Reviewed by Anne Donchin
Indiana University, Indianapolis

Mary Mahowald’s Genes, Women, Equality serves as a much needed antidote to the welter of volumes that have recently appeared on the human genome project and genetic practices relating to it. Few have explored the impact of the "new" genetics on women and other marginalized groups so thoroughly. It is encyclopedic in scope ranging over a broad array of issues including clinical and behavioral genetics, sex selection techniques, genetic ties to children, disabilities, genetic testing and screening, abortion, discrimination in health insurance and employment, and human cloning. Readers are likely to dip into it at many places following their particular interest. The wealth of fresh references included shows a firm command of the literature making it particularly useful as a sourcebook to facilitate further inquiry into issues at the intersection of ethics and genetics. My focus in this review will concentrate on the book’s relevance to feminist scholarship.

For some readers, the chapters on genetic testing are likely to arouse the keenest interest. They include a comprehensive summary of arguments against objections to genetic intervention that rely on a supposed threat to personal identity. Along the way she makes evocative points about the ways genetic enhancement might threaten social equality unless the technology were to become available to all, thereby losing its point! Through an exploration of specific cases she explores arguments for and against complying
with requests for testing and makes public policy recommendations that have not before been seriously entertained in the mainstream literature. For instance, she proposes that policy-making bodies involve in their membership representatives of affected groups (such as including breast cancer survivors in the formation of policies related to breast cancer treatment). She is often at her best in drawing insights from her personal observation of medical situations, or calling attention to gender issues often neglected by authors who ignore the impact of caregiving responsibilities on the caregiver, or stressing the impact of economic policies on marginalized groups (such as Blacks with sickle cell disease). Particularly sensitive to the nuances of gender inequities is her thought-provoking discussion of women and alcoholism, especially her exploration of issues bearing on continued pregnancy in the face of evidence of fetal disability.

Mahowald’s principal aim is to explore within the context of genetic issues differences among individuals and groups that bear on equal treatment and a just distribution of burdens and benefits. She seeks to articulate a feminist conception of justice that is responsive to demands for both individual liberty and social equality. She shows very clearly how moral analysis of genetic issues and formulation of genetic policy is deficient if it fails to take systematic account of the differential impact of genetic practices on women and other marginalized groups. The many detailed examples provided show how women bear an unfair share of social and familial burdens, particularly by virtue of their reproductive role and greater traditional involvement in caregiving. Of particular interest for feminist perspectives on genetic issues is her emphasis on the importance of biological sex differences, a point often ignored by feminist scholars who emphasize a social constructionist account of gender. In her discussion of sex-linked genetic anomalies as well as pregnancy, childbirth, and lactation, she points to biological differences that often disadvantage women in both their family relations and workplace activities—noting, for instance, how women are often regarded as "small men" in the workplace. Her remarks point to the need for social policies that will reduce the inequitable impact of biology on the distribution of social resources.

Mahowald identifies her own point of view as an "egalitarian feminist standpoint" which she equates with the socialist feminist tradition. She rejects that term, however, because of its pejorative connotations. After summarizing Nancy Hartsock’s conception of a standpoint, she opts for a looser reading than has been common within that tradition. First, she uses the term to characterize various versions of feminism rather than a self-conscious epistemic standpoint arising out of the material conditions of particular social groups. Second, she extends the conception beyond application to oppressed social groups to individual experiences because, as she explains, "individual women are not adequately definable as a group or even as members of multiple groups because of the uniqueness of each one’s context and relationships" (21). So understood, the term refers not to a situated group but to each individual woman. Though she occasionally refers to the impact of socialization on women, she seldom finds good reason to discourage individual women from pursuing the high-tech reproductive and genetic interventions they request.

This tendency is particularly evident in discussion of genetic testing where she considers possible reasons for withholding tests from those requesting them. She does discuss both cost-related reasons for refusing a request for genetic testing and reasons based on preservation of traditional family values (which she critiques), but she rarely turns her attention to the political background that shapes the genetics industry or the power and influence of commercial laboratories that rush inaccurate tests to market and benefit financially by exaggerating the advantages of testing. Her egalitarian feminist standpoint is invoked even to grant qualified support to embryo cloning and to sanction in vitro fertilization because a woman wants to fulfill her husband’s desire for genetically related offspring. Feminist readers, particularly, are likely to take exception to such acquiescence to a spouse’s preferences and suspect either internalized medical norms or a propensity to give excessive weight to individual interests. Pressures on women to undergo personal risk out of deference to a spouse are likely to intensify as the array of high-tech interventions continues to escalate.

As the book progresses her usage of the term "standpoint" oscillates even more. For example, even genetic and environmental accounts of human behavior are characterized as standpoints. Such broad usage is confusing. One wonders how any particular standpoint qualifies as feminist, say, how libertarian feminists differ from libertarian nonfeminists or how nonfeminist versions of an egalitarian bioethics (e.g., Robert Veatch) differ from LeRoy Walters’ position—which she identifies as feminist in her discussion of genetic enhancement (Veatch 1997, Walters and Palmer 1997). It is often unclear why a given course of action (such as referring a retarded woman seeking sterilization reversal to adoption experts) would accord with an egalitarian feminist standpoint. Argument supporting conclusions is often vague, sometimes overlooked. One suspects that the notion of an egalitarian feminist standpoint has been so attenuated that it cannot serve as a reliable guide in making morally relevant discriminations.

Readers may also wonder how Mahowald’s frequent appeal to a standard lexicon of moral principles—autonomy, beneficence, nonmaleficence—fits into an egalitarian feminist standpoint. Discussions of autonomy, for instance, often seem to import an individualistic bias. She implies that increase in women’s autonomy could only come about by decreasing men’s or that expanding benefits for some would necessarily intensify others’ burdens. Such individualistic assumptions are at odds with many of the book’s other claims about relational interdependence. In a discussion of autonomy and physician-assisted suicide she asserts that "if assisted suicide is a legal right for those who are currently able, it should also be a right of those who are disabled" (150). Why? Should personal autonomy always trump other moral values? In another context she insists that an egalitarian version of feminism must insist on government measures to enable disabled women to implement their choices (145). Is this a call for a redistribution of resources that bear on autonomous pursuits? This claim too calls for substantially more qualification than is offered here.

Given the book’s initial agenda, I had hoped for a more comprehensive integration of the epistemic positions of marginalized groups within the book’s content. Instead, she seems to be diverted by an overly evenhanded approach that detracts from the book’s central message. In contrast to frequent feminist practice, she never speaks of women or any other group as "oppressed." Instead, all groups denied a fair share of social goods are referred to as "nondominant." Potential conflict between individual and group values comes up only in connection with genetic intervention. Her use of the concept "feminist" is so broad it includes even "Feminists for Life" (a right wing organization that coopts feminist rhetoric to advance an antithetical agenda).

Despite her effort to include multiple feminist viewpoints, the many feminists who have voiced serious reservations about the rapid escalation of technological interventions surrounding pregnancy aren’t given a hearing. The book is written principally from the perspective of a clinical bioethicist whose focus is concentrated on the particular issues that have arisen within the health delivery system. In the end, her egalitarian feminist standpoint seems to come down to a case for distributing presently available health care resources in a manner more responsive to individual needs and desires irrespective of gender, ethnicity, or race. Some readers might wish for more attention to how this particular selection of resources is generated or why more women-friendly options never make it to the clinical level. Others, who question the need to reconfigure bioethical theory to address the particular conditions that affect women are unlikely to be converted.

Fortunately, the limitations I mention are outweighed by the wealth of sources provided and the powerful case made against gender blindness. This book should surely find its way into courses in advanced bioethics, allied health professions, and genetic counseling. Students would benefit from her careful readings of particular cases and facets of clinical situations. For other readers the book provides a good jumping off point for future efforts to refine or reject traditional moral approaches to bioethics that slight the differential impact of the new genetics on the privileged and the powerless.

Works Cited

Veatch, Robert M. 1997. Medical Ethics, 2nd ed. Boston: Jones and Bartlett.