The following appeared in Volume 98, Number 2 (Spring, 1999) of the APA Newsletters

This interdisciplinary book might appear at first glance to be an edited anthology. Instead, it is a collaborative work of loosely related articles, each authored by a member or members of "The Feminist Health Care Ethics Research Network," of which Susan Sherwin is the coordinator. The Network is comprised of Canadian-based philosophers, doctors of family medicine and obstetrics/gynecology, a sociologist, an anthropologist, a geneticist, a historian, and a scholar of law and social work.

This book will be of interest to bioethics scholars, to anyone in the field of medicine (especially those with a particular interest in women’s issues), and to women’s studies scholars. Various articles, in isolation, could easily be used for teaching both undergraduate and graduate courses as the articles do not greatly depend on one another. It is 321 pages long with an index and lengthy list of references useful for further reading as necessary.

The book is feminist in that gender is taken as an important feature in the way that individuals experience the world. Furthermore, the authors recognize that women are oppressed in society, i.e., they have less power and authority, and find themselves in subordinate economic, political, legal and social positions, in comparison with their male counterparts. The authors take oppression to be morally wrong, and are committed to ending existing oppression.

The task of writing this collection of articles was approached with the belief that a society’s practice of medicine has tremendous potential to either heighten or reduce existing oppression. The authors contend that medicine perpetuates some aspects of women’s oppression while it reduces others. The social and economic conditions of women’s lives are relevant factors for women’s health, and this theme is touched upon throughout the collection. These important details of oppression should be prominently addressed by bioethics, and by medicine.

Two main themes in the book are 1) autonomy and agency, and 2) criticism of modern health care structures’ tendency to ignore the importance of social conditions, and instead focus attention on individuals as the center for health promoting practices and procedures.

The authors struggled with the question of how to acknowledge women’s decision making under an oppressive system that limits the options available to them. Autonomy and agency are related concepts that are sometimes confused with one another. Agency is demonstrated when women make decisions and choices about their health care; however, this decision making and choosing does not constitute autonomy. Autonomy, according to how it is usually understood, does not address the ways in which oppression limits the range of choices available, and affects the weight assigned to each option by individuals. Agency is used to reflect informed choice from a limited range of options. Autonomy, on the other hand, ought to reflect a more comprehensive notion of freedom, i.e., not only uncoerced choice, but more importantly insure that the circumstances that structure the choice are free of oppression. This kind of full autonomy requires that we remove oppressive barriers which structure options in such a way as to further perpetuate oppression. Susan Sherwin calls this kind of autonomy "relational autonomy," and labels it a feminist alternative. It is particularly useful in elucidating the apparent paradox of women who are seen as freely choosing options which reinforce oppression.

A very good example to which Sherwin alludes concerns risky and expensive cosmetic surgeries. Many women may believe that they have no real choice in this matter. They are well aware that their chance for success (Sherwin says, in love and work) is tied to how well they fit an externally defined beauty standard. So, the choice is made to have the face-lift, tummy-tuck, etc., and agency is exercised. However, autonomy is not reflected here, at least not in Sherwin’s sense. The particular woman’s sense of herself, her range of opportunities, have been constructed in such a way as to leave her little choice but to pursue any available options toward the goal of beauty. Traditional views of autonomy are inadequate here because they fail to capture this important dimension. "By focusing only on the moment of medical decision making, traditional views fail to examine how specific decisions are embedded within a complex set of relations and policies that constrain (or, ideally, promote) an individual’s ability to exercise autonomy with respect to any particular choice."(p.32)

Insofar as such choices adapt to the existing structure of oppression, the description of autonomy fails to capture the essence of the problem. Accepting the prevailing social arrangements as given helps to perpetuate the oppression itself. Thus autonomy in its traditional sense seems inadequate. Sherwin advocates a more politically sensitive standard of autonomy that ought to make visible the way in which oppression affects a person’s choices. This way attention focuses on removing the conditions of oppression.

Sherwin calls her notion of autonomy "relational" although she says it could also be described as "contextualized" autonomy, or "socially situated" autonomy. She notes that her use of the term "relational" is not to be confused with Carol Gilligan’s and other feminist authors’ use of the word. Gilligan, et. al., refer to a narrower set of interpersonal relations, while Sherwin refers to a larger range of both personal and public human relations.

Although Sherwin finds the traditional notion of autonomy inadequate and proposes her own version, it is important to note that she places a strong value on autonomy on the whole. Her notion is a stronger, or expanded, notion, that she believes will better serve feminist concerns by increasing the scope of personal control for women. She recognizes the important need to protect autonomy in the health care setting.

I liked Sherwin’s chapter the best of all the articles in the book, and its placement as first, after the introductory chapter, is ideal. This chapter is the most useful to the widest variety of interests.

Margaret Lock, an anthropologist, explains how Western conceptions of health have become centered on the individual. In her article, "Situating Women in the Politics of Health," Lock explains that "healthism" is the shifting of responsibility for health from the experts to the individual. Political moves to foster this sense of individual responsibility have coincided with a rising public awareness that individuals largely lack control over their polluted environments, the quality of food available to them, etc. Lock argues that greater attention ought to be paid to the responsibility of society for the health of the individuals.

Abby Lippman, a geneticist, warns of "geneticization," an emerging ideology that directs attention away from the structural changes necessary for promoting true health. Geneticization is the tendency to distinguish people from one another on the basis of their genes, and is combined with normative demands on people to identify genetic susceptibilities and take action to ward off the occurrence of the illness. It fosters the idea of personal "genetic responsibility." Women who are expected to undergo pre-natal testing are particular targets of geneticization (and they are expected to ward off "the occurrence of individuals" with certain illness). The ideology of geneticization obscures the reality that economic and social conditions, e.g., wealth distribution, housing arrangements, etc. (areas in which women have historically had little input) are primary determinants of health. By obscuring the importance of these conditions, this ideology perpetuates the status quo. Lippman thinks that changes must be made in the way women experience life, if we want to improve women’s health status.

Margaret Lock’s "Anomalous Women and Political Strategies for Aging Societies," is a cross-cultural study of North American and Japanese approaches to women of middle age. North America’s medicalization of menopause is contrasted with Japan’s lack of such a view. Lock argues that the body is seen in a cultural context and is subject to various cultural interpretations, and so wants to do away with the prevalent notion of a universalist biology.

The final article includes a rather disappointing postscript. Francoise Baylis, Jocelyn Downie, and Susan Sherwin illustrate the Network’s interactions with another group, toward the goal of drafting a common set of ethics guidelines to cover all government sponsored research involving human subject-participants. This article shows how Sherwin’s notion of relational autonomy was translated into specific recommendations for the ethics guidelines. The postscript indicates that in the end, few, if any, of the Network’s recommendations were adopted.