, we cannot assume unproblematically that PAS differentially burdens women. Indeed, the availability of PAS might ease the burden of some female caregivers.
Minimally, women's greater involvement in care for the ill and dying suggests that women may be well suited to serve as health care proxies and to participate in processes that involve "substituted judgment. Thus, a more complex understanding of PAS requires that we consider women's roles not only as patients but also as caregivers and providers. While Wolf's position neither entails nor requires the simplistic scenario I am criticizing, its focus on women in only one of many roles tends to push her view towards a narrow vision of what might constitute "care. Rights approaches tend to conflate "dignity" with the ability to express and act on whatever "choice" one makes.
Care approaches, on the other hand, might reject the very notion as overdetermined by patriarchal and liberal discourse; the danger here is that that normative stance soon becomes indistinguishable from nonfeminist defenses of paternalism, including moral paternalism. In contrast, a context-based feminism must assess a variety of factors, including constraints and options, material circumstances, and inter personal values. A fully developed elaboration of the notion of "dignity" would require much more analysis than this essay permits.
But if one can imagine circumstances in which a decision to die is "dignified," where death is preferable to one's current condition, then--at least at the level of individual morality--suicide would appear to be justified. If so, then assisting one in that project cannot be wrong even if not obligatory. Ironically, if death is, under some circumstances, a benefit, then one of the injustices women, people of color, and the socially and economically deprived suffer is that where PAS and euthanasia are a benefit, they are deprived of it.
Given that Wolf eschews absolutist arguments, it is reasonable to infer that she does not absolutely condemn suicide. For her, the real danger lies in any attempt to codify in law and policy the practice, particularly a third party's assistance; thus, in this context even if some individual's wish to die is genuine , paternalism is justified. Unless one posits an afterlife, a move I am unwilling to make, there seems no meaningful way to imagine the physician as enabling the dying patient to achieve greater future autonomy, either through assisted suicide or through sedating one to unconsciousness.
Wolf suggests in her application of paternalism that a difference inheres in the two practices, and that the latter maintains autonomy. I do not see that difference. Wolf's use of John Stuart Mill, who rejects selling oneself into slavery in his libertarian rejection of paternalism, is problematic for similar reasons. First, while scholars disagree on how to interpret that exception, Mill seems to imply that selling oneself into slavery is a kind of contradiction, that one enters into a contract one can never under any circumstances break. But Mill does defend suicide, though Wolf is correct to point to the often-confused distinction between what one may do and what one may require others to do.
As she puts it, "the negative right to be free of unwanted bodily invasion does not imply an affirmative right to obtain bodily invasion or assistance with bodily invasion for the purpose of ending your own life" Wolf , But Wolf seems to confuse what one may require a third party to do an "affirmative right" and what third parties are justified in doing.
Defenders of euthanasia, including Mill, need not insist on a more extreme position requiring third parties to accede to one's desires; rather, all that is claimed is that third parties may accede to those desires if they wish. Further, one could argue that the concept of rights, even as negative entitlements, is absurd without protections for those who facilitate the exercise of those rights; imagine, for example, the right to abortion without laws protecting the providers who agree to perform them.
These "fatal practices" are part of a broader social pattern and that pattern, for Wolf, should make us "extremely wary" , But her conclusion opts for far more than "wariness" even of the extreme variety. Is she right about that? That is, can laws be constructed that attend to context, that do not exacerbate existing inequality?
Taking seriously Wolf's warnings about the power of medical hegemony, we should be reluctant to permit any policy that might enhance that power and lead to greater abuse. The citizens of California, Washington, and most recently Michigan who rejected referenda legalizing PAS may have been expressing precisely that point of view. On the other hand, we cannot know if they would have been willing to permit the practice with stricter and clearer constraints.
Even separate from new statutes, creative legal modifications or reappropriations of our current system might be considered. For example, Wolf rejects prematurely, I believe Howard Brody's suggestion that "compassionate and competent medical practice" might operate as a defense in a criminal proceeding in Wolf , Such a policy suggests the seriousness of the action killing but its exceptional permissibility as analogous to, for example, a self-defense plea.
A "euthanasia defense" would not require new, possibly over- or under-inclusive legislation, but would allow prosecutors discretionary power over whether to try such cases; if tried, juries would decide the merits. Less permissive than Dutch policy, that legal strategy provides disincentives for careless decision-making or outright misconduct. Another strategy might permit physicians to prescribe lethal doses of drugs to terminally ill and suffering patients without allowing them directly to kill patients. Here what are traditionally known as "Good Samaritan" laws might be triggered to protect a provider who can demonstrate that she has carried out a patient's wish to die.
Other sorts of legal modifications deserve fuller moral and practical analysis than is possible here; 16 such modifications might cohere with the public's putative intuitions on PAS and serve to formalize and regularize practices now occurring. If, as poststructuralist feminists suggest, normative problems do not lend themselves to a priori solutions, then any policy involves risk and uncertainty.
Communication Error Occurred.
While Wolf's seems the more cautious approach, her position risks colluding with the very patriarchal power relations she seeks to undermine including the Catholic Church, the American Medical Association, and the Supreme Court , reminding us of the Foucauldian notion that everything is dangerous. Such a perspective suggests that any feminist vision that embraces or rejects a priori a specific practice must be reconsidered.
In producing discourse attentive to women's subjective experience, feminists are committed not only to a normative principle that subjugated knowledges ought to be treated seriously but also to a multiple rather than binary epistemology whose implications reach into ethical analysis. Theorists like Joan Tronto have examined cultural constructions of "autonomy" and "dependence" to demonstrate how the western tradition's valorization of autonomy has led to a devaluing of women's relational styles 17 as well as women's caring work.
Feminist critiques of autonomy are grounded in the simple but transformative realization that "actual people are not independent, and their decision-making does not always meet the norms that define rationality" Sherwin , Such an awareness forces a rethinking of assumptions about dependence and traditional notions of subjectivity that have posited a "healthy" self as autonomous and have pathologized implicitly or explicitly female subjectivity.
Acknowledging both human interdependence and the reality of dependence as inevitable in the human life narrative has transformative implications both for political ideology and for practice for example, welfare policy ; those implications reach far beyond a narrow focus on gender qua gender. Indeed, as feminists of color have insisted, for feminists to center gender as the feminist lens operates to occlude differences among women and to efface multiple aspects of identity.
While de-centering has not come without struggle, it does seem increasingly true that "as feminism grapples with the significance of gender differences, it also cultivates a heightened sensitivity to other kinds of differences" Nelson and Nelson , While the risk of solipsism must not be trivialized, underlining differences among women does not leave us in nihilism but rather enables us to articulate the situatedness of identity and the multiple memberships that mark us all.
While feminists cannot afford easily to abandon the category "woman," concepts like, for example, Gloria Anzaldua's "Borderlands" , offer extremely useful metaphors for understanding both shared aspects of identity and relevant differences. Further, once we abandon an illusory, exclusionary notion of "sisterhood," those differences are no longer perceived as a threat to political organizing and social transformation; indeed, moving the margins to the center hooks makes possible inclusive, progressive feminist praxis.
By virtue of being "in all cultures at the same time," the mestiza must operate in an unstable, pluralistic mode where privilege and oppression coexist. As Allison Weir notes: "Central to self-identity, then, is the capacity to sustain and in some sense reconcile multiple and often conflicting identities, and to understand, criticize, and reconcile multiple and often conflicting interpretations of those identities. Not to mention the capacity to live with and somehow reconcile all of the ambiguity and complexity of our lives that does not and never will readily lend itself to this identity work" Weir , And the "special vantage point" hooks , 15 of operating from the margins shapes consciousness and grounds epistemological advantage; indeed, in contrast to standard deficit models of oppression, an "oppositional world view" will "sustain us, aid us in our struggle.
This approach has obvious implications for the "subjects of knowledge" who have been the fictionalized and realistic fodder of ethical analysis and for knowledge itself. In embracing heterogeneity and multiplicity, this stance encourages a "proliferation of voices" and a subversion of monopolistic conceptions of knowledge replaced by a transformed vision of rationality that is nonhierarchical, contextual, and grounded in lived experience.
While still undertheorized, such insights offer important critical perspectives and make substantive contributions to analysis of PAS and euthanasia. Most obviously, the dominant tendency to characterize these issues as genderless collapses upon feminist scrutiny. In this context, feminist work exploring patriarchal ideology of sickness and dependence--an ideology that tends to feminize all patients--has implications for men and women, especially regarding end-of-life treatments.
Contextualized feminism's insistence on women's multiplicity and difference leads to a number of suggestive implications, most obvious that we must see patients not simply as gendered but also as having a class, a race, a sexual orientation, an age, and so forth. This recentering also suggests that some women in some contexts may have more in common with some men than with some other women, making it dangerous to generalize incautiously about Women.
There is, as feminist ethicists have pointed out, a sound moral principle embedded in the notion that we should give the interests of the disadvantaged special consideration. But this principle only points us in a direction; it does not, like some standard approaches to ethics, offer easy answers to thorny moral dilemmas. Further, how do we retain a meaningful notion of agency in the face of an attention to the material and cultural constraints that frame people's lives? Similarly, notions like "principled caring" or "autokoenony" can transform the ways we approach ethical problems and reframe ethical inquiry; but they do not provide answers to the cliched question "What ought I to do?
Perhaps we should remind ourselves of Aristotle's instruction that we not expect more of our subject than it can deliver. A blanket prohibition against euthanasia, while clear and easy to maintain, seems to me inconsistent with feminism's rejection of rigid absolutism and its embracing of context and ambiguity. My point here has not been unequivocally to defend one alternative over another but rather to suggest that Wolf's dismissal of euthanasia and PAS is premature. Regardless of what position one adopts, I would insist that a feminist perspective on this issue must put euthanasia and PAS in the context of a health care system that denies millions adequate care based on morally irrelevant criteria; to defend a modified policy allowing physician-assisted suicide is not to confuse that policy with a desperately needed solution to broader societal injustice.
Wolf notes in her essay's introduction that the most important aspect of her overall project is "to urge the necessity of feminist analysis" , of PAS and euthanasia, and that reasonable people may disagree on the moral rightness or wrongness of these practices.
I offer this response in that same spirit. I am grateful to Rick Momeyer and the three anonymous Hypatia reviewers for their helpful comments at various stages during the writing of this paper. My special thanks go to Angelique Davi for her emotional and editorial support, graciously given at a point in her life when she could ill afford the time. Wolf, Feminist Bioethics: Beyond Reproduction Page citations refer to the Wolf essay and are noted otherwise only when the context makes its referent unclear. For example, a U. Today poll revealed that 67 percent of Americans favored physician-assisted suicide for the terminally ill; 77 percent of Canadians polled agreed.
Yet voters have been reluctant to vote on this sentiment, as most state referenda to legalize physician-assisted suicide have been defeated. Strikingly, juries have been equally reluctant to convict agents like Quill and Kevorkian of any misdoing; Kevorkian's latest case involves active euthanasia rather than suicide and is clearly intended to push these limits. Mothers, often described in stereotypical terms relating to maternal care and nurturance, figure significantly in these scenarios. The stereotypes discursively function to defend the trustworthiness of the mother's substituted judgment.
I know of no cases in the euthanasia debate where race is alleged to be a factor. The fact that the earlier cases deal with withdrawal of treatment means that these cases are already class- and probably race-biased. Poor people and people of color are less likely to have private medical insurance, personal physicians, and access to private hospitals.
When critics of euthanasia including Wolf point to the vulnerability of such audiences in the face of the prospect of legalized euthanasia, they subtly ignore the reality that members of such marginalized groups are already the targets of--for lack of a better term--"passive"! For these reasons, issues like national health insurance and infant mortality loom larger as normative priorities. Finally, polls indicate for example, see Rosenbaum that the better educated and more well-off tend to favor PAS, and blacks 70 percent to 20 percent oppose it more often than whites 55 percent to 35 percent.
Thanks to one of my anonymous reviewers for pointing out the use of ethnic names to hint at identity.
Pence does emphasize Bouvia's depression and McAfee is described as "spoiled" and "demanding" , 57 ; but, though these labels are gender-stereotypical, he does not clarify whether, from his point of view, Bouvia's and McAfee's strategies for coping with disability and with the medical profession have anything to do with their genders.
This discursive distinction lends support to a later point I make about gendered perceptions of "quality of life" issues. I have yet to see any analysis of these gendered patterns. Remarkably, feminist treatments of bioethics tend to do the same. Susan Sherwin's No Longer Patient devotes at least a third of the book to ethical issues related to reproduction; though she has a chapter on paternalism, there is no mention of euthanasia or suicide and no listings in the index for those topics.
Examples are easy to find, so I'll mention only one: the fourth edition of Thomas Mappes and David DeGrazia's edited collection, Biomedical Ethics The publisher's marketing brochure notes that the new edition has an "extensively revised" General Introduction that includes "the ethics of care, and feminist ethics. In no way is this point meant to suggest that it is Wolf alone whose language reflects her normative inclinations. I reject any notion that implies an originary, innocent language and have no doubt that a closer examination of my text would expose my own presuppositions as well.
For example, note how on page 9 I refer to Quill's "helping" Diane to die; Wolf would obviously reject that innocuous-seeming verb. Wolf cites Quill's essay in her essay. Ian Hacking makes the provocative claim that suicide may be a cultural construction and not a "timeless option" , 85 as Jean Paul Sartre and others have suggested. Hacking points to the historicity of suicide--that it seems to be nonexistent in some cultures, and that where it exists it takes a variety of forms according to differing cultural ethos. This claim, if reasonable, suggests that labeling suicide either masculine or feminine--where now both sides of the equation are highly mutable terms--is misleading and dangerous.
Margaret Farley points out that at least 34 states have "pregnancy clauses" that invalidate women's living wills; while that issue is far too complex to take up in this essay, the existence of such restrictions offers yet another example of the ways women's agency is juridically contravened. This case is far more complex than can be fleshed out here. McAfee ultimately died of complications from two strokes; my point here is not meant to imply gender determinism but rather to suggest some of the ways a complex ideological practice like gender might function.
Though I am describing these recommendations as "uncontroversial," taking them seriously would be a significant step for the medical profession. Indeed, one study Saltus revealed that most cancer specialists did not receive any formal training in caring for dying patients, 40 percent of whom are diagnosed as clinically depressed and 20 percent of whom die in pain.
Bioethics - UBC Wiki
The class and cultural biases here are obvious. I rehearse this model not because I favor it but because I want to draw out some of its implications. Oregon's "Death with Dignity Act" comes close to such a policy. Further, "immunities" protect providers from criminal liability or professional disciplinary action if the provisions of the Act have been met. Finally, the Act makes clear that a provider's compliance is voluntary and not a legal or contractual obligation. Of course, none of these provisions meet Wolf's objections; nor do they reach opponents' predictions of an inevitable slippery slope.
One might, for example, consider viewing the person who commits an act of euthanasia as one who is civilly disobedient; that is, we can retain laws against euthanasia while recognizing that the family member or provider who assists in a suicide is not the typical lawbreaker and must not be treated as such. Many of the euthanasia trials on record seem to treat the "offender" in precisely this way without making the label explicit.
Guilty verdicts are rare and sentences, when given, are generally quite light. Such work is the philosophical offspring of Gilligan's work, though many theorists including Tronto reject the gender essentialism many theorists influenced by Gilligan for example, Nel Noddings have adopted. My discussion here cannot engage the wealth of materials devoted to the care debate. Rather, my concern is to underline shifts in thinking and practice that feminist interrogations stimulate.
Traditionally, philosophers have been eager to grant this claim with respect to women's decision-making. But in doing so they normalize men's modes of thinking and assume that men are independent. Psychoanalytically-oriented feminist thinkers like Dorothy Dinnerstein might assess such a maneuver as a pathological or at least dysfunctional response to fear of dependence connected psychically to fear of mothering and thereby leading to misogyny and fear of death.
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