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HYPATL SPECIAL ISSUE Feminist Ethics & Medicine

SUMMER 1989

A Journalof FeministPhilosophy

HYPATI SPECIAL ISSUE FeministEthics& Medicine

editedby Helen BequaertHolmes Universityof Massachusetts

VOL.4, NO. 2 SUMMER 1989

A Journalof FeministPhilosophy

Hypatia

Hypatia (Hy-pay-sha)was an Egyptianwoman philosopher,mathematician, and astronomerwho lived in Alexandriafrom her birth in about 370 A.D. until her death in 415. She was the leaderof the NeoplatonicSchool in Alexandria and was famous as an eloquent and inspiring teacher. The journal Hypatiais namedin honorof this foresister.Her nameremindsus that although many of us are the first women philosophersin our schools, we are not, after all, the first in history. Hypatiahas its roots in the Society for Women in Philosophy,manyof whose membershave for yearsenvisioned a regularpublicationdevoted to feminist philosophy.Hypadais the realizationof that vision;it is intendedto encourage and communicatemany differentkinds of feminist philosophy.

Hypatia(ISSN 0887-5367) is owned by Hypatia, Inc., a tax exempt corporation, and publishedby IndianaUniversity Press, which assumeno responsibility for statementsexpressedby authors.Hypatiais publishedthree times a year. Subscriptionrates for 1989-90 are: Institutions$40/year; Individuals, $20/year. Foreignsubscribersadd $10/yr surfacepost. Single copies are $20 (institutions) and $10 (individuals). A discount is availableon bulk orders for classroomuse or bookstoresales. to the JournalsManager, Addressall subscriptionsand businesscorrespondence IndianaUniversity Press, 10th and MortonStreets, Bloomington, IN 47405. Notice of nonreceipt of an issue must be sent within fourweeks afterreceipt of subsequentissue. Pleasenotify the Pressof any change in address;the Post Office does not forwardthird class mail. Manuscriptsand other editorialcorrespondence should be addressed to: Editor, Hypatia, Southern Illinois University at Edwardsville,Edwardsville,IL 62026-1437. Hypatiais indexed in the AlternativePressIndex,Studieson WomenAbstracts, Women'sStudiesAbstracts,The Philosopher's Index, and in The Philosopher's Indexdatabase,file 57 of DIALOG. Copyright? 1989 by Hypatia, Inc. All rights reserved. Hypatiawas published in 1983, 1984, and 1985 as special annual issues of Forum. Women'sStudiesInternational

Hypatia

EDITOR MargaretA. Simons, SouthernIllinoisUniversityat Edwardsville ASSISTANT EDITOR Kim Bishop MaryEllen Blackston Xiufen Lu GUEST EDITORFOR SPECIALISSUE Helen BequaertHolmes, Universityof Massachusetts ASSOCIATE EDITOR FOR SPECIALISSUE LauraM. Purdy,HamiltonCollege MANUSCRIPT EDITOR Faye Love COPY EDITOR Toni Oplt BOOK REVIEWEDITOR JeffnerAllen, State Universityof New York,Binghamton ASSOCIATE EDITORS Azizah al-Hibri (Editor 1982-84), New York SandraBartky, Universityof Illinois,Chicago Ann Garry,Califoria State University,Los Angeles SandraHarding, Universityof Delaware Helen Longino, MillsCollege Donna Semiak-Catudal,Randolph-Macon College Joyce Trebilcot, WashingtonUniversity ADVISORY BOARD ElizabethBeardsley,TempleUniversity GertrudeEzorsky,BrooklynCollegeof City Universityof New York ElizabethFlower, Universityof Pennsylvania Virginia Held, GraduateCenterof City Universityof New York Graciella Hierro, MexicoCity Instituteof Technology JudithJarvisThompson, Massachusetts Genevieve Lloyd, Universityof New SouthWales, Sydney,Australia MaryMothersill, BarnardCollege MerrileeSalmon, Universityof Pittsburgh Anita Silvers, San FranciscoState University EDITORIALBOARD KathrynPyne Addelson, SmithCollege JacquelineAnderson, Olive HarveyCollege,Chicago

Hypatia

Asoka Bandarage,BrandeisUniversity Sharon Bishop, CaliforniaState University,LosAngeles Judith Butler,JohnsHopkinsUniversity Claudia Card, Universityof Wisconsin,Madison LorraineCode, YorkUniversity Blanche Curry, ShawCollege ElizabethEames, SouthernIllinoisUniversityat Carbondale Ann Ferguson,Universityof Massachusetts,Amherst Jane Flax, HowardUniversity Nancy Fraser,NorthwesternUniversity Carol Gould, Steven'sInstituteof Technology Susan Griffin, Berkeley,California Donna Haraway,Universityof California,SantaCruz Nancy Hartsock, Universityof Washington Hilda Hein, Collegeof the Holy Cross Sarah Lucia Hoagland, NortheasternIllinoisUniversity Helen BequaertHolmes, Universityof Massachusetts Alison Jaggar,Universityof Cincinnati ElizabethJaneway,New York Evelyn Fox Keller, NortheasternUniversity Carolyn Korsmeyer,State Universityof New York,Buffalo Rhoda Kotzin, MichiganState University LyndaLange, Universityof Alberta Linda LopezMcAlister, Universityof SouthFlorida MariaLugones, CarletonCollege PatriciaMann, City Collegeof New York KathrynMorgan, Universityof Toronto Janice Moulton, SmithCollege Andree Nichola-McLaughlin,MedgarEvarsCollege LindaNicholson, State Universityof New York,Albany Susan Ray Peterson, New York Connie Crank Price, TuskegeeInstitute LauraM. Purdy,HamiltonCollege Sara Ruddick, New Schoolof SocialResearch Betty Safford,CaliforniaState University,Fullerton Naomi Scheman, Universityof Minnesota Ofelia Schutte, Universityof Flordia,Gainesville Ruth Schwarz, Universityof Pennsylvania ElizabethV. Spelman, SmithCollege JacquelineM. Thomason, Los Angeles Nancy Tuana, Universityof Texas at Dallas KarenWarren, MacalesterCollege Caroline Whitbeck, Massachusetts Instituteof Technology Iris Young, WorcesterPolytechnicInstitute JacquelineZita, Universityof Minnesota

Contents

1 Helen BequaertHolmes A Call to Heal Medicine 9 LauraM. Purdy FeministsHealingEthics 15 MargaretUrban Walker MoralUnderstandings: Alternative"Epistemology" for a FeministEthics 29 Paul Lauritzen A FeministEthicand the New RomanticismMotheringas a Modelof MoralRelations 45 Betty A. Sichel Ethicsof Caringand the Institutional EthicsCommittee 57 Susan Sherwin FeministandMedicalEthics:Two DifferentApproaches to ContextualEthics 73 Virginia L. Warren FeministDirectionsin MedicalEthics 88 Sara T. Fry The Roleof Caringin a Theoryof NursingEthics 104 Susan Wendell Towarda FeministTheoryof Disability 125 Sue V. Rosser Re-visioningClinicalResearchGenderand the Ethicsof Experimental Design 140 Don Marquis An EthicalProblemConcerningRecentTherapeutic Researchon BreastCancer 156 Helen BequaertHolmes Can ClinicalResearchBe Both 'Ethical'and 'Scientific'? A CommentaryInspiredby Rosserand Marquis

Review Essays 169 Nora K. Bell WhatSettingLimitsMay Mean: A FeministCritiqueof CaUahan'sSetting Limits 179 Christine Overall The Politicsof Communities: A Reviewof Engelhardt's The Foundationsof Bioethics Book Reviews 186 Shirley Wagner Women and MoralTheory,editedby Eva FederKittay& DianaT. Meyers 190 Ellen Dorsch In the Patient's Best Interest by Sue Fisher 193 KathrynPyne Addelson The Regulation of Sexuality by CaroleJoffe The Tentative Pregnancyby BarbaraKatzRothman 198 Notes on Contributors 201 Announcements 207 SubmissionGuidelines

A Call to Heal Medicine HELENBEQUAERTHOLMES

Authorsin thisspecialHypatiaissueseemcalledto healethics,medicine,andthe newfield- medicalethics.Afterexplainingwhyfeministsshouldfeel thiscalling,I as responsesto questions:1. Whyhasn'tmedicalethics groupauthors'contributions alreadyhealedmedicine?2. Whatrole should'caring'play?3. Must we firstheal science?4. Are we callinghealtha virtue?5. Whyhaven'tthemanymedicalethics bookshelped?6. How do our sistersin sociologysupportus?

A middle-class,suburbanmother paces the floor cuddlingher sick toddler who screams from the pain of earache. Should she call the pediatrician? Since her insurancepremiumsare paid, the resourcesof modem medicine can be hers: an arsenalof antibiotics, an assemblageof devices and equipment, an inventory of tests - all in the local hospital. Why then does she hesitate? Will the pediatrician,busy with "the really serious"cases, simply prescribean antibiotic over the phone? Will she be told to bringthe child to the office in the stormyweather?Then - as happenedlast time - will her child catch what's "goingaround?"Will she be askedto "waitand see" as if she isn't alreadydoing that? Then, she meditatesabout the effects of childhood antibiotics and tonsillectomies on some of her friends- would "wait and see" indeed be better for her child? A poor, inner city mother paces the floor cuddlingher sick toddler who screamsfrom the pain of earache. Should she make her way to the clinic at the inner city teaching hospital?She knows friendswho were indeed healed when they visited that clinic. But will some unskilledintern use her child to practicea tonsillectomyor eardrumpuncture?She knows she'd have to wait on a snowy corer for the bus, to endurethe clinic's waiting room while trying to comforther child, and, finally, to beara patronizingfive minuteswith the professional.Would borrowinga heateror some blanketsfroma neighbor be better for her child? Consider other women: the lesbian buddy of an AIDS victim deciding whether to call the ambulancefor her friend, whose care has become too complicatedfor his circle of loving, supportivefriends. Or the sixty-year-old caringfor her mother with Alzheimers,exhaustedfrom the physicalcare duties, who learnsthat at last a bed is availablein a nursinghome. Or the drug addictwho wants to breakher habit by attendingthe local methadoneclinic, Hypatiavol. 4, no. 2 (Summer1989)? by HelenBequaertHolmes

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but knows that then she'll be requiredto reveal her sexual contacts. Or the pregnant teenager who fears the scolding she'll get at Planned Parenthood when she appearsto requestanother abortion.1 "I go because I must," is often the choice made. Using a utilitariancalculus, a woman often decides that the benefits of going for medical care may outweigh the risks. She may fear not going, may hope that pain can be controlled. When a loved one is involved, some generalprinciplesmay unconsciously inform her decision, something like: medicine is based on science, which in turn is based on truth, which can solve physicalproblems.I would be wrong if I didn't give my loved one this chance. In sum, what do we have, in the richestnation of the world, in the nation with the most sophisticatedmedical technology? Is the malaise of modem medicine in largepartcausedby social conditions, especiallythe faultyorganizationof the health care system?In these everydayexamples- not the crisis cases found in medical ethics case books or blazonedacrossfront pagesof the WashingtonPost- we find ordinarywomen, ordinarywomen by the tens of thousands,who confrontas "personal"their own bits of the larger"political" questions of medical ethics. How should medicalresourcesbe distributedequitably?How can "care"be given in any "care-giving"professionthat has such a tremendouspower imbalance between care-giver and receiver? When are medical technologies truly life-saving, and when are they given simply because they exist, or because the hospital needs to recoup equipmentcosts via third-partypayment, or because an intern needs to practice?Can health promotionof the public ever take precedenceover personalautonomyand privacy?What is a "good" death and where should it take place? Note the common theme in the internalquestioningof the women above. Surely if a friendwould say to any of them, "Go to Dr. X's office - they really care about you there," much indecisionwould vanish. I claim that when someone is deeply distressedabout the health of a loved one, the help most wanted is true caring (empathy, a listening ear, concern about comfort and pain, scrupulousassessmentof risks/benefits,etc.) - caring combined with knowledgeabout diagnosisand treatment, of course. Can curingbe severed from caring? WHY BRINGIN FEMINISTS?

Here, for medicine, I pilferfromVirginiaWoolf's statementaboutscience: Medicine, "it would seem, is not sexless;she is a man, a father, and infected too" (Woolf 1938, 139). I sense that the feminist philosopherswho have contributedto this issue are concernedaboutthis infection and that they feel called to be healers. They are kindheartedand compassionatecritics. Some may believe they owe their health (perhapseven their lives) to the thauma-

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turgyof modem medicine, such as the 'right'antibiotic, a well-runintensive care nursery,or an appropriatelyused diagnostictest or device. Also, some feel compromisedor inconsistentwhen they earn their breadteaching ethics simply as it has been taught over the decades. I see three reasonswhy feministsshouldfeel called to heal medicine. In the 1980s most feminists have become champions for other oppressedgroups, having turned away from an earlier, ratherself-centeredmission. Sick and disabledpeople are oppressedin our society;those who are also poor, female, gay, and/or elderly are further oppressed. As membersof the globally oppressedmajority,we must use what I call "epistemicempathy"2towardoppression and offer other oppressedgroupsour help and insights - in both theory and practice. A second reasonfor feministsto be concernedis that women do morethan 90 percentof hands-onsick care:feeding, bathing, cleaningup (vomit, feces, urine, mucus, blood), providing comfort, raising morale. Any infection of the health care system also toxicates the care-givers. A thirdreasonwhy we ought to try to "dis-infect"medicine is that we may have an epistemicprivilegein "caring."If our health caresystemregularlyincorporatedtrue caringabout other human beings and genuine feelings of interdependence,many problemsmight vanish. Caringmay be stereotypically assignedto women; it may ghettoize women in the down-sideof powerrelationships,but it cannot be thrownout if it is vital to the healingof medicine. A FEMINIST PHARMACOPOEIA

I have collected into six categoriesthe questions raisedby the would-be healersof medicine who have contributedto this issue. Let us considereach. 1. Whyhasn'tthenewfieldof medicalethics,concernedas it is abouttherightsand wrongsof medicalpractice,alreadyhealedmedicine?Or, put anotherway, have aspectsof the malestreammedical ethics pharmacopoeiaactuallyobstructed the healing of the discipline? Virginia Warren points out two metaproblemswith medical ethics: the questionsselected and the processused. In her opinion these aresexist. Inappropriatequestions(which may be an importantfactorin the failureof medical ethics to find solutionsto the health carecrisis) includeones that revolve aroundcompetition for power or status or have no validity for those not in the dominantculture. Warrenurgesus to substituteother categoriesof questions. One such categoryis questionsabout"housekeeping"issuesinsteadof crisis issues. Glamorouscases make the headlines, but housekeepingissuesare the ones that concern everyone, day in and day out, in health care work. One housekeepingquestion is, "Howshouldwe fosterthe conditionswhich make

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informedconsent possible?"to contrastwith a crisisquestion, "Wasinformed consent obtained from the patient before this treatment?" As for processof discussingethical dilemmas,Warrenis sharplycritical of the "EthicsGame"in which opponentsargueto win, to provethe superiority of their theory over another's. What I dub her "new games"suggestionsinclude having discussantsconstruct theory from life experience and work on the actual relationshipsbetween each other. Susan Sherwin'sanalysisbegins by praisingthe field of medical ethics for its sensitivityto the powerimbalancebetween doctorand patient, and for developing awayfrom strict utilitarianand deontologicalreasoning.She commends several male authorswho favor consideringcontext when struggling with an ethical dilemma. But then Sherwin points out a very seriousdefect, the desperateneed in medicalethics forpoliticalanalysis.Formedicalethics simplyacceptsthe institution of medicine. The fact that medical ethics, in turn, has itself been accepted almost everywhere in medicine as an appropriateenterpriseis evidence that it seldom rocks boats. Indeed, it helps that institution by legitimating norms. Another issue is the use of universalprinciplesin medicaland other applied ethics areas. Most of our authorssee this use as a sourceof oppression.Warren and MargaretWalkerurgestrict avoidanceof the "universalist/impersonalist tradition." According to Walker, we need to "challenge 'principled' moralstances . . . where these are surrogatesfor, or defensesagainstresponsiveness in actual relationships."And she remindsus, "The rhetoricof universalityhas been entirely compatible. . . with the most complete (and often intentional) exclusion of women as moralagentsfrom ... loftily universal constructs." LauraPurdyand Sherwintake a moretemperedview. Purdyarguesthat we need principles- not necessarilytraditionalprinciples- to guideour thinking and provideconsistency. She hopes that feministswill set up as universalizablethose principlesimportantto us, to permeateall ethics. "Whatwe do not want is another 'special interest'ethics that can be ignored." Sherwinurgesus to maintaina certain level of generalizationin a feminist analysis.As a specific example she takes the new techniquesfor circumventing infertility. Here the conventional focus is alreadystronglycontext-specific: each individual should choose what fits her situation. A feminist, however, should worrymore about the dangersinherent in the ever-increasing medical control over women'slives. Since most interferencein women's reproductionin the past has not been physicallyand emotionallyto women's benefit, the expanding dependence of women on male skills and authority should be a crucial concern. I believe that all our authorswouldagreethat no single theory, or no single strategy, is adequate for settling every kind of ethical question. Sherwin

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states, "The importantconstant is that we mustalwaysdecide these questions within the wider political context of. . . our generalfeminist objectives of eliminating oppressionin all its forms." 2. Whatpreciseroleshould'caring'playin a feministprescription for thehealingof medicine?Our first book review, Shirley Wagner's analysis of Kittay and Meyers'sWomenand Moral Theory(1987), points out strengthsand weaknesses of the first stronglyfeminist, stronglyphilosophical,edited collection on the place of caring, compassion,and responsivenessin feministmoraltheory. In her essayWalkerprovidesvaluableannotationboth to the extensive literaturevalorizingmaternalparadigms/nurturant responsivenessand to the almost-as-extensiveliteraturethat questionswhether"women'smoralityisn't a familiarghetto ratherthan a liberatedspace."Walkerthen deriveselements from a too-simplisticnotion of 'caring'to form the basis of the "alternative epistemologyof moralunderstanding"that she advocates:attention, contextual and narrativeappreciation,and communication. Authors Paul Lauritzen,Betty Sichel, and Sara Fryare strongactivist advocates of 'caring'in appliedethics. Lauritzenurgesus to stripcaringfrom its dependence on biologicallyrelated experiencesto make it availableto men and to women who are not mothers. Caringneeds to be made nonexclusive, he claims, to help move us "towarda morecompassionateand less violent society." He quotes Ehrenreichand English, "The human values that women were assignedto preserve[must]expandout of the confines of privatelife and become the organizingprinciplesof society" (Ehrenreichand English 1978, 324). Fromher experienceon an ethics committee, Sichel firstdescribeshow institutional ethics committees can use caring in resolving ethical dilemmas, then arguesfor their doing so. Fromher experienceas a nurse, Fryarguesfor caring as the foundationalvalue for nursingethics. In building her case she describesthe advocacy of caring in the writingsof nursesGadow, Watson, and Griffin;she discusseshow Noddings'sworkcan applyto nursing,and she shows that two male ethicists (Pellegrinoand Frankena)have each deviated somewhat from the mainstream,in that they include caring as an integral part of their theories. 3. If moder medicineis basedon science,butscience(d la VirginiaWoolf)is infected,mustwe firstcurescience?Sue Rosserand Don Marquisquell any complacency on this issue. Drawingon her long experience critiquingscience, Rosserdocumentsthe sexism in clinical experimentation- a strange,paradoxical, worst-of-all-worlds historyof both failing to considergenderas a variable and usingwomen unethicallyas guineapigs. She describessome hopeful signs of re-vision and urgesstrongfeminist input into the design and implementation of clinical experiments.

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Marquisgives a case study analysisof clinical trialson breastcancer therapy, concluding that a study that violated the rights of (many) women will neverthelessbenefit all those who get breastcancer in the future.We are left to ponder (and we must ponder) whether we want to sanction such experiments. Is there any other way that good dataon curinghumandiseasescan be obtained? 4. If we healmedicineso thatit can betterfulfillITS missionof healing,can we do so withoutsettingup healthand theperfectlyfunctioningbodyas virtues?Or put another way, how can we avoid unwittinglyfurtheroppressingsick and disabled people? Wendell's essay reveals the dubiousassumptionsunderlyingmuch of our currenttheorizingabouthealth care. Manyof our authorsarecriticalof medicine as an institution and of the institutionalizationof medical ethics. Implicit in such criticismsis the assumptionthat medicine and ethics arenot restoringhealth to enough people in a fairway, that their activities may actually impedeattaininghealth. But there is no criticismof healthitselfas a value or virtue and no questioningof the venerationof the physicallyperfectbody. Wendell shows us that mainstreammedicine and society marginalizepeople whose illnesses cannot be cured, whose bodies cannot be restoredto perfect shape. We design society so that only those with perfectbodiescan function easily and then discriminateagainstand blame those who function with difficulty. Can we value and work for health without these consequences? 5. Whyhasn'ttherecentplethoraof medicalethicsbooks(texts, casebooks,singleissue books,proceedings of conferences)helpedto healmedicine?Nora Bell and Christine Overall each look at a specific sexist aspect of a recent maleauthoredbook; their analysessuggestanswersto this question. Overall shows the danger to women in the notion of 'communities' in Englehardt'sThe Foundationsof Bioethics(1986), and Bell, the dangerof setting age limits on health care in Callahan'sSettingLimits(1987). Here we break with Hypatiaprecedent:normallyonly feminist books are reviewed, and review essaysconsideronly groupsof books. But now we want to emphasizean importantmessage,a call to action, for feministmedicalethicists. Influentialbooks from this bright new field are appearingby the dozen. Unfortunately,most of them (authoredby malesor nonfeministwomen) are implicitly sexist, perhapsoften unwittinglyso. Such books will confirmand furtherembedsexism in medicine and ethics. We need investigative sensitivity, like Bell's and Overall's, to expose this subtle sexism. 6. How can our sistersin medicalsociologyhelpus healmedicine?Three books reviewed here describe studies "in the trenches" on specific aspects of women's health: Fisher'sstudy of doctor/patientinteractions in gynecology clinics (reviewedby Ellen Dorsch);Joffe'swork with abortionclinic person-

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nel; and Rothman'sresearchon patientsand counselorsin genetic counseling (both reviewed by KathrynAddelson). These books document specific unbalancedpowerrelationshipsin health care provisionand the lack of control by women patients. They presenta more ambivalentpictureof femalenurses and counselors.In some caseswomen health careworkershave been assertive in providingbetter service to, and a more caringenvironmentfor, patients. In other cases, women have been powerfulreinforcersof institutionalmedicine and championsof the physicallyperfect body. As armchairtheorists, we need studies such as these. Empiricalinformation about exactly how sexism and power imbalances are manifested challenges our theories. Thus this issue of Hypatiaends by pulling us out of our armchairs,out of our ivorytowers.Here is a call for action to all ourreaders.3

NOTES 1. I do not wish to give the mistakenimpressionthat all women are waryof the health care systemand pondertheir own personalbits of these questionswheneverthey or their loved ones areconfrontedwith illness. Women (and men) mayfall into other categories.One, the devotee, has faith in medicine as in a god; such iatrophilesnever hesitate to approacha medical practitioner. A second, the iatroholic, is addictedto one or another medical speciality:examplesare the personwho never missesthe weekly visit to the psychiatristand follows him or her fromcity to city; another, the in-vitro-fertilizationpatient who comes back again and againfor treatment after every failure. 2. Oppressedpeople have epistemic'privilege'by their "immediateknowledgeof everydaylife underoppression"(Narayan1988, 36). However, when I speakof white, middle-class,healthy women understandingthe oppressionof the sick and disabled,the word'privilege'seems to keep its conventional meaning. Therefore, I use 'epistemicempathy'instead, to mean that there are aspectsof oppressionof the sick that are part of the knowledgeof all healthy women. 3. I am gratefulto Siobhan Craigand Leslie Morrisfor their assistancein esential office work duringthe preparationof this issue. REFERENCES

Callahan, Daniel. 1987. Settinglimits.New York:Simon & Schuster. Ehrenreich,Barbaraand DeirdreEnglish. 1979. Forherowngood.New York: Anchor/Doubleday. Engelhardt,H. Tristram. 1986. The foundationsof bioethics.New York:Oxford. Fisher, Sue. 1986. In thepatient'sbestinterest.New Brunswick,NJ: Rutgers University Press. Joffe, Carole. 1986. Theregulationof sexuality.Philadelphia:Temple University Press. Kittay, Eva Federand Diana T. Meyers,eds. 1987. Womenandmoraltheory. Totowa, NJ: Rowan & Littlefield.

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Narayan, Uma. 1988. Working together acrossdifference:Some considerations on emotions and political practice. Hypatia3(2):31-47. Rothman, BarbaraKatz. 1987. The tentativepregnancy.New York:Viking Penguin. Woolf, Virginia. 1938. Threeguineas.London:Harcourt,Brace,Jovanovich.

FeministsHealing Ethics LAURA M. PURDY

renaissance.Traditionaltheories The field of ethicsis enjoyinga much-needed under and approaches are appropriately coming fire, althoughnot everynew idea will standtime'stest. Feministthinkingsuggeststhatwe at leastemphasizetheimportanceof womenandtheirinterests,focuson issuesspeciallyaffectingwomen,rethinkfundamentalassumptions,incorporate feministinsightsand conclusions from otherareas,andbe consistentwithrespectto ourconcernsaboutequalitybypaying attentionto raceand class.

It's an exciting time to be in ethics. The need for moral awarenesshas never been greater. On one hand, we face the 'sleazefactor' of dishonesty that has infested government lately. On the other, we are being ceaselessly assaultedby new technologies (in vitro fertilization,for instance), problems (like AIDS), and possibilities(such as the separationof biologicaland social parenting). Attempts to addressthese developmentsrangefrom Presidential Commissionsto ethics codes for government officials, from lead articles in Time and Ms. to general education requirementsat elite colleges. Meanwhile, scholarshipflourishes,continuing its reboundfromthe legacyof positivism. Feministshave been drawn, I suspect, in disproportionatenumbersto the field known as "appliedethics." For one thing, it has provideda haven for analyzingparticularcases with an eye to women'shitherto ignoredinterests. Foranother, it has allowedus to do moreconcretework, workthat has immediate prospectsof improvingwomen's lives. In the last few years,however, we have been venturinginto moretheoretical territory,and there has been an extraordinaryexplosion of imaginative new ideas. Among them are persuasivecriticismsof widely acceptedassumptions and new models of human interaction. Yet philosophershave not quite recoveredfrom the onslaught of relativism, and there is reason to worryabout where this new researchis leading. Thus, for example, a lot of us who have been in the trenchesteaching ethics are having doubts about the usefulnessof theory altogether. As we are all acutely aware, there are several moral theories. Their conclusions about a given case are often incompatible;even where conclusions coincide, justification diverges. We are thereforecompelled to pick only one theory if we Hypatiavol. 4, no. 2 (Summer1989) ? by LauraM. Purdy

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wish to be consistent. But which to choose, and why?Complicatingthe picturefurtheris the obscurity,and even inconsistency,of some moraltheorists, so that radicallydifferentinterpretationsof any given theorymaybe possible. Interpretationonce chosen, we may discoverthat there is, even so, no guarantee of help with a particularproblemwe wish to address.So although we still march our students through theory, its link with moralproblemsseems ever more tenuous. It is tempting to fault our students:they are just not sophisticatedenough to graspthe essentials. The issueswe face in our own researchbelie this conclusion, however. Most of us adopt a stable of principles,arrangedneatly in our preferredpecking order. But it is hard to have much confidence in any particularranking, and, as VirginiaWarren1suggests,the thrill is gone. Besides, many of us are noticing that attemptingto resolve concrete problems bringsus nose to nose with difficultiesfor which the standardtheories have no wisdom. What kind of a situation are we dealingwith? How is it most appropriatelydescribed,and why?Who is to count in the moraldeliberations, and why? What are the most relevant facts, and what are the criteria for choosing them? As we grapple with such matters, the question of which moral principle should prevail may recede almost to the vanishing point. MargaretWalkereloquently encouragesus to acknowledgestill more such "suppleattentiveness"to the nuancesof particularsituations,an attitudeone might be tempted to regardas a prerequisitefor moral thinking, but which could better be viewed as integralto it. A greatdeal of workon this aspect of moral thinking clearly awaits us. Once beyond this stage, what then? Recent feminist work in ethics suggests that 'caring'will help: if we care, it will be obvious what matters,what to do. There is much to be said for this view. Many, perhapsmost, situations calling for moral decision-makinginvolve choosing between our own selfish desiresand others'welfare. Should a doctor lie to cover up negligence or suggest unnecessarysurgeryto make an extra buck? Should we invest in SDI when AIDS patients languish without care? Everybodyknows the answers: the question is whether we care enough about others to do the right thing. But not every problemcan be resolvedin this appealingway. What about situationswhere peoples' legitimate interestsconflict? Caringwill not automatically tell us which of our desires count as good reasonsfor discounting another'sinterest. May I reasonablyargueagainstsocial policy that places the burdenof caringfor the elderlyor sick upon my shoulders?Reliance on caring to decide conjuresup caricaturesof altruismwhere we are alwaysexpected to subordinateour own good to that of others. This approachmight work if everybodydid it, but in the meantimefor feministsto embraceit is just business as usual:we perpetuateour own subordination. Nor will caring necessarilyshow us how to resolve moral tensions in the lives of others. How shall we, as a society, allocate scarceresourcesbetween

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young and old? Caring will compel us to consider the kinds of communication, compromise,and concern about long-termeffectsevident in Amy'sresolution of the Heinz case. It mayhelp us rule out practicesthat belittle or ignore suffering.But it may also narrowour vision to exclude awarenessof the broaderkinds of social and political context rightlyemphasizedby Sherwin. Caring may lead us to focus on particularcases. Concern for particularsis an admirableantidote to the lifeless, overly broadstrokesto which we have been so often subjectedby moralphilosophers.But I think that we must beware of any correspondingtendency to devalue principleexcessively. Is our instinct (and is it only that?) for consistency-for principlesby which to measureour choices-merely a graduate-schoolartifact,or the productof two thousandyearsof 'masculine'philosophizing?'Situationethics' never caught on, and for good reason: it providedno criterion for judgingthe quality of moral decision-making.Are we in dangerof falling into the same trap? Even those who are skeptical about principles use them. For instance, there seems to be something of an emergingconsensusabout characteristics of distinctivelyfeministmoralthinking. Among them areattention to particular cases, to relationships,to responsibility,to context. These may or may not be traditionalmoralprinciples,but they are principlesnonetheless:they guide our thinking and provide consistency. Some, eager for a warrantto deny our values, would refuseto recognizetheir correspondingprinciples:are we going to collaboratewith them? Without principles,we cannot consistentlypressthe most basicclaimsmotivating moraltheories. Thus valueslike caringaredefensibleagainstpossible alternativesonly if we conceive of ethics as a social institution whose chief function should be to justlypromotethe well-beingof all. Furthermore,only this kind of basic moralassumptionsafeguardsus fromthe naturalisticfallacy and equips us to wend our way with some art throughthe moral labyrinth. Consistencycan also be used as a bludgeon,to lumpsuperficiallylike cases together, obscuringmorallyrelevant distinctions. The right responseto this tendencyis not to chuckconsistency,but to patientlyshowhow crudelyit cuts. I think caprice is the only alternativeto that critically importantform of consistency, universalizability.You may have an abortion,I maynot: what is the differencebetween our two cases? Surely, we do not want to rule such questionsout of order. Moreover, it would be misconceivedto supposethat the concept of universalizabilitydetermineshow narrowlyto draw distinctions or what their content should be. The kind of close attention to detail, circumstanceand interest we think appropriateto good ethics is not incompatible with universalizability.On the contrary, if we can show why these characteristicsare important, universalizabilityshould compel every moral thinker to heed them. This point is central. Never will we have a decent society without good people; but good people still need guidelines.One of our chief aims as moral

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philosophersshould be to create justifiable formal and materialprinciples that, as Lauritzenemphasizes,can be understoodand used by all. Without such a structurewe are in dangerof creatingyet another ghetto. When the dust settles, there is no telling what feminist ethics will look like. But what we do not want is a 'specialinterest'ethics that can be ignored,or relegated to the alreadylargecollection of theories amongwhich people can arbitrarily pick and choose. What I hope for in the long run is that feminismwill permeate all ethics, leaving 'feminist ethics' to wither away. Only this outcome securesus from 'respectable'theories that ignore women's interests. With some trepidation, then, I raise the question: what can we now say aboutfeminist ethics? Treadinglightly over thin ice, let us embracethe very broadestconception of feminism: "recognitionthat women are in a subordinate position in society, that oppressionis a formof injusticeand hence is intolerable, that there are furtherformsof oppressionin addition to gender oppression. . ., that it is possibleto change society in waysthat could eliminate oppression, and that it is a goal of feminism to pursue the changes necessaryto accomplish this" (see Sherwin, p. 70, n. 7). Feminist ethics might then be taken to include discussionswhich do the following: (1) emphasizethe importanceof women and their interests. Stressingjustice for women seems to me to be a minimumcondition for describingany work as 'feminist.' But I think we want, duringthis time of experimentationand ferment, to avoid any semblanceof rigidorthodoxyabout the form that this emphasis should take. We shouldn't be brandingsome workas 'not reallyfeminist'so long as it is premisedupon the aforementioned feminist assumptions.This does not mean, of course, that we should not feel free to criticize other views or arguefor our own. Feministscholarshave been documentingin damningdetail the invisibility (or worse) of women and their interestsin most traditionalwork. Insisting on genderas a requiredcategoryof analysis,as Rosserand othersurge, is a step in the right direction. Reviews of mainstreammedicalethics books that fail in their applicationto women (like Bell's and Overall's)are good examples of another. (2) focus on issuesspecially concerning or affectingwomen. Although this might seem an obvious category,quite a bit of disagreement surfacedas we put together this volume aboutwhetherto considersuch work trulyfeminist. My own opinion is that we need to be broadmindedhere, in partto avoid the kind of sectarianwarfarethat could undermineour still fragile enterprise.However, subject matter alone is not enough to renderwork feminist: it should not be classifiedas such unless it also falls undercategory (1) above. A broadarrayof narrowlydirectedcase studiessuch as Marquis'spiece on breastcancer researchbelong in this category. It may also include 'unsexy,'

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'housekeeping'issuesthat might be ignoredas too trivialto merit philosophical treatmentby non-feminists (see Warren). (3) rethink fundamentalassumptions. This heading includes consideration of both substantive principles and those concerningphilosophicalmethod. Excellent instancesof the formerare the criticismsof atomism (Jaggar1983), proposalsfor new models of human relationships(Held 1987), and discussionof the moral relevance of gender (Okin 1987), as well as the aforementionedprinciplesabout detail and context. Sensitivity to more or less hospitabletheoreticalframeworksis another. For example, as I have arguedelsewhere, utilitarianismmay be a useful resource for us, despite the fact that it can be misapplied(1988). A wide varietyof methodologicalquestionsalso fits in here, for example, Warren'scriticism of the GladiatorTheory of Truth. (4) incorporatefeminist insightsand conclusionsfromother fields and disciplines; use race and class as categoriesof analysis. Interdisciplinarywork like ethics (and medical ethics, in particular)requiresboth vast generalknowledgeand thoroughunderstandingof other possible forms of oppression. Awareness of how feminist work is transforming other disciplineshelps us fit our own contributionsinto an organic, growing whole. Sensitivity to relatedkinds of injusticeoften still eludes us, although many of us (like Bell and Overall) are trying to take this next step. These categoriesare neither exhaustivenor mutuallyexclusive: surelythe futurewill reveal a fascinatingvariety of approaches,strategies,arguments, and values. Let us hope that the rich streamof work we are witnessingwill steadily broaden its reach to every comer of the moral landscape. In the meantime, we scrambleto tackle new problemsoverwhelmingus even as we agonizeover the old. Luckily, our numbersare growing, even as the political landscapedarkens:more than a hundredsubmissionsdelugedthe in FeministEthics, planning committee for the recent conferenceExplorations and some three hundredregistrantsconvergedon remote Duluth from as far awayas Holland and Hawaii. We hope that this Hypatiavolume and the next (on reproductiveethics) will encouragefurtherdialogue, by informing,provoking, and inspiringdebate. Our thanks to all those who made it possible!

NOTE 1. All references(unless otherwise noted) are to authorsin this special issue of Hypatia.

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REFERENCES

Held, Virginia. 1987. Non-contractualsociety. Science,moralityandfeminist theory.MarshaHanen and Kai Nielsen, eds. CanadianJournalof Philosophy (supplementaryvolume) 13. Jaggar, Alison. 1983. Feministpoliticsand humannature. Totowa, N.J.: Rowman and Allenheld. and PublicAffairs Okin, Susan Moller. 1987. Justice and gender. Philosophy 16(1). Purdy, LauraM. 1988. Do feminists need a new moral theory? Paperpresented at the conference on Explorations in feministethicsat the University of Minnesota, Duluth.

Moral Understandings: Alternative "Epistemology" for a Feminist Ethics MARGARETURBAN WALKER

women'svoicesin ethicshas produceda visionof moral Workon representing conceptionof philosophical understanding profoundlysubversiveof the traditional moralknowledge.I explicatethisalternativemoral"epistemology," identifyhowit challengesthe prevailingview, and indicatesome of its resourcesfor a liberatory ethics. feministcritiqueof philosophical

When Annette Baieraskeda few yearsago what women wantedin a moral theory, the answershe arrivedat was that moraltheorywas just what women didn'twant, if a moraltheory is a "fairlysystematicaccountof a fairlylargearea of morality,with a keystone supportingall the rest"(Baier 1985, 55). Yet the latter is what a still dominant traditionof moralphilosophy-stretching fromSocratesthroughSidgwickto Rawls-does want:a fairlycompactsystem of very generalbut directly action-guidingprinciplesor procedures.Current philosophicalpracticestill largelyviews ethics as the searchfor moralknowledge, and moral knowledge as comprisinguniversalmoralformulaeand the theoreticaljustificationof these. If one asks the somewhatdifferentquestion of what a feministethicsis, or should look like, one might have in mind some differentthings. One is that feministethics is one which clarifiesthe morallegitimacyand necessityof the kindsof social, political, and personalchanges that feminismdemandsin order to end male domination, or perhapsto end domination generally.1Another conception of feminist ethics is that of one in which the moralperceptions, self-images, and senses of moral value and responsibilityof women have been representedor restored.Philosophicalethics, as a culturalproduct, has been until recently almost entirely a product of some men's thinking. There are the usual reasons to suspect that those men will not have represented, or will not have representedtruly,modesof life and formsof responsibility which aren'ttheirs, or which they could recognizefully only at the cost of acknowledgingtheir interlockinggender, race and class privileges.While UrbanWalker Hypatiavol. 4, no. 2 (Summer1989)? by Margaret

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female voices alone may not be sufficientcorrectivesto this, they promiseto be importantones. Here the tasks of restoration, reconstruction,and new constructionare not sharplydivided;all involve suspensionand re-examination of unquestionedassumptionsand standardforms. The reconstructive project has been pioneered in work by Baier (1985; 1986; 1987), Carol Gilligan (1982), Nel Noddings (1984), Adrienne Rich (1976; 1979), SaraRuddick(1984), CarolineWhitbeck (1983), and others. While the result in each case is distinctive, a lattice of similarthemes-personal relations, nurturanceand caring, maternalexperience, emotional responsiveness, attunement to particularpersons and contexts, sensitivity to open-ended responsibilities-has become the object of sharpcriticismfrom otherfeministquarters.While the criticismstoo arevaried, they includea variety of cognate concerns about whether the values and paradigmsvalorized in the reconstructivework are not mistakenand politically retrograde.Jean Grimshaw (1986), Claudia Card (1985), Jeffner Allen (1986), Lorraine Code (1987), BarbaraHouston (1987), and others have askedwhether maternal paradigms,nurturantresponsiveness,and a bent towardresponsibility for others'needs aren'tour oppressivehistory, not our liberatingfuture, and whether "women'smorality"isn't a familiarghetto rather than a liberated space.2 It is fair, if oversimple, to say that some feministsquestion whether the reconstructive project can meet and nourish the politically normative one.3 The many crossingstrandsof this conversationbeg for close consideration, but I will pull one threadloose fromthe reconstructiveprojectand commend it to ourfurtherdeliberationas a part, but only part, of an adequateand flexible feminist ethic. The thread I referto in the reconstructivework is a profound and original rebellion against the regnant paradigmof moral knowledge mentioned in my opening paragraph.Hence, it might be called an altera very differentway of identifyingand appreciating nativemoralepistemology, the formsof intelligence which define responsiblemoralconsideration.This view does not imagine our moral understandingscongealed into a compact theoretical instrument of impersonaldecision for each person, but as deployed in sharedprocessesof discovery, expression, interpretation,and adjustment between persons. Facets of this alternative view which appearrepeatedly in reconstructivediscussionsare: attention to the particular;a way of constructing morally relevant understandingswhich is "contextual and narrative"(Gilligan 1982, 19); a pictureof deliberationas a site of expression and communication. Here are my limited aims. First, I model this alternativeepistemologyof moral understandingsby describing its three elements and their affinities. Second, I identify how its features challenge the still hardy mainstream universalist tradition on moral knowledge. Finally, too briefly, I indicate some ways this particularresult of the reconstructiveapproachto feminist

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ethics answersto some concerns of the first, politically normativeapproach. Refusingthe canonical "theory"option does not mean going without guidance in judgmentsand practicesof counteringdomination. Neither does the alternativemoral epistemologyby itself requirecommitmentsto the specific moral values and paradigmslately in dispute among feminists. MORALEPISTEMOLOGY OFAN ALTERNATIVE I. ELEMENTS

A substantialnumber of contemporarywomen writerson moralityhave sounded the theme of attention to "particularothers in actual contexts" (Held 1987, 118). Iris Murdoch (1970) sets an oft-cited precedent for this theme in her defense of attention("lovingregard"(40); "patientand just discernment"(38)) as the "characteristicand propermarkof the active moral agent" (34). In pointed oppositionto the emphasisin most moralphilosophy on conscientious adherence to principle, Murdoch insists instead on the "endlesstask" (28) of "good vision: unsentimental,detached, unselfish, objective attention" (65-66), which she calls love.4More recent women writers who see acute and unimpededperception of particularhuman beings as the condition of adequatemoral responseconcur in Murdoch'sepistemological point-her emphasison a certain kind of understandingas central to moral-

ity.5 Ruddick(1984), for example, finds in the normativestructureof maternal practices a rich display of that openness which allows for revelation of the particularindividual. Maternalresponsibilityto foster growth, on Ruddick's account, requirescertain recognitions:of the separateconsciousnessof another making its own sense of the world; of the common humanity of the other'sfamiliarlongings and impulses;of the need to give up expectationsof repeatabilityin orderto follow the distinct trajectoryof a particularlife (218220). Such maternalvirtues are ones Ruddickthinks it urgent to cultivate more widely. Whitbeck (1983) sees a similar sensibility enabling practices (such as teaching the young, nursing the sick, tending the body) for "the (mutual)realizationof people" (65) which are typicallyconsidered"women's work."Relatedthemes are soundedby others:Gilligan'sreconstructionof the "careethic" involves "the abilityto perceivepeople in their own termsand to respond to their needs" (1984, 77); Benhabib (1987, 164) explores the "epistemic incoherence" of strategies of reversabilityand universalization once the concreteness of other individuals has been covered over by the "generalized"conception of others in terms of an abstractstatus.6 Attention to particularpersons as a, if not the, morallycrucial epistemic mode requiresdistinctive sorts of understanding.Gilligan has usefully describedthe patternof this thinking as "contextualand narrative"ratherthan "formaland abstract,"where the latter "abstractsthe moralproblemfromthe interpersonalsituation"(1982, 32), while the formerinvokes a "narrativeof

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relationshipsthat extends over time" (1982, 28). Two elements are at work here:context and concretenessof individualswith specific "history,identity, and affective-emotionalconstitution"(Benhabib1987, 163), and the special context that is a relationship,with its history, identity, and affectivedefinition. The two are linked by the notion of a narrative,of the location of human beings'feelings, psychologicalstates, needs, and understandingsas nodes of a story (or of the intersectionof stories) that has alreadybegun, and will continue beyond a given junctureof moral urgency. Conceptually, this means that we don't and can't identifypeople'semotions, intentionsand other mental states with momentary (and especially not momentaryinner, private) phenomena. Instead,we identifythese featuresof people by attendingto how their beliefs, feelings, modesof expression,circumstancesand more, arranged in characteristicwaysand often spreadout in time, configureinto a recognizable kind of story. Practically,this means that individualembroideriesand idiosyncracies,as well as the learned codes of expressionand responsebuilt up in particularrelationships,and built up culturallyaroundkindsof relationships, requireof us very acute attention to the minute and specific, to history and incident, in graspingcases in a morallyadequateway. If the others I need to understandreallyare actualothers in a particularcase at hand, and not repeatable instances or replaceableoccupantsof a general status, they will requireof me an understandingof their/ourstoryand its concrete detail. Without this I reallycannot know howit is with others towardswhom I will act, or what the meaning and consequence of any acts will be. Whitbeck arguesfor a relationalview of persons,of their historicalbeing as "fundamentallya historyof relationshipsto other people," and their actions as responsesto the "whole configurationof relations"(1983, 76). She connects this view with the essentially responsive, discretionarycharacter of moralresponsibilitiesthat relationshipsgenerate,responsibilitiesthat cannot then be reducedto obligationsand specifiedin uniformterms. SharonBishop (1987) has also examined the different light cast on moral responsibilities, problems,deliberation,resolutionand guilt when one sees moralresponseas the attempt to mediate multiple, sometimes conflicting, moral claims that ariseout of our many actual connections with other people and our needs to maintainthem with integrityand sensitivity. This intertwiningof selves and stories in narrative constructions which locate what is at stake, what is needed, and what is possible is at the heart of moral thinking for many women and feministwriters.The understandingof such storiesrequiresmany formsof intelligence;all are at workin the competent moralagent, according to these views.7 One formof intelligence that very often, if not typically, offerscrucialresources for the resolution of moral problems is the abilityto communicate among persons involved or affected. While this avenue to understandingis

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not alwaysopen, it often enough is, and its efficacy is so obvious that it is astonishinghow little attention is paid it in most nonfeministmoralphilosophy. Even in that strain of theory that postulatesor simulatesan original agreementor compact, the role of communicationin, as it were, the moral event is routinely ignored, and the moral agent on the spot is depicted in lonely cogitations (or sometimesin admirablebut solo displayof fixed habits of virtue). Given the particularisticparadigmof understandingand the situated conception of responsibilityalreadydiscussed, it is not surprisingthat the resourceof communicationis often stressedin women'swritingon morality. Gilligan stressesthe commitmentin the "care"ethic she describesto "activating the network [of relationships]by communication"(1982, 30); and Bishop'sreconstrualof moralresponseas "offeringcompensationand mediating settlements" (1987, 12) pictures us as engaging those affected by our moralchoices in tight places in a common searchfor constructivewaysof answeringunsatisfiableor competingclaims. Benhabibeven moredirectlychallenges the "monological model of moral reasoning"with a proposalfor a "communicativeethic of need interpretation,"in which actual dialoguereplaceshypotheticalmethodsand fixed, priorconstraintson "admissible"concerns (1987, 167; 169). Murdochspeaksof a mutual"obscurity"which makes the workof love endless (1970, 33), and urgeson us the studyof literatureas an education in how to "pictureand understandhumansituations"(34). We need not make our obscurityto each other worseby unnecessarilyunilateral decision. We might just try turningto each other: talking and listening and imaginingpossibilitiestogether. TO MORALUNDERSTANDINGS II. FROMMORALKNOWLEDGE

The three elements of attention, contextual and narrativeappreciation, and communication in the event of moral deliberation might be seen, in their naturalinterdependence,as an alternativeepistemologyof moralunderstanding, or the basisof one. This view, gleanedfrom the worksof a variety of female and feminist writers,providesan alternativeto a now standardand canonical (which is to say: professionallyinstitutionalized)view of the form and point of ethics (or its philosophicalelaboration).8This view is both old and continuousenough to be called a traditionin the strongestsense, and we tradition.In the wordsof one of its might call it the universalist/impersonalist most explicit proponents, nineteenth-centuryutilitarianphilosopherHenry Sidgwick,9its goal is systematizationof moralunderstanding,and its ideal of systemis that of "precisegeneralknowledgeof what ought to be" (1907, 1), encoded in "directiverules of conduct" (2) which are "clearand decisive" (199) and "in universalform"(228). The rationalefor pursuinga "scientifically complete and systematicallyreflective form"(425) in moralsis that it "corrects"and "supplements"our scatteredintuitions, and resolves "uncer-

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tainties and discrepancies"in moraljudgment. By usefulabstractionit steers us awayfrom, in Sidgwick'swords, "obvioussourcesof error"which "disturb the clearness"of moral discernment (214). For Sidgwick, such distractions include complexityof circumstances,personalinterests,and habitualsympathies. Thus, accordingto Sidgwick, only precise and truly universalprinciples can providefor "perfectionof practiceno less than for theoreticalcompleteness" (262). This capsuledescriptionof standardintent and methodologyaims to bring into relief its very general picture of moralityas individualsstandingbefore the barof impersonaltruth. Moralresponsibilityis envisioned as responsiveness to the impersonal truths in which morality resides; each individual standsjustifiedif he or she can invoke the authorityof this impersonaltruth, and the moral community of individualsis securedby the conformity (and uniformity) guaranteed by obedience to this higher authority.10From an epistemologicalangle, one might gloss this view as: adequacyof moralunderstanding increasesas this understandingapproachessystematicgenerality. The alternative moral epistemologyalreadyoutlined, holds, to the contrary,that: adequacyof moralunderstandingdecreasesas its formapproaches generalitythroughabstraction.A view consistent with this will not be one of individualsstandingsinglybeforethe impersonaldicta of Morality,but one of humanbeings connected in variouswaysand at variousdepths respondingto each otherby engaging together in a search for shareableinterpretationsof their responsibilities,and/orbearableresolutionsto their moralbinds. These interpretationsand resolutionswill be constrainednot only by how well they protect goods we can share, but also by how well they preservethe very human connections that make the sharedprocessnecessaryand possible. The long oscillation in Western moral thought between the impersonaland the personalviewpoints is answeredby proposingthat we consider, fully and in view. earnest, the interpersonal The resultof this alternativeepistemologyis not, then, an "oppositenumber"or shadowimageof impersonalistapproaches;it is insteada point of departurefor a varietyof differentproblematics,investigations,focal concerns, and genresof writingand teaching aboutethics, manyof which we have not, I suppose,yet clearly imagined. Some philosophicalendeavorsare obviously relevant. We might pay greaterattention to the pragmaticsof communication (of what people mean and do when they addresseach other, and not just what their wordsmean). We could explore more fully how moralparadigms and exemplary particularcases are made points of reference for shareable judgments,how they are explicatedand how analogiesaredrawnwith them. A lively interest in understandinghow various factors (semantic, institutional, political) shape our ability to arrive at shared interpretations is needed, as is a questioningof barriersbetween philosophical, literary,critical, and empirical investigations of moral life. These endeavors can,

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however, be carriedout in a cheerfullypiecemealfashion;we need not expect or requirethe resultsto eventuate in a comprehensivesystematization. The analogueof this on the practicallevel is the expectation of constant "moralremainders,"to adopt a phrase in recent philosophical use. 'Moral remainders'refersto some genuine moraldemandswhich, becausetheir fulfillment conflicted with other genuine moraldemands,are "leftover"in episodes of moral choice, and yet are not just nullified. l Whether this sort of thing is even possible is an issue in contemporarymoralphilosophy.12 But if morallife is seen as a tissueof moralunderstandingswhich configure,respond to, and reconfigurerelations as they go, we should anticipate residuesand carry-oversas the rule ratherthan the exceptions:one's choice will often be a selection of one among various imperfect responses, a response to some amongvariousclaimswhich can't all be fulfilled.So there will just as often be unfinished and ongoing business, compensations and reparations, postponementsand returns.Moralproblemson this view are nodal points in progressivehistoriesof mutualadjustmentand understanding,not "cases"to be closed by a final verdict of a highest court. III. FROMEPISTEMOLOGY TO PRACTICE

Although I've cast the discussionhere in terms of moral "epistemology," my point has been that there is a way of looking at the understandingcritical to and distinctive of full moralcapacityon which this understandingis not really an episteme,not a nomologically orderedtheory. From the alternative view, moralunderstandingcomprisesa collection of perceptive,imaginative, appreciative,and expressiveskills and capacities which put and keep us in unimpededcontact with the realities of ourselvesand specific others.13 It's also true that a picture of moral understandingis not a whole moral view. Indeed, the alternative moral "epistemology"sketched here leaves open to consideration many questions about which sorts of values enable moral agents to expressthemselves and hear others, to interpretwisely, and to nourisheach other'scapacitiesfor suppleattentiveness. It also leaves open what other values not directly related to these expressiveand receptive capacitiesare those a feminist ethics ought to endorse. It does not promoteone kind of relationshipas paradigmaticof moralencounter, and invites us to explore the resourcesand impedimentsto expression,reception and communication in relationshipsof many kinds. Yet the priorityit gives to voicing and hearing, to being answerablein and for specific encountersand relationships promises,I believe, potent criticalresources.The most obviousones I see are its structuralcapacity to challenge "principled"moral stances in the concrete, where these are surrogatesfor, or defenses against, responsivenessin actual relationships;to export an insistence on the primacyof personalacknowledgementand communicationto institutionaland "stranger"contexts;

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and on a philosophicalplane to pierce throughthe rhetoricof ethics to the politicsof ethicsas a routine matter.14 In the firstinstance, an ethic basedon this alterative pictureof moralunderstandingis set to challenge fundamentallyand consistently the way the universalisttradition has institutionalizedindirectways of relating as moral paradigms.By 'indirect'here I mean ways of appreciatingpersonsand situations mediatedthroughwhat are typicallysome few, entrenched parameters of status,right, principle, or duty. The alternativepicturediscussedhere confronts this "policed sociability"(Skillen 1978, 170) of universalismwith an that of unimpeded,undistorted,and flexalternativeideal of moralobjectivity: ible appreciationof unrepeatableindividualsin what are often distinctive situations and relationships. Morallyrelevant categorieson this view include the full, nuancedrangeof expressiveresourcesfor articulatingand constructing interpersonallife. By contrast, the ways of describingand expressingto which universalistmoralitypermitsmoral relevance are typically limited to those which are "repeatable," "universalizable,""impartial,"or "impersonal," i.e., those that embody the forms of detachment that are taken by universalismas constitutive of "the moral point of view." Universalismpressesme to view you, for instance, as a holder of a certain right, or a promisee,or a satisfaction-function,or a focus of some specifiable set of obligatoryresponses.I am pressedto structuremy responseor appealto you in terms which I can think of as applyingrepeatablyto any numberof other cases. If we step into the alternative framework,however, we see universalist morality as thus "curbingour imaginations"(Lovibond 1983, 199) by enforcing communicative and reflective strategies which are interpersonallyevasive.Universalism, for example, tends to regiment moral thinking so that negligent or willful inattention to need and expectation in the courseof daily life is readilyseen as "mereinsensitivity,"a non-moralfailing, when it is not in dereliction of explicit "duties."Worse, it legitimates or juridicalpostureof "the"(i.e., uniformlyassumingthe quasi-administrative in Yet of view. moral many cases assumingthat viewpoint universal) point if sometimes painful, path of expression, may foreclose the more revealing, could otherwiselead to genuinely that acknowledgement,and collaboration responsivesolutions. A principledappeal to "fairness"or "whatone promised"or what "right" one has to something or why "anyone"should expect a certainresponsemay be a summarilyeffective arguingpoint. But if it is broughtforth in an intricate situation of an ongoing relationship, it may also be the most effective way to stymie or silence your interlocutor-spouse, lover, friend, student, partner,patient-without addressingmanyquestions.The avoidedquestions may include just the morally relevant ones about the particularneeds and harms, the expectations and formsof trust, and the characterand futureof thatrelationship. Feministshave special and acute needs to fend off this sys-

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tematic de-personalizingof the moraland de-moralizingof the personal. For on a practicallevel what feministsaspireto dependsas much on restructuring our senses of moral responsibilityin intimate partnerships,sexual relations, communitiesof personalloyalty, and day-to-daywork relationsas it clearly does on replacinginstitutional, legal, and political arrangements. The alternativepicturealso invites us not to be too temptedby the "separate spheres"move of endorsingparticularismfor personalor intimate relations, universalismfor the large-scaleor genuinelyadministrativecontext, or for dealingswith unknownor little-knownpersons.While principled,generalizedtreatmentsmay reallybe the best we can resortto in manycasesof the or inlattersort, it is well to preservea lively sense of the moralincompleteness adequacyof these resorts.This is partlyto defend ourselvesagainstdispositions to keep strangersstrangeand outsidersoutside, but it is also to prevent our becomingcomfortablewith essentiallydistancing,depersonalizing,or patemalistic attitudeswhich may not reallybe the only resortsif roles and institutions can be shapedto embodyexpressiveand communicativepossibilities. It is often claimed that more humanlyresponsiveinstitutionsare not practical (read:instrumentallyefficient). But if moral-practicalintelligence is understoodconsistentlyin the alternativeway discussed(the way appropriateto relationsamongpersons), it may insteadbe correctto saythat certainincorrigibly impersonalor depersonalizinginstitutionsare too morallyimpracticalto be tolerated. It is crucial to examine how structuralfeaturesof institutionalized relations-medical personnel, patients and families;teachers, students and parents;case workersand clients, for example-combine with typicalsituations to enable or deform the abilities of all concerned to hear and to be heard. Some characteristicallymodem forms of universalistthinking may project a sort of "moralcolonialism" (the "subjects"of my moral decisions disappearbehind uniform"policies"I must impartially"apply")preciselybecause they wereforgedhistoricallywith an eye to actualcolonization-industrial or imperial.15 Finally, this kind of moral epistemologyremindsus that styles of moral thinking are not primarilyphilosophicalbrain-teasers,data begging for the maximally elegant theoretical construction, but are ways of answeringto otherpeoplein termsof some responsibilitiesthat are commonlyrecognizedor recognizable in some community. Philosophical representationsof these styleswill both reflect and reinforcethe relationsof authority,power, and responsibilitythey encode. Hence, for moralphilosophyto be sincerelyreflective, it must attend focally to questions heretoforeconsidered"philosophically" inappropriate:questions about the rhetoric and politics of ethics. These are questionsabout the discursiveand expressiveformatswhich have been declared appropriateto the task of representingmoral life, and about who has the standing (and the access to institutionalizedforums)to make, and to challenge, the "rules" (including substantive assumptions)of the

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genre. When we construct and consider representationsof our moral situations, we need to ask: what actual community of moral responsibilitydoes this representationof moralthinking purportto represent?Who does it actually represent?What communicativestrategiesdoes it support?Who will be in a position (concretely, socially) to deploy these strategies?Who is in a position to transmitand enforce the ruleswhich constrainthem? In what forms of activity or endeavor will they have (or fail to have) an application, and who is served by these activities? These questions are hard for philosophersto ask; it flies in the face of the professional self-image of supposedlydisinterested searchersafter timeless moraltruth to recognizethat a moralphilosophyis a particularrhetorictoo, situatedin certainplaces, sustainedand deployedby certaingroupsof people. Its apparentform may belie its real applicationand meaning. For example, philosophershave long insistedon "the universal"in ethics, and continue, I find, to insist on formaluniversalityof norms, concepts, or proceduresas the key moralbulwarkagainstbias and injustice. Yet the rhetoricof universality has been entirely compatible, as feminist philosophers have repeatedly shown, with the most complete (and often intentional) exclusion of women as moral agents from such loftily universalconstructsas the social contract, purepracticalrationality, or the good life for man, and with bypassingaltogether in applicationwhole areasof life that are the provinceof women (voluntarilyor not), such as the rearingof children.16 Further,not only the substanceand presuppositionsbut also the standard discursiveforms of moral philosophy-its canonical styles of presentation, methods of argument, characteristicproblems-require pragmaticevaluation. These forms include starkabsence of the second personand the plural in projectionsof philosophicaldeliberation;virtualexclusionof collaborative and communicative modes of formulatingand negotiating moral problems; regimentationof moral"reasoning"into formatsof deductiveargument;reliance on schematicexamplesin which the few "morallyrelevant"factorshave alreadybeen selected and in which social-political context is effaced; and omission of continuing narrativesthat explore the interpersonalsequels to moral "solutions."These are rhetoricalconventions which curb the moral imaginationsof academicphilosophersdrastically.Alarmingly,we visit them on our studentsas we "refine"their moralthinking, obscuringmorallysignificant featuresof everydaylife, personal relations, and the social conditions which structurethem. There are alternativesto the abstract,authoritarian,impersonal,universalist view of moral consciousness.The picture of direct mutual responseand responsibilityis not a whole ethics, but it is one way of rotatingthe axis of our investigationaroundthe fixed point of our real need. 17

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NOTES 1. This view of feminist ethics does not rule out in principlethat some currentlyprominent view in philosophicalethics, properlyapplied,can be a feministethics. Although this possibility seems less promising currently, early feminist discussions of issues like abortion, rape, and pornographyoften invoked standardnotions of rights, respect, or the promotionof happiness. And it is still a fact that in our given political cultureappealsto moralstandardswhich cohere with liberalpolitical ideasare potent and indispensabletools in pursuingfeministsocial and legal objectives. 2. Grimshawis specially critical of claims that women's moral thinkingis characteristically different; Code criticizes "maternalism;"Houston discusses objections by Card, Allen and others. Forcritical reactionsto Gilligan'swork, see Nails et al. (1983), Kerberet al. (1986) and Michaels (1986). 3. I don't mean to make this dialoguesound too bipolar.VirginiaHeld (1987) is cautiouson the issueof jettisoningprinciplesto particularism.MarilynFriedman(1987) combinesa plea for the integrationof justice and caring values with the view that the characterof particularized moralcommitmentsdoes not combine with rule-basedrespect. Both Held and Friedmantentatively suggest the application of different moral approachesto different "spheres"of life or differentkinds of relationships.But see my section III, below, on the "separatespheres"idea. 4. Murdochherselfcreditsher conception of a "justand loving gazedirectedupon an individual reality" (34) to Simone Weil, whose views are complicated enough, (and ambivalent enough, from the viewpoint I'm discussinghere) to requirequite separateconsideration. 5. Many may not sharethe Platonism,Freudianpsychology,theoryof art, or other views to which Murdochjoins her views on love. One subtle critiqueof the deep social conservatismof Murdoch'sviews is providedby Sabina Lovibond (1983, 189-200). 6. See Held (1987); Noddings (1984, chapters 1 and 4). See also Nussbaum(1983) on reviving the Aristotelian notion of perceptionas "appropriateacknowledgement"of the particular person in the face of the blinding urge to preservepreconceived,harmoniousorderingsof abstractedvalue. 7. See also Diamond (1983) on the importanceof graspingthe moral "texture"of individuals (an idea she attributesto Iris Murdoch). 8. The difference between representingmorality and "rationallyreconstructing"it philosophically is not always clear, and this is itself a source of deep problems, substantivelyand methodologically. Addelson (1987), for example, deeply challenges the appropriatenessand morallegitimacyof an academicpracticeof philosophicalethics (if I understandher correctly).I take this challenge quite seriously, even as I right now continue to do a version of academic philosophicalethics. 9. Sidgwick'sworkrichly repaysstudyif one wants to see in explicit and self-consciousform the "rules"of the genre of today'sphilosophicalethics. But one could find the samerulesformulated (or implicitly honored) in any numberof mainstreamtwentieth century authors. 10. Since writing this I have discovered a parallel characterizationin Anthony Skillen's descriptionof moder bourgeoismoral consciousnessas a blend of "abstractauthoritarianism" and "generalizeddisciplinarianism"(Skillen 1978, 153). 11. A standardexamplewould be that in which two promises,each sincerelyand responsibly made, turn out to be contingently incapable of both being kept. In such cases, whichever commitment I fulfill, another will have been neglected. Bishop (1987, 13ff.) discusses the importanceof taking the longer view of such cases. 12. A number of widely known essays which debate the issues about dilemmasand moral remaindersare collected in Gowans (1987). 13. A moral epistemologyof the sort describedfinds common or overlappingcause with a numberof other contemporarydeviations from dominant views. For critics of impartialityon behalf of the personallife, see Williams (1981), Blum (1980), and Stocker (1976). On interrogating moralviews for their concrete social and historicalconditions, see Maclntyre(1981). For insistenceon the primacyof judgmentsin particularcases, see the new Aristotelians,Nussbaum (1986) and Wiggins (1978). For other versions of "responsibilityethics" which situate moral claims in relationalstructuresof power and dependency, see Goodin (1985) and Jonas (1984).

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andrefusals, seeCavell(1979,Parts3 and4). And On moralityasa tissueof acknowledgements on moralityas constitutedby socialpracticesand as expressiveof relationsof authorityin, vein see Skillen(1978)andLovibond a Marxistanda Wittgensteinian-Hegelian respectively, fora differentkindof ethics.Yetfeminists (1983).All thesemaybe, usedselectively,resources mightremainwaryof unwantedresiduesandomissionsin someof theseviews. of modesof rationality andstyles anddeployment 14. On the politicalaspectsof construction of thoughtwithrespectto gender,seeessaysbyRuddick,Addelson,andHardingin Kittayand neglectof Meyers(1987). See alsoCalhoun(1988) fora discussionof the wayphilosophers' moralideologies. certaintopicsreinforces 15. In thisconnectionseeSkillen(1978,Chapter4) on bothKantianandutilitarian disciplihouseutilitarianism." andWilliams(1985,Chapter6) on Sidgwickian narianism "government humaneandlucidon this topic. 16. Baier(1986;1987)is particularly on anearlierandbrieferdraftof 17. Specialthanksto SandraBartkyforverygoodsuggestions thispaper,andto the editorsandreadersforhelpfulsuggestions.

REFERENCES

Addelson, Kathryn. 1987. Moral passages.In Womenand moraltheory.Eva FederKittay and Diana T. Meyers, eds. Totowa, New Jersey:Rowman and Littlefield. Explorations.Palo Alto, Califoria: Allen, Jeffner. 1986. Lesbianphilosophy: Institute of LesbianStudies. Baier,Annette. 1985. What do women want in a moraltheory?Nous 19: 5363. Baier, Annette. 1986. Trust and anti-trust. Ethics96: 231-260. Baier, Annette. 1987. The need for more than justice. In Science,morality& feministtheory.MarshaHanen and Kai Nielsen, eds. Calgary,Canada: University of CalgaryPress. Benhabib, Seyla. 1987. The generalizedand the concrete other. In Women and moraltheory.Eva FederKittay and Diana T. Meyers, eds. Totowa, New Jersey:Rowman and Littlefield. Bishop, Sharon. 1987. Connections and guilt. Hypatia2(1):7-23. Blum, Lawrence. 1980. Friendship,altuism and morality.London:Routledge & Kegan Paul. Calhoun, Cheshire. 1988. Justice, care, genderbias. TheJournalof Philosophy 85: 451-463. Card, Claudia. 1985. Virtuesand moralluck. WorkingSeries I, No. 4, Institute for Legal Studies, University of Wisconsin, Madison, Law School. Cavell, Stanley. 1979. The claimof reason.Oxford:OxfordUniversity Press. Code, Lorraine.1987. Second persons.In Science,morality& feministtheory. Marsha Hanen and Kai Nielsen, eds. Calgary, Canada: University of CalgaryPress. Diamond, Cora. 1983. Having a roughstoryaboutwhat moralphilosophyis. New LiteraryHistory15: 155-169.

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Friedman,Marilyn. 1987. Beyond caring:The de-moralizationof gender. In Science,morality& feministtheory.MarshaHanen and Kai Nielsen, eds. Calgary,Canada:University of CalgaryPress. Gilligan, Carol. 1982. In a differentvoice. Cambridge:HarvardUniversity Press. Gilligan, Carol. 1984. The conquistadorand the darkcontinent: Reflections on the psychologyof love. Daedalus113: 75-95. Goodin, Robert. 1985. Protectingthevulnerable.Chicago: Universityof Chicago Press. Gowans, Christopher. 1987. Moraldilemmas.New York:OxfordUniversity Press. andfeministthinking.Minneapolis:UniverGrimshaw,Jean. 1986. Philosophy of Minnesota Press. sity Hanen, Marshaand Kai Nielsen, eds. 1987. Science,morality& feministtheory. Calgary,Canada:University of CalgaryPress. Held, Virginia. 1987. Feminismand moraltheory. In Womenand moraltheory. Eva FederKittay and Diana T. Meyers, eds. Totowa, New Jersey: Rowman and Littlefield. Houston, Barbara.1987. Rescuingwomanlyvirtues:Some dangersof moral reclamation. In Science,morality& feministtheory.MarshaHanen and Kai Nielsen, eds. Totowa, New Jersey:Rowman and Littlefield. Jonas, Hans. 1984. The imperativeof responsibility.Chicago: University of Chicago Press. Kerber,Linda, et al. 1986. On In a differentvoice:An interdisciplinaryforum. Signs 11: 304-333. Kittay, Eva Federand Diana T. Meyers,eds. 1987. Womenandmoraltheory. Totowa, New Jersey:Rowman and Littlefield. in ethics.Minneapolis:UniLovibond, Sabina. 1983. Realismand imagination versity of Minnesota Press. MacIntyre,Alasdair. 1981. Aftervirtue.Notre Dame, Indiana:Universityof Notre Dame Press. Michaels, Meredith. 1986. Morality without distinction. The Philosophical Forum17: 175-187. Murdoch, Iris. [1970] 1985. The sovereigntyof good. London: Routledge & Kegan Paul. Nails, Debra, MaryAnn O'Loughlinand JamesC. Walker, eds. 1983. Social research50. Noddings, Nel. 1984. Caring:A feminineapproachto ethicsand moraleducation. Berkeleyand Los Angeles: University of CaliforniaPress. Nussbaum,Martha. 1983. Flawedcrystals:James'sThegoldenbowland literature as moral philosophy. New LiteraryHistory15: 25-50. Nussbaum, Martha. 1986. The fragilityof goodness.Cambridge:Cambridge University Press.

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Rich, Adrienne. 1976. Of womanborn.New York:W. W. Norton & Company. Rich, Adrienne. 1979. On lies,secrets,andsilence.New York:W. W. Norton & Company. Ruddick,Sara. 1984. Materal thinking. In Mothering.Joyce Trebilcot, ed. Totowa, New Jersey:Rowman and Allanheld. Sidgwick, Henry. [1907] 1981. The methodsof ethics. Indianapolis:Hackett Publishing. Skillen, Anthony. 1978. Rulingillusions.Atlantic Highlands, New Jersey: Humanities Press. Stocker, Michael. 1976. The schizophreniaof modem ethical theories. The Journalof Philosophy73: 453-466. Whitbeck, Caroline. 1983. A differentreality:Feministontology. In Beyond domination.Carol C. Gould, ed. Totowa, New Jersey: Rowman and Allanheld. Wiggins, David. 1978. Deliberationand practicalreason. In Practicalreasoning. Joseph Raz, ed. Oxford:Oxford University Press. Williams, Bernard. 1981. Moral luck. Cambridge:Cambridge University Press. Williams, Bernard.1985. Ethicsand the limitsof philosophy.Cambridge:Harvard University Press.

A Feminist Ethic and the New RomanticismMotheringas a Model of Moral Relations PAUL LAURITZEN

Thispaperclaimsthatrecentattemptsto drawon the maternalexperiencesof womenin orderto articulatean ethicof careandcompassion is a newromanticism. Likeearlierromanticviews,it is bothattractiveandpotentiallydangerous.Thepain orderto identifybothits per examinesthe basicclaimsof thisnew romanticism strengthsandweaknesses.I concludethatthereareat leasttwo versionsof thisnew one thatreliesprimarily on theexperiences in groundromanticism, of child-bearing on child-rearingan ethicof careandcompassion,anda secondthatreliesprimarily is deeplyflawedbeing. I suggestthattheformerversionof thenew romanticism to womenand will be inaccessibleto causesucha view oughtto be unacceptable men.

In their book, ForHer Own Good, BarbaraEhrenreichand DierdreEnglish (1978) tracethe dialecticalmovementbetween "romanticism"and "rationalism" that has characterizedAmerican feminist thought duringthe past 150 years. On the one hand, the romanticshave wanted to claim a distinctive role and place for women, one that resiststhe dehumanizingvaluesof a market economy. According to this view, women are more nurturing,tender, and caringthan men and, thus, women'sexperienceprovidesa correctiveto an economic world that is competitive and unfeeling. Indeed, accordingto this view, insofar as women's place has been in the home, the home has been, in ChristopherLasch'swords (1977), a "haven in a heartlessworld." The home, a place where a woman'sexperience dominates, has been a refuge, a clearing in the jungle, so to speak, carvedout by a woman'scare and compassion.On the other hand, the rationalistshave arguedfor the importance of assimilation.According to this view (Ehrenreichand English 1978, 20), it is a mistaketo identifydistinctivelywomanlytraits, for the goal is "to admitwomen into modem society on an equalfooting with men." In orderto gain admission,however, one muststresswomen'sabilityto competesuccessHypatiavol. 4, no. 2 (Summer 1989) ? by Paul Lauritzen

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fully, not their unwillingnessto enter the competition. So rationalistshave embracedthe competitive individualismof the male work world and have sought access for women to that world. According to Ehrenreichand English, American feminismhas traditionally "oscillated"between romantic and rationalist ideas, with romanticism clearly dominating, until the 1960s and 70s. At that point, according to Ehrenreichand English (1978, 317), romanticismcollapsedutterly, without hope of revival; in their words, it "tumbleddown like an ornate Victorian mansion in the face of a hurricane."So it must have seemed in 1978 when ForHer Own Goodwas published,for romanticismwas clearlyon the wane. The feminist movement of the sixties and seventies had indeed defined itself in opposition to what was consideredto be an oppressiveromanticideal, and romanticismhad largelycome to be associatedwith opposition to the equal rightsamendmentand with the sort of mindlesspap offeredby MarabelMorgan's (1973) The Total Woman,a fact that suggestshow irretrievablethe romantic view must have appeared. Yet, the judgmentthat romanticismhad been irreparablydestroyedseems to me to have been premature,and as evidence I offer the recent revival in feminist literatureof many of the claims of the romantic view of women. Once againfeministsare claimingthat women have a distinctive moralsensibility; once again feminine virtuesare being celebrated;and once again it is claimed that women'sexperiencebearswitness to the valuesof intimacyand compassionabsent in the competitive and dominant male work world. It is this new romanticismthat I want to explore in this essay. In particular,I want to examine the claim that it is possibleto develop an entire ethic of care and compassionout of the experiencesof intimacy, nurturing,and affection evident in many women's lives. Although the preciseformsuch an ethic wouldtake is still in dispute, there is enough commonalityamong the variouseffortsto envision a new approach to moralityin orderto speakabouta distinctiveethic. Moreover,becausethis efforthas come largelyfromwriterswho areself-consciouslyfeministand who see the developmentof an ethic of care and compassionas an importantcontributionof feministthought, such an ethic might reasonablybe called a feminist ethic. In speakingof "a feminist ethic," however, I do not mean to suggest that there is complete agreementamong feministseither about the precise nature of such an ethic or even whether the development of such an ethic is in fact desirable. Nevertheless, in this paper I will use "a feminist ethic" to referto those accountsof moralitythat emphasizecare and compassion and which are said to be rooted in women's experience. Since the model for care and compassionin this new romanticismhas frequentlybeen the relationshipof a mother to her children, I will be especially interestedto considerthe appealto the experienceof motheringin the development of a feminist ethic of care and compassion.This attemptto develop a

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feminist ethic, and especially the attempt to draw on the experiences of mothering,has all the markingsof a new moment of the romanticist/rationalist dialectic. If romanticismis no longerthe elaboratelyadornedand spacious house it once was, neither is it in ruin. Partof what I want to do in this paper is to ask whether it is a house in which feminists really want to live. Although much of the groundI will cover in discussinga feminist ethic of care and compassionhas been well workedin recent literature,the question of whether the new romanticismis a viable alternative to the old has not been sufficientlyaddressed.Nor is this an idle question. Fora movement towardsmotheringas a model of moralrelationssuggestedby the new romanticism has importantimplicationsfor how both women and men think about their lives. Yet, as we will furthersee, preciselyhow a feministethic is understood to be relatedto motheringis crucialfor answeringour question;for under at least one versionof this relation, a feministethic shouldbe unacceptable to women and will be unopen to men. This paper, then, will examine some of the recent attempts by feminist writers to draw on women's experience-especially the experience of mothering-to constructa feministethic of care and compassion.Although I will assumethat the basic contoursof this ethic are well known, I will try to indicate the preciseways in which such an ethic is rooted in women'sexperience, particularlyin the experience of mothering. This discussionwill ultimatelyput us in a position to considerthe questionof whether, if the recent work on the idea of a feminist ethic is a new moment in the romanticist/rationalist dialectic, it is also a higher synthesisin this dialecticalprogressionof the sort devoutly hoped for by Ehrenreichand English. THE REMERGENCE OFROMANTICISM

It is importantto keep in mind as we turn to considerthe re-emergenceof romanticism,that the new romanticismis not what Ehrenreichand English referto as the "neo-romanticism"associatedwith the emergenceof the New Right. Rather the new romanticismis, as I see it, the attempt to rekindle a moral opposition to the competitive and atomistic model of moral relations dominantin the marketplaceand in most contemporary(male) moralphilosophy. As Ehrenreichand English recognized,the romantic view has always had adherentspreciselybecause it has "moralforce." It asserted, in however trivializedand sentimental a fashion, the supremevalue of love as againstself-interest,human persons as against dead things. It affirmed the human needs which could not be met in the marketplace-needs for love and intimacy, for nurturanceand caring. It upheld the weak, the infant, the elderly, in an economic worldwhich rewarded

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only the victorious and the strong. (Ehrenreichand English 1978, 314) That this is in fact the appealof the new romanticismcan be seen by turning to the workof almost any of the writerscalling for a recognitionof a distinctive approach to moral relations rooted in the experience of women. Although the literaturein this areais continuallyexpandingand is alreadyquite extensive, we can perhapssee this point most clearlyby recallingtwo "classic" sources in the field, Carol Gilligan's In a Different Voice and Nel Noddings'sCaring. Gilligan'splace in the romantic'scamp is signaledby the very title of her book, In a DifferentVoice. Her claim that women have a distinctive voice to offer in discussionsof morality, her suggestionthat women understandthe worldas a place of "careand protection,"whereasmen tend to see the world as a place of "dangerousconfrontation,"her insistence (Gilligan 1982, 19), that "[w]henone begins with the studyof women and derivesdevelopmental constructsfrom their lives, the outline or a moralconception differentfrom that describedby Freud, Piaget, or Kohlbergbegins to emergeand informsa differentdescriptionof development," all place her on the romanticside of Ehrenreichand English'sromanticist/rationalistdivide. Noddings'swork, too, clearly capturesthe spiritof this new romanticism. Her explicitly articulateddesire to substitutean ethic of caringfor what she takes to be an unfulfillingand destructivemale ethic is clear evidence of her romanticism.Like Gilligan, Noddings (1984, 1) believes that ethics has for too long been discussedin the "languageof the father"and that mothersmust no longer be silenced or silent. Further,she agreeswith Gilligan that when mothers speak, they speak tenderly in a languageof care and compassion. If we turn to examine this new versionof romanticismat closerrange, a familiarset of contrastsemerges:responsibilityvs. rights;seeing vs. willing; affective responsevs. detached calculation;web vs. hierarchy;connection vs. competition; self in communityvs. self in isolation. Each of these contrasts has servedto give formand substanceto a feminist ethic. Take, for example, the contrastbetween personalrelationshipsand individualrights. Readersof Gilligan and Noddingswill certainlybe familiarwith the claim that the traditional attention paid to rules, principles,duties, and rightsobscuresthe importanceof attendingto the needs of those with whom we are in relation. In contrastto the traditionalfocus on rights, a feminist ethic, it is said, might highlight the importanceof responsibilityto concrete individualsratherthan commitment to abstractprinciples. In fact, this contrastbetween concretenessand abstractionhas been seen to be at the heart of a feminist ethic. Women's experienceteaches individuals to be waryof abstractprinciplesbecausea commitmentto principlesmay lead one to do violence too quickly in the name of a generalcause, be it reli-

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gion, justice, or rights. By contrast, on the more traditional(male) models, one approachesmorality according to what Stanley Hauerwas(1977) has called the "standardaccount of moralrationality."On the standardaccount, one typically seeks moral objectivity above all else; one attemptsto ground moral judgmentsin some notion of "impersonalrationality."The upshot is an emphasison universaland impartialmoralnorms, fromwhich moralrules and principlescan supposedlybe deduced. Feministethics generallyrejectsthe preoccupationwith objectivity;complete objectivity, it says, is both impossibleto attain and a flawedideal to begin with. It is suspiciousof the principleof universalizability-treatlike cases alike-because this principlenecessarilyrequiresa degreeof abstractionthat flattens out the rich texture of the morallife. As Noddings (1984, 5) puts it, "[s]inceso much dependson the subjectiveexperiencesof those involved in ethical encounters, conditions are rarely'sufficientlysimilar'for me to declare that you must do what I must do." An ethic of care thus seeks to be morecontextual in the sense of focusingattention on the particularityof concrete cases. It seeks to capture the uniquenessrather than the samenessof moral situations. Or consider the contrasts between web and hierarchy, connection and competition, and self in communityand self in isolation. All reflect a fundamental feminist commitment to the propositionthat humans are essentially relational beings. Thus, as Ruth Smith (1985, 242) points out, no matter how much the rationaliststrain within feminist thought stressedthe importance of freedomand autonomy, no matterhow much emphasiswas laid on the significanceof equal opportunityand self determination,"at no point is the autonomousindividualin its classicalformfully intact within feminism." That is to say, feministthought has generallyrecognizedthe povertyof a conception of human life that views human nature as fundamentallyatomistic and competitive. When Smith speaksof the "autonomousindividualin its classical form," she has in mind the traditionalliberal notion of the moral subject who can somehow be defined independentlyof any particularcommitments, values, or life plans and of moralityas a procedureby which to constraingenerallyunsympatheticcompetitorsin a situation of overall scarcity. On this view, classicallyassociatedwith Hobbes, Locke, and Kant, society is constituted primarilyfor the service of particularends which are individualistic in nature.2 By contrast, for feminist ethics the idea that the moralsubjectis metaphysically independentof society is an unhappyone. This is why a feministethic stressesthe image of a web, the importanceof connection and cooperation, and the centrality of community as opposed to hierarchy,competition and separation.The image of the web, for example, symbolizesthe interdependence that is thought to characterizehuman relations accordingto feminist thought. We are, each of us, at every point in our lives, inextricablytied to

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others. We are alwayssomeone'sdaughteror sister, mother, son, brotheror father; we are always membersof a community. We are never, though we may try to be, the isolatedatomsof liberaltheory. The imageof the web thus servesto representa central insight of a feminist ethic, namely, that self and other are connected. MOTHERING AS A MODELOF MORALRELATIONS

We have just seen some of the characteristicfeaturesof a feminist ethic of care and compassion. Such an ethic stressesthe importanceof human relatedness and community; it insists on the centrality of human affective response; it demands the sort of attention to the particularitiesof individual cases that will allow us to recognizeneed. Yet, we are left with a question. In what way can this ethic be said to be rooted in women'sexperience?The answerto this question is instructive,for the appealto women'sexperiencesin constructingan ethic of care is not just to the abstraction"womanhood,"but to actual experiences of women, and, often, to the particularexperience of mothering.As VirginiaHeld (1987, 115) notes, becausethe most centralsocial relationshipseems to be that between mother and child, proponentsof an ethic of care who have wanted to emphasizerelationshipshave arguedthat moralityshouldperhaps,"makeroomfirstfor the humanexperiencereflected in the social bond between motheringperson and child, and for the human projectsof nurturingand of growth apparentfor both in the relationship." When Noddings unpackswhat she means by caring, for instance, the example to which she repeatedlyreturnsis that of the mother caring for her child. At a numberof points Noddings insists that caringis natural,and it is clear that what she envisageshere is the spontaneouscare that a mothergives her infant. The most intimate situations of caring are thus natural. I do not feel that taking care of my own child is "moral"but, rather, natural. A woman who allows her own child to die of neglect is often consideredsick ratherthan immoral;that is, we feel that either she or the situationinto which she has been thrustmustbe pathological.Otherwise,the impulseto respond, to nurturethe living infant, is overwhelming(1984, 83). In Noddings's view, natural caring is the foundation of the moral life and motheringis the best model we have of naturalcaring.Thus motheringserves as a sort of paradigmfor moral relations. There is some evidence, however, that, for Noddings, mothering is more than simplya model for naturalcaring, that motheringis somehowthe source of caring in our lives. For, accordingto Noddings, caring is naturalto us becausewe have experiencedthe goodnessof caring. Eitherwe are mothersand have thus experienced,firsthand, the value of caringfor another, or we have been caredfor by mothersand thus have availableto memorythe importance

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of care in our lives. Eitherway, for Noddings, an ethic of care and compassion is ultimately rooted in a woman'sexperience of caring for her child. Much the same connection between an ethic of care and the role of motheringcan be seen in Gilligan'swork as well. For althoughGilligan says that such an ethic is differentiatedby theme ratherthan by gender, she also says(1982, 74) that an ethic of care is "matemal."And it is maternalbecause it is derivedfromwomen'sexperienceof nurturingand caringfor others, the paradigmaticinstance of which is a mothercaringfor her family. As Gilligan (1982, 17) puts it, "[w]omen'splace in man'slife cycle has been that of nurturer,caretaker,and helpmate. .. ," in short,wife and mother.And it is these rolesthat have given shapeto women'sdistinctiveapproachto morality. Now it is importantto recognizeat this point that merely connecting an ethic of care and compassionto motheringas a model of moralrelationsdoes not fully explain how such an ethic is rooted in women'sexperience, for we have not yet said anything about how motheringgives rise to the distinctive featuresof an ethic of care and compassion;nor have we said anythingabout the relation of an ethic of care to the experience of women who are not mothers. Let us turn to consider these issues. CHILD-REARING

In addressingthe question of how mothering is related to particularfeaturesof a feminist ethic of care, we can identifyat least two generalformsof the appealto the experienceof mothering,one that highlightschild-rearing, and a second that underscoreschild-bearing.The first approachplaces the emphasison a woman'sexperience of caring for a child. According to this view, it is significantthat it is almost alwayswomen who care for the young, becausethe experienceof caringfor childrencan give rise to particularcharacter traitsthat sustaincare and compassionmore generally.In other words, the parent-childrelation may be morallyformativefor the parent as well as for the child. This appeal to the importanceof the experience of child-rearingis often developed in relation to the workof Nancy Chodorow(1978), and it is thus worth looking brieflyat her work. As is well known, Chodorowoffersa developmental theory of gender formationin men and women. According to Chodorow, the fact that women are almost alwaysthe primarycaretakersis significantbecause the parent-childrelationhas importantconsequencesfor ego formationand the identificationof gender. Drawingon object relations theory, Chodorowarguesthat a child's "social-relational"experienceduring infancy and childhood serves to shape his or her personalityin important ways. Moreover,becausea relationwith a same sex parentwill necessarilybe differentfromthat with an oppositesex parent, the trajectoryof this development will be quite differentfor girlsthan for boys. Both, of course,will begin along the same path, for both will initially identifywith their mother. But as

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each begins the process of individuationand gender formation, their paths will diverge. On the one hand, the girl will not need to distinguishherself sharplyfrom her mother in order to establish her own gender identity, and her mother, herself identifyingwith the female child, will not encouragedifferentiation.As a result, the girl'sidentitywill be formedin attachment, and separationwill be difficult. A boy'sdevelopment, on the other hand, will be quite different. Becausehe will need to differentiatehimself sharplyfromhis mother in orderto establishgender identity and becausehis mother will encourage this, a boy's identity, will be formed in detachment, and intimacy will be difficult. The significanceof Chodorow'stheory to our question about the relation between motheringand a feminist ethic of care is that it mayprovideone explanation of the relation between motheringand particularaspectsof caring and of how an ethic of care is rooted in women'sexperience. On Chodorow's account, for example, an ethic of care could be said to be distinctivelyrooted in women's experience because women are preparedpsychologicallyfor caring and nurturing through the developmental situation in which women mother (Chodorow 1978, 39). If Chodorow is correct, because women's identity is not forged through separation,because women'sgender roles are learnedthroughexamplesratherthan throughrules, becausewomen'sidentity is not threatenedby intimacy, a concern for relationshipand an easy acceptance of attachment will appearnatural to women. Thus an ethic that emphasizeshuman interdependence,emotional commitment, and concern for communitywould seem readilyderivablefrom women'sexperience. That Chodorow'swork providesan importantexplanatoryframeworkfor understandinga feminist ethic of care is attested to by the fact that both Gilligan and Noddings draw on her work in sketching their respective accounts of this ethic. Gilligan, for example, suggeststhat the differencebetween a woman'sapproachto moral decision makingand a man's is tied to differingviews of the self.3 When the self is defined in relation to others, a concern for relationshipsratherthan for rightswill be the naturaloutgrowth. When the self is defined through separation, relationshipsthemselves are likely to seem threatening, and rules and rights are likely to be comforting. Similarly, when Noddings (1984, 128) suggeststhat mothering and caring are "deeplyrelated,"she explicitly appealsto Chodorowfor a possibleexplanation of why women are both mothers and caring. For both Gilligan and Noddings, the deep psychologicalprocessessuggestedby Chodorowhelp explain why it is that women displayin their lives, especiallyin their lives as mothers, the virtues, attitudes, commitments, and beliefs that constitute a feminist ethic of care and compassion. Apart fromChodorow'sexplanatoryaccount of the psychologicaldynamic by which women acquirethe traitscharacteristicof an ethic of care and compassion, others have pointed to some of the moreobvious, but no less signifi-

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cant, consequencesof the fact that women mother. A numberof writershave pointed out, for example, that child-rearingis an activity that places certain demandson women and, in turn, fosterscertain skills. SaraRuddick(1983) has argued this point straightforwardlyand convincingly. According to Ruddick,motheringis a social practicein the sense that it is a humanactivity governedby certain interestsand definedby certainends. In this case, the interests and goals cohere aroundthe developing child. As Ruddickputs it: Maternalpracticerespondsto the historicalrealityof a biological child in a particularsocial world. The agents of maternal practice, acting in responseto the demandsof their children, acquirea conceptualscheme-a vocabularyand logic of connections-through which they orderand expressthe facts and values of their practice (1983, 214). The historical reality of the child will demand that agents of maternal practice seek to promote the health and well being of this child. Maternal practicewill thus be directedtowardpursuingthe "preservation,growth, and acceptability"of a child within a particularcommunity, and the upshot is that maternalpracticecan give rise to distinctive waysof thinking about and ordering the world which promote these goals. So, for example, Ruddick (1983, 217) arguesthat a commitmentto the goal of preservingthe child may give rise to a "metaphysical"attitudeof "holding,"namely, a commitmentto "the priorityof keepingover acquiring,of conservingthe fragile,of maintaining whateveris at hand and necessaryto the child'slife." Or again, a concern for fosteringa child's growthmay give rise to an openness to change. It may lead women to eschew the certainty of the naturalscientist and to adopt a non-judgmentalwait-and-seeattitude. Ruddick'stalk of a metaphysicalattitude of holding, of the necessity for non-judgmentaland non-absolutistmaternalresponses, or of the tolerance for ambiguityand disorderrequiredof a child-carer, is strikinglysimilar to what Gilligan and Noddings have endorsed.In fact, Ruddick'sdescriptionof the social practiceof child-rearingallows us to see how the activity of raising childrenmay generateand sustaina set of priorities,commitments,attitudes, virtues, and beliefs that may reasonablybe said to informa view of interpersonal relations that I have called a feminist ethic of care and compassion. When Noddings and Gilligan point to the importanceof the priorityof relationships over rights, of concretenessover abstraction,of caringover calculating, they are drawingattention to preciselythe sortsof commitmentsthat Ruddicksuggestsare characteristicof maternalpractice. Once again, then, the experienceof mothering,construedas child-rearing,appearsto be important to the articulationof a feminist ethic.

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CHILD-BEARER

Alongside this appeal to the experience of caring for children, however, can be seen a second versionof the new romanticismthat emphasizesthe significance of the fact that it is women who give birth. Whereasthe previous view highlights women's experience of caring for children, this view underscoresthe experience of bearingchildren. And the appealto childbirthhere is symbolicof a much greateremphasison the biologicaldifferencesbetween women and men (Rossi, 1977). If women and men approachmoralitydifferently, it is suggested,at least part of the reason is that the biological differences between women and men lead them to experience the world differently.4 Consider, for example, an essay by Caroline Whitbeck (1983) entitled "The MaternalInstinct." Whitbeck is concerned in this essayto account for the particularattachment that many women feel towardtheir children and that leads them to care for their children more deeply than many men. She acknowledgesthat socializationis an importantfactor, but it is not the only, or indeed the primary,one. Rather, what is trulycrucialhere is that women simply have different experiences vis-a-vis their children, experiences that are mediatedby biological differencesbetween the sexes. Whitbeck puts her point succinctly: I shall arguethat factorsother than those which are solely the productof socializationinfluencewomen, and not men, in their attachmentto their children, and that these factorsarise from biological differences. According to my analysis, these factors are the experiencesof pregnancy, labor, childbirth, nursing, and postpartumrecovery. (1983, 186) It is importantto be clearhere that Whitbeck is not offeringa biologicallydeterministicunderstandingof the nurturingcapabilitiesof women. She is not suggestingeither that women are innately more nurturingthan men or even that differencesbetween women and men in this regardcan be explainedsimply in termsof differentialhormone levels. On the contrary,as the emphasis on "experiences"in the above passagesuggests,she is concernedwith how biological differencesgive rise to qualitativelydistinct consciousexperiencesin women and men. In the case of attachment to and care for one's children, these differences are mediated by the fact that women, but not men, can give birth and can nurse their children. Yet, this difference in biological ability assuresthat a woman'sreproductiveexperience will be differentfrom a man's, and it may be differentin a way that is relevant to the ability or willingnessto care. We can see this point by understandingthat the processof identifyingwith another seems to be an importantcondition of the ability to care. Yet, if this is

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the case, a woman'sreproductiveexperiencewould seem to put her in a better position to care than would a man's. As Whitbeck points out, a woman has carriedthe fetus; she has experiencedthe helplessnessof labor and the physical weakness of the postpartumperiod; she has adjustedthe schedule and contents of her own meals to accommodatethe fetus or infant; she has experienced the symbiotic relation of the let-down responseas she nurses. And each of these experiencesfostersthe identificationwith the child in a way that helps explain both the particularattachment of a woman to her child and the care she exhibits towardher. Whitbeck's thesis supplementsour earlier discussion of the relation between mothering and a feminist ethic of care and compassion. For just as Chodorow'saccount of ego formationmay help to explain why a woman's identity is not threatenedby intimacyand thereforewhy a woman may more easilyformthe attachmentsnecessaryto caring;and just as Ruddick'saccount of the practiceof child-caremay explain why the agentsof maternalpractice maybe moreskilledat caringthan others, so too mayWhitbeck'sobservation about the biological aspectsof motheringhelp explain how the self-otherdichotomy that stands in the way of an ethic of care is less prominent in women'slives. For a womanwhose milk lets down at the soundof her child's cry or whose womb contracts in responseto her child's sucking, separation will not appearontologicallybasic;on the contrary,relationwill appearbasic to human existence. PROSPECTS FORTHENEWROMANTICISM We must pauseto ask at this point whetheran exclusive appealto the biologically unique experiences of women is ultimately a satisfactorybasis on which to rest a feminist ethic. My own view here is that it is not. Foran appeal to distinctive, biologicallymediatedexperienceswould seem to commit one to the view that over an importantrangeof life situationswomen'sand men's experiences are simply incommensurable.And this commitmentwill in turn lead to another when combined with the view that the capacity to care is in some way determinedby these life experiences,namely, that a feminist ethic is not fully open to men. Here we see why it is importantto distinguishthe two sorts of appealsto the experience of mothering. For an appeal to the experience of caring for childrenis verydifferentat this point froman appealto the biologicallymediated experienceof mothering.While it is possible, if not likely, that men will assumeprimaryresponsibilityfor child-care- and thus presumablybecome more caring- men cannot experience the close identificationwith another that resultsfromcarrying,giving birthto, and nursinga child. Thus, if a feminist ethic of care is groundedin these experiences, if the abilityfully to care for another is contingent upon the biologicalexperienceof mothering,it will necessarilybe an exclusive ethic.

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It is, of course, possible to arguefor such an exclusive ethic, and such an argumentmight perhapsbe one more featuredistinguishingan ethic of care frommore traditionalmoraltheoriesthat typicallyarenot so restricted.I suppose, too, that if one were to arguefor the exclusivityof an ethic of care, the fact that the promiseof such an ethic, e.g., of moving us towarda morecompassionate and less violent society, would be diminished, would not be of greatconcern. Nor would the fact that such an ethic appearsto tie women to an exclusivelydomesticrole. Radicalseparatistscould simplyendorsethese as unavoidableconsequencesof biologicaldifferences,thus makingvirtueout of necessity. Yet, if an ethic of care and compassion is not construedas a separatist ethic, the attempt to ground it in the biologicallymediated experiencesof child-bearingwill be deeply troubling.And my sense is that most advocates of such an ethic do not understandan ethic of care as a sortof sectarianethic. CertainlyGilligan and Noddings, the two writerson whom I have focused, do not so understandit. Noddings (1984, 2), for example, saysat the startof her work that she sees "no reason why men should not embraceit [i.e., an ethic of care]."In fact, she repeatedlysaysthat an ethic of care is universally accessible. Gilligan, too, would appearto reject the separatistthesis. She is quite emphatic (1982, 2) that the distinctive voice she has discernedin discussions of morality is "characterizednot by gender but [by] theme." And even when she discussesthese distinctive voices in gender-specificterms, she is clear that an ethic of care is open to men; indeed, it is somethingto which they should aspire. "Development for both sexes," Gilligan writes (1982, 100), "wouldthereforeseem to entail an integrationof rightsand responsibilities throughthe discoveryof the complementarityof these disparateviews."5 Unfortunately,if the capacityto care is significantlyconditionedby access to the experiencesassociatedwith child-bearing,the call for men to become more caring and compassionatebegins to sound a bit like past exhortations within Christianityfor women to emulatethe VirginMary:the ideal is simply not capable of realization.The pessimismthat such a conclusion should engenderought to raiseseriousquestionsabout an exclusive appealto the biologicallyuniqueexperiencesof women as the foundationfor an ethic of care. Moreover, there ought to be serious misgivings about a second consequence of this sort of appeal, namely, the fact that it appearsto assign primaryresponsibilityfor caringto women. Indeed, Ehrenreichand Englishsuggest that one of the fatal flawsof earlierromanticviews was that these views saddledwomen with sole responsibilityfor caring. Unfortunately, "the romantic 'solution',"they write: was to take all responsibilityfor love and caring and place it squarelyon the backsof women: individualwomen, each one in isolation, holding out against the anarchyof the market-

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place. And in this lay the fatal moralcompromiseof sexualromanticism:it chose not to remakethe world, but to demand that women make-upfor it (Ehrenreich and English 1978, 314). If caring is experientiallygroundedin mothering and if mothering is construedprimarilyin termsof the experiencessurroundingchildbirth, then all responsibilityfor caringwill be placed "squarelyon the backsof women."Nor will there be any incentive to attempt to remakethe world, becausethe biological world is given. Indeed, what Adrienne Rich (1986, 92) said of Elizabeth Gould Davis'sworkis equallyapt here: "Since reformsarepointless, this is an invitation to drift into the futureon the currentof women'spresumed superiority."6 Nevertheless, as we have seen, the appealto the biological experiencesof motherhoodneed not, and, I would argue,shouldnot, be the exclusive basis of the articulationof a feminist ethic of care and compassion.For one may drawon the experiencesof women and mothersin their roles as primarycaretakersof society. And if, in drawingon these experiences,a new romanticism is constructed,it is at least a romanticismwith a difference.Forunlike earlier romantic views, the romanticism of a Noddings or a Gilligan is not constructednegatively in reaction to the perceivedevils of the male workworld or merelyto meet the needs of the males in that world. Ratherit is positively developedout of women'sexperience, by women. This last point is important for, as Ehrenreichand English make clear, earliercelebrationsof feminine virtues were often orchestratedand legitimatedby males and served to perpetuate male domination. Thus 19th centuryromanticismwas cloying in its idealizationof women. It placed women on a pedestalfrom which, it made clear, she must not descend--say, into the work world-lest she soil her untarnishedvirtue. It thus providedno futurefor a womanother than carefor her family. And even here it was oppressivebecause family life was understood to be a place of almost gushingwarmthand emotionality. Reason had no place there, for rationalitybelonged to the marketplace. By contrast, the new romanticism, developed by women, in part for women, emphasizes the intellectual and emotional skills required of mothering. Further, it need not simply idealize the role of mother, for it acknowledgesthat motheringcan be oppressive,that it can straightforwardly be drudgery,that alongsidethe particularvirtuesto which it gives rise can be found some characteristicvices. Most importantly,however, it insists that women do not look out at only one horizon. A feminist ethic may turn to motheringfor a model of moralrelations, but it does not say that only mothers, or for that matter, only women can be nurturing.Thus, it does not suggest, even tacitly, that women should be mothers. On the contrary, it says that personsshould be caring and compassionateand that they should be so

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whetherthey are mothersor corporateexecutives, men or women. And here, I believe, the new romanticism,at least one that does not over-emphasizethe biologicalcomponent of caring, escapesthe central difficultyof its predecessors: it does not make the fatal compromise. The conviction that women must simplyhold out againstthe valuesof the male work world is absent from the new romanticism.For accordingto the new romanticism,one of the goalsof a feministethic of careis to "remakethe world." And it is clear that this sort of transformationrequiresstructural change. What is requiredis not individualwomen in isolation holding out against the system;what is requiredis a change in the system. Gilligan and Noddings and Ruddickwould all accept that we must work towardeliminating the split between home and work that effectively confines care and nurturanceto the domestic world. Further,this particularversionof the new romanticism, i.e., the version that stressesthe importanceof motheringconstrued as child-rearing,would suggest that the most effective way to bring about structuralchange is preciselyto take the burdenoff the backs of individualwomen. That is, Chodorow'swork, as well as that of Ruddick,suggests that change may be facilitated by encouragingmen to assumeprimary,or at least equal, responsibilityfor child-care. On the one hand, it is arguedthat such a change would disrupt the psychological dynamic that reproduces motheringonly in women. On the other hand, it is said that such a change would introducemen to the demandsand interestsof mothering,which help to generate and sustain care and compassion. Ehrenreichand Englishclose their book by suggestingthat the romanticist/ rationalistalternative is unacceptable. "[WJerefuse,"they write: to remain on the marginsof society, and we refuse to enter that society on its terms. If we reject these alternatives,then the challenge is to framea moraloutlook which proceedsfrom women's needs and experiences but which cannot be trivialized, sentimentalized, or domesticated. A synthesis which transcends both the rationalist and romanticist poles must necessarilychallenge the masculinistsocial orderitself. It must insist that the human values that women were assignedto preserveexpandout of the confines of privatelife and become the organizingprinciplesof society (1978, 324). It seems to me that this is essentiallythe vision offeredby the new romanticism, for a feminist ethic of care and compassionseeks to framea moraloutlook which proceedsfromwomen'sexperienceand which radicallychallenges the existingsocialorder.Whethersuch an ethic can avoidthe sentimentalityof earlier romantic views and whether it can underwritethe sort of structural changethat is requiredto makecareand compassionorganizingprinciplesof society are questionsthat will ultimatelydeterminethe fate of this ethic.7

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NOTES 1. See, for example, Andolsen (1985) and Kittay and Meyers (1987). 2. On this view, rights come to have a certain primacyinsofaras they serve as fences, so to speak, protectingcompeting individualinterests. 3. In "MoralOrientation and Moral Development," however, Gilligan (1987, 28-29) discusses some of the problemsshe sees with Chodorow'saccount. 4. The qualification,"at least partof the reason"is important,for those who have pressedthis position have not wanted to deny the way in which the experienceof women caringfor children gives rise to manyof the most distinctivefeaturesof a feministethic of careand compassion.The real issue, as we will see below, is how much emphasisis placed on biological difference. 5. In a later essay (1987), Gilligan is much less certain about the complementarityof these two perspectives.The analogyto the phenomenonof ambiguousfigureperceptionto makesense of the relation of care and justice is useful, she writes (1987, 30), becauseit guardsagainstthe idea "that these two perspectivesare readily integratedor fused." 6. This comment appearsin a footnote added in the tenth anniversaryedition publishedin 1986. 7. Thanks to HowardEilberg-Schwartz,Helen BequaertHolmes, Thomas E. Kelly, Gilbert Meilaender, Karen Michney, Louis Newman, LauraPurdy, and the anonymousreviewersfor Hypatiafor their valuable contributionsto this essay.

REFERENCES

Andolsen, BarbaraHilkert, Christine E. Gudorf, and Mary D. Pellauer. 1985. Women'sconsciousness,women'sconscience.San Francisco:Harper and Row. Chodorow,Nancy. 1978. The reproduction of mothering.Berkeley:University of CaliforniaPress. Ehrenreich,Barbaraand DeirdreEnglish. 1979. Forherowngood.New York: Anchor/Doubleday. Gilligan, Carol. 1987. Moralorientationand moraldevelopment. In Women and moraltheory.Eva FederKittay and Diana T. Meyers, eds. Totowa, NJ: Rowman and Littlefield. Gilligan, Carol. 1982. In a differentvoice.Cambridge,MA: HarvardUniversity Press. and Tragedy.Notre Dame:University Hauerwas,Stanley. 1977. Truthfulness of Notre Dame Press. Held, Virginia. 1987. Feminismand moraltheory. In WomenandMoralTheory. Eva FederKittay and Diana T. Meyers,eds. Totowa, NJ: Rowman and Littlefield. Kittay,Eva Federand Diana T. Meyers,eds. 1987. WomenandMoralTheory. Totowa, NJ: Rowman and Littlefield. Lasch,Christopher.1977. Havenin a heartlessworld.New York:BasicBooks. Morgan, Marabel. 1973. The totalwoman.Old Tappan, NJ: F. H. Revell. Noddings, Nel. 1984. Caring:A feminineapproachto ethics& moraleducation. Berkeley:University of CaliforniaPress.

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Rich, Adrienne. 1986. Of womanbor. New York:Norton. Rossi, Alice. 1977. A biosocialperspectiveon parenting.Daedalus106:1-31. Ruddick, Sara. 1984. Maternal thinking. In Mothering:Essays in feminist theory.Joyce Trebilcot, ed. Totowa, NJ: Rowman and Allanheld. Smith, Ruth L. 1985. Feminism and the moral subject. In Women'sconsciousness,women'sconscience.BarbaraHilkert Andolsen, Christine E. Gudorfand MaryD. Pellauer, eds. San Francisco:Harperand Row. Whitbeck, Caroline. 1984. The maternal instinct. In Mothering:Essaysin feminist theory. Joyce Trebilcot, ed. Totowa, NJ: Rowman and Allanheld.

Ethics of Caring and the InstitutionalEthics Committee BETTYA. SICHEL

Institutionalethicscommittees(IECs) in healthcarefacilitiesnow createmoral policy,providemoraleducation,and consultwithphysiciansand otherhealthcare workers.Aftersketchingreasonsfor thedevelopment of IECs, thispaperfirstexammoralstandardsit is oftenassumedIECsarenow using,these inesthepredominant standardsbeingneo-Kantianprinciplesof justiceand utilitarianprinciplesof the greatestgood. Then, it is arguedthata feminineethicsof care, as positedby Carol basisfor IEC discussions anddeGilliganandNel Noddings,is an unacknowledged cisions.Further,it is suggestedthatfeminineethicsof carecan and shouldprovide underlyingtheoreticaltoolsand standardsfor IECs.

Institutionalethics committees' may be ideal vehicles for the ethical decision makingand standardsadvocatedin the feminine ethics of Nel Noddings (1984) and women'smoralreasoningof CarolGilligan (1982). If it acceptsa Gilligan-Noddingstheoretical framework,an institutionalethics committee (IEC) can be a communicativenetwork with everyone concerned with the moral dilemma, can contribute to problemresolution, and can even frame policy. The ethical standardsof a Gilligan-Noddingstheory would include caring-for,compassion,concern, responsiveness,2and sensitivityto context. At present, however, studiesof institutionalethics committees3rarelymention any of these standardsas the basisfor the goals, functions, and processes of these committees.4 After briefly discussingthe inception of IECs, their goals, structure,and functions, and the ethical standardsthey use, I examine how theoriesderivedfromGilligan and Noddings'sworkcan providea different theoretical frameworkfor these committees. HISTORICAL PERSPECTIVE: WHY INSTITUTIONAL ETHICSCOMMITTEES

The impetusto form IECsin partderivedfromthe consequencesof a cluster of legal cases and federal mandates. Three of these indicate why health care professionalswere motivated to establish IECs: (i) The New JerseySupremeCourtdecisionin the KarenAnn Quinlancase (Weir 1977): Karen Quinlan, a comatose patient, was on a respirator. Hypatiavol. 4, no. 2 (Summer1989) ? by BettyA. Sichel

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Though she was incompetent and irreversiblybraindamaged(in a persistent vegetative state), KarenQuinlan was not brain-dead.Her father, a religious man, petitioned the SuperiorCourt of New Jerseyto have the respiratorremoved. The Court justifiedits decision not to authorizeremovalof the respiratorin a numberof ways, e.g., citing expert medical testimony against removing the respirator,noting that the rapidadvancementof medical knowledge made it impossibleto foresee what future knowledgewould mean for the patient'shealth, recognizingthe absence of medical traditionto warrant the act, and referringto legal precedent. When KarenQuinlan'sfather then appealedthe case to the SupremeCourt of New Jersey,that Court reversed the firstdecision and authorizedthe removalof the respirator5on the basisof an individual'sright of privacy (Weir 1977). The specific featuresof this case and both court decisions are unimportant here. However, one aspect of the decision drasticallychanged the character of medical institutionalethics. The SupremeCourtjudgestated that such institutions should seek the prior approvalof an "ethics committee"for decisions regarding dilemmas like the Quinlan case. As noted by Fost and Cranford(1985, 2688), the expression "hospitalethics committee" in this decision "wasa misnomer"since what the Court "clearlyintendedwas a neurologicalconsultation committee: a groupof personsexpert in the medical, and particularlyneurologicalprognosisof the patient." The Court assumed that an ethical dilemmacould be settled with the empiricalfacts of the case. The judge'sdecision in retrospectcan be interpretedas positivisticsince it assumed that facts would speak for themselves to reveal ethical choices; that expert medical knowledge alone could determine what decision should be made in a medicalcase. Though they realizedthat the judgehad pinpointeda method and structureto resolveunusuallydifficultmedicalethical dilemmas, some health care workersalso recognizedthat expert knowledgealone would not suffice. Thus, they implicitly rejected a positivistic approach. (ii) The BabyDoe Case:The consequencesof this 1982 Bloomington, Indiana, case frightenedhealth care professionalsand providedfurtherimpetus for the formationof IECs.6When BabyDoe was bor with Down Syndrome and a malformedesophagus,the parents,agreeingwith one of two conflicting medical opinions, decided that no operation should be performedand that the baby should just be kept comfortable.The hospital administrationwent to court to reverse the parents' decision. The legal efforts of the hospital failed when Baby Doe died. However, the Case created considerablepublic outcry that includednumerousnewspaperand magazinearticlesand editorials. One ominous consequence of this Case was intervention by the Federal Government. The first set of Federalregulationson neonatal care was struck down in court for proceduralreasons. Even though ensuing Federalregulations were far less pernicious, administratorsof health care facilities clearly saw the specterof massivefederalintervention into medicalpolicy and deci-

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sion making. The question asked by health care professionalswas, how can we avoid federal intervention?The American Academy of Pediatrics,in its desireto avoid "compulsoryhospitalnotices, hotlines, and BabyDoe Squads" (Kuhseand Singer 1982, 177), promulgatedpolicy on criticallyill newbors. This policy included recommendationsabout the formationof IECs. ReviewBoards(IRB) to reviewexperimen(iii) The mandatingof Institutional tationwithhumanbeingsin healthcarefacilities:Biomedicalresearchin hospitals and other health care institutionsoften createda wide varietyof ethical problems. When patients were used as subjects in these experiments,problems might include what comprisedinformedconsent and what sorts of experiments should not be conducted even if subjectsgave informedconsent. For example, if one groupof patientswere to be given a medicationthat might alleviate symptomsof life-threateningillness and anothersamplewith the same illness were given a placebo, should the experimentbe permittedeven if all patientsgive informedconsent?The FederalGovernmentwas not concerned with the answerto this question, but with the method for makingthe decision. In 1966, the FederalGovernmentmandatedthe establishmentof IRBsto evaluate the acceptabilityof biomedicalresearchwith patientsof health care institutions and prescribedminimum guidelines for the membershipof the boards(Glantz 1984). With this mandating,health careworkersrealizedthat there was considerableprecedentfor FederalGovernmentintervention.Even if IRBs are now consideredbeneficial, the mandatingof these Boardswas a furtherreasonfor health careprofessionalsto seek other internalmeansto resolve day-to-daydifficult and sensitive ethical dilemmasin all clinicalsituations. In addition,the relativesuccessof IRBssuggesteda generalstructureand method by which health care institutionscould make ethical policy, provide consultativeservices,make ethical decisions,and offereducationalservices. In addition to court cases and governmentintervention, other conditions during the late 1970s and early 1980s contributed to the belief that IECs could resolve new, unique, and complex health care ethical dilemmas.First, new medicaltechnology createdethical situationswith few if any precedents (Rosner 1985). Second, patients and their families no longer accepted passive roles but demandedactive partsin makingdecisionsaboutmedicaltreatment. The rightsmovement resultedin the belief that each humanbeing was an autonomousagent capable of making informeddecisions regardinghis or her own life and medical care. Even when patients such as infants, minor children, individualswith dementia senility, and comatosepatients were incompetent to make decisions, physiciansfelt constrainedand without the right to make the ultimate decision about medical treatment. The question raisedwas, who had the right to make these decisions? A change in the ethical climate of society is a fifth reasonfor the development of IECs.Just as with every other profession,there have been questions

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about the ethical behaviorof physicians,e.g., questionsaboutphysiciansreceiving excessive Medicareand Medicaidpaymentsand questionsabouthow some familiesobtain infantswithout "normal"adoptionprocedures.Furthermore, malpracticesuits against hospitals and physicianshave causedhealth care professionals and institutions considerable concern about how they might protect themselves. INSTITUTIONAL ETHICSCOMMITTEES: PRESENTSTATUS

This brief backgroundsketch indicates that, in the late 1970s and early 1980s, the time was ripe for a new structurefor makingmedicalethical decisions; an autonomousphysicianno longercould make all medicaland ethical judgmentsfor his or her patients. The structurechosen went beyond what was recommendedby the Court in the Quinlan Case. IECs were formed; their purpose,accordingto Fost and Cranford(1985, 2688), is the "improvement of intrainstitutionalor extrainstitutionalpublic relations, education, development of policy and guidelines, a consultation for active decisions." No matter what articles about IECs state, a primarypurposefor these committees is to protect health care institutions and personnelagainstmalpractice claims. Therefore, committees usually include an attorney with expert knowledgeof legal precedentsin health care cases, e.g., such mattersas the rightsof patients of familiesto decide that a do-not-resuscitate(DNR) order be issued; instances of withdrawalof life supportsystems;questions about what treatmentand care is considereda "life supportsystem;"and courtdecisions overridingreligiousfreedom especially in the case of minors. Even if protectionagainstmalpracticesuits is mentioned as only one of a spectrumof purposes,legal ramificationsstill seem a majorconcern. The emphasison the legal consequencesof health care policy and medical decisionsmay be one reasonfor arguingthat a principledethic of justice and rightsunderliesdeliberationsof IECs.A second reasonthat a theoryof rights, principles,and justice seems basic to the deliberationsof IECsis that certain policies and decisions involve questions of competition, prioritization,and scarce resources.Such a committee might justify the unequal allocation of scarce resources,providedthat ethical principlesgovern the procedures,deliberation, and decisions on the distributionof these resourcesand the making of medical policy about such distribution. As an example of scarceresourceallocation, let us look at a case described by Macklin (1987, 155-156). All 15 beds in an intensive careunit (ICU) are taken. One patient is "an intravenousdrug abuserwith a diagnosisof acquiredimmunedeficiency syndrome(AIDS) who . . . [is] consideredterminally ill." Another is a brain-deadnineteen-year-oldman whose familyinsists that every meansbe used to keep him alive. If a 63-year-oldphysicsprofessor with a heart attack is broughtto the emergencyroom, what decision should

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be made about who has priorityfor an ICU bed? Who has the right to this scarceresource?Should one of the patients in the ICU be transferredto a regular medical care floor? Should prioritybe given to the physicist?On what ethical basis should this decision be made?Should a theory of rightsand justice or a form of utilitarianconsequentialismbe used to make the necessary choice? A theory of utilitarianconsequentialismwould insurethe maximization of the good, the greatestgood for the greatestnumber.The savingof the physics professor'slife by giving him the scarce resource,a bed in the ICU, the utilitarian might argue, would maximize the good since the physicist could subsequently contribute much greater good to human life than the brain-deador the AIDS terminallyill patient. Deliberationsand decisions might also be basedon deontologicaltheories, on neo-Kantianethics, e.g., the principlesof John Rawls'stheoryof justice as fairness.Rawlsprovidesphilosophicaljustificationfor the lexical or serialorderingof competingmoralprinciples.Ratherthan acceptingintuitivelychosen principles, Rawls argues: We can supposethat any principle in the (lexical) orderis to be maximizedsubjectto the condition that the precedingprinciples are fully satisfied.As an importantcase I shall . . . propose an orderingof this kind by rankingthe principleof equal liberty prior to the principle regulatingeconomic and social inequalities. This means, in effect, that the basic structureof society is to arrangethe inequalitiesof wealth and authorityin waysconsistent with the equal libertiesrequiredby the preceding principle. (Rawls 1971, 43) Justas Rawlsgives priorityto equal liberty,those deliberatingon medicalethics policy might arguethat certain principleshave priority.The question to be answeredby an IEC that accepts the notion of lexical ordering,would be which principleshave priority,not the question of whether there should be such priority. In still another sense, the decisions of IECs can be seen through a Rawlseanframework.When an IEC formulatesmedicalpolicy, the committee is following a Rawlseandistinction between justifyingrulesor policy and justifyingactions under rules (Rawls 1955). In the case of justifyingrules or policy, the problemis how one justifiesprinciplesor generalrulesthat would then be standardsfor makingmoraljudgments.Though a moralprincipleor general moral rule could apply to a large class of moral dilemmas, it is logically possiblefor a moralrule to applyto a class of one or zero. Forexample, an IEC might stipulatepolicy for proceduresin the adoptionof newbornsin the hospital and for physician involvement in these practices.Though there is policy for medical personnelto use in makingdecisions in potential adoption cases, there is no need for an adoption case ever to occur.

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In the case of justifyingactions undera rule, accordingto Rawls, an agent faced with a concrete moraldilemma uses appropriatemoral rules or principles to resolve the dilemma. This is not a matterof automaticallyapplyinga set of rules to the moral dilemma and thereby having a simple formulato solve all moraldilemmaswithin an appropriateclass. Even if a moralprinciple or rule exists, considerablereasoningwill be necessary.The agent will have to decide the parametersof the problem,how the moraldilemmarelates to the largerexperientialsituation, what moralprincipleor ruleappliesto the dilemma, and how hypothetical judgments relate to action and consequences. For example, an IEC may have developed policy confirminga competent patient'srightof informedconsent priorto treatmentor intrusiveprocedures. In a concrete moral dilemma, however, there often is a grey area between competencyand incompetency. If a patient is unquestionablyincompetentto make an informeddecision, e.g., in the case of a comatosepatient, who has the right to make decisions for the patient? AN ETHICSOFCAREAND IECS

A differentvantage point can reveal that many IECscan and do operate differently and tacitly seem to make use of the theories of Gilligan and Noddings. With a theory of universaland abstractprinciples,e.g., as articulated by Rawls, moral agents are not particular,concrete individualswith their own unique life histories, desires, and emotions. Further,neither these dimensions nor relationships with others, neither friendshipsnor community, should affect moraljudgments.Instead, the moralagent is like a placemark, a variablein an algebraicequation, no better and no worse than any other person in that given moral situation. The criteria of deontological moraltheoryrequirethat moralagentsput themselvesinto the role of all relevant others, all of whom should be given equivalent weight. Women'smorallanguageof responseand caringstartsfroma verydifferent perspective:Moral dilemmas are particular,unique situations in which all partiesretain their individual identities, their life histories, emotions, feelings, and relationships. Caring and relationship occur between particular concrete individuals.Moralsituationsexist within a particularhistoricaland sociological context; they are bound by time and place. Women's morality emphasizesconcrete situations, networksof relationships,caring, interpersonal communication, not hurting others, and responsibility. Nel Noddings'sfeminine ethical theory distinguishesbetween "caringfor" and "caringabout."Caringabout somethingcan distancethe agent fromthe object of caring and involves impersonality,the cause and institution, numerousothersnever seen or known, the scientific experimentand the mathematicalproblem.Caringfor focusseson emotions, feelings, and attitude;yet,

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as with Hume (1967) and others, reasoningand intellectualprocessesare at the service of sentiment and emotion. The change of venue advocatedby Noddings does not wholly ignore the theoreticalcontributionsof traditional ethics, but assumesthat only certain aspectsof these ethics can informand enrich the moral life of the one who cares for. The interpretation of Noddings'stheory as accepting dimensionsof traditionalethics may at first seem at odds with the stance she takes. Fortwo reasonshowever, Noddings's theorycan accommodatecertainfeaturesof traditionaltheories, first, by virtue of a numberof characteristicsof public life and second, due to featuresof traditionaltheories that can interlock with her theory. (i) Ethicaltheoriesandformsof publiclife. Noddings'sfeminine ethical theory refersto the individualmoralagent, the caring-one,the one who caresfor another. The theory can affect how hospital and nursinghome workersresolve moraldilemmasand how they care for another. However, the institution itself might very well not subscribeto this feminine ethic of caring. In other words, some health care professionalswithin the institutionswould ascribe to an ethic of caringand would carefor others, but the institution itself would ascribeto a differentethic. The institutionaluse of ethical principles of justicewouldnot undermineNoddings'stheory;but wouldembedit within a wider social, political, and legal context. In a sense, this is the continual struggleof morality,that a person'smoralbeliefs conflict with those of other individuals, institutions, or groups.7Individualsat times may change the qualityof relationshipswithin a groupor institutionthroughtheir adherence to an ethical theory other than the one underlyingthe institution. (ii) TraditionalethicaltheoriesandNoddings'stheory.Noddings'stheorydoes not entirely strayfromcertain ideas in traditionalethical theories. Noddings accepts the idea that someone using an ethics of caring, someone caringfor another, mustoften reasonto makejudgmentsto know what is rightor wrong in orderto care for another. We can find theoretical structuresfor this reasoning in recent workson feminist epistemologyand feminist waysof knowing, and even in a wide rangeof traditionalphilosophicaltheories. Some of these ideas are hidden in the crevices of commonly accepted ethical theories,8 and others are found in such resourcesas literature(Nussbaum1983). Noddings would avoid the abstractprinciples of traditional theories. She wouldwalk a narrowridgeto avoid the excessive abstractnessand generalizations of traditionalviews and simultaneously,would sidestep a profusionof unorganized,anarchic, fragmentedfacts. AN ETHICSOFCAREAND IEC PRACTICE

When we examine the procedures,deliberations,goals, and functions of IECs,we realizethat a rightsand justice model is not necessarilyappropriate, even though an IEC mustoften considerlegal dimensionsor precedents.In a

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numberof ways, the workingsof some IECscan be seen to be consistent with the feminine ethics of Noddings and women's moral reasoningof Gilligan. As in other caringrelationships,the relationshipbetween the one-caring, in this case the IEC, and the cared-for,the patient, requiresa delicate balance. If the cared-foris a fully competent adult and thus able to makea decision, at what point does the one-caring intrudeand overridethe cared-for'schoice? Should an IEC ever overridethe cared-for'schoice? (i) A Jehovah'sWitnesscase. A particularlydifficult case is the cared-for who is a memberof Jehovah'sWitness.9 IECsoften develop policy regarding the refusalof a memberof Jehovah'sWitness to have blood transfusions.This policy may stipulatesuch items as when a personis fully competent and capable of making an informedconsent, and what decisions medical personnel can make when an incapacitatedJehovah'sWitness requiresemergencycare. The moraldilemmaof Jehovah'sWitness'spatientswho refuseblood transfusions is not settled becausethe patient has legal rightsor becausethere is legal precedentand hospitalpolicy. There maybe problemssuch as whetherfamily membersapply undue pressureon the patient to refuse the transfusionor questions about when a patient is incapacitated. Medical professionsmay have a differenttype of moraldilemmain that they personallycannot accept the consequencesof a patient'srefusinga blood transfusion.Health care professionalsmay thus consult with an IEC about a particularpatient. In this consultation, an IEC is not an extraneousor artificialone-caring, but rather the committee joins an alreadyestablishedcommunicativenetworkof ones who carefor the patient. When a fullycompetentpatient makes a decision to reject a blood transfusion, she probablyhas considered her membershipin a caringnetworkand has questionedwhat is requiredto continue to belong to that network. The patient judgeson the basis of the values, beliefs, and the way of life that are accepted by herself and numerous other cherishedmembersof the communicativenetwork, in this case, other Jehovah'sWitnesses. An IEC may accept this patient'sdecision not merely becauseof legal precedentsand the patient'srights,but also becausethe committee puts aside its valuesand beliefs and becomesa memberof the patient's primarycaringnetwork. By doing this, the IEC recognizeswhat it means to care-forand be cared-forwithin the patient'sown primarynetwork.Through the choices and caring-forothers of this IEC, the quality of relationshipsin both the Jehovah'sWitness local communityand in the IEC itself has been strengthenedand changed. Macklin (1987, 21-22) termsthis type of problema proceduralproblem.In an ethics of caring, who decides for an incompetent patient may be part of the ethical dilemma. For example, accordingto legal precedent, in the case of an elderlyincompetentperson, the spousewould usuallydecide; if there is no spouseor the spouseis incompetent, the oldest child wouldmakethe decision. Since Gilligan, in women's morallanguageof care, stressesthe impor-

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tance of communicativenetworksfor the resolutionof a moraldilemma, one person making a moral decision for an incompetent patient might destroya primarycommunicativenetwork. Thus, the decision of who is involved in making the decision, whether it is the entire familial network or only one person, is itself a critical component of a moral dilemma. (ii) A fictionalizedcasehandledby an IEC. The responsiblephysicianat Big City Hospital bringsa case to the hospital'sIEC. The case concerns an 87year-oldman who lives by himself in a two-familyhome where his youngest daughterand her family live in the upperfloor apartment.The living conditions are ideal. For the father can take care of himself, go to the senior citizens center, play cardswith his cronies, make his own tea and lingerover his newspaper,invite his friendsto visit, have his other children and grandchildren visit him in his apartment,have privacy, take walks, etc. At the same time, his youngest daughterand her family can keep an eye on him and he can enjoy the intimacyof their relationshipwith him. One day he is brought to the hospital with chest pains and then admittedsince the medical team is not certain of diagnosis. Fromthe time Mr. A enters the hospital, he keeps repeatingthings like, "I do not want to be connected to any of those fancy devices." "I do not want to be kept alive if I am a vegetable.""Don't let me suffer.""I'vehad a good life and now it is probablytime to go." Membersof the medical team describehim as a feisty, self-willed, confident person. He may not have had a college education, but he does have what is traditionally known as commonsense. By the time the IECbegins to considerthe case, Mr. A is in a coma. In addition to the heart condition, there are other more life-threateningconditions including pancreaticcancer. Mr. A. is now consideredterminallyill. The responsiblephysician asks whether the patient'searliercomments warrant the issuance of a DNR order. In other words, should the earliercomments be interpretedas informedconsent?The youngestdaughter,who lives with the father in the two-familyhouse, agreeswith the physician, that a DNR ordershouldbe issued.However, the youngestdaughteris a minorityof one. The remainingchildren are horrifiedat the suggestionof issuinga DNR order.The IEC agreeswith the physicianand youngestdaughterthat the patient, when competent, gave permissionfor a DNR order.They arguethat no matter what medical treatment and care may be given, Mr. A. will never have the human relationshipswith family and friendsthat had made life so valuable for him. He is irrevocablyseparatedfrom his caring network. His networkof caringothers can carefor him, but he can never againcarefor the other membersof the network. According to a theory of rights and justice, the committee'sdeliberations about this case might be consideredcompleted;but with an ethics of caring, this cannot be the end of this case. The IECalso considerswhat the issuingof a DNR orderagainstthe wishesof the majorityof the familywill mean. It will

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not result in a malpracticesuit against the physicianor hospital, but serious damagemay very well be done to a caringnetwork. The other siblings may reject the youngestdaughteror may argueamong themselves as to why they had not been more strenuousin their objections. In orderto avoid a serious rupturein a caringnetwork, the IECsuggeststhat two of its members,a social workerand a cleric, should meet with the familyto discussthe problemof the DNR order. At the meeting, these membersof the IEC ask the familyabout their father, about his values and beliefs, about the father'sconversations with them concerning their mother'ssufferingand treatmentat the time of her death. In the end, aftergreatemotional turmoil,thought, memories,and tears, the children themselves state that the DNR ordershould be issued. In this face-to-facerelationshipwith the family, the IEChas indeed become the one-caring for a family. They encouragefamily membersto recognizewhat they have to do if they are to continue to be the ones caringfor their father. In all of this, the IEC membershave been compassionate, collaborative, communicative,and sensitive. They have acted accordingto an ethic of care and compassion. These examples by themselves do not provethat ethical theories derived from the work of Gilligan and Noddings can or should underlie the procedures, deliberations,and decisions of IECs. The examplesdo forcefullysustain two assertionsmade in this paper.First,the deliberationsand methodsof some IECs can presentlybe interpretedas consistent with an ethics of care and second, that such an ethics ought in the future to contribute to the strengtheningof the quality of the decision-makingprocessof IECs.10

NOTES 1. In additionto the expression"institutionalethics committee,"these committeesareoften known as medical ethics committees, clinical ethics committees, or hospitalethics committees. The institutional ethics committee should not be confused with an institutionalreview board that decides on the safety, efficacy, and ethics of experimentswith human subjects. 2. The term "responsiveness"is not used by Gilligan. ThroughoutIn A DifferentVoice, she uses the term "responsibility."However, since responsibilityhas traditionallybeen aligned with deontological theories, theories of rights and justice, I modify her term "responsibility"to "responsiveness."See Lyons 1983; Sichel 1985. 3. For a bibliographyof studies of IECs or Hospital Ethics Committees, see Macklin and Kupfer1988, A5-A9. 4. Dugan (1987) attempts to understandthe feminine voice in the ethical decision making of medical ethics committees, but does not recognizethe theoreticalcomponentsof that voice. He describesthe model as the one "utilizedby hospital MedicalEthicsCommittees"and as consistent with an integration of the "masculineand feminine voices." However, the model presented by Dugan could be interpretedas John Dewey's method of reflective thinking. 5. It is noted that the SupremeCourt did not authorizethe removalof all life-supportapparatus.KarenQuinlan continued to receive nourishmentthroughvariousdevices. Forthe distinction between life-supportsystemsand normal care in this case, see Rachels 1986, p. 101. 6. Two other cases are frequentlymentioned as triggersfor institutionalethics committees. These were the BabyJane Doe Case in New YorkState and the Case of the People v. Barberand Nejdl. For these and similarcases, see Kuhse and Singer 1982; Macklin 1987, 113-129.

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7. Fora discussionof these two moralitiesand the conflicts between the two, see Hampshire 1983, esp. pp. 101-125, 140-169. 8. One examplecan be found in the Socraticdialogues.Classicalscholarstraditionallyhave stressedSocrates'searchfor an abstract,universalmeaningof an ethical termand the aporiaending of the earlydialogues.What has receivedlimitedattention is the particularityof Socratesand an interlocutor'sdialogue. Both Socrates and each interlocutorare actual personswith unique life histories.Furthermore,the earlydialoguescannot be understoodwithout understandingtheir particularity.Thus, in a varietyof ways, these dialoguescould yield ideas to strengthenfeminist ethics. 9. According to most legal decisions, a fully competent adult who explicitly refusesa blood transfusionin a life threateningsituation on religiousgroundshas a right to make this decision even if it resultsin his or her death. The patient accordingto this view has a rightguaranteedby the FirstAmendment to the Constitution. There have been dissentersto this interpretationof the Constitution in that some legal opinions have assertedthat even with a fully competent adult, there can be conflicting rights and that the religiousright to choose not to have a blood transfusionis not absolute. 10. I thank Ruth Macklinfor the wide varietyof knowledgeand experienceI acquiredin her trainingprogramfor hospital ethics committees. I thank Helen BequaertHolmes and a reviewer for their suggestions.

REFERENCES

Dugan, Daniel 0. 1987. Masculineand feminine voices: Makingethical decisions in the care of the dying. The Journalof MedicalHumanitiesand Bioethics8: 129-140. Fost, Norman and Ronald E. Cranford. 1985. Hospital ethics committees. JAMA 253: 2698. Gilligan, Carol. 1982. In a differentvoice. Cambridge,Mass.: HarvardUniversity Press. Glantz, LeonardH. 1984. Contrastinginstitutionalreviewboardswith institutional ethics committees. In Institutionalethicscommitteesand health caredecisionmaking.Ronald E. Cranfordand A. EdwardDoudera, eds. Ann Arbor. Mich.: Health AdministrationPress. Hampshire,Stuart. 1983. Moralityand conflict.Cambridge,Mass.: Harvard University Press. Kuhse, Helga and Peter Singer. 1985. Shouldthe babylive?Oxford:Oxford University Press. Lyons,Nona Plessner. 1983. Two perspectiveson self, relationship,and morality. HarvardEducationalReview53: 125-145. Macklin, Ruth. 1987. MortalchoicesNew York:Pantheon Books. Manual Macklin, Ruth and Robin B. Kupfer.1988. Hospitalethicscommittees: for a trainingprogram.New York:Albert Einstein College of Medicine. Noddings, Nel. 1984. Caring,a feminineapproachto ethicsandmoraleducation. Berkeley,Calif.: University of CaliforniaPress.

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Nussbaum,MarthaCraven. 1983. Flawedcrystals:James'sThe GoldenBowl and literatureas moral philosophy. New LiteraryHistory15: 25-50. Paget, MarianneA. 1988. The unityof mistakes.Philadelphia:Temple University Press. Rachels, James. 1986. The end of life. Oxford:Oxford University Press. Rawls,John. 1971. A theoryof justice.Cambridge,Mass:HarvardUniversity Press. Review64: 3-32. Rawls, John. 1955. Two concepts of rules. Philosophical A review of their medical ethics committees: 1985. Fred. Rosner, Hospital development. JAMA 253: 2693. Sichel, Betty A. 1985. Women's moral development in search of philosophical assumptions.TheJournalof MoralEducation14: 149-161. Weir, Robert F., ed. 1977. Ethical issues in death and dying. New York: ColumbiaUniversity Press.

Feminist and Medical Ethics: Two DifferentApproaches to Contextual Ethics1 SUSAN SHERWIN

moraltheoryin Feministethicsand medicalethicsare criticalof contemporary severalsimilarrespects.Thereis a sharedsenseof frustrationwiththe levelof abworkin ethicsand traditional stractionandgeneralitythatcharacterizes philosophic a commoncommitmentto includingcontextualdetailsand allowingroomfor the in ethicalanalysis.Thispaperexploresthewaysin personalaspectsof relationships whichcontextis appealedto in feministand medicalethics,thesortof detailsthat narrativeapproachesto ethicalproblems, shouldbe includedin the recommended andthedifferenceit makesto ourethicaldeliberations feminist if we addan explicitly It thatan analysisof gender context. is claimed to our discussion of politicalanalysis is neededfor feministmedicalethicsand thatthisrequiresa certaindegreeof generof context. ality, i.e. a politicalunderstanding

INTRODUCTION Feministethics and medical ethics are relativelynew areasof philosophic specialization; each is developing at a dizzying rate, and some intriguing trendscan be seen as common to both. They are both interestedin developing the sort of analysis that can offer meaningfulguidance in the morally troublingsituationsof real life. In the literatureof each field, we find a sense of frustrationwith the level of abstractionand generalitythat characterizes traditionalphilosophic work on ethics. Both speak of the limitations of restrictingethical analysisto the level of generalprinciples,and they demonstrate a need to focus quite explicitly on the contextual details of life situations that are problematicfor morallyconcernedpersons.The use of context is quite differentin the two fields, however, and I shall arguethat there are importantlessons to be learnedfrom the details of contextual focus found in the literatureof feminist and medical ethics. In this paper, I shall explore the ways in which context is appealedto in both feminist and medicalethics, and I shall arguethat particularsortsof details should be included in the recommendednarrativeapproachesto ethical Hypatiavol. 4, no. 2 (Summer1989) ? by SusanSherwin

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I claimthat incorporating an explicitlyfeministpoproblems.In particular, liticalanalysisin ourdiscussionof contextis criticalto ourethicaldeliberations. I hope to showthat an analysisof genderis an importantelementof moraltheoryand that suchanalysisrequiresa degreeof contextually-based of context.By which oughtto be madeexplicitin ourdiscussions generality and the of sort of context about the degree generalitywhich beingspecific in to shouldbe keptcentral analysis practicalethics,we can beginto define of a feministmedicalethicsandprovidedirectionto other the characteristics areasof feministethics. ETHICS THE ROLEOFCONTEXTIN FEMINIST

Turningfirstto examinethe roleof contextin feministethics,we mustacknowledgethe importantinfluenceof CarolGilligan(1982). In identifyinga contextual femaletendencyto approachethicalproblemsin a personalized, manner,Gilliganhelpedarticulatethe senseof alienationmanywomenhave moral of contemporary experiencedin tryingto workwithinthe structures theory.2She identifieddistinctmasculineandfemininevoicesin ethicalreaethicaltheoryhasbeencarsoning,allowingusto recognizethatmainstream masculine-the voicesof women riedon in a voice that is overwhelmingly havebeenlargelyexcludedor ignored.Feministsstressthatit is importantin andreasoningin ethics,as in allfields,to includewomen'smoralexperiences the deliberations.Hence, most theoristsseekingto developa feministapto the gendermapwhich proachto ethicshavegivenseriousconsideration tried to have and has manyof herobservations incorporate Gilligan provided into theirapproachto ethics.3 ethIn herresearch,Gilliganfoundthatgirlsandwomentendto approach narrativewaythat looksforresolutionin icaldilemmasin a contextualized, detailsof a problemsituation;in contrast,boysandmenseeminparticular clinedto tryto applysomegeneralabstractprinciplewithoutattentionto the famousHeinz of the case. Forinstance,in Kohlberg's uniquecircumstances in the terms of to answer tended males logicalimplicase,Gilliganfoundthat cationsof a generalrule,suchasthatstealingis wrongorthatthedutyto save a lifeoutweighsothermoralrules.In contrast,shefoundthatfemalesubjects andto findnew optionsthroughbettercomtriedto preserverelationships of co-operation; municationand a presumption they tendedto respondby orby tryingto re-conceivethe termsset by the exseekingmoreinformation ample.Gilliganrecognizedtwo differentpatternsof reasoninghere:one whichpursuesuniversalrulesin an endeavourto ensurefairness,and one whichis focusedon the actualfeelingsand interactionsof those involved. withmalemoralthinkThe firstapproach,whichshefoundto be associated ing, she labelledan ethic of justice;the latter,whichshe foundto be more commonlyexercisedby femalesubjects,she identifiedas an ethic of care.

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The gender difference she describes is two-fold, characterizedby differences in both scope and values:men seem to be preoccupiedwith developing comprehensive, generalizable,abstractethical systemswhich are based on rights, while women seem to be concerned with understandingthe specific human dynamicsof a situation and, hence, concentrateon particularnarrative details with the aim of avoidinghurt and providingcare. As a result, we can identify distinct methodologicaldifferencesbetween men and women in their approachesto morallytroublingquestions. But we shouldbe cautiousin interpretingthe significanceof the gender correlationsof these differences; much of the discussionin feminist ethics has been occupiedwith evaluating the implicationsof developing what might be called a feminine ethics or a woman-centeredethics.4 Since, in our sexist society, gender is inseparable fromoppression,we shouldbe sensitive to the fact that characteristicsassociated with genderare also likely to be associatedwith oppression.Obviously, it is importantthat women'sdistinctive moralreasoningbe (at last) acknowledged as worthy of respect, but many feminists-including Gilligan herself-have expressedcaution in interpretingthe genderpatternsher research reveals in the context of a society that systematicallyoppresseswomen. In particular, many feminists are wary of enthusiasm for virtues like caring which areassociatedwith both genderand oppression.5Gilliganrecommends that we work towardsan androgynousethics that could combine elements of both approaches,but other feministshave pointed out that notions of androgyny seem, themselves, to perpetuatethe old gender system. In any event, Gilligan has helped to identifyalternativeapproachesto ethics from those found in traditionalapproaches;whateverwe might make of the widerclaims of her analysis,the focus on context and the value of caring are widely recognizedas attractivefeaturesto be incorporatedin any ethical theory. I would certainly expect these features to play some part in any womancentered (or even woman including)look at ethics and, therefore,in any approachto feminist ethics. It is clear that in doing feminist ethics, it is importantto be critical of the malenessof mainstreamethical theory, given its tendencies to demanda very high degreeof abstractnessand to deny the relevanceof concrete considerations,since this orientationrestrictsthe scope and analysisof ethics. If we are to build feminist approachesto ethics, we need to clarifythe sort of contextual details that are relevant to an ethical analysis. THE ROLE OF CONTEXTIN MEDICALETHICS

The theme of seekinga practical,context specificapproachto ethics is not restricted to feminist literature, however. The literatureof medical ethics also contains frequentdiscussionsaboutthe inadequacyof abstractmoralreasoning for resolvingreal moraldilemmas;there, too, we can find evidence of

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a widespreadrecognition that we must go beyond "meretheory." Further, there is frequentmention of the need to engage considerationsof caring in medical ethics, usuallycouched in the languageof the beneficence which is owed to patients. When placed in context (even if hypothetically), medical dilemmasare often discussedin termsthat appearto ranksensitivityand caring ahead of applicationsof principle.6 In the "earlydays"of philosophicalmedicalethics (i.e., the 1970s), there was an attempt to try to fit responsesto moral dilemmas into the general frameworkoffered by standardmoral theories, especially utilitarianismand Kantian deontology. It became apparentquite early on, however, that the simple appeal to theory and principledid not offer satisfyinganalysesof the sortsof dilemmasthat arise in medical ethics. Case studiesbecame a central element in influentialjournals,in many textbooks, and in individualarticles. The texture and the details of cases have become importantin tryingto decide about perennial issuessuch as confidentiality, truth-telling, and euthanasia. Clear answersdeducedfrompreciseprinciplesare not at hand for most of the topics addressed;manyauthorsnow accept the assumptionthat universal principlescannot be found which will govern such issues in all cases. Engelhardt,for example, in his basicallydeontologicaltext, The Principles of Bioethics(1986), claims that The obligation to do to others their good is a fundamental one. . . . However, the obligationas such is abstract.Only in concrete contexts can one determinethe extent of the obligation, and how to rank the variousgoods that can be at stake. (Engelhardt1986, 92) RonaldChristie and BarryHoffmasterhave been quite explicit abouttheir rejection of a theory-basedmedical ethics in their text EthicalIssuesin Family Medicine(1986). They arguethat "generalmoral theory does not illuminate specific cases and therefore is not helpful" since "[t]he principlesof moral philosophyare simplytoo abstractand too formalto contributeto the resolution of concrete cases"(Christie and Hoffmaster1986, xv). ArthurCaplan's (1980) clear rejection of the notion that moral theories can simply be wheeled on stage and appliedwithout carefulattention to the detailsof a particular case is widely endorsed in the current literature.We can see, then, that the trend in medicalethics is to examine issuesin context and avoid dependence on general abstractrules and rights. Some philosophersstill entrenched in mainstreammoraltheoryhave difficulty in seeing the distinction being cited here, since surelyall moraltheories are context sensitive to some degree. Kantiantheory, for example, demands an interpretationof context in orderto determinewhich maxim appliesin a given case. But Kantian theory does assumethat the maxims, once identified, will be universaland our policy on suicide, truth-telling, or confiden-

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tiality will be consistent acrossthe full spectrumof relevantcases. It does not direct us to make our ethical assessmentsin termsof particulardetails of the lives of the individuals. Utilitarianismis often espousedpreciselyas an antidote to such a rigidethics. It certainlyseems to be extremelysensitive to contextualfeatures,in that it recommends we calculate relevant utilities for all possible options in a given set of circumstances.Nonetheless, it discountssome importantfeatures which medical ethics and feminist ethics considerimportant.Utilitarianism requiresthat we calculatethe relevantutility valuesfor all persons(or beings) affectedby an action or practiceand proceedaccordingto a calculationof the relevant balances. In contrast, those engaged in doing feminist or medical ethics often reflect a desireto take account of the details of specificrelationships and to give addedweight to some particularutility relatedqualitieslike caring and responsibility.Many of those engaged in feminist ethics diverge even furtherfrom standardutilitarianism,for they arguethat the preferences of the oppressedought to be counted differentlyfrom those of the dominant group. (Feministobjections to pornography,for instance, do not rely merely on the weighing of harmsdone againstpleasureproducedbut reflect concern about the dehumanizingeffect of the messageof porography whatever the utilities involved turn out to be.) In feminist and medicalethics, it is important to considerfactorsthat do not carryany specialweight in utilitarianism. There is need to look at the nature of the personsand the relationshipsinvolved in our analysisand not merelyto recordsuch values as preferencesatisfactionor pleasureor pain; while the lattervaluesarespecificallyheld, their importancecomes fromsome abstractsum and not fromtheir attachmentto any particularpersons in particularsituations. Hence, neither Kantian nor utility theory satisfies the requirementof particularityas it is conceived in feminist and medical ethics. IMPORTANCE OF RELATIONSHIPS AND CHARACTER

The focus on context in feminist and medical ethics helps make evident that the nature of specific relationshipsis an importantelement of ethical analysis,i.e., that an ethics of actions is incompletewhen evaluationis done in abstractionfrom the relationshipholding between the participantsperforming them and those affected by them. Within feminist ethics, there is widespreadcriticismof the assumptionthat the role of ethics is to clarifyobligations among individualswho are viewed as paradigmaticallyequal, independent, rational, and autonomous(see, for instance, Baier 1987 and Held 1987). Few women conceive of human relationshipsas being primarilybetween equal, autonomousbeings, for their experience characteristicallyinvolves complex relationshipsof varioussortsof interdependenciesamongpersons of widely differentdegreesof power. Fromthe perspectiveof feminism, it

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is clear that the relationshipsstudiedin ethics mustattend to the interdependent, emotionallyvaried, unequalrelationshipsthat shapeour lives. Further, feministtheoristshave noted that ourethics mustbe concernednot only with actions and relationships,but that it shouldalso focuson questionsof character and the development of attitudesof trust within those relationships(see Baier 1986). Similarclaims are found within the literatureof medicalethics, where it is widely recognizedthat the relationshipbetween physicianand patient is far from equal (especially if the patient is very ill) and that the model of contractsnegotiated by independent, rationalagents does not providethe ideal perspectiveon this sort of relationship;in particular,the disadvantagedposition of the dependentpatient is a majortheme in the manydiscussionsof paternalismfound throughoutthe medical ethics literature. We can also find parallelclaims in the literatureof feminist and medical ethics regardingthe importanceof evaluatingbehaviourin termsof its effect on the quality of relationships.For instance, discussionsin medical ethics of the importanceof telling patients the truth about their condition often refer to the effect that a discoveredlie would have on the patient-physicianrelationship; these discussions could be redescribedin Baier'slanguageof the place of trust and anti-trustin ethics (Baier 1986). There seems, then, to be agreementthat mattersof character,responsibility, and other featuresthat affecttrustarerecognizedas importantin both domains. Moreover,as we have seen, medicalethics shareswith feministethics a commitment to focus on context and an understandingof the significance of inequalitywithin relationships,and some authorsin medicalethics express a desirereminiscentof feminismto includecaringvaluesin their analysis.Becauseof all these sharedcritiquesof contemporarymoraltheory, it might appearthat medicalethics is alreadywell on its way to being feminist, yet there are some significantdifferencesin the two approacheswhich disqualifymost of contemporarymedical ethics from any claim to feminist ethics. ETHICS FORA FEMINIST SOMEREQUIREMENTS

Formedicalethics to be thought feminist, it mustalso reflecta political dimension, but this is mostly lacking in the literatureto date. Although there are currentlymany diverseattemptsto characterizefeminist ethics, all share some political analysis of the unequal power of women and men, of white people and people of colour, of firstworldand thirdworldpeople, of rich and poor, of healthy and disabled, etc.7 Ours is a worldstructuredby hierarchies and a sense of supremacyon the partof the powerful;there are numeroussocial patternswhich shape the people we are and the sortsof relationshipswe will have with one another. In attendingto the qualityof actual interactions among people in ethics, we need to account for the influence of social and

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political factorson the nature of those relationships.Fromeither the caring or the justice perspective (to use Gilligan's language), we can see that empowermentof people who are currentlyvictims of oppressionis an ethical as well as a political issue, and ethical investigationsof particularproblem areas should reflect these dimensions. Many feminist critics have observed that currentmedical practice constitutes a powerfulsocial institution which contributesto the oppressionof women. They have demonstratedthat the practice of medicine serves as an important instrument in the continuing disempowermentof women (and membersof other oppressedgroups)in society and thrives on hierarchicalpower structures.By medicatingsocially induced depressionand anxiety, medicine helps to perpetuateunjustsocial arrangements.With its authorityto define what is normal and what is pathological and to coerce compliance to its norms, medicine tends to strengthen patternsof stereotypingand reinforceexisting powerinequalities.It servesto legitimizepracticessuch as woman batteringor male sexual aggressionthat might otherwisebe evaluated in moral and political terms.8 Nonetheless, the discussionin medicalethics to date has been largelymyopic, failing to comment on this importantpolitical role of medicine. That is, the institution of medicine is usuallyaccepted as given in discussionsof medicalethics, and debatehas focusedon certainpracticeswithin that structure: for example, truth-telling, obtaining consent, preservingconfidentiality, the limits of paternalism,allocation of resources,dealing with incurable illness, and mattersof reproduction.The effect is to providean ethical legitimizationof the institution overall, with acceptance of its general structures and patterns.With the occasionalexception of certaindiscussionsof resource allocation, it would appearfrommuch of the medicalethics literaturethat all that is needed to make medical interactionsethically acceptableis a bit of fine-tuning in specific problemcases. A good indication of the legitimizingfunction of medical ethics can be seen by noting its gradualacceptanceamongthose who are influentialwithin the medical profession.Increasingly,medicalpractitionersseem to be recognizing the value of incorporatingdiscussionsof medical ethics within their own work, for they can thereby demonstratetheir seriousinterest in moral matters.Such seriousprofessionalconcern in mattersof medicalethics serves to encouragethe public to place even greatertrustin their judgement.Keeping the scope of medical ethics narrowedto specific problemsof interaction helps physiciansmaintain their supportivestance towardsit. Feminists must be critical of the fact that medical ethics has remained largelysilent about the patriarchalpracticeof medicine. Few authorswriting on medicalethics have been criticalof practicesand institutionsthat contribute to the oppressionof women. The deep questions about the structureof medical practice and its role in a patriarchalsociety are largelyinaccessible within the framework;they are not consideredpart of the standardcurricu-

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lum in textbooks of medical ethics. Consequently, medical ethics, as it is mostly practicedto date, does not amount to a feminist approachto ethics. There are other importantdifferences,as well. Feminist theory has gone beyond medical ethics in the criticismof traditionalethics by re-conceiving some of the central concepts of ethical theory. It has, for instance, provided groundsfor rejecting an ontology of personsconceived as isolated, fully developed individuals.Rather, it acknowledgesthe social roots of a personas a being who develops within a specific social context and who is, to a significant degree, a product of that context (or, in the term of Baier 1985 and Code 1987, a "secondperson"). Although we may continue to considerthe individualto be a key unit of ethical analysisto the extent that we value persons as unique individualswhose lives areof concern to us, most feministsreject the assumptionof individualismunderlyingcontractarianapproachesto ethics throughwhich individualsare encouragedto considerthemselves and their interestsas independentfromothers. Personsdo not exist in abstraction (i.e., not apartfrom their social circumstances),and moraldirectivesto disregardthe details of personal life under some imaginary"veil of ignorance" are actuallyperniciousfor ethical and political analysisbecauseof their trivializationof these importantfacts. Moralanalysisshouldexamine personsand their behaviourin the context of political relationsand experiences,but this dimensionhas so farbeen missingfrommost of the debatesin medicalethics. It is importantto explore how the sharedpreceptsof medical and feminist ethics have, in the case of medicalethics, produceda field which is meant to be critical of all morallyunacceptablemedicalpractice, but which implicitly supportspatriarchalpolicies in the medical establishment. In this way, I hope, we can gain insight for feminist ethics into how to develop the commonly held ideas while still preservingtheir feminist force. I fear that the earlyformulationsof some of these insights in feminist ethics were oversimplified to a degree which makes them dangerousto a feminist program.By contrastingthe formulationsof these ideas within feminist ethics with their role in the relativelyconservativeprogramof medical ethics to date, we will be able to see more clearlywhat must be addedto them to turn existing approachesto medical ethics into feminist medicalethics. In so doing, we will have a clearer idea of how to characterizefeminist ethics and, at the same time, we will be able to identify the direction in which medical ethics must move if it is to be truly compatiblewith feminist ideals. CONTEXT UNDERSTANDING

In particular,it is importantthat we add the political dimension of feminist analysisto each of the sharedinsightspreviouslycited. We must, for instance, be more precise about the view found throughoutmuch of feminist ethics which rejectsthe notion of an ethics foundedon generalprinciplesin

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favourof a context specific ethics.9 There is a growingtendency in feminist theory to reject any sort of general analysis, arguingthat the experiencesof womenare so variedand diversewe cannot formgeneralconclusionswhich are inclusiveof all women. But I believethat the experienceof medicalethicsoffers groundsfor maintaininga certainlevel of generalityin our moralclaims. Consider, for instance, how the methodologicalconcern for contextual specificity is carriedout in discussionsof reproductiveissues in medical and feministethics. We can see importantdifferencesin their definitionand handling of the ethical issuesassociatedwith the new reproductivetechnologies. Those in the seculartraditionof medical ethics tend to hold fast to the case by case approach.They seem to think that, barringreligiousobjections to technological intervention in reproduction,the use of such techniquesas artificial insemination, in vitro fertilization,embryotransplant,and sex selection are mattersbest determinedin context. They recognizethe need for informed consent (though they seem willing to accept remarkablylow standardsfor consent here) and the need to protect confidentiality,etc., but by and large most authors in medical ethics deny that there are any new or unique problemsposed by the new reproductivetechnologies (e.g., Gorovitz 1982). Feminist theorists, in contrast, recognize that reproductivetechnologies are a productof existing social patternsand values, and most find reasonsto believe that these technologies will shape attitudesand opportunitiesregarding reproductionin the future. They are unwilling to allow decisions about such practices as in vitro fertilization, sex preselection or "surrogate"pregnancies to be addressedin isolation from the generalpattern constituted by the combineduse of these technologies;they resistattemptsto decide on the acceptableuse of such practiceson the meritsof each individualcase. Surely, if we were to adopt a context specific approachto case analysis, we could identifyvery stronggroundsfor allowing individualsto choose such arrangements in specifiedcircumstances,but, becausethere is a real dangerthat the increasedspreadof such practiceswill contributeto social attitudesthat further undermine the social position of women and children in society, we must examine the use of such technology in general. We can and shouldrecognize and sympathizewith the desireof affluent, marriedwomen to circumvent infertilitythroughtechniquessuch as in vitro fertilizationand contractual pregnancy,but we must also evaluatethese practicesin termsof their effect on other women-including those who are not approvedfor such medical "assistance"or who are used as medical means to the reproductiveinterests of others-before making up our minds on such practices. Further,we shouldbe sensitive to the ideologyof racism,sexism, classism,or bias against the disabledwhich often underlieseffortsto pursuethe productionof "quality" babies, for such attitudesare at the heart of many developmentsin the new reproductivetechnologies.10

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A principalgroundfor concernfroma feministperspectiveis that the technology is being developed and marketedin such a way as to furtherincrease the control of medical professionalsand decreasethe control of women over reproduction.A generalperspectiveallows us to see how the new reproductive technologiesfunction within the largermedicalpatternof claimingmedical authorityover an ever expandingsphereof women'spersonallives. Historically, male institutionshave alwayssought to control women'sreproduction: male religious, political, and economic leadershave used a variety of means to achieve control over women's reproductivecapacities. Until very recently, the law in North America ensuredthat husbandshad full sexual access to their wives' bodies; in many cases, men still presumethemselves to have de facto claims on women's bodies as is evidenced by the continuing practices of rape, sexual harassment, woman-battering,and other acts of woman-directedviolence. The medical professionhas claimed its share of this patriarchalcontrol. All phasesof a woman'sreproductivelife, frommenstruationthroughmenopause,have been medicalizedand subjectedto expert control by the male dominated medical profession. Feminists have documented ample evidence to suggestthese arrangementshave not all been in the best interestof women (consider,for example, the shockinglyhigh rateof hysterectomiesand Cesariansections and the growingtendency to medically initiated, court-orderedCesarians). Many women have sufferedseriousand unnecessarycomplications from unwarrantedmedical interference.The effect of the medicalizationof women's reproductivelives has been to make women dependent on male authorityfor whatever control they can muster over their own reproduction. Increasedreproductivetechnology generallymeans increasedmedicalcontrol. In manycases, one technologicalmeasureengendersthe need for further technological treatment in the future (e.g., the sterility which now drives many women to seek medical means to circumventit can often be tracedto medicallyprescribeduse of the notoriousDalkon Shield or to the absence of safe reversiblesterilizationtechniques). Given the patriarchalbias and authoritariannature of medicine and the fact that the new reproductivetechnologies furtherextend the potential power of this male dominated institution, feminists have groundsfor viewing increasedmedical control of reproduction with alarm. Thus, fromthe perspectiveof feministethics, we mustevaluatethe new reproductivetechnologies as general practicesand not just examine particular applicationsof them. But the generalanalysiswill not be a purelyabstractexercise as it is commonly practiced in mainstreammoral theory; it will not look only at abstractpropertieslike rights, autonomy, personhood, or even utility measures-properties which people hold anonymouslywithout regard to their particularcircumstances.In doing feministethics, we must appealto contextual details, and the context cited should involve the broadpolitical

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context of reproduction in a given society. It is not enough to consider merely the details of a particularwoman'sreproductivesituation. Abortion is the one areaof reproductionwhere discussionin both medical and feminist ethics seems to accept the need to develop a clear, universal moral policy so as not to leave space for evaluation on a case by case basis. Most authorswritingon this topic seek to determinesome generalpolicy regardingthe moralacceptabilityof abortionor the propersocial policy governing access to abortion. Within medical ethics, analysestend to consist of argumentsfocusingon such abstractmattersas the definition and value of life, the definition of personhood,the scope of human rights, or the social consequencesof toleratingor prohibitingabortionon a wide scale;some authorsin medicalethics even acknowledgethe importanceof autonomyfor women in controlling their own reproduction.The argumentsfound in medical ethics tend to focus the debate on the moralstatusof the fetus and treat the pregnant womanmerelyas a fetal environment,or else they focuson the property rights of women to expel unwanted invaders(e.g. Thomson 1971). But the sortof generalityappealedto is quite differentforfeministsthan for nonfeministswritingwithin medicalethics. Feministssee the implicationsfor women's overall freedom and relative power if we accept a policy whereby others are able to coerce women into seeing an unwantedpregnancythrough to term. In other words,feminist analysesaddressquestionsabout the difference it makesto all women'slives if women are free to decide whetheror not to continue each pregnancy,whereasmany writersin medical ethics try to formulatea generalabstractrule about the relative importanceof preserving life or protectingautonomy. In both cases, a generalposition on abortionis sought, but in the traditionof male-dominatedmedical ethics, the policy is formulated in terms of abstractvalues and rules which are to be invoked whatever the effect on particular persons' lives. In the case of feminist thought, the analysislinks women'sfreedomfromcoercionover pregnancyto other aspects of women's relative power in society. Hence, feminist ethics still addressesquestionsof context, but it does so in termsof a generalpolicy within a society afflicted with patriarchaldominance relations. In medical ethics, abortionis seen as a moralproblemfor doctorsand/orsociety;in feminist ethics, it is perceived as a choice embeddedwithin women'slives. The tendency in medicalethics to see abortiondecisionsas isolatedfromother aspects of women'slives missesthe most importantfeatureof the feministcampaign for reproductivefreedomfor women. These differencesbetween the analysesdevelopedby theoristsworkingprimarilyfrom the perspectiveof medicalethics and by those workingfromthe perspectiveof feminist ethics are significantto our understandingof the injunction to avoid generalethical analysisin favourof a contextualized,narrative approachto ethics. Feminismdiscussesthe pervasivenature of sexism and its effects on all human relations;so, issuesmust be examinedin light of

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their connection with patternsof genderdominance. Clearly, abortion, too, must be addressedin termsof a broadlydefinedsocial context which is sensitive to the historical fact that male dominated institutions have always sought to manipulatewomen'ssexual and reproductivelives. Although pregnancy and childbirthhave profoundsocial and economic effects on women, women have not been allowed control over them. Since women's control over their own reproductionis central to all aspectsof division of powerbetween women and men, argumentsabout abortionmust be couched in this political recognition. The argumentssurroundingthe new reproductivetechnologies and abortion indicate that feminists should interpretthe ideal of consideringethical questionsin a contextuallybasedframeworkquite broadly.There is a need to define context in social and political termsand to consideractions in termsof the practice they are part of, attending to the effect of these practices on them. women'spursuitof greaterpowerin a societythat currentlysubordinates This is not to say that all questionsin feminist medicalethics must be addressedin termsof the practice(s) they represent.Manydecisionswill still be best carriedout by looking to the details of the specific circumstancesand people involved. Forexample, questionsaboutwho has the final authorityin determiningthe best interestsof a child when there is disagreementbetween parentsand physiciansmust, I believe, be resolvedby consideringthe details of the particularcases. Sometimesparentsare best at identifyingtheir child's interests,e.g. when the child is sufferingfroma terminaldiseaseand the doctors want to try a painful, and largely unsuccessfultherapy to provide the child at least with "a chance." In situationswhere the child has been subject to violent abuse or seriousneglect, however, parents are not to be trusted with their child'swell-being. To resolve these sortsof controversies,we must look not just to broadsocial policy (though this is likely to still be an important factor) but also to the details of the relationshipsamong the child, the parents,and the physician. In other words,we mustkeep in mind the wisdom of VirginiaHeld's (1984) analysisof ethics, namely that we ought not to expect a single theory or strategyto be adequatefor settling all kinds of ethical questions. Different forms of analysis are appropriateto different sorts of moraldilemmas.The importantconstant is that we must alwaysdecide these questionswithin the widerpolitical context of consideringhow this analysis effects (if at all) our generalfeminist objectives of eliminatingoppressionin all its forms. Which sort of analysisis appropriateto which sort of problemis a matterfor feminist medical ethics to explore. MEDICALETHICS TOWARDSA FEMINIST

There are numerousother directionsin which work in feminist ethics can inform and transformwork in medical ethics and where medical ethics can

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providemodels (both good and bad) for workin feministethics. Forinstance, the literaturein both feminist and medicalethics reflectsan interest in questions concerning the nature and qualityof particularrelationshipsin light of the recognition that rights and responsibilitiescannot be assumedto be universalbut depend on existing roles and relationshipsamongpersonsof differing power and status. In medicalethics, discussionsaboutthe idealformof the doctor-patientrelationship have consideredvariousmale models:Robert Veatch (1972), for instance, rejected the "engineeringmodel," the "priestlymodel," and the "collegialmodel," and found himself left with the "contractualmodel."Others have observedthat the very differentpower statusof patients and physicians makes the contractualmodel inappropriateand have suggestedother contractuallybasedmodelsas alternatives(e.g., Michael Bayles's(1981) suggestion of a fiduciarymodel). Feminists, too, have been suspiciousof appealsto contractualmodels in manyhuman interactions.They have also been searchingfor bettermodelsof relationshipsthat are not based in equal poweror need, and it is interesting to speculatehow discussionsof the ideal patient-physicianrelationshipmight be modifiedby discussionsin feministethics of the place of mother-childrelationships (Held 1987, Ruddick 1980, and Whitbeck 1984), or friendship (Code 1987, Stocker 1987, and Raymond1986). The inclusionof female experiences widens the conceptual map significantly for this long-standing problemin medicalethics. The medicalcontext againdemonstrates,though, the need to be cautious in generalizingfrom certain female experiences, for the modelswhich feministshave focusedon are ones suitableto relationships of love and trust, but medicine, froma feministperspective,is a domainbetter suited to "antitrust"(Baier 1986). While feminists have acknowledgedthe existence and legitimacyof relationshipsof dependency,they are, nonetheless, concernedto transformmedical interactionsin such a way as to reduce the power of medical authority. As a result, feminist discussionsof medical practice frequentlywarn of the abuse of medical power in situationsthat are disempoweringto patients. In contrast with authoritariannorms of medical practice, feminists aspireto a systemof personalcontrol over health care. They seek to spreadhealth information widely and fosterself-help approachesto health matters.Medicalexpertise ought to be a resourceheld under the control of patients and their caregivers.The institution of medicine should be transformedfrom one of crisismanagementto one of health empowerment.Perhapsthe nurse-patient model is worth examiningin this context, for, ideally,nursesdefine their role as one of informingand empoweringpatients, ratherthan controllingthem. The difficulty, though, is that nurses, like mothers, are limited in the effectiveness of their effortsat empowermentof others becausethe constraintsof hierarchicalstructureslimit their own authority.

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A principaltask of feminist medicalethics is to develop conceptualmodels for restructuringthe power associatedwith healing by distributingmedical knowledge in ways that allow persons maximum control over their own health. It is importantto clarifyways in which dependence can be reduced, caring can be offered without paternalism,and health services can be obtained within a context worthyof trust. A clearunderstandingof the dynamics of the power structuresnow inhibiting these processesis an importantaspect of our ethical analysis. We must look at the structuresof medicine and medical interactionwhen attemptingto understandthe details of any particularmedicalexperience. Such lessonsfromfeministmedicalethics are significant to other areasof feminist ethics, suggestingguidanceto feministspursuing ethical theory and its applications.We look to feminist medicalethics to provide a more comprehensive, and fairer, approachto medical ethics than has been evident to date.

NOTES to RichmondCampbell,Lorraine 1. I wishto expressmygratitude Code,KathleenMartinassistance of thisspecialissuefortheirgenerous dale,DebraShogan,andtheeditorsandreferees of this paper. in the development 2. Foran apt descriptionof the "moralmadness"womencommonlyexperiencewhen ethicaldemands,see Morgan(1987). withpatriarchal confronted in the collection,WomenandMoralTheory, 3. See, for instance,the variousdiscussions KittayandMeyers,1987. 4. Nel Noddings(1984) has spelledout the full implicationsof pursuingthe feminine to ethicsexclusivelyin Caring.ThoughI wouldnotclassifyherasa feminist,Noddings approach hasgiventheoreticalvoiceto the ethicof caredescribed byGilligan,rejectingall aspectsof an relationin favourof anethicsconcered onlywithparticular ethicsbasedin abstract principles shipsbasedon caring. 5. See, forinstance,the arguments by Houston(1987)andWilson(1988). putforward to of physicians 6. Thistendencyseemsto meto be especiallycommonin thecontributions in the field. discussions medicalethics;it is lessapparentin the philosophical 7. I am well awareof the rich diversityof viewsclusteredunderthe labelof "feminist whichdivide thedifferences butI thinkthattherearesomecoreviewsthattranscend analysis," feministsin their internaldebates.Forthe purposesof this paper,I will focusonly on the commonthemeswhich includea recognitionthat womenare in a subordinate positionin society,that oppressionis a formof injusticeandhence is intolerable,that therearefurther in additionto genderoppression formsof oppression (andthattherearewomenvictimizedby thatit is possibleto changesocietyin waysthatcouldelimieachof theseformsof oppression), to accomplish andthatit is a goalof feminismto pursuethe changesnecessary nateoppression, howeverwe explainthe this. I believethatthe argument presentedin thispaperis unchanged and whateverwe imagineis bestfor bringingaboutthe desired causeof women'soppression changes.Therefore,I shallspeakof a feministanalysiswithoutbeingspecifichereaboutwhich variationI havein mind. particular 8. See Stark,Flitcraft,and Frazier(1983). Fora morefar rangingdiscussion,see the of womenin the surveyby to the oppression powerfulindictmentof medicine'scontribution andEnglish(1979). Ehrenreich 9. Thisproposalis foundin manyplaces.I madeit myselfin myfirstattemptsat defining Postures feministethicsin Sherwin,(1984). AnnetteBaiermakessimilarclaimsthroughout of andFeminist theMind(1985);severalauthorsin Science,Morality, Theory(HanenandNielsen,

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1987) and Womenand MoralTheory(Kittay and Meyers, 1987) also presentvariationson this claim. 10. I spell out this argumentmore fully in Sherwin (1987). REFERENCES

Baier,Annette. 1985. Posturesof themind:Essayson mindandmorals.Minneapolis:University of Minnesota Press. Baier, Annette. 1986. Trust and antitrust.Ethics96: 231-260. Baier, Annette. 1987. The need for more than justice. In Science,morality and feminist theory. Marsha Hanen and Kai Nielsen, eds. Canadian Journalof Philosophy(supplementaryvolume 13). Bayles, Michael. 1981. Professionalethics. Belmont, CA: WadsworthPublishing Co. Caplan, Arthur. 1980. Ethicalengineersneed not apply:The state of applied ethics today. Science,Technology,and HumanValues6 (33): 24-32. Christie, Ronald J. and C. BarryHoffmaster. 1986. Ethicalissuesin family medicine.New York:Oxford University Press. Code, Lorraine. 1987. Second persons. In Science,moralityandfeministtheory. MarshaHanen and Kai Nielson, eds. CanadianJournalof Philosophy (supplementaryvolume) 13. Ehrenreich,Barbaraand DeirdreEnglish. 1979. Forherowngood:150 yearsof theexperts'adviceto women.GardenCity, NY: Anchor Press,Doubleday. Engelhardt,H. Tristram,Jr. 1986. The foundationsof bioethics.New York: Oxford University Press. Gilligan, Carol. 1982. In a differentvoice:Psychological theoryandwomen'sdevelopment.Cambridge,Mass.: HarvardUniversity Press. Gorovitz, Samuel. 1982. Doctors'dilemmas:Moralconflictand medicalcare. New York:Oxford University Press. Hanen, MarshaHanen and Kai Nielsen, eds. 1987. Science,morality,and feministtheory.CanadianJournalof Philosophy(supplementaryvolume) 13. Held, Virginia. 1987. Non-contractualsociety. In Science,moralityandfeminist theory. Marsha Hanen and Kai Nielsen, eds. CanadianJournalof Philosophy(supplementaryvolume) 13. Held, Virginia. 1984. Rightsandgoods:Justifyingsocialaction.New York:The Free Press. Houston, Barbara.1987. Reclaimingmoral virtues:Some dangersof moral reclamation.In Science,morality,andfeministtheory.MarshaHanen and KaiNielsen, eds. CanadianJournalof Philosophy (supplementaryvolume) 13. Kittay, Eva Federand Diana T. Meyers,eds. 1987. Womenandmoraltheory. Totowa, N.J.: Rowman and Littlefield.

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Morgan, Kathryn. 1987. Women and moral madness. In Science,morality, and feminist theory. Marsha Hanen and Kai Nielsen, eds. Canadian Journalof Philosophy(supplementaryvolume) 13. Noddings, Nel. 1984. Caring:A feminineapproachto ethicsand moraleducation. Berkeley:University of CaliforniaPress. Raymond,Janice. 1986. A passionfor friends:Towardsa philosophyof female affection.Boston: Beacon Press. Ruddick, Sara. 1980. Maternalthinking. FeministStudies6 (2): 342-367. Scheman, Naomi. 1983. Individualismand the objectsof psychology.In Dison epistemology, coveringreality:Feministperspectives metaphysics,methodology, and philosophyof science. Sandra Hardingand Merrill Hintikka, eds. Dordrecht, Holland: D. Reidel PublishingCompany. Sherwin, Susan. 1984. A feminist approachto ethics. DalhousieReview64

(4): 704-713. Sherwin, Susan. 1987. Feminist ethics and in vitro fertilization.In Science, morality and feminist theory. Marsha Hanen and Kai Nielsen, eds. CanadianJournalof Philosophy(supplementaryvolume) 13. Stark, Evan, Anne Flitcraft,and William Fraxier.1983. Medicine and patriarchalviolence: The social constructionof a "private"event. In Women and health:Thepoliticsof sex in medicine.ElizabethFee, ed. Farmingdale, N.Y.: BaywoodPublishingCompany. Stocker, Michael. 1987. Duty and friendship: Towards a synthesis of Gilligan's contrastive moral concepts. In Womenand moraltheory.Eva Feder Kittay and Diana T. Meyers, eds. Totowa, N.J.: Rowman and Littlefield. Thomson, JudithJarvis. 1971. A defense of abortion. Philosophyand Public

Affairs1 (1): 47-66. Veatch, RobertM. 1972. Modelsfor ethical medicine in a revolutionaryage. HastingsCenterReport2 (3): 5-7. Whitbeck, Caroline. 1984. A differentreality:Feministontology. In Beyond on womenand philosophy.Carol C. Gould, domination:New perspectives ed. Totowa, N. J.: Rowman & Allenheld. Wilson, Leslie. 1988. Is a "feminine"ethics enough?Atlantis5 (17): 15-23.

FeministDirectionsin MedicalEthics* VIRGINIA L. WARREN

I exploresomenewdirections-suggested byfeminism-formedicalethicsandfor ethicsgenerally.Moralphilosophers needto confronttwo issues.The philosophical firstis decidingwhich moralissuesmeritattention. Questionswhichincorporate theperspectives of womenneed to be posed-e.g., aboutthe unequaltreatmentof womenin healthcare,abouttherolesof physicianandnurse,andaboutrelationship issuesotherthanpowerstruggles."Crisisissues"currentlydominatemedicalethics, to theneglectof whatI call "housekeeping issues."The secondissueis how philomoral debates are conducted, sophical especiallyhow ulteriormotivesinfluence our beliefsand arguments.Bothwhatwe select-and neglect-to studyas well as the "games"we playmaybe sendinga messageas loudas thewordswe do speakon ethics.

We might as well admit it. Medical ethics has growna bit stale. Hot new topics continue to arise-such as whether to withhold artificial food and fluidsfrompatients, or to "harvest"organsfor transplantfromfetusesand anencephalic newborns. But calling on the same list of Basic Moral Principles does not producethe thrill it once did, thoughthe issuesare as significantand heart-breakingas ever. My aim here is to see whether feminismcan suggest some new directionsfor medicalethics, and for philosophicalethics generally. I shall begin with two disclaimers.First, I am not claiming that a feminist medical ethics must develop in any particularways, only that certain paths are suggestedby feminism. Second, I am not claiming that these possibilities could only have come from a feminist perspective.These directionsmay, for example, reinforce some ideas from Marxism or from the holistic health movement. I have no desire to plant a flag on the moon and claim, "Feministsgot here first." I do hope, however, that the speculationsemerging fromthe cross-fertilizationof medicalethics and feminismwill bearfruit. "SEXISTETHICS"

Beforeponderingwhat a feministmedicalethics might look like, however, muse about what a SexistEthicsmight be like (as Overall 1987, 1-73, does). Hypatiavol. 4, no. 2 (Summer 1989) ? by Virginia L. Warren

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My aim is neither to condemn philosophic ethics throughcaricature,nor to searchfor sexist villains. The sexism-of which I, too, am guilty-is mostly unintended. Rather, I want to spurthe imagination.What would academic moralphilosophybe like if it were sexist? Let us begin with substance-with what questions and solutions are discussed. Later we will consider process: how moraldebates are conducted. And, should the resultingpicturefit real life, let us recognize it. First,a Sexist Ethicswould use a male perspectiveto framemoralquestions and to shape solutions. Magicians know to keep the audience's attention away from the action. But moral philosophersmay be magicianswho have trickedeven themselvesby concentratingon the topic at hand, without asking which topic most deservesstudyor what will resultfromapproachingthis topic this way. In a Sexist Ethics, moralquestionswould often involve competitions for power, statusor authority.Forexample, the autonomy-pateralism debate in medical ethics concerns who has the moral authorityto make the final decision: patient or physician. And solutions to moral problems would often downplayor ignore the interestsof women (and children). For example, when medical costs are contained by sending hospital patients home "quickerand sicker," family members-usually females-must nurse them at home. This unpaidlabor-by mothers,wives, daughters,and daughters-in-law-needs to be given more weight. Even now, women'swork is often "invisible." Second, a Sexist Ethicswouldnever appearsexist. It wouldbe clothed in a cloak of neutrality because favoring some group or position would be unthinkable. The dominant trend in philosophical ethics has been to regard people as best able to decide what is moralwhen least tied to place and time, when least connected through ties of partialityto family and community. Ideal moraldecision-makersare viewed as common denominators-e.g., rational egos (Kant) or calculatorsof utility-who are more likely to adopt the proper universal perspective when the veneer of particularityis stripped away. Two distortions may result from this approachto ethics. First, although some moral agents may adopt a common denominator moral perspective without feeling that anything of value is lost, others may feel the loss intensely. The reason for this loss is that persons whose unique experiences have been largelyomitted fromthe dominantculture-e.g., women, Blacks, gay males and lesbians-may find the strippingawayof particularityfromthe moralobserverto be anathemato self. By subtractingthose featuresthat shed light on their experience and life, such individualsmay become, at least in part, invisible to themselves. A second distortionmay arisebecauseadoptinga universalperspectivetowardmoral situationstends to (although it does not need to) reveal generic persons and relationshipswhose psychologicalsubtleties have been washed

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away. Specifically, the fact that human beings are genderedis likely to be deemed irrelevant to moral deliberation. It is too bad if the stereotypic woman-with all her reproductiveorgans,emotions, and kinship ties to particular others-does not fit the category of Plain Wrap Human Being. Of course, men are also gendered. Sexist Ethics would not take sufficient account of malesquamales, any more than it does of femalesquafemales. Ironically, distortionmay be the likely resultof our tryingso hardnot to distort. Third, a Sexist Ethicswouldframethe ethical debateso that women would be kept on the defensive. Women would spend much time for little gain. A Sexist Ethics would seduce women to workwithin its frameworkby offering hope for improvement-but only if they did not rockthe patriarchalboat too vigorously."Strivefor equalitywith men," it would say, "andall will be well. There is no need for more fundamentalchange."Such a domesticatedethics would, for example, allow women and men to compete equallyfor the positions of nurse and physician, without questioning the roles themselves, which were founded on an unequalpowerrelationshipbetween femalesand males. Women might be kept on the defensive in anotherway: topics chosen for moraldebate might have the unintendedeffect of fanning the flamesof sexism. In moral philosophy in the past fifteen years, the two most commonly discussedtopics concerningwomen have been abortionand preferentialhiring. In both cases, women's interestsand rights are pitted againstthe interests and rights of "innocent"others: fetuses, and young (white) male applicants to law or medical school who were not principallyresponsiblefor the worst sexist practices. The centralplace of preferentialhiring in the "contemporarymoralissues" literatureis particularlyinstructive.Women (and minorities)studyingpreferential hiring are made to feel how many expectationsof males (and whites) they are crushing, and how much hostile backlashawaits, if they push too hardto be let into the club. With sexism (and racism)so prevalent,it borders on the scandalousthat so much philosophicalenergyis focusedon preferential hiring. For, while this issue clearly merits attention, it directly affects a relatively small percentageof job-holdersfor brief periods, mainly in decisions abouthiring and promotion. I say this even though I know that believing that one has been, or might be, passedover for a desiredjob may profoundlyaffect one's self-conceptionand self-worth;hence, the indirecteffects of a policy of preferencemay extend far beyond the period of hiring. My point is threefold. First, enough moral philosophershave focused so narrowlyon preferentialhiring and on whetherwhite malesarewrongedby it that the full burdenon women (and minorities) of sexist (and racist) practices tends to get insufficientattention. (By contrast, Wasserstrom1977 is a modelfor portrayingthe cumulativeimpactof racism.)Second, the preferential hiring debate is inflammatorybecause a zero-sum,us-against-thematti-

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tude is presupposed,and often goes unchallenged.Alternative, non-zero-sum approachesto ending discriminationand to securingwomen's (and minorities') rightfulinterestsusuallygo unexplored.Third, even if the preferential hiring debate (framednow in termsof justice and utility) were resolvedone way or the other, that would not help people of differentgenders(and races) to relateto each other better on the job: to respecteach other, and to overcome suspicion and hostility. A strong messageis sent by which moral questionsare selected for study. Not only are some importantissuesneglected, but some debates-especially if not prefacedby a patient, thorough probingof the nature and extent of prejudice-may inflame prejudices. Tavris (1982, 131-35) concludes from the experimentalevidence that talking out one's anger tends to make one moreangryat a person, ratherthan less (as the catharsistheory claims), and the anger endures. Hence, concentrating in the classroomon preferential hiringand abortionas they arenow standardlytaughtmaydo morethan raise the issue of backlash;it may help unleash the lash. In addition to substantive questions about the rightnessof actions, how philosophicalethics is done-the process-is important. First, the theories and argumentsof Sexist Ethics would be used as weapons in a competitive powerstruggle.Participantsin the ethical debatewould have an ulteriorpurpose. Over and above seeking the truth about what is morally right, they would want to win the debate, includingto look good at someone else's expense. Second, the "star"systemwould be partof the Sexist Ethics game. In academia,a huge disparityexists between ability and productivity(as judged on a fair merit system), on the one hand, and reputation, on the other. Would-be "stars"aim at advancingtheir reputations,and at gainingprestige and the power and perquisiteswhich accompanyprestige. Thus, over and above any substantivedifferencesbetween sexist and feministethics, we must attend to how the philosophical "ethics game" is played in discussions, at conferences, and in print. In my view, contemporaryphilosophical ethics-including medical ethics-has all of the featuresdescribedunder "Sexist Ethics"to some degree, even though the intention to be sexist is usuallyabsent. The degree varies dramaticallywith the topic, the authoror speaker,and the occasion. Imagining how philosophical ethics might become increasinglyless sexist is the challenge. FEMINIST MEDICALETHICS:WHAT IS STUDIED

Which questions moral philosopherschoose to study-and choose not to study-is itself a moralissue, yet one that is hardlyever raised.In this section I will sketch some changes-suggested by feminism-in the questions addressedin medical ethics.

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Feministscould add the perspectivesof women of differentraces, classes, sexual preferences,etc., to questions and solutions alreadydiscussedin the literatureof medical ethics. For example, more weight would be given in cost-cuttingdebates to the effects on families-especially on female caretakers-of patients releasedfrom hospitals earlier. In addition, feministscould include women'sperspectives-along with the perspectivesof males qua males, and the interestsof children-by posingnew questions.Carol Gilligan (1982) interviewedwomen who were considering abortion, and listened to how they framed moral questions and to which moralvalues they appealed.We, too, need to listen. I will discussfour categories of new questions: (1) inequalities, (2) sexist occupational roles, (3) personalissues, and (4) relationshipissuesthat do not involve deciding the winner of power struggles. (1) Inequalities.The treatmentof women patients, women physicians,and people in traditionally female occupations such as nursing or social work should be examined. After exposing any unequal treatment of women in health care, solutions could be sought. An example of unequaltreatmentof female patients is the policy in many in vitrofertilizationprogramsof excluding all women who are not marriedheterosexuals;that is, only women who want to raise a child with a husbandneed apply. When this policy is criticized, one response is to point out the scarcity of places in IVF programs-with no attempt to defend this particularallocation of scarce resources.The issue is deflected, but not taken seriously;and male privilege is protected, but not justified. (2) Sexistoccupationalroles. Historically, the roles of physician and nurse were designedfor males and females, respectively.Taskswere assignedbased on what was appropriatemasculine and feminine behavior, with nursesexpected to defer to physicians (see Stein 1967). So far, the basic question in nursing ethics has been what hospital nurses should do when their moral views clash with those of physicians, who have more institutionaland legal power. Moreover,physicians'trainingis largelytheoreticaland technological, and they have final decision-makingauthorityfor patient treatment. The role of nurse has always included nurturingpatients' psyches (and although much knowledgeand skill is requiredto performnurturingtaskswell, that is often overlookedand labeled"intuition");and nurses'decision-makingauthorityis subordinated to "doctor's orders." This division of labor in health care-based on which gender the role was designed for-remains, even though an increasingnumberof physiciansare now female. (Male nursesremain a rarity.) A second type of new question would go further, examining sexism in occupational roles. We need to stop segregating nurturing from theory-whether in health care (the workof nursesand social workersfromthat

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of physicians)or in academia(undergraduateteaching from research).Giving females and males equal opportunityto enter occupationsin which nurturingand theory are pulled apartdoes not solve the problem.The answeris not to have fifty percentof nursesbe caring, responsivemales, while fifty percent of physiciansare oriented towardtechnology and researchand professionally distant-but are female. Nor is the answerto have RNs imitate the higherpaid, higher status, traditionallymale occupations;for then the caring taskswould be delegatedto others (e.g., to licensed vocationalnurses). Nurturingneeds to be valued more highly, includingmonetarily,and integrated with technical and theoreticalexpertise,particularlyin medicine. (Nursingis alreadyattemptingsuch integration.)We need to redefinethe roles and relationshipsof all membersof the "healthcare team,"makingrolesmore androgynous. (3) Personalissues. A third type of new moral question examines issues which usuallyare not elevated to the status of the seriousin academiccontexts, although they matterconsiderablyto health care professionals.Forexample, medicalethics has been virtuallysilent aboutproblemsinfluenced(to varyingdegrees)by job-relatedstress.One is on one's own. However, the incidence of drug and alcohol abuse by physicians and nurses-people who know the health risks-is much higher than that of the generalpopulation. Divorce and suicide rates are also high. Familiesof health care professionals are also harmed by this stress. We need to probe social and institutional causes(e.g., the natureof medicaleducation-including the 24- and 36-hour shifts residentswork), and to seek solutions that addressmore than one person's private failure. Moreover,philosophicalethics routinelyignoresthe little-and not so litissues."These "pertle-domestic problemsof life, which I call "housekeeping sonal" issuescontrastwith the "crisisissues"(e.g., abortionor withdrawalof life-support)that arethe breadand butterof contemporarymoralphilosophy. Perhapsan analogue to the feminist slogan, "The personal is political," is needed: "The personal is professional."That is, what is "merely"personal mayprofoundlyaffecthow one acts on and off the job, and thus shouldplay a significantrole in professionalethics. An exampleof an importanthousekeepingissue1is how to help people use such valuablelegislation (in Californiaand some other states) as the Durable Powerof Attorney for Health Care. Should one become incompetent, a Durable Power specifies what medical treatment one does and does not want, and invests a designatedperson(e.g., spouse, friend)with the legal authority to make one's other medical decisions. While bioethicists have discussed moral reasons for and against passing such legislation (a crisis issue), they rarely addressproblems of implementation (housekeeping issues). Nor do physiciansraise the possibilityof signing such a documentwith patients very often. When physiciansdo think of it, they mayfearthat even raisingthe is-

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sue with terminal patients will cause despairand hasten death. Often it is thought of too late: when patients are alreadycomatose, or weakenedby illness and confusedby drugs.Nor do we help familiesleam how to discusssuch grave mattersopenly and "beforeneed" (the phraseused in cemeterycommercials). If most laypeople are unaware that such legislation exists, they cannot raise the issue of signing a DurablePowerwith physicians.And few physiciansare raisingit with them. (Nursessometimesdo, but riskbeing criticized for encroachingon the physician'sprerogative.) These two categoriesof moralissues-crisis and housekeepingissues-contrast in several ways. First, with crisis issues, moral decisions are more or less final. A moral problemarises;one decides;one moves on and feels a sense of progress.With situationis on-going,ratherthan housekeepingissues, however, theproblematic resolvedonceandfor all;and decisionsneed to be madecontinually.Job stress, for example, can be contained but not eliminated. Second, the significanceof crisisissuesimmediatelycatches our attention. We take pridein facinga difficultchallenge. By contrast,housekeepingissues seemtrivial.Even if we handle these problemswell, we feel we have not accomplishedmuch, and others are unlikely to laud our efforts. For example, we discusscrisis issuesrelatedto AIDS, such as whetherAIDS antibodytesting should be mandatoryin some cases. But few are discussinghousekeeping issues,e.g., how sexuallyactive personscan raisethe questionof AIDS exposure and protection with prospectivesexual partners,while tryingto respect privacy and avoid manipulation. Even if housekeeping issues were trivial when consideredone at a time, their collective impacton individualsand institutions would be anything but trivial. Third, crisisissuesusuallyinvolve a narrowrangeof alternativeactions. By contrast, housekeepingissuescommonlyrequireus to reassesslargepartsof our lives:our charactertraits,how we think aboutourselves,and how we relateto others. Their impact is thus felt long after a particularcrisis is past. But do not some crisis issues, such as abortion, also requireus to reassess our lives?Yes, a woman'slife will probablybe dramaticallyaffectedby whichever alternativeto an unwantedpregnancyshe chooses, especiallyraisingthe child. My point is that while crisisissuesmay indeedhave far-reachingconsequences, housekeepingissuesforce us to examine an issue in a wide context, calling into question an intertwinedweb of everydayactivities and relationships that is usuallytaken for granted. For example, informedconsent is standardlyinterpretedas a crisis issue: "Wasan autonomousand informedconsent obtainedfromthe patient before this treatment, or did the physician withhold relevant informationor pressure the patient?"Comparethis to informedconsent interpretedas a housekeeping issue: "How should we foster the conditions which make informed consent more likely?"The whole physician-patientrelationshipis thereby

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called into question:How much time should physiciansspend with patients, and on whose terms-when it is convenient for the doctor or when the patient is well-restedand psychologicallyprepared?How involved shouldphysicians be with patients' value choices and anguish?Should the relationship between physicians and nurses be changed so that they can work together more effectively to encouragepatient autonomy? Fourth, crisis issues are more readily handled using such standardmoral principlesas justice, autonomy, beneficence and non-maleficence, and utilissueshelpsonlyup to a point.These ity. Applyingtheseprinciplesto housekeeping principlesdo not deal satisfactorilywith psychologicalsubtleties, especially with the intricaciesof longer-termrelationships.Forexample, autonomyand beneficence will offeronly rudimentaryguidanceto a health professionaldeciding whether and how to approacha specificpatient about signing a Durable Powerof Attorney. Utilitarians, it is true, hold that the Utility Principle alwaysapplies. Yet, reducingcharactertraits and relationshipsto how much happinessand unhappinessthey can be expected to produceseems to me to drain them of much of their significance. Overall, what are we to make of these housekeepingissues, which referto one's everydaylife and to on-going relationships, and which are routinely overlooked?On a given topic, should housekeepingissues replace crisis issues?Not necessarily.I view it as an open questionwhether, for a given area, both crisis and housekeepingissuesneed to be discussed,or whether one of these sets of issuesis sufficient.What mattersis that we neither ignoreimportant questions, nor distortthe moraldebateby askingquestionsin the wrong way-for we sometimesturn housekeepingissuesinto crisisissuesjust so they will be resolved. (4) Relationshipissues that do not involvedecidingwho wins variouspower struggles.The main relationship questions in medical ethics now involve competitionsfor power, status or authority.Who should have the moralauthorityto make the final decision: the patient or the physician(in the autonomy-paternalismdebate), the physicianor the nurse (in nursingethics)? Relationshipsare incorrectlyassumedto be fine when there is no overt struggle for power. Moralphilosophersshould considerwaysof resolvingpowerconflicts other than declaringa winner. Forexample, a strategyof"preventive ethics"could be adopted. Insteadof askingwho shouldbe "Kingof the Hill"-physician or patient-ask how the conflict might be prevented in the future. Changes might be needed in medical education or in the social organizationof hospitals. On a largerscale, I believe that the feminist goal of eliminatingconflicts over power can be permanentlyattained only by solving this problem:How can people be helped to develop a sense of self and of self-worth(identity) that is not based on putting down or controlling someone else (power over

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others)? This question is importantbecause simply trying to eliminate one form of discrimination-against women, gays and lesbians, the disabled-and then another will never have an end. We will be playingmusical chairs:there will alwaysbe an odd person out. To eliminate discrimination acrossthe board,a radicalstrategyis needed:educatingpeople to value themselves in a way that does not depend on brandinganyone else inferior. In addition to preventing or eliminating power struggles,other questions aboutrelationshipsmight be askedby a feminist medicalethics. Relationship ethics should discussopenness, responsivenessand caring. Forexample, how personallyinvolved with patients should health care professionalsbe in different situations?In orderto encouragemore sensitivityto their patients and co-workers,how should health care professionals-including physicians-be trained, and what should their workingconditions be? Some issues in medical ethics have been much debatedbut, in those discussions, crucial questions about relationshipshave been downplayedor ignored. For example, in the philosophical literature,abortion is often interpretedas a powerstruggle.Whose rightsare more important:the fetus'sright to life, if it has one, or the mother'sright to autonomouslyguide her life? What is usuallyleft out of the abortiondebate is a networkof issuessurrounding the parent- (especiallymother-) child relationship.2 I have been amazed by the casualness with which many opponents of abortionoffer adoption as an alternative.Nor have moralphilosophersconsideredthe followingquestion in any depth:If a pregnantwomanhas decided not to abort, when is it morallypermissiblefor her to give up the newbornfor adoption?Whenever she wants to? Is adoption permissibleonly if the baby would be better off being raised by someone else-and, then, only if the mother is unwed?(Can you imagine telling your parentsor in-laws that you and your partnerhave decided to give up their grandchildfor adoption?Or telling an older child that its sibling-to-bewill be given up for adoption?)Is it permissiblefor a woman to conceive in orderthat the child be adopted-if everyone, includingthe child and the adoptiveparents,benefit?If it is, then surrogatemotherhood (money issues aside) would have a more solid moral foundation. My point is that, regardingabortion and adoption (as well as child custodydisputesduringdivorce), we need to get to the heart of matters of the heart: relationshipsbetween parentsand children, between life partners, between siblings, between grandparentsand grandchildren.At present, we have not identifiedwhat the importantrelationshipissuesare, nor do we know how to weigh these values againstsuch standardones as rights, autonomy, and beneficence/utility. One way to move health care relationshipsaway from the issue of power strugglesis to downplay the traditionalview of the physician as authority, and to emphasizetheir role as educators.In most fields, teaching non-experts has traditionallybeen viewed as a female task. Not surprisingly,patient edu-

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cation is often delegatedto the predominantlyfemale occupationsof nursing and social work. Observewhat happenswhen informedconsent is viewed in termsof an educational model, with the physicianas teacher, instead of a medical model, in which treatingdisease is paramount.Using the medicalmodel, manyphysicians relate to patients based on whether the interactionwill promotepatient health. Thus, informationis given to patients only if it will not harm the patient's medical condition. For example, a physician might ponder, "Will these facts depress the patient, thereby lowering her immune response?"Moreover, using the medical model, when a patient fails to understand the risksand benefits of alternativetreatments,the first explanation is probablypsychiatric: the patient is in denial, unable to accept disturbing facts. Maybe, maybenot. Of coursepeople sometimesrefuseto hear frightening facts. But, as a teacher, I know how hardit is to communicateeven when the subjectis emotionallybland, as in logic. Teachersneed to repeat, to connect with thisstudent'sexperience, and to get feedbackfromstudentsso that inaccuraciescan be corrected.Teaching skills are hard-won-requiring practice, experimentation, and sensitivity to audience. The medical model downplaysthe difficultiesof teaching well, tends to attributefailuresof communication to patients, and lets physicians who are poor teachers off the hook.3 In sum, there are manywaysto add the perspectivesof women to the questions askedin medical ethics. Existingquestionscan be rethought.And new questionscan be posed: about inequality, occupationalroles, "housekeeping issues,"and relationshipissues other than power struggles. MEDICALETHICS:HOW ETHICSIS DEBATED FEMINIST

Over and above which questionsarestudied,how discussionsin moralphilosophy are conducted is crucial. I will brieflydiscussthree feminist themes which suggestdirectionsfor how academicmedicalethics might be done: (1) diversity, (2) relationships,and (3) basing theory on ordinaryexperience. (1) The first theme is diversity.Women (and other groups)have had their perspectivesand interestsminimizedor omitted fromtextbooksand theories. After devising theories that take account of women's experiences, feminist theoristsare often ambivalentabout establishingthese ideas as the paradigm for all humanity. (Forexample, Gilligan 1987 is still workingout to what degree the "justiceperspective"and the "careperspective"in ethics are both needed, and to what degreethey compete.) And rightfullyso: feministsknow that "one size fits all" usuallydoes not. We need fully to explorethe degreeto which philosophicalethics should accommodatemultiplicity. One way of fosteringdiversityin ethics is finding ways to ask more moral questionsfrommanydifferentperspectives.Currently,medicalethics is over-

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whelminglyphysicianethics. But, fromthe philosophicalarmchair,we might ask what questions about health care an Hispanic woman from the barrio wouldwant answered.Or, leaving the armchair,an ethicist might observeon her own-or team up with social scientists to observe-the moral issues which differentsortsof people grapplewith.4 I do not underestimatethe difficulty of interpretingsuch data, but facing these difficultiesis betterthan continuing to ignoreimportantmoralquestions.In medicalethics, we need to do a lot more listening. We need to explore not only new questions, but also alternative moral principlesor values. Those we have now (except in virtue ethics) are best suited to handling conflicts over power and authority. I believe that autonomy, in particular,needs to be reconceived. In medicalethics, the principle of autonomyis most frequentlyused to fend off others'attemptsto makeone's decisions. But it may prove wanting as a positive conception of human agency at its noblest. Alternative conceptions might include self-expression (as opposed to self-mastery)or effortlessness(that is, not needing to "make laws for oneself"). More radically,we should questionwhether the aim is to find one, rather small, set of moral principles or values for everyone (all races, genders,cultures,etc.) at all times in their lives. Some feminists(e.g., Noddings 1984; Sommers 1987; Held 1987) have questioned universalizabilityor have otherwise tried to find room in moral theory for caring for particularothers. Universalizabilitymay indeedbe compatiblewith caringfor particularpersons. Still, we may seek a tolerable, even desirable,amountof diversityin ethics-both in the normativeprinciplesthemselves and in the solutionsthey yield when appliedto specificsituations-that will not lead to chaos. (2) A second feminist theme is relationships. Accordingly, a feminist apin examine how academia relate to each other when disproachmight people ethics. cussing First, the social interactionoccurringduringacademicdebates (writtenor oral) about ethics should itself be morallyevaluated. Did people treat each other with respect?Was good will fosteredamong the participants?Motives are important.Sometimes, people simply serve as soundingboardsfor each other as they try to discoverwhat the right responseto a morallycomplex issue is. However, the absenceof ulteriormotives in ethics discussionsis, I suspect, at least as rare in academiaas in the rest of life-that is, rare indeed. When participantsin moraldialogueshave ulteriorpurposesco-existingwith (and sometimesovershadowing)the desire to seek the truth about right and wrong, they are playing a "game":The EthicsGame. In academia, the Ethics Game is sometimesplayed to one-up the opposition. The goals include proving oneself right (about what is morallyright) and proving the "opposition"wrong. Moraltheories and argumentsare used as weapons. Philosophicalreputationsare at stake:who can poke holes in the

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opponent's position and defend an alternative position against all objections-for all to see?5 Winning may take precedence over truth. Most women and some men feel demeanedby playing this game; they feel sullied when they win, foolish when they lose. When we think of ulteriormotives-anything besides simply seeking the truth about right and wrong-we usuallythink of bad motives, especiallyof manipulatingothers in ways that harm their interests. However, playingthe Ethics Game need not be bad; both the intentions and the results may be good. Forexample, duringclassroomethics discussions,teachersoften desire (an ulteriormotive) that studentswill learnto expresstheir ideasmoreconfidently in public and increase their self-esteem. Here the Ethics Game is played to encouragetrust and respect among participants,insteadof scoring points at others'expense. Feministscould explore the moralmeritsof different variationsof the Ethics Game. Destructiveformsof competitiveness-which arepartof how the academic Ethics Game is often played-might be avoided by experimentingwith how papersare authored.Collective authorship(a rarityin philosophy)could be encouraged.Authorscould devise waysof minimizingthe problemsof collaboration. And the processwhich the authorsgo throughin workingtogether might inform the topic studied (especially if the topic concers relationships). The collaborativeprocessmight even change the authors'lives for the better.6 Anonymous authorshipis another possibility. Each feminist, singly or with others, could-once in a career-write an article under the same pseudonym.Laterauthorswouldnot need to be consistentwith priorwritings publishedunderthis name. My favoritecandidatefor identifyingthis collective feminist identity is "Sue D. Nym." This pseudonymwoulddeliverboth a political statement and a Kierkegaardianinvitation: the reader should considerthe ideas and look within, without consideringthe author'sreputation. Second, when we are writing or teaching about ethics, we should address not only the intellect but the entire personalityof the moraldecision-maker. Moral argumentsadvance reasonsfor a conclusion, but there is more to do. Learningabout the lives of people-real or fictional-can inspire;and others can serve as models for solving moralproblems.Forexample, I once found it immenselyhelpful to ask myself: "If Gandhi were in my shoes (sandals, of course), how would he deal with the Dean of the Facultyon this matter?" Moreover, we are often ambivalent about which position is morallycorrect. It is tempting to reduceinternalconflict by aligningwith one side, and by projectingthe feelings and beliefs we deny onto an opponent-whom we then try to grind into the dust. On differentoccasions, we may even align with opposite sides-depending on our mood, and on what positions others have already staked out. Helping people-students, readers, and ourselves-to claim all of their ambivalent voices as their own (through role-

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playing, writing journals, etc.) may be one of the biggest contributionswe can make as teacher-scholarsto increasingboth self-understandingand social harmony. (3) A thirdfeminist theme is that theoryshouldbe constructed fromone'slife experience,that life precedestheory. In the 1960s and 70s, small consciousness-raisinggroups were pivotal in spreadingthe feminist spirit. Accepted ideas in politics, morality, science, and everyday living had to be reexamined; and the bedrock of this critique and exploration was to be each woman's experience. It was thought that feminist theory should not come down from on high by "experts" and famous authors, even if they were feminists. The belief that feminist theory should be groundedon the experiencesof ordinarywomen is not a naive philosophicalclaim. Feministsknow that our experience is shaped, even constructed, by our system of (patriarchaland other) beliefs. Rather, it is a political commitmentwhich accomplishestwo things. First,one learnsto trustone's own judgment,listening to oneself and to other ordinaryfolk, even if all the bookssay otherwise. (Not until I taught my first Philosophyof Wmen curse did I realizethat my conception of God was basedon my mother-not on my father, as Freudhad said.) Second, the authority of established experts-and one's relationshipto them-is challenged. If knowledge is power, "life precedestheory"is social revolution. This social revolutioncould be extended to academicethics. Moralphilosophy would not be assumedmainly to trickle down from the experts to students. (See Harding1987,8-10, on alternativesto "trickledown"in feminist social science research.) Despite the fact that we philosopherschampion "criticalthinking," our students are expected, to a great degree, to accept their teachers'framework,methods, and basic assumptions-which form the criteria for doing good philosophy. (How many times did I force students, when they offeredmoral reasons, to "identifythe relevant moral principle" from a short list, before I realizedhow many of their reasonssimplydid not fit, unless mutilated?)I have no desire to expel the philosophicalbaby with the bathwater,but maybe, all along, we have been discardingonly partof the water aftereach bath. It may be time for moralphilosophersto question not only the power relationshipbetween physiciansand patients, but that between themselves and those they would instruct;and that between themselves and the philosophers(fromPlato to Rawls) they turn to for guidance. CODA

I have describedsome directionswhich a medicalethics inspiredby the insightsof feminismmight take. Two overallpoints will, I believe, proveuseful in rethinking philosophical ethics, particularlymedical ethics. First, moral shoulddecidewhichmoralissuesmeritattention.Neglect is not alphilosophers

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ways benign. And raising certain questions-especially in the absence of a widercontext-may deeply influence people'sbeliefs and attitudes. Second, we needto considerhowphilosophical moraldebatesshouldbe conducted,including how ulterior motives influence us. What we select-and neglect-to studyas well as the "games"we play may be sending a messageas loud as the wordswe do speak on ethics. These two points are instancesof the claim that doingphilosophy-including moralphilosophy-isa partof life, andso maybeevaluatedmorally.Workingon a particularphilosophicalissue in a particularway shouldbe partof a searchfor truth, but it is more. It may influenceour relationshipswith studentsand colleagues;it may affect how well our readersand students listen to themselves and treat others. We are responsiblefor all of our choices. NOTES I readearlierversionsof this paperat the Society of Women in Philosophy,Pacific Division meetingsin Los Angeles in April, 1988, and at the conferenceon "Explorationsin FeministEthics: Theory and Practice,"in Duluth, MN, in October, 1988. I thank the membersof both audiences for their comments, and GregoryS. Kavka,who commentedon an earlyversion. Thanks for helpful substantive and editorial suggestionsgo to Helen BequaertHolmes and LauraM. Purdy,the editors of this issue of Hypatia,and to the two anonymousreviewersof this paper. 1. In our priornon-medical example, the crisisquestion is: "When hiring, should preference be given to women/minorities?"The housekeepingquestion is: "How can I behave at work to The latter invites an examinationof discriminatoryattitudesand goes help end sexism/racism?" farbeyondwhetherpreferenceto women/minoritiesshould be given in the final hiring decision. Reexaminationof the entire job search is needed, and of how the new employee (of whatever genderor race) will be treatedon a daily basis in yearsto come. Moreover,facultytreatmentof students should be addressed.For example, should classroomproceduresbe changed? (Letting the big talkersspeakwhenever they want to may favor male studentsand-if the school is predominantly white-whites). And are faculty membersmore likely to encouragemale (white) students to attend graduateschool or to try for prestigiousjobs? 2. While some authorshave discussedthese issues, as yet they have had relativelylittle influence in changing the terms in which the debate is framed.See Addelson 1987, Callahan 1986, Harrison1984, and Whitbeck 1982; Tooley and Purdy1974 give a utilitarianperspective. 3. Perhaps preventive medicine would gain more prominence if the physician-patient relationshipwere viewed more in terms of teaching and guiding, and less as a contest for final decision-makingauthority (the autonomy-paternalismdebate). 4. I would like to ask people which moral questions in health care they want most to avoid-and then to study those. In my experience, the most explosive issue does not concern when to withhold life-support,or other crisisissues, but a housekeepingissue:the hospital'sown hierarchicalsocial structure.In particular,should the dramaticallyunequal power distribution between physiciansand nurses (social workers,etc.) be maintained? 5. See Lakoff and Johnson (1980, 61-65 and 77-81) on the "rational argument is war" metaphor. It might be objected that the best way to get to the truth is for others to try their mightiest to slay one's arguments;an idea'ssurvivalis purportedto be evidence of its truth. In a conciliatory moment, I might replythat differentstylesof argumentmayworkbetterfor some people, and for some topics, than others. However, my considered opinion is harsher. Though schooled to accept the GladiatorTheory of Truth, I have never found it to be the only way to get to the truth. Moreover, I have often found it to distort truth and to crush creativity. Do not take my word for it; ask your students about it. 6. These and other issues about academic competition are discussedin Miner and Longino 1987; many of the articles are jointly authored.

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REFERENCES Addelson, KathrynPyne. 1987. Moralpassages.In Womenandmoraltheory, Eva FederKittayand Diana T. Meyers,eds. Totowa, N.J.: Rowmanand Littlefield. Callahan, Daniel. 1986. How technology is reframingthe abortiondebate. HastingsCenterReport16 (1): 33-42. Gilligan, Carol. 1982. In a differentvoice.Cambridge,MA: HarvardUniversity Press. Gilligan, Carol. 1987. Moralorientationand moraldevelopment. In Women and moraltheory,Eva FederKittay and Diana T. Meyers, eds. Totowa, N.J.: Rowman and Littlefield. Harding, Sandra. 1987. Introduction:Is there a feminist method? In FemiSocialscienceissues,SandraHarding,ed. Bloomingnism& methodology: ton: IndianaUniversity Press. Harrison,BeverlyWildung. 1984. Our rightto choose:Towarda new ethicof abortion.Boston: Beacon Press. Held, Virginia. 1987. Feminismand moraltheory. In Womenand moraltheory, Eva FederKittayand Diana T. Meyers,eds. Totowa, N.J.: Rowman and Littlefield. Kittay, Eva Federand Diana T. Meyers,eds. 1987. Womenandmoraltheory. Totowa, N.J.: Rowman & Littlefield. we liveby. Chicago:UniLakoff,Georgeand MarkJohnson. 1980. Metaphors versity of Chicago Press. A feministtaboo? Miner, Valerie and Helen Longino, eds. 1987. Competition: New York:The Feminist Pressat the City University of New York. Noddings, Nel. 1984. Caring:A feminineapproachto ethics& moraleducation. Berkeley:University of CaliforniaPress. A feministanalysis. Overall, Christine. 1987. Ethicsand humanreproduction: Boston: Allen & Unwin. Sommers,ChristinaHoff. 1987. Filial morality.In Womenandmoraltheory, Eva FederKittayand Diana T. Meyers,eds. Totowa, N.J.: Rowmanand Littlefield. Stein, LeonardI. 1967. The doctor-nursegame. Archivesof GeneralPsychiatry 16 (6): 699-703. emotion.New York:TouchTavris, Carol. 1982. Anger:The misunderstood stone, Simon & Schuster. Tooley, Michael and LauraPurdy.1974. Is abortionmurder?In Abortion:Pro and con, Robert L. Perkins, ed. Cambridge,MA: Schenkman. Wasserstrom,Richard. 1977. Racism, sexism, and preferentialtreatment: An approachto the topics. UCLA Law Review24 (3): 581-622. Whitbeck, Caroline. 1982. The moral implicationsof regardingwomen as people: New perspectiveson pregnancyand personhood.In The concept of person and its implicationsfor the use of the fetus in biomedicine. Dordrecht:D. Reidel.

The Role of Caring in a Theory of Nursing Ethics SARA T. FRY

The development of nursingethicsas a fieldof inquiryhas largelyreliedon theoriesof medicalethicsthatuseautonomy,beneficence,and/orjusticeas foundational ethicalprinciples.Such theoriesespousea masculineapproachto moraldecisionmakingandethicalanalysis.Thispaperchallengesthepresumption of medicalethics and its associatedsystemof moraljustificationas an appropriate modelfor nursing ethics.It arguesthatthe valuefoundationsof nursingethicsare locatedwithinthe existentialphenomenonof human caringwithin the nurse/patientrelationship insteadof in modelsof patientgoodor rights-based notionsof autonomyas articulatedin prominenttheoriesof medicalethics.Modelsof caringare analyzedand a (MPV) theorywithcaringas a fundamentalvalueis proposed moral-point-of-view to for thedevelopment of a theoryof nursingethics.Thistypeof theoryis supportive to, andnot merelythe feministmedicalethicsbecauseit focuseson thesubscription acceptanceof, a particularview of morality.

INTRODUCTION Duringthe past ten years, a numberof books on ethics in nursingpractice have appeared(Benjaminand Curtis 1986; Davis and Aroskar1983;Jameton 1984; Muyskens 1982; Thompson and Thompson 1985; Veatch and Fry 1987). Unlike earlierwritingsthat viewed ethics in nursingas primarilyfeminine etiquette (Aikens 1916; Gladwin 1937; Robb 1900), these books view nursingethics as a subsetof contemporarymedicalethics. Accordingly,they apply medical ethics to the practice of nursing using frameworksfrom bioethical theory (Beauchampand Childress1983), theologically-basedcontract theory (Veatch 1981), pluralisticsecular-basedtheory of human rights (Engelhardt1986), and a well-known, liberaltheoryof justice (Rawls 1971). This influence on the developmentof nursingethics has been quite extensive. Currentnursingethics discussionstend to revolve arounddeontological versusutilitariantheories, the weight of medical ethical principlesand rules in nurses'decision-making,and the relative importanceof nursing'scontract with society and individualpatients. Empiricalstudiesin nursingethics have almost exclusively used justice-basedtheoriesof moralreasoningfromcogniHypatiavol. 4, no. 2 (Summer 1989) ? by Sara T. Fry

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tive psychologyto interprettheir findings on nurses'moralbehavior, moral judgment, and moral reasoning (Crisham 1981; Ketefian 1981a, 1981b, 1985; Munhall 1980; Murphy1976). In addition, medicalethical frameworks guide the majority of normative discussions of ethics in nursing (Cooper 1988; Silva 1984; Stenberg 1978). The resultis a trend in nursingethics that does not take into considerationthe role of nursesin health care, the social significance of nursing in contemporarysociety, or the value standardsfor nursingpractice. By focusingon the termsof justification,gender-biasedconsiderationsof justice, and the languageof principlesand rules, nursingethics has seeminglyadoptedthe "languageof the father,"to use Noddings'sapt terminology (1984, 1). This paper challenges the presumption of medical ethics, especially a "masculine"medical ethics, as an appropriatemodel for nursingethics. By a "masculine"medical ethics, I mean ethical theorizingand associatedargumentation that proceedsas if it were governedby an implicit, logical necessity between hierarchicallyarrangedlevels of ethical principles,rules, and actions. Often called "the engineeringmodel"of medicalethics (Caplan 1982, 1983), this type of theorizinghas been criticizedby bioethicistsfor a number of years (Ackerman 1980, 1983; Basson 1983; Toulmin 1981). Medical ethics basedon this type of theorizingoften relieson a lexical orderingof principles (Toulmin 1981) or the context of justificationfor ethical decision-making rather than the context within which such decision-makingtakes place (Noddings 1984) or the kinds of reasonsthat are regardedappropriateto the makingof moral judgments(Frankena,1983). Drawingon the resultsof empiricalstudies on physician and nurse decision-makingas well as philosophicaldiscussionsof nursingethics, I show that the theoretical and methodologic foundationsof nursing ethics have been largelyderivedfrom "masculine"formsof medical ethics. I arguethat caring ought to be the foundationalvalue for any theory of nursingethics. In addition, caringmust be groundedwithin a moral-point-of-viewof personsrather than any idealizedconception of moral action, moralbehavior, or systemof moraljustification. If successful,my argumentmight be significantin two respects.First,it just might be supportiveto a feminist medical ethic. While we might agree that medical ethics, in general, ought to be cpale ofbeing practiced by both males and females, surelyfeminist medicalethics necessarilymust be capable of being practicedby females. Since the nursingprofession,the largestgroup of health careprovidersin the United States, has alreadyarticulatedcaringas an importantvalue (Fry 1988; Gadow 1985; Watson 1985) and nursing is usuallypracticedby females, this means that caringand the type of functions that are usuallyassociatedwith the practiceof nursingare relatedto one another-at least in the minds of a significant portion of individualsin the health care arena. Hence, the connections between the value of caring and

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feminismcannot be easily denied. Since the phenomenon of human caring need not be gnderrelated, any claim to feminist medicalethics must demonstratethat it has broaderapplicationsthan either just to medical practiceor just to females.After all, patients arecaredfor by individualsother than physicians, and those who do this caringare not alwaysfemales. A nursingethic with caring as a foundationalvalue might be an importantasset to the perceived need to articulatea feminist medical ethic. Second, since articulationof the phenomenonof humancaringhas already challengedjustice based theories of moraldevelopmentand moraljudgment (Gilligan 1982, 1987) and theories of ethics and moraleducation (Noddings 1984), a theory of nursing ethics with a moral-point-of-viewof caring as a central value might also challenge any theory of medical ethics that utilizes traditionalethical principlesor that depends on the context of justification for determining what is morally right and/or wrong in medical practice. Given the present dissatisfactionwith traditionalfoundationsof biomedical ethics, moral-point-of-viewtheories as well as a caring-basedethic might prove very attractive as the discipline of bioethics moves into the 21st centuryand faces new tests for its moralfoundationsand traditionalarguments. OFNURSINGETHICS VALUEFOUNDATIONS TRADITIONAL

Several interestingapproacheshave been used to identify the moralfoundationsof nursingand the centralvalue(s) of the nursingethic. Forexample, empiricalstudies of the clinical decision-makingof nurses have pinpointed autonomyas a fundamentalvalue affectingmoraldimensionsof nursingpractice (Alexander, Weisman, and Chase 1982; Prescott, Dennis, and Jacox 1987). The resultsof one other studyhave suggestedthat subjectivevalues, such as producingthe greatestgood for the greatestnumber,arefoundational to nurses'ethical decision-making(Self 1987). Unfortunately,the resultsof these studieswere interpretedin termsof these valuesas predeterminedideologies for nursing practice. In other words, autonomy and producinggood were categoriesthat the researchersexpected to find because autonomyand producinggood are prominentfeaturesof medical ethics. What was assumed to be the case in medicalethics was assumedto be the case in nursingethics, as well. This should not surpriseus. Both of these values-autonomy and producing good-are prominent featuresof theories of medical ethics. Engelhardt (1986), for example, posits autonomy as the foundationalvalue of secular bioethics while Pellegrinoand Thomasma(1981, 1988) urge the restoration of beneficence as the fundamentalprinciple of medical ethics. As used in these theories, autonomyand roducinggood constitute idealizedvalue components of a social ethic for the practice of medicine and function within a structuredframeworkof ethical principles and rules for physician decision-

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making. Both theoriesrelyon traditionalinterpretationsof their centralprinciples and utilize traditionalpatternsof moraljustificationas articulatedby leadingbioethicists. The sameviews of autonomyand beneficencehave even been claimed by some nurses as the moral basis for needed socialreformon the institutional setting in which nursing is practiced (Yarling and McElmurry1986). However, there is no good reason to assumethat autonomy and producinggood are, de facto, the appropriatevalue foundationsfor the practice of nursingsimply because they are accepted for the practiceof medicine. While no one would dispute that autonomy and producinggood are related to the practice of nursing, neither of these values, derivedfrom theories of medical ethics, have been convincingly arguedto be the primary moralfoundation(s) of the nursingethic. Other approachesto identifyingthe moral foundationsof nursingor the fundamentalvalue of the nursingethic have been both analyticaland normative. For example, Stenberg (1979) analyzesvalue concepts of severaltheoretical frameworksin medical ethics for their relevance to the practice of nursing. She analyzes the concepts of code, contract, and context as discussedin the worksof May (1975) and Fletcher(1966) and finds them inadequate basesfor the nursingethic. However, the concept of covenant as discussedin the medicalethical worksof Ramsey(1970) and May (1975) is adequate as an "inclusive and satisfying model for nursing ethics" (Stenberg 1979, 21). Viewing covenant as the foundational value for such health workeractions as fidelity, promise-keeping,and truth-tellingin patient care, Stenberg adopts it without alteration. Becausecovenant is a moralfoundation for the physician/patientrelationship,Stenbergconsidersit valid for the nurse/patientrelationship, as well. This tendency to adopt medical ethical frameworksas valid moralfoundationsfor the practiceof nursingis repeated in morerecent analysesof the moralfoundationsof the nursingethic (Bishop and Scudder 1987; Cooper 1988). Again, what is appropriateto the practice of medicine or is arguedas a moralfoundationfor the physician/patientrelationshipis not necessarilythe case for the practice of nursingor the nurse/patientrelationship. THE MORALVALUEOFCARINGAS A FOUNDATIONFORNURSINGETHICS

Foregoingrecourseto medicalethics, a few nurseshave attemptedto articulate other foundational values for the moral practice of nursing. Sally Gadow (1985), for example, arguesthat the value of caringprovidesa foundation for a nursingethic that will protectand enhance the humandignityof patients receiving health care. Viewing caring in the nurse/patientrelationship as a commitment to certain ends for the patient, Gadow analyzesexistential caring as demonstratedin the nursing actions of truth-telling and touch. Through truth-telling, the nurse assiststhe patient to assessthe sub-

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jective as well as objective realities in illness and to make choices based on the unique meaning of the illness experience. Throughtouch, the nurse assists the patient in overcoming the objectnessthat often characterizesa patient's experience in the health care setting. To touch the patient is to affirm the patient as a personratherthan an object and to communicatethe value of caringas the basisfor nursingactions. This approachidentifiesa moralfoundation for nursingethics basedon the realityof the nurse/patientencounter in health care. It has also been supportedby others who wish to articulate caring as a foundation of the nurse/patient relationship and its meaning (Griffin 1983; Huggins and Scalzi 1988; Packardand Ferrara1988). Buildingon the ideas of Gadow, Jean Watson (1985) proposesa slightly differentview of caring as the foundation of "nursingas a human science" (13). Viewing nursingas a means to the preservationof humanitywithin society, Watson posits caringas a humanvalue that involves "awill and a commitment to care, knowledge, caringactions, and consequences"(1985, 29). Such a view of caring requiresa commitmenttowardprotectinghuman dignity and preservinghumanityon the partof the nurse. Caringbecomesa professionalideal when the notion of caringtranscendsthe act of caringbetween nurse and patient to influence collective acts of the nursingprofessionwith importantimplicationsfor human civilization. Like Gadow, Watson views caring as a moral ideal that is rooted in our notions of human dignity. However, unlike Gadow, Watson'shumancaringconstitutesa philosophyof action with many unexplained metaphysical and spiritual dimensions. As such, her view of caring supportsher abstractphilosophyof nursingbut does not adequatelysupportcaring as a moralvalue that ought to be a foundation for the nursing ethic. The value of caring remainsan ideal rather than an operationalizedaspect of nursingjudgmentsand/or actions. Like Gadow (1985) and Watson (1985), Griffin (1983) posits caring as a central value in the nurse/patientrelationship. She considerscaring to be, first, a mode of being. A naturalstate of human existence, it is one way that individualsrelate to the worldand to other humanbeings. This is not unlike Heidegger's(1962) notion of care as a fundamentalway that humansexist in the world and Noddings' (1984) view of caringas a naturalsentiment of being human. As a mode of being, caring is natural-a feeling or an internal sense made universalin the whole species;it is neither moralnor non-moral. Second, caring is considereda preconditionfor the care of specific entities-other things, others, or oneself (Griffin 1983). This meansthat a conceptual idea about caring exists as a structuralfeatureof human growth and developmentpriorto the point at which the processof caringactuallycommences. Third, caringis identifiedwith social and moralideals. Forexample, Watson views caringas occurringin society in orderto serve humanneeds such as protection from the elements or the need for love. Gadow views caring as a

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means to protect the human dignity of patients while their health care needs are met. Thus, caring, a phenomenon of human existence, gains moral significance because it is consistently reinforcedas an ideal by those who have responsibilityto serve the needs of others (Griffin 1983). Since the practice of nursing is socially mandated to assist the health needs of individuals (AmericanNurses'Association 1980) and the nurse/patientrelationshiphas undeniablymoral dimensions, caring becomes stronglylinked to the social and moral ideals of nursingas a profession. THREEMODELSOFCARINGRELEVANT TO NURSINGETHICS

Given these attributesof caringas definedby accountsof the nurse/patient relationship,at least three models are relevant for a theory of nursingethics which posits caring as a foundationalvalue. NODDINGS'SMODELOFCARING

The first model is found in the work of Nel Noddings (1984) and is theoreticallybasedon ethics and social psychology.Buildingon the workof Carol Gilligan (1977, 1979, 1982), Noddings has combined knowledge of ethics with perspectiveson moraldevelopmentin women. She statesher purposeto be "feminine in the deep classical sense, rooted in receptivity, relatedness, and responsiveness"(Noddings 1984, 2), yet she is carefulto develop her notion of caring to be applicableto both females and males. Caringis a feminine value in that the attitudeof caringexpressesour earliest memoriesof being caredfor-one's store of memoriesof both caring and being caredfor is associatedwith the mother figure. However, caring is also masculinein that it involves behaviorsthat have moralcontent and that can be adoptedand embracedby men, even though it is not in their naturaltendencies to adoptsuch notions. In definingcare, Noddingsstates, ". . . to care may mean to be charged with the protection, welfare, or maintenance of something or someone" (1984, 9). Rather than an attitude that begins with moralreasoning, it representsthe attitudeof being moralor the "longingfor goodness" (Noddings 1984, 2). Rather than an outcome of behavior, Noddings'sview of caringis ethics itself. As such, it is not necessarilygenderdependent but is gender-relevant. Central to this view of caring are the notions of receptivity, relatedness, and responsiveness:the acceptanceor confirmationby the one-caringof one who is the cared-for(receptivity), the relation of the one-caringto one who is cared-foras a fact of human existence (relatedness),and commitmentfrom one-caringto one who is cared-for(responsiveness).Ethical caring is simply the relationin which we meet anothermorally.Motivatedby the ideal of caring in which we are a partnerin human relationships,we are guidednot by

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ethical principles but by the strength of the ideal of caring itself, claims Noddings. Thus, insteadof the notions inherent in conditionsfor traditional moraljustification(Beauchamp1982), Noddings'sethic of caringdependson "the maintenanceof conditions that will permitcaringto flourish"(1984, 5). It is a person-to-personencounter that ultimatelyresultsin joy as a basic human affect within relationshipsbound by ethical caring. Scholarshipon the caring phenomenon, in general, has been stronglyinfluencedby Noddings'smodel of caring. Her view has stressedthe ethics and morality of caring from a perspective that is definitely gender-relatedalthough Noddings herself would undoubtedlydeny that she is advocating a "feministmodel." Yet, the model's relevance to the practice of nursingremains largely unexplored. For those who recognize the limitations of the bioethical model of ethical decision-making,however, Noddings'smodel is a rich groundfor the futurediscussionof nursingethics. It mayalso prove to be an acceptable model for the descriptivestudy of ethical decision-makingin nursingpractice. While its focus on the ethic of caringas feminine might not be attractiveto nurseswho are not also female, its foundationsin the notions of receptivity, relatedness, and responsivenessbetween the one-caring and the one who is cared-formake it a viable frameworkfor the realisticnatureof the nurse/patientrelationship. MODELOFCARING MORALOBLIGATION PELLEGRINO'S

EdmundPellegrino, a humanistand physician, has written extensively on caring as a derivative value of the physician'sobligation to do good (1985; Pellegrinoand Thomasma 1988). When discussingthe role of the physician to the patient, Pellegrinonotes that there areat least foursenses in which the word"care"is understoodby the practiceof medicine (1985). The firstsense is "careas compassion"or being concerned for another person. This is a fel ing, a sharing of someone's experience of illness and pain, or just being touched by the plight of another person. To care in this sense, accordingto Pellegrino, is "to see the person who is ill" as more than the object of our ministrations(1985, 11). He or she is "a fellow humanwhose experienceswe cannot penetrate fully but which we can be touched by simply because we share the same humanity"(Pellegrino 1985, 11). The second sense of caring is "doingfor others"what they cannot do for themselves (1985). This entails assistingothers with the activities of daily living that are compromisedby illness (for example, feeding, bathing, clothing, and meeting personal needs). Pellegrino recognizesthat physiciansdo little of this type of caring but that nursesand nurses'assistantsdo a great deal. The third sense of caringdiscussedby Pellegrinois caringfor the medical problemexperiencedby the patient (1985). It includes:(1) inviting the pa-

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andanxietyaboutwhatis wrongto the physitient to transferresponsibility that cian, (2) assuring knowledgeandskillwill be directedto the patient's problem,and (3) recognizingthat the patient'sanxietyneedsa specialized typeof caringthat is presumedavailablefroma physician. fourthsenseof caringis to "takecare"(1985, 12). Thismeans Pellegrino's to carryout all the neessaryprocedures (personalandtechnical)in patient carewithconscientious attentionto detailandwithperfection.He findsthis a corollaryof the thirdsenseof carebut arguesthat it is differentiated from of medicine.Together, the thirdsenseby its emphasison the craftmanship the thirdandfourthsensesof caringcomprisewhatmostphysiciansunderstand as competence.

Pellegrinodoes not find thesefoursensesof caringseparablein clinical practice.Carethatsatisfiesthe foursensesthathe hasdefinedis called"integralcare"(1985). This typeof careis, forPellegrino,a moralobligationof It is not an optionthat can be exercisedor interpreted healthprofessionals. "in termsof some idiosyncraticdefinitionof professionalresponsibility" (1985, 13). The moralobligationto carein thismanneris createdbythe special humanrelationshipthat bringstogetherthe one who is ill andthe one who offersto help (1985). In assessing whetherthe caringmodelis foundational formedicalpractice, the rolesof physiciansto theirpatientsandconcludes Pellegrinoreexamines that "to carefor the patientin the full and integralsense,requiresa reconstructionof medicalethics"(1985, 17). What is needed,he claims,is an ethicthatattendsto the conceptof carein itsbroadestsenseandthatmakes Insteadof caringa strongmoralobligationbetweenpatientandprofessional. of curingbetweenphysicianandpatient,a relationof caringis a relationship neededto expressthe natureof the obligationbetweenphysicianandpatient. notionof careis the goodof the individual,a comUnderlyingPellegrino's notion has at that least threecomponents.ForPellegrino,"a morally plex clinical decision should attendto all threesensesof patientgoodand good resolve conflicts satisfactorily amongthem"(1985, 20). Thefirstsenseof goodis "biomedical good"-the gooda medicalinterventioncanofferbymodifyingthe naturalhistoryof diseasein a patient.It takes into consideration the craftsmanship of physicians(andpresumably, nurses), of science,and the medicalindicationfortreatment(1985, 21). The secondsenseof goodis the patient'sconceptof hisorherowngood.It takesinto consideration whatpatientsconsiderworthwhile,or in theirbest and can be decision-makers interests, (1985, 21). designatedto surrogate The thirdsenseof patientgoodis "thegoodmostproperto beinghuman" (1985, 22). ForPellegrino,this is the capacityto makechoices,to set up a lifeplan,andto determineone'sgoalsfora satisfactory life. It is whateverfulfillsourpotentialitiesas individuals of a rationalnature,respectspatientdignity, andexpresseshumanfreedom.

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In comparingthese three senses of patient good to one anotherand to our ideas of social good, Pellegrinoarguesthat patient good is priorto any other notion of good within the practiceof medicine. Within a human obligation model of caring, patient good ultimatelyguidesa physician'sdecision-making wherea patient'shealth and illnessareconcerned. Hence, while the sensesof caring engender desirablephysician behaviorswith the patient, the physician's decision-makingis primarilyguidedby the notions of patient good. In the final analysis, Pellegrino's "integralcaring" is reduced to a derivative value of patient good. It succumbsto typical medical ethical frameworksby utilizinga moregeneral(and traditional)value as the foundationalvalue for a theory of medical ethics. Rather than a theory of caring, Pellegrinoactually proposesa theoryof patient good that simplyusescaringto operationalizepatient good. While Pellegrino'sideas about caring, in general, fit in with the practical sense of nursingpractice, caring'ssubordinaterole within his theoryof medical ethics makes it problematicfor nursingethics. For nursing, caringseems to be morethan a merebehaviorbetween nurseand patient and might not alwaysbe derivedfrom a notion of patient good. For example, even when the good of the patient is undecidedor unknown, the nursecarriesout interventions designed to care for the patient (as in emergency situations). Conversely, even when the patient's good has been made evident, nursing interventionsmay be carriedout that do not, in fact, contributeto this sense of patient good (for example, when the physician'sinterpretationof the patient's good is not acceptedby those planningand administeringnursingcare for the patient). The value of caring, for the nurse, extends beyond the notion of patient good as conceived by Pellegrinobecausenursecaringrelatesto the patient's status as a human being (Gadow 1985; Griffin 1983). For this reason, Pellegrino'smoralobligation model of caringis not trulyappropriate to the practice of nursing. ONCARING THEORY MORAL-POINT-OF-VIEW FRANKENA'S The third and final model of caringrelevantto the developmentof nursing ethics is the moral-point-of-view(MPV) version. It is largelydiscussedby William Frankenain his critique of other MPV theories (1983) and entails adopting a certain point of view by defining its moral principle or central moral value. The result is a type of ethical theory (MPVT) for which Frankenaseems to be a majorspokesman. In essence, one takes a moral-point-of-viewby (1) subscribingto a particular substantivemoralprinciple (or value) and (2) taking a generalapproach, perspective, stance or vantage point from which to proceed. While most MPV theoriescontain views aboutmoraljudgmentsand principles,aboutthe differencesbetween them and nonmoralprinciples,and views aboutthe gen-

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eral nature of their justification,taking the MPV, by itself, simplymeans to adopt a moral principle (or value) and one's methodologyto arguefor that principle. It entails endorsinga generaloutlook or method by someone seeking to reach conclusions in a particularfield (Frankena1983). Accordingto Frankena,variousmoralprincipleshave servedas the central principles(or values) of MPV theories. Mill, for example, acceptsa principle of utility that is pivotal to his MPV theory-that of utilitarianism(1863). Mill startswith a particularoutlook (his moralpoint of view) and adoptsthe principleof utility as themoralprinciplethat indicatesthe kinds of facts that one would make moraljudgmentsabout. Frankena,however, arguesfor taking the MPV morefully than simplyacceptinga certainview of morality.For him, taking the MPV entails not only acceptanceof a particularview of moralitybut enteringthe moralarenaoneself, "usingmoralconsiderationsof the kind defined as a basis for evaluative judgments"(Frankena1983, 70). It means subscribingto a particularview of moralityand living that moralityin one's life ratherthan merelyacceptinga certainview of moralityand the conditions for the separationof the moral from the nonmoral. This is a significant move for Frankenaas it establishesthe crucial difference between his conception of takingthe MPV and the approachesof others who espouse MPVs and their related theories. Like Hume (1751) who espouses sympathy as his "sentiment of humanity," Frankenabelieves that there is alwayssomethingthat "movesus to approveor disapproveof persons" (1983, 70). This something is an attitude or preconditionthat is ultimately the source or motivating factor of anyone who takes the MPV. In other words,the setting forth of any particularfact is not so much the reasonfor deciding what is good and right in taking the MPV as is what generatesthe setting forth of that particularfact (and not some other fact). ForFrankena,this attitude or preconditionconcerns the fundamentalstatus of persons and their human dignity. While he never explicitly defines what this attitude or preconditionis for his own MPV, he eventuallyclaims that this attitudegeneratesthe MPV of Caringor, as he puts it, "aNon-Indifference aboutwhat happensto personsand conscioussentient beingsas such" (1983, 71). Frankena'ssubstantive moral value is the value of caring and takes the form of Kantian respect-for-personsor Christian love. It includes makingnormativejudgmentsand a concern for being rationalin one's judgments but does not entail the acceptanceor use of any particulartest of justifiability, validity, or truth. A judgmentbasedon caringis assumedto be morally justifiablebecause it "wouldbe agreedto by all who genuinely take the MPV and are clear, logical, and fully knowledgeableabout relevantkinds of facts (empirical, metaphysical,or whatever)"(1983, 72). Frankena'sview on caring is quite differentfrom the view of Pellegrino. Where Pellegrino'snotion of patient good providesthe basis for the physician's evaluative judgments, Frankenaposits caring as the basis of human

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normativejudgments, in general. His focus on caring is direct and involves taking the MPV towardcaring as a fundamentalmoralvalue or principlefor normativejudgmentsinvolving personsratherthan the indirectfocus on caring (throughpatient good) that is characteristicof Pellegrino'smedical ethics. Like Noddings, Frankenaeschews the structuresof moral justification that typify traditional medical ethical theorizingand the separationof the conditions for justificationfrom the context of ethical decision-makingwith persons. Where much of moral philosophy takes the MPV by simply acting on principleor out of duty, Frankena'sMPV requiresa human responsefrom the one taking the MPV in the formof respect-for-persons or Christianlove. It requiresan identifiableform of responsefrom the one-caring to the one cared-for,to use Noddings'sterminology. Unfortunately, Frankenamakesno attempt to define exactly what he interpretsas respect-for-personsand certainlydoes not discusshis principleof caring in terms relevant to feminist philosophy. However, he does indicate that adopting the MPV of caring is made from an undefinedpreconditional attitude toward personhood and human dignity. This is not unlike Noddings'snotions of receptivity, relatedness,and responsivenesswhich anchor her view of ethical caring. While it would not be appropriateto interpretFrankena'sview of caringas identicalor even similarto Noddings'sview, certainlyhis method of arrivingat caring as a lived principlefor a systemof morality(taking the MPV) bearssome relevance to Noddings'sviews and a feminist approachto medical ethics. CONCLUSIONS

Given the models of caring proposed by Noddings (1984), Pellegrino (1985), and Frankena(1983), and the views on caringthat have been developed by nurses (Gadow 1985; Griffin 1983; Watson 1988), several recommendationsfor the futuredevelopmentof a theory of nursingethics and any system of feminist medical ethics seem relevant. First, theories of medical ethics as currentlyproposeddo not seem appropriateto the developmentof a theoryof nursingethics. The context of nursing practicerequiresa moralview of personsratherthan a theoryof moralaction or moralbehavioror a systemof moraljustification.Presenttheories of medical ethics have a tendency to supporttheoretical and methodological views of ethical argumentationand moral justificationthat do not fit the practical sense of nurses'decision-makingin patient care and, as a result, tend to deplete the moralagency of nursingpracticeratherthan enhance it. Any theoryof nursingethics will need to considerthe natureof the nurse/patient relationship within health care contexts and adopt a moral-point-ofview that focusesdirectly on this relationshipratherthan on theoretical interpretations of physician decision-making and their associated claims to

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moraljustificationfor this decision-making.The same might be said for any theory of feminist medical ethics, dependingon how the natureof the relationship between the one-caring and the one who is cared-foris perceived. Second, the value of caring ought to be central to any theory of nursing ethics and any theory of feminist medicalethics, as well. Given the need for nursingcarewithin our society, nursing'sperceivedsocial mandateto provide the "diagnosisand treatmentof humanresponsesto actualor potentialhealth problems"(American Nurses' Association 1980, 9), and the nature of the nurse/patientrelationship,nursinghas a significantopportunityto influence the qualityof patient care throughthe acceptanceand use of its theories. The professionof nursinghas alreadymade substantialcommitmentto the role of caring in severalconceptions of nursingethics and nursingscience. In addition, there appearsto be an importantlink between the value of caringand nursing'sviews towardpersonsand humandignity. As proposedby Frankena, there is good reasonto subscribeto a MPV that is rooted in an attitudeof respect towardpersons. If a theory of nursingethics is to have any purpose,it must necessarilymake evident a view of moralitythat not only truly represents the social role of nursing,as a profession,in the provisionof health care but that also promisesa moralrole for nursingin the care and nurtureof individualswho have health care needs. For theory to achieve this purpose, its view of moralityought to turn on a philosophicalview that posits caringas a foundationalvalue rather than a derivitive value. The same might also be saidfor any theoryof feministmedicalethics that usescaringas a gender-relevant (but not gender-dependent)moral principleor value. Third, taking the moral-point-of-viewand developinga MPV theoryneed not necessarilyinclude the acceptanceor use of any particulartest of moral justification.This means that any theory of nursingethics need not endorse typical frameworksof justificationcontained in theoriesof medicalethics for moraljudgmentsmade within its parametersto be regardedas true, valid, or rationallyjustified.It is true that such judgmentsmustbe justifiedwithin the MPV and pertain to the sorts of facts consideredrelevant accordingto the MPV theory. However, the MPV of the theory of nursingethics itself is not defined by referenceto such a systemof justification.This means that feminist models of moraldecision-makingwith similarviews about moraljustification may have particularrelevance to the development of nursingethics and vice versa. To the extent that any theoryof nursingethics takesseriouslythe claimsof MPV theorizingand the role of caring as a central value within its framework, there is reasonto believe that medicalethics will benefitfor such a theory cannot develop apartfromthe practiceof medicalethics or fromthe evolution of bioethics as an appliedethics discipline.Likewise,claimsto feminist medicalethics cannot be made apartfromall health carepractices(medicine as well as nursing)and necessarilydrawon the developmentof moralthought

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within bioethical theorizing.Perhapsthe links between all three typesof theorizingare more importantthan currentlyrealized.

ACKNOWLEDGEMENTS The author would like to thank the anonymousreviewersof this journal, and editorsHelen Holmes and LauraPurdyfor their helpfulcriticismson the first drafts of the manuscript. Their comments significantly improvedthe clarity of my argumentsand are gratefullyacknowledged.

REFERENCES

Ackerman, TerranceF. 1980. What bioethics should be. Journalof Medicine and Philosophy5:260-275. Ackerman,TerranceF. 1983. Experimentalismin bioethics research.Journal of Medicineand Philosophy8:169-180. Aikens, Charlotte A. 1916. Studiesin ethicsfor nurses.Philadelphia:W.B. SaundersCompany. Alexander, Cheryl S., Carol S. Weisman and GaryA. Chase. 1982. Determinantsof staffnurses'perceptionsof autonomywithin differentclinical contexts. NursingResearch31 (1):48-52. AmericanNurses'Association. 1980. Nursing:A socialpolicystatement.Kansas City: The Association. Basson, Marc D. 1983. Bioethical decision-making:A reply to Ackerman. Journalof Medicineand Philosophy8:181-185. ethof biomedical Beauchamp,Tom L. andJamesF. Childress. 1983. Principles ics (2nd. ed.). New York:Oxford University Press. Benjamin, Martinand Joy Curtis. 1986. Ethicsin nursing.New York:Oxford University Press. Bishop, Anne H. and John R. Scudder,Jr. 1987. Nursingethics in an age of controversy.Advancesin NursingScience9 (3):34-43. Caplan, Arthur 1982. Applying moralityto advances in biomedicine:Can and should this be done? In New Knowledgein the BiomedicalSciences. William B. Bondeson, H. TristramEngelhardt, Stuart F. Spiker and John M. White, eds. Boston: D. Reidel. Caplan, Arthur. 1983. Can applied ethics be effective in health care and should it strive to be? Ethics93:311-319. Cooper, C. Carolyn. 1988. Covenantal relationships:Grounding for the nursingethic. Advancesin NursingScience10 (4):48-59. Crisham, Patricia. 1981. Measuringmoral judgment in nursingdilemmas. NursingResearch30:104-110.

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Davis, Anne J. and Mila A. Aroskar.1983. Ethicaldilemmasandnursingpractice. Norwalk, Conn.: Appleton-Century-Crofts. Engelhardt,H. TristramJr. 1986. Thefoundationsof bioethics.New York:Oxford University Press. Fletcher, Joseph. 1966. Situationethics: The new morality. Philadelphia: WestministerPress. Frankena,William K. 1983. Moral-point-of-viewtheories. In Ethicaltheoryin thelastquarterof the twentiethcentury.Norman E. Bowie, ed. Indianapolis: Hackett PublishingCompany. Fry, Sara T. 1988. The ethic of caring:Can it survive in nursing?Nursing Outlook36 (1):48. Gadow, Sally. 1985. Nurse and patient: The caringrelationship.In Caring, Anne H. Bishopand curing,coping:Nurse, physician,patientrelationships. John R. Scudder, Jr., eds. Birmingham,Ala.: University of Alabama Press. Gilligan, Carol. 1977. In a differentvoice: Women's conception of self and of morality. HarvardEducationalReview47:481-517. Gilligan, Carol. 1979. Woman'splace in man'slife cycle. HarvardEducational Review49:431-446. Gilligan, Carol. 1982. In a differentvoice. Cambridge,Mass.: HarvardUniversity Press. Gilligan, Carol. 1987. Gender differenceand morality:The empiricalbase. In Womenand moraltheory.E.R. Kittayand D.T. Meyers,eds. Totowa, N.J.: Rowman & Littlefield. Gladwin, Mary E. 1937. Ethics:A texbookfor nurses. Philadelphia:W.B. SaundersCompany. Griffin, Anne P. 1983. A philosophicalanalysisof caringin nursing.Journal of AdvancedNursing8:289-295. Heidegger,Martin. [1927] 1962. Beingand time.J. Macquarrieand E. Robinson, trans. New York:Harper& Row. Huggins,ElizabethA. and Cynthia C. Sclazi. 1988. Limitationsand alternatives: Ethical practice theory in nursing.Advancesin NursingScience10 (4):43-47. Hume, David. [1751] 1957. An inquiryconcerningtheprinciples of morals.Indianapolis:Bobbs-MerrillCompany. Jameton, Andrew. 1984. Nursing practice:The ethical issues. Englewood Cliffs, N.J.: Prentice-Hall. Kant, Immanuel. [1785] 1964. Groundwork of themetaphysic of morals.H. J. Paton, trans. New York:Harper& Row. Ketefian, Shake. 1981a. Critical thinking, educationalpreparation,and development of moral judgment among selected groups of practicing nurses. NursingResearch30:98-103.

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Ketefian,Shake. 1981b. Moralreasoningand moralbehavioramongselected groupsof practicingnurses. Nursing-Research30:171-176. Ketefian, Shake. 1985. Professionaland bureaucraticrole conceptions and moral behavior among nurses. NursingResearch32:248-253. May, William F. 1975. Code, covenant, contract, or philanthropy.Hastings CenterReport5(1):29-38. Mill, John S. [1863] 1971. Utilitarianism.S. Gorovitz, ed. Indianapolis: Bobbs-MerrillCo., Inc. Munhall, Patricia. 1980. Moralreasoninglevels of nursingstudentsand faculty in a baccaluareatenursingprogram.Image12(3):57-61. Murphy,Catherine C. 1976. Levelsof moralreasoningin a selectedgroupof New York, TeachersCollege, ColumbiaUniversity nursingpractitioners. doctoral dissertation). (unpublished L. 1982. Moral investigaMuyskens,James problemsin nursing:A philosophical tion. Totowa, NJ: Rowman & Littlefield. Noddings, Nel. 1984. Caring:A feminineapproachto ethics& moraleducation. Berkeley,CA: University of CaliforniaPress. Packard,John S. and MaryFerrara.1988. In searchof the moralfoundation of nursing. Advancesin NursingScience10 (4):60-71. Pellegrino, EdmundD. 1985. The caringethic: The relation of physicianto patient. In Caring,curing,coping:Nurse, physician,patientrelationships. Anne H. BishopandJohn R. Scudder,Jr., eds., Birmingham,Ala. :Universityof Alabama Press. Pellegrino,EdmundD. and David C. Thomasma.1988. Forthepatient'sgood. New York:Oxford University Press. Prescott, PatriciaA., KarenE. Dennis, and Ada K. Jacox. 1987. Clinical decision makingof staffnurses.Image19(2):56-62. Ramsey,Paul. 1970. Thepatientas person.New Haven:Yale UniversityPress. Rawls,John. 1971. A theoryof justice.Cambridge,Mass.:HarvardUniversity Press. Robb, IsabelH. 1900. Nursingethics:For hospitalandprivateuse. Cleveland: E.C. Loeckert. Self, Donnie J. 1987. A studyof the foundationsof ethical decision-making of nurses. TheoreticalMedicine8:85-95. Silva, MaryC. 1984. Ethics, scarce resources,and the nurseexecutive: Perspectives on distributivejustice. NursingEconomics2:11-18. Stenberg,MargorieJ. 1979. The searchfor a conceptualframeworkas a philosophic basisfor nursingethics: An examinationof code, contract, context, and covenant. MilitaryMedicine144:9-22. Thompson,Joyce B. and HenryO. Thompson. 1985. Bioethicaldecisionmakingfor nurses.Norwalk, Conn.: Appleton-Century-Crofts. Toulmin, Stephen 1981. The tyrannyof principles. The HastingsCenterReport 11 (6):31-39.

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Veatch, RobertM. 1981. A theoryof medicalethics.New York:Basic Books. Veatch, Robert M. and Sara T. Fry. 1987. Case studiesin nursingethics. Phildelphia:J.B. LippincottCompany. Watson, Jean. 1985. Nursing: Human science and humancare. Norwalk, Conn.: Appleton-Century-Crofts. Yarling,Roland B. and BeverlyJ. McElmurry.1986. The moralfoundation of nursing. Advancesin NursingScience8 (2):63-73.

Towarda FeministTheory of Disability SUSAN WENDELL

We needa feministtheoryof disability,bothbecause16 percentof womenare disabled,and becausethe oppressionof disabledpeopleis closelylinkedto the culturaloppression given;likegender,it is soof thebody.Disabilityis not a biological ciallyconstructedfrom biologicalreality.Our cultureidealizesthe bodyand demandsthatwe controlit. Thus, althoughmostpeoplewillbe disabledat sometime in theirlives, the disabledare made "theother,"who symbolizefailureof control and the threatof pain, limitation,dependency,and death.If disabledpeopleand intosociety,everyone'srelationto her/hisreal theirknowledgewerefully integrated bodywouldbe liberated.

In 1985, I fell ill overnightwith what turnedout to be a disablingchronic disease. In the long struggleto come to termswith it, I had to lear to live with a body that felt entirely different to me-weak, tired, painful, nauseated, dizzy,unpredictable.I learnedat firstby listening to other people with chronic illnesses or disabilities;suddenly able-bodiedpeople seemed to me profoundlyignorantof everythingI most needed to know. Although doctors told me there was a good chance I wouldeventuallyrecovercompletely, I realized after a year that waiting to get well, hoping to recover my healthy body, was a dangerousstrategy.I began slowly to identifywith my new, disabled body and to lear to workwith it. As I movedback into the world, I also began to experience the world as structuredfor people who have no weaknesses.1 The processof encounteringthe able-bodiedworld led me gradually to identifymyselfas a disabledperson, and to reflect on the natureof disability. Some time ago, I decided to delve into what I assumedwouldbe a substantial philosophicalliteraturein medicalethics on the natureand experienceof Index, looking under "Disability," disability. I consulted The Philosopher's This was a depressingexperience. At "Disease." and "Illness," "Handicap," least 90% of philosophical articles on these topics are concerned with two questions:Under what conditions is it morallypermissible/rightto kill/let die a disabledpersonand how potentiallydisableddoes a fetus have to be before it is permissible/rightto prevent its being born?Thus, what I have to say here Hypatiavol. 4, no. 2 (Summer1989)? by SusanWendell

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about disability is not a responseto philosophical literatureon the subject. Instead, it reflects what I have learned from the writingsof other disabled people (especially disabledwomen), from talking with disabledpeople who have sharedtheir insightsand experienceswith me, and frommy own experience of disability. It also reflects my commitmentto feminist theory, which offersperspectivesand categoriesof analysisthat help to illuminatethe personal and social realitiesof disability,and which would, in turn, be enriched by a greaterunderstandingof disability. We need a theory of disability. It should be a social and political theory, because disability is largelysocially-constructed,but it has to be more than that; any deep understandingof disabilitymust include thinking about the ethical, psychologicaland epistemic issuesof living with disability.This theory should be feminist, becausemore than half of disabledpeople are women and approximately16% of women are disabled (Fine and Asch 1988), and becausefeminist thinkershave raisedthe most radicalissuesaboutculturalattitudes to the body. Some of the same attitudesabout the body which contributeto women'soppressiongenerallyalso contributeto the social and psychological disablementof people who have physicaldisabilities.In addition, feministsare grapplingwith issuesthat disabledpeople also face in a different context: Whether to stresssamenessor differencein relationto the dominant group and in relation to each other; whether to place great value on independence from the help of other people, as the dominant culturedoes, or to question a value-systemwhich distrustsand de-valuesdependence on other people and vulnerabilityin general;whetherto take full integrationinto male dominated/able-bodiedsociety as the goal, seeking equal power with men/ able-bodiedpeople in that society, or whetherto preservesome degreeof separateculture, in which the abilities, knowledgeand valuesof women/the disabled are specificallyhonoured and developed.2 Disabled women struggle with both the oppressionsof being women in male-dominatedsocieties and the oppressionsof being disabled in societies dominated by the able-bodied. They are bringing the knowledge and concerns of women with disabilitiesinto feminismand feministperspectivesinto the disabilityrights movement. To build a feminist theory of disabilitythat takes adequateaccount of our differences,we will need to know how experiences of disabilityand the social oppressionof the disabledinteractwith sexism, racismand class oppression.Michelle Fine and Adrienne Asch and the contributorsto their 1988 volume, WomenandDisabilities,have madea major contributionto our understandingof the complex interactionsof genderand disability. BarbaraHillyer Davis has written in depth about the issue of dependency/independenceas it relatesto disabilityand feminism(Davis 1984). Other importantcontributionsto theory are scatteredthroughoutthe extensive, primarilyexperiential,writingby disabledwomen;3this workoffersvital insights into the nature of embodimentand the experience of oppression.

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Unfortunately, feminist perspectiveson disabilityare not yet widely discussed in feminist theory, nor have the insights offered by women writing about disabilitybeen integratedinto feminist theorizingabout the body. My purposein writingthis essay is to persuadefeminist theorists,especiallyfeminist philosophers,to tur moreattention to constructinga theoryof disability and to integrating the experiences and knowledge of disabledpeople into feminist theory as a whole. Towardthis end I will discussphysicaldisability4 froma theoreticalperspective,including:some problemsof definingit (here I will criticizethe most widely-useddefinitions-those of the United Nations); the social construction of disabilityfrom biological reality on analogy with the social construction of gender;culturalattitudes towardthe body which oppressdisabledpeople while also alienating the able-bodiedfrom their own experiencesof embodiment;the "othemess"of disabledpeople; the knowledge that disabledpeople could contributeto culturefromour diverseexperiences and some of the waysthis knowledgeis silenced and invalidated.Along the way, I will describebrieflythree issuesdiscussedin disabilitytheory that have been taken up in differentcontexts by feminist theory:samenessvs. difference, independence vs. dependencyand integrationvs. separatism. I do not presumeto speakfor disabledwomen. Like everyone who is disabled, I have a particularstandpointdeterminedin part by both my physical condition and my social situation. My own disabilitymay be temporary,it could get better or worse. My disabilityis usuallyinvisible (except when I use a walkingstick). I am a white universityprofessorwho has adequatemedical and long-termdisabilityinsurance;that makesme very privilegedamong the disabled. I write what I can see from my standpoint. BecauseI do not want simplyto describemy own experience but to understandit in a much larger context, I must venture beyond what I know first-hand.I rely on others to correct my mistakesand fill in those partsof the picture I cannot see. DISABLED? WHO IS PHYSICALLY

The United Nations offers the following definitions of and distinctions among impairment,disabilityand handicap: Any loss or abnormalityof psychological,physio"Impairment: logical, or anatomicalstructureor function. Disability:Any restriction or lack (resultingfrom an impairment)of ability to performan activity in the manneror within the rangeconsidered normalfor a human being. Handicap:A disadvantagefor a given individual,resultingfrom an impairmentor disability, that limits or prevents the fulfillmentof a role that is normal, dependingon age, sex, social and culturalfactors,for that individual."

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Handicap is therefore a function of the relationship between disabledpersonsand their environment. It occurswhen they encounter cultural,physicalor social barrierswhich prevent their access to the various systems of society that are availableto other citizens. Thus, handicapis the loss or limitation of opportunitiesto take part in the life of the community on an equal level with others. (U.N. 1983:I.c. 6-7) These definitionsmay be good-enoughfor the political purposesof the U.N. They have two advantages:First, they clearly include many conditions that are not alwaysrecognizedby the generalpublic as disabling,for example, debilitatingchronic illnessesthat limit people'sactivitiesbut do not necessarily cause any visible disability, such as Crohn'sDisease. Second, the definition of "handicap"explicitly recognizesthe possibilitythat the primarycause of a disabledperson'sinability to do certain things may be social-denial of opportunities, lack of accessibility, lack of services, poverty, discrimination-which it often is. However, by trying to define "impairment"and "disability"in physical termsand "handicap"in cultural,physicaland social terms, the U.N. document appearsto be makinga shakydistinction between the physicaland the social aspectsof disability.Not only the "normal"rolesfor one's age, sex, society, and culture, but also "normal"structureand function, and "normal" abilityto performan activity, dependon the society in which the standardsof normality are generated. Paradigmsof health and ideas about appropriate kinds and levels of performanceareculturally-dependent.In addition,within each society there is much variation from the norm of any ability; at what point does this variationbecome disability?The answerdependson such factors as what activities a society values and how it distributeslabourand resources.The idea that there is some universal,perhapsbiologicallyor medically-describableparadigmof humanphysicalabilityis an illusion. Therefore, I preferto use a single term, "disability,"and to emphasizethat disabilityis socially constructedfrom biological reality. Another objection I have to the U.N. definitions is that they imply that women can be disabled, but not handicapped,by being unable to do things which arenot consideredpartof the normalrole for their sex. Forexample, if a society does not consider it essential to a woman'snormalrole that she be able to read, then a blind woman who is not providedwith education in Braille is not handicapped,accordingto these definitions. In addition, these definitions suggest that we can be disabled, but not handicapped,by the normal process of aging, since although we may lose some ability, we are not handicappedunless we cannot fulfill roles that are normalfor our age. Yet a society which providesfew resourcesto allow disabled people to participatein it will be likely to marginalizeall the disabled,

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including the old, and to define the appropriateroles of old people as very limited, thus handicappingthem. Aging is disabling.Recognizingthis helps us to see that disabledpeople are not "other,"that they are really "us."Unless we die suddenly,we are all disabledeventually. Most of us will live partof our lives with bodies that hurt, that move with difficultyor not at all, that deprive us of activities we once took for granted or that others take for granted, bodies that make daily life a physical struggle.We need an understandingof disabilitythat does not supporta paradigmof humanityas young and healthy. Encouragingeveryoneto acknowledge,accommodateand identify with a wide rangeof physicalconditions is ultimatelythe roadto self-acceptance as well as the road to liberatingthose who are disablednow. Ultimately, we might eliminate the categoryof "the disabled"altogether, and simply talk about individuals'physical abilities in their social context. For the present, although "the disabled"is a categoryof "the other" to the able-bodied, for that very reason it is also a politically useful and socially meaningfulcategoryto those who are in it. Disabledpeople shareformsof social oppression,and the most importantmeasuresto relieve that oppression have been initiated by disabledpeople themselves. Social oppressionmay be the only thing the disabledhave in common;5our struggleswith our bodies are extremelydiverse. Finally, in thinking about disabilitywe have to keep in mind that a society's labelsdo not alwaysfit the people to whom they areapplied.Thus, some people are perceived as disabledwho do not experience themselves as disabled. Although they have physicalconditions that disableother people, because of their opportunitiesand the context of their lives, they do not feel significantlylimited in their activities (see Sacks 1988); these people may be surprisedor resentfulthat they are considereddisabled. On the other hand, manypeople whose bodies cause them greatphysical, psychologicaland economic strugglesare not considered disabled because the public and/or the medicalprofessiondo not recognizetheir disablingconditions. These people often long to be perceived as disabled,becausesociety stubbornlycontinues to expect them to performas healthy people when they cannot and refusesto acknowledgeand supporttheir struggles.6Of course, no one wants the social stigma associated with disability, but social recognition of disabilitydetermines the practicalhelp a person receives from doctors, government agencies, insurancecompanies, charityorganizations,and often from family and friends.Thus, how a society definesdisabilityand whom it recognizesas disabled are of enormouspsychological,economic and social importance,both to people who are experiencingthemselvesas disabledand to those who are not but are neverthelessgiven the label. There is no definitive answerto the question:Who is physicallydisabled? Disability has social, experiential and biological components, present and recognizedin different measuresfor differentpeople. Whether a particular

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physical condition is disabling changes with time and place, depending on such factorsas social expectations, the state of technology and its availability to people in that condition, the educational system, architecture,attitudes towardsphysical appearance,and the pace of life. (If, for example, the pace of life increaseswithout changes in other factors, more people become disabled simply because fewer people can keep up the "normal"pace.) THE SOCIALCONSTRUCTION OF DISABILITY.

If we ask the questions:Why are so many disabledpeople unemployedor underemployed,impoverished,lonely, isolated;why do so many find it difficult or impossibleto get an education (Davis and Marshall1987; Fine and Asch 1988, 10-11); why are they victims of violence and coercion; why do able-bodiedpeople ridicule, avoid, pity, stereotypeand patronizethem?, we maybe temptedto see the disabledas victims of natureor accident. Feminists shouldbe, and many are, profoundlysuspiciousof this answer.We areusedto counteringclaims that insofaras women are oppressedthey are oppressedby nature, which puts them at a disadvantagein the competition for powerand resources.We know that if being biologicallyfemale is a disadvantage,it is because a social context makes it a disadvantage.Fromthe standpointof a disabledperson, one can see how society could minimizethe disadvantagesof most disabilities, and, in some instances, turn them into advantages. Consider an extreme case: the situation of physicist Stephen Hawking, who has had AmyotrophicLateralSclerosis (Lou Gehrig'sDisease) for more than 26 years. ProfessorHawkingcan no longer speakand is capableof only the smallestmuscle movements. Yet, in his context of social and technological support,he is able to function as a professorof physicsat CambridgeUniversity; indeed he says his disabilityhas given him the advantageof having moretime to think, and he is one of the foremosttheoreticalphysicistsof our time. He is a courageousand talented man, but he is able to live the creative life he has only becauseof the help of his family, three nurses,a graduatestudent who travels with him to maintain his computer-communicationssystems, and the fact that his talent had been developed and recognizedbefore he fell seriouslyill (Newsweek1988). Many people consider providing resourcesfor disabledpeople a form of charity, superogatoryin partbecausethe disabledare perceivedas unproductive membersof society. Yet most disabled people are placed in a doublebind: they have access to inadequateresourcesbecausethey are unemployed or underemployed,and they are unemployedor underemployedbecausethey lack the resourcesthat would enable them to make their full contributionto society (Matthews 1983; Hannaford1985). Often governmentsand charity organizationswill spend far more money to keep disabledpeople in institutions where they have no chance to be productivethan they will spendto en-

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able the same people to live independentlyand productively. In addition, many of the "special"resourcesthe disabledneed merelycompensatefor bad social planning that is based on the illusion that everyone is young, strong, healthy (and, often, male). Disabilityis also frequentlyregardedas a personalor familyproblemrather than a matterfor social responsibility.Disabledpeople are often expected to overcome obstacles to participation by their own extraordinaryefforts, or their familiesare expected to providewhat they need (sometimesat greatpersonal sacrifice). Helping in personalor familymattersis seen as superogatory for people who are not membersof the family. Many factorscontributeto determiningwhetherprovidinga particularresource is regardedas a social or a personal (or family) responsibility.7One such factoris whether the majoritycan identifywith people who need the resource. Most North Americansfeel that society should be organizedto provide short-termmedical care made necessaryby illness or accident, I think because they can imagine themselves needing it. Relatively few people can identify with those who cannot be "repaired"by medical intervention. Sue Halpem makes the following observation: Physicalhealth is contingent and often short-lived.But this truth eludes us as long as we are able to walk by simplyputting one foot in front of the other. As a consequence, empathyfor the disabledis unavailableto most able-bodiedpersons. Sympathy, yes, empathy, no, for every attempt to projectoneself into that condition, to feel what it is like not to be ambulatory, for instance, is mediatedby an ability to walk (Halpem 1988, 3). If the able-bodiedsaw the disabledas potentiallythemselvesor as their future selves, they wouldbe more inclined to feel that society shouldbe organizedto provide the resourcesthat would make disabledpeople fully integratedand contributingmembers. They would feel that "charity"is as inappropriatea way of thinking about resourcesfor disabledpeople as it is about emergency medical care or education. Carefulstudy of the lives of disabledpeople will reveal how artificialthe line is that we drawbetween the biological and the social. Feministshave already challenged this line in part by showing how processessuch as childbirth, menstruationand menopause,which may be represented,treated, and thereforeexperiencedas illnessesor disabilities,are socially-constructedfrom biological reality (Rich 1976; Ehrenreichand English 1979). Disabledpeople's relationsto our bodies involve elements of strugglewhich perhapscannot be eliminated, perhapsnot even mitigated, by social arrangements.But, much of what is disablingabout our physicalconditions is also a consequence of social arrangements(Finger 1983; Fine and Asch 1988) which could, but

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forourphysicalconditions,oraccommodate do not, eithercompensate them or so thatwe canparticipate our and us fully, support struggles integrate into intothecultural the communityandourstruggles concept oflifeas it is ordinarily lived. Feministshaveshownthatthe worldhasbeendesignedformen.InNorth Americaat least,lifeandworkhavebeenstructured as thoughno one of any in the and no one whoworksoutsidethe importance publicworld, certainly a babyor lookaftera sickchild.Common homeforwages,hasto breast-feed colds can be acknowledgedpublicly,and allowancesmadefor them, but menstruation cannot.Muchof the worldis alsostructured as thougheveryone is physicallystrong,as thoughall bodiesare"ideallyshaped,"as though everyonecanwalk,hearandsee well, as thougheveryonecanworkandplay at a pacethatis not compatible withanykindof illnessorpain,asthoughno one is everdizzyor incontinentor simplyneedsto sit or lie down.(Forinif you neededto?) Not stance,wherecouldyou sit downin a supermarket but the entirephysicalandsocialorganization of life, only the architecture, assumesthatwe areeitherstrongandhealthyandableto dowhatthe average able-bodied personcando, or thatwe arecompletelydisabled,unableto participate in life.

In the splitbetweenthe publicandthe privateworlds,women(andchildren) have been relegatedto the private,andso have the disabled,the sick andthe old (andmostlywomentakecareof them).The publicworldis the worldof strength,the positive(valued)body,performance andproduction, the able-bodied andyouth.Weakness,illness,restandrecovery,pain,death andthe negative(de-valued)bodyareprivate,generallyhidden,andoften neglected.Cominginto the publicworldwith illness,pain or a de-valued body,we encounterresistanceto mixingthe two worlds;the splitis vividly revealed.Muchof ourexperiencegoesunderground, becausethereis no soof it and our ciallyacceptableway expressing having physicalandpsychological experienceacknowledged andshared.A few closefriendsmayshareit, butthereis a strongimpulseto protectthemfromit too, becauseit seemsso I foundthat, aftera coupleof yearsof illness,even private,so unacceptable. the "How areyou?"becamea difficult,conflict-ridden answering question, business.I don'twantto alienatemyfriendsfrommyexperience,butI don't wantto risktheirdiscomfortandrejectionby tellingthemwhattheydon't wantto know.8 Disabledpeoplelearnthatmany,perhapsmost,able-bodied peopledo not wantto knowaboutsuffering causedbythe body.Visiblydisabledwomenreandthe sexportthatcuriosityaboutmedicaldiagnoses,physicalappearance ualandotherintimateaspectsof disabilityis morecommonthanwillingness to listenandtryto understand the experienceof disability(Matthews1983). It is not unusualforpeoplewithinvisibledisabilities to keepthementirelysecretfromeveryonebut theirclosestfriends.

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Contraryto what Sue Halpem says, it is not simplybecausethey are in able bodies that the able-bodiedfail to identify with the disabled. Able-bodied people can often make the imaginativeleap into the skins of people physically unlike themselves; women can identify with a male protagonistin a story, for example, and adultscan identifywith childrenor with people much older than themselves. Something more powerfulthan being in a different body is at work. Sufferingcausedby the body, and the inabilityto control the body, are despised,pitied, and above all, feared.This fear, experiencedindividually, is also deeply embeddedin our culture. THE OPPRESSION OF DISABLEDPEOPLE REALBODY. OFEVERYONE'S IS THEOPPRESSION

Our real human bodies are exceedingly diverse-in size, shape, colour, texture, structure, function, range and habits of movement, and development-and they are constantlychanging. Yet we do not absorbor reflectthis simplefact in our culture. Instead,we idealizethe humanbody. Our physical ideals change from time to time, but we alwayshave ideals. These ideals are not just about appearance;they are also ideals of strength and energy and propercontrol of the body. We are perpetuallybombardedwith images of these ideals, demandsfor them, and offersof consumerproductsand services to help us achieve them.9 Idealizingthe body preventseveryone, able-bodied and disabled, from identifyingwith and loving her/his real body. Some people can have the illusion of acceptance that comes frombelieving that their bodies are "close enough" to the ideal, but this illusion only drawsthem deeperinto identifyingwith the ideal and into the endlesstaskof reconciling the reality with it. Sooner or later they must fail. Before I became disabled, I was one of those people who felt "close enough"to culturalideals to be reasonablyacceptingof my body. Like most feministsI know, I was awareof some alienation from it, and I workedat liking my body better. Nevertheless, I knew in my heart that too much of my liking still depended on being "close enough." When I was disabledby illness, I experienceda much more profoundalienation frommy body. After a year spent mostly in bed, I could barely identify my body as my own. I felt that "it"was torturing"me,"trappingme in exhaustion, pain and inabilityto do many of the simplestthings I did when I was healthy. The shock of this experienceand the effortto identifywith a new, disabledbody, made me realize I had been living a luxuryof the able-bodied.The able-bodiedcan postpone the task of identifyingwith their real bodies. The disableddon't have the luxuryof demandingthat their bodies fit the physical idealsof their culture. As BarbaraHillyer Davis says:"Forall of us the difficultworkof finding (one's) self includesthe body, but people who live with disabilityin a society that glorifiesfitness and physical conformityare forced to understandmore fully what bodily integrity means" (Davis 1984,3).

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In a society which idealizesthe body, the physicallydisabledare marginalized. People lear to identifywith their own strengths(by culturalstandards) and to hate, fearand neglect their own weaknesses.The disabledarenot only de-valuedfor their de-valuedbodies (Hannaford1985), they are constant remindersto the able-bodiedof the negative body-of what the able-bodiedare trying to avoid, forget and ignore (Lessing 1981). For example, if someone tells me she is in pain, she remindsme of the existence of pain, the imperfection and fragilityof the body, the possibilityof my own pain, the inevitability of it. The less willing I am to accept all these, the less I want to know about her pain; if I cannot avoid it in her presence, I will avoid her. I may even blameher for it. I may tell myselfthat she couldhaveavoidedit, in orderto go on believing that I can avoid it. I want to believe I am not like her; I cling to the differences.Gradually,I make her "other"because I don't want to confront my real body, which I fear and cannot accept.10 Disabled people can participatein marginalizingourselves. We can wish for bodies we do not have, with frustration,shame, self-hatred.We can feel trappedin the negative body; it is our internalizedoppressionto feel this. Every (visibly or invisibly) disabledperson I have talked to or read has felt this; some never stop feeling it. In addition, disabledwomen suffermorethan disabledmen from the demand that people have "ideal"bodies, because in patriarchalculture people judge women more by their bodies than they do men. Disabled women often do not feel seen (because they are often not seen) by others as whole people, especially not as sexual people (Campling 1981; Matthews 1983; Hannaford1985; Fine and Asch 1988). Thus, partof their struggleagainstoppressionis a much harderversionof the struggleablebodied women have for a realistic and positiveself-image (Bogle and Shaul 1981). On the other hand, disabled people who cannot hope to meet the physicalidealsof a culturecan help reveal that those idealsare not "natural" or "normal"but artificialsocial creations that oppresseveryone. Feministtheoristshave probedthe causesof our patriarchalculture'sdesire for control of the body-fear of death, fearof the strongimpulsesand feelings the body gives us, fear of nature, fear and resentmentof the mother'spower over the infant (de Beauvoir1949; Dinnerstein 1976; Griffin 1981). Idealizing the body and wanting to control it go hand-in-hand;it is impossibleto say whetherone causesthe other. A physicalideal gives us the goal of our efforts to control the body, and the myth that total control is possible deceives us into striving for the ideal. The consequencesfor women have been widely discussedin the literatureof feminism. The consequencesfor disabledpeople are less often recognized.In a culturewhich loves the idea that the body can be controlled, those who cannot control their bodies are seen (and may see themselves) as failures. When you listen to this culture in a disabledbody, you hear how often health and physicalvigourare talkedaboutas if they weremoralvirtues. Peo-

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pie constantlypraiseothers for their "energy,"their stamina, their ability to worklong hours. Of course, acting on behalf of one's health can be a virtue, and underminingone's health can be a vice, but "success"at being healthy, like beauty, is alwayspartlya matter of luck and thereforebeyond our control. When health is spokenof as a virtue, people who lack it aremadeto feel inadequate. I am not suggesting that it is always wrong to praise people's physical strength or accomplishments,any more than it is alwayswrong to praisetheir physicalbeauty. But just as treatingculturalstandardsof beautyas essentialvirtuesfor women harmsmost women, treatinghealth and vigouras moral virtues for everyone harmspeople with disabilitiesand illnesses. The myth that the body can be controlledis not easilydispelled,becauseit is not very vulnerableto evidence againstit. When I became ill, severalpeople wanted to discusswith me what I thought I had done to "makemyself"ill or "allowmyself"to become sick. At first I fell in with this, generatingtheories about what I had done wrong;even though I had alwaystaken good care of my health, I was able to find some (ratherfar-fetched)accountsof my responsibilityfor my illness. When a few close friendsofferedhypothesesas to how theymight be responsiblefor my being ill, I began to suspectthat something was wrong. Gradually,I realizedthat we were all tryingto believe that nothing this importantis beyond our control. Of course, there are sometimescontrollablesocial and psychologicalforces at work in creating ill health and disability(Kleinman 1988). Nevertheless, our culturalinsistence on controlling the body blamesthe victims of disability for failing and burdensthem with self-doubtand self-blame.The search for psychological,moraland spiritualcausesof illness, accident and disability is often a harmfulexpressionof this insistenceon control (see Sontag 1977). Modem Western medicine plays into and conformsto our culturalmyth that the body can be controlled. Collectively, doctorsand medical researchers exhibit very little modestyabout their knowledge. They focus their (and our) attention on curesand imminent cures, on successfulmedical interventions. Research, funding and medical care are more directed toward lifethreatening conditions than toward chronic illnesses and disabilities. Even pain was relatively neglected as a medical problemuntil the second half of this century. Surgeryand savinglives bolsterthe illusionof control much better than does the long, patient processof rehabilitationor the managementof long-termillness. These latter, less visible functions of medicine tend to be performedby nurses, physiotherapistsand other low-prestigemembersof the profession. Doctors are trained to do something to control the body, to "make it better" (Kleinman 1988); they are the heroes of medicine. They maylike being in the role of hero, but we also like them in that role and tryto keep them there, becausewe want to believe that someone can always"make it better."ll As long as we cling to this belief, the patientswho cannot be "repaired"-the chronically ill, the disabledand the dying-will symbolizethe

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failureof medicine and more, the failureof the Wester scientific projectto control nature. They will carrythis stigmain medicine and in the cultureas a whole. When philosophersof medicalethics confine themselvesto discussinglifeand-death issues of medicine, they help perpetuatethe idea that the main purposeof medicine is to control the body. Life-and-deathinterventionsare the ultimate exercise of control. If medical ethicists looked more closely at who needs and who receives medical help, they would discovera host of issues concerning how medicine and society understand,mediate, assist with and integrateexperiencesof illness, injuryand disability. Becauseof the heroic approachto medicine, and becausedisabledpeople's experience is not integrated into the culture, most people know little or nothing about how to live with long-termor life-threateningillness, how to communicatewith doctors and nursesand medical bureaucratsabout these matters, how to live with limitation, uncertainty, pain, nausea, and other symptomswhen doctorscannot make them go away. Recently, patients'support groupshave arisento fill this gap for people with nearlyevery type of illness and disability.They are vitally importantsourcesof knowledgeand encouragementfor manyof us, but they do not fill the culturalgulfbetween the able-bodiedand the disabled.The problemsof living with a disabilityarenot privateproblems,separablefrom the rest of life and the rest of society. They are problemswhich can and shouldbe sharedthroughoutthe cultureas much as we share the problemsof love, work and family life. Considerthe example of pain. It is difficultfor most people who have not lived with prolongedor recurringpain to understandthe benefitsof accepting it. Yet some people who live with chronic pain speak of "makingfriends" with it as the road to feeling better and enjoying life. How do they picture their pain and think about it; what kind of attention do they give it and when; how do they live aroundand throughit, and what do they learnfrom it? We all need to know this as part of our education. Some of the fear of experiencingpain is a consequence of ignoranceand lack of guidance. The effort to avoid pain contributes to such widespreadproblemsas drug and alcohol addiction, eating disorders,and sedentarylives. People with painful disabilitiescan teach us aboutpain, becausethey can'tavoid it and have had to learnhow to face it and live with it. The perniciousmyth that it is possible to avoid almost all pain by controllingthe body gives the fearof pain greater power than it should have and blamesthe victims of unavoidablepain. The fear of pain is also expressedor displacedas a fear of people in pain, which often isolatesthose with painfuldisabilities.All this is unnecessary.Peoplein pain and knowledge of pain could be fully integrated into our culture, to everyone'sbenefit. If we knew more about pain, aboutphysicallimitation, about loss of abilities, about what it is like to be "too far"from the culturalideal of the body,

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perhapswe would have less fear of the negative body, less fear of our own weaknessesand "imperfections,"of our inevitable deteriorationand death. Perhapswe could give up our idealizationsand relax our desirefor control of the body; until we do, we maintain them at the expense of disabledpeople and at the expense of our ability to accept and love our own real bodies. AS "OTHER" DISABLEDPEOPLE

When we make people "other,"we groupthem together as the objects of ourexperience insteadof regardingthem as fellow subjectsof experiencewith whom we might identify. If you are "other"to me, I see you primarilyas symbolic of somethingelse-usually, but not always,somethingI reject and fear and that I projectonto you. We can all do this to each other, but very often the processis not symmetrical,becauseone groupof people may have more power to call itself the paradigmof humanityand to make the worldsuit its own needs and validate its own experiences.12Disabledpeople are "other"to able-bodiedpeople, and (as I have tried to show) the consequencesare socially, economically and psychologically oppressive to the disabled and psychologicallyoppressive to the able-bodied. Able-bodied people may be "other"to disabledpeople, but the consequencesof this for the able-bodied are minor (most able-bodiedpeople can affordnot to notice it). There are, however, several political and philosophical issues that being "other"to a more powerfulgroupraisesfor disabledpeople. I have said that for the able-bodied,the disabledoften symbolizefailureto control the body and the failure of science and medicine to protect us all. However, some disabledpeople also become symbolsof heroic control against all odds;these are the "disabledheroes,"who arecomfortingto the able-bodied because they re-affirmthe possibilityof overcomingthe body. Disabled heroes are people with visible disabilitieswho receive public attention because they accomplishthings that are unusualeven for the able-bodied.It is revealing that, with few exceptions (Helen Keller and, very recently, Stephen Hawkingare among them), disabledheroes are recognizedfor performing feats of physical strength and endurance.While disabledheroes can be inspiringand hearteningto the disabled, they may give the able-bodiedthe false impressionthat anyone can "overcome"a disability. Disabled heroes usuallyhave extraordinarysocial, economic and physical resourcesthat are not availableto most people with those disabilities.In addition, many disabled people are not capable of performingphysical heroics, because many (perhapsmost) disabilitiesreduceor consumethe energyand staminaof people who have them and do not just limit them in some particularkind of physicalactivity. Amputee and wheelchairathletes are exceptional, not because of their ambition, discipline and hard work, but because they are in better health than most disabledpeople can be. Arthritis, Parkinsonismand

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stroke cause severe disabilityin far more people than do spinal cord injuries and amputations(Bury1979). The imageof the disabledhero mayreducethe "otherness"of a few disabledpeople, but because it creates an ideal which most disabledpeople cannot meet, it increasesthe "otherness"of the majority of disabledpeople. One recent attempt to reducethe "otherness"of disabledpeople is the introductionof the term, "differently-abled."I assumethe point of using this term is to suggestthat there is nothing wrongwith being the way we are, just different. Yet to call someone "differently-abled"is much like calling her or "differently-gendered." It says:"This person is not "differently-coloured" the norm or paradigmof humanity."If anything, it increasesthe "otheress" of disabledpeople, because it reinforcesthe paradigmof humanityas young, strongand healthy, with all body partsworking"perfectly,"fromwhich this also suggestsa (poperson is "different."Using the term "differently-abled" lite? patronizing?protective?self-protective?)disregardof the specialdifficulties, strugglesand sufferingdisabledpeople face. We are dis-abled.We live with particularsocial and physical strugglesthat are partlyconsequencesof the conditions of our bodies and partlyconsequencesof the structuresand expectationsof our societies, but they arestruggleswhich only people with bodies like ours experience. The positive side of the term "differently-abled" is that it might remindthe able-bodiedthat to be disabledin some respectsis not to be disabledin all respects. It also suggeststhat a disabledpersonmayhave abilitiesthat the ablebodied lack in virtue of being able-bodied.Nevertheless, on the whole, the term "differently-abled" should be abandoned,becauseit reinforcesthe ablebodied paradigmof humanityand fails to acknowledgethe strugglesdisabled people face. The problemsof being "the other" to a dominant groupare alwayspolitically complex. One solution is to emphasizesimilarities to the dominant groupin the hope that they will identifywith the oppressed,recognizetheir rights, graduallygive them equal opportunities, and eventually assimilate them. Many disabledpeople are tired of being symbolsto the able-bodied, visible only or primarilyfor their disabilities, and they want nothing more than to be seen as individualsratherthan as membersof the group,"the disabled." Emphasizingsimilaritiesto the able-bodied,making their disabilities unnoticeable in comparisonto their other human qualitiesmay bring about assimilationone-by-one. It does not directlychallenge the able-bodiedparadigm of humanity, just as women moving into traditionallymale arenasof powerdoes not directly challenge the male paradigmof humanity, although both may producea gradualchange in the paradigms.In addition, assimilation may be very difficultfor the disabledto achieve. Although the able-bodied like disabledtokens who do not seem verydifferentfromthemselves,they may need someone to carrythe burdenof the negative body as long as they

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continue to idealizeand try to control the body. They maythereforeresistthe assimilationof most disabledpeople. The reasonsin favourof the alternativesolution to "otherness"-emphasizingdifferencefrom the able-bodied-are also reasonsfor emphasizingsimilarities among the disabled, especiallysocial and political similarities.Disabled people sharepositionsof social oppressionthat separateus fromthe able-bodied, and we sharephysical, psychologicaland social experiencesof disability. Emphasizingdifferencesfrom the able-bodieddemandsthat those differences be acknowledgedand respectedand fosterssolidarityamong the disabled. It challenges the able-bodiedparadigmof humanityand creates the possibility of a deeper challenge to the idealizationof the body and the demandfor its control. Invisiblydisabledpeople tend to be drawnto solutions that emphasize difference,becauseour need to have our strugglesacknowledgedis great, and we have far less experience than those who are visibly disabledof being symbolic to the able-bodied. Whether one wants to emphasizesamenessor difference in dealing with the problemof being "the other"dependsin parton how radicallyone wants to challenge the value-structureof the dominantgroup.A very importantissue in this categoryfor both women and disabledpeople is the value of independence from the help of others, so highly esteemed in our patriarchalculture and now being questionedin feminist ethics (see, for example, Sherwin 1984, 1987; Kittayand Meyers1987) and discussedin the writingsof disabled women (see, for example, Fisherand Galler 1981; Davis 1984; Frank1988). Many disabledpeople who can see the possibilityof living as independently as any able-bodiedperson, or who have achieved this goal afterlong struggle, value their independenceabove everything. Dependenceon the help of others is humiliatingin a society which prizesindependence.In addition, this issue holds special complications for disabled women; reading the stories of women who became disabled as adults, I was struck by their strugglewith shame and loss of self-esteem at being transformedfrom people who took physicalcareof others (husbandsand children) to people who werephysically dependent. All this suggeststhat disabledpeople need every bit of independence we can get. Yet there are disabledpeople who will alwaysneed a lot of help fromother individualsjust to survive(those who have very little control of movement, for example), and to the extent that everyone considersindependence necessary to respect and self-esteem, those people will be condemnedto be de-valued. In addition, some disabledpeople spendtremendous energy being independent in ways that might be consideredtrivial in a culmore ture less insistent on self-reliance;if our culturevalued interdependence activities. for more that use could satisfying energy highly, they In her excellent discussionof the issue of dependencyand independence, BarbaraHillyer Davis arguesthat women with disabilitiesand those who care for all of us, if we are willing to for them can work out a model of reciprocity

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learn from them. "Reciprocityinvolves the difficulty of recognizingeach other'sneeds, relyingon the other, askingand receivinghelp, delegatingresponsibility, giving and receiving empathy, respecting boundaries"(Davis 1984, 4). I hope that disabledand able-bodiedfeministswill join in questioning our culturalobsessionwith independenceand ultimatelyreplacingit with such a model of reciprocity.If all the disabledare to be fully integratedinto society without symbolizingfailure, then we have to change social values to recognizethe value of dependingon others and being dependedupon. This would also reduce the fear and shame associated with dependency in old age-a condition most of us will reach. Whether one wants to emphasizesamenessor differencein dealing with the problemsof being "other"is also related to whether one sees anything valuable to be preservedby maintaining, either temporarilyor in the longrun, some separatenessof the oppressedgroup.Is there a specialcultureof the oppressedgroupor the seeds of a specialculturewhich could be developed in a supportivecontext of solidarity?Do membersof the oppressedgrouphave accumulatedknowledgeor ways of knowing which might be lost if assimilation takes place without the dominant culturebeing transformed? It would be hard to claim that disabledpeople as a whole have an alternative cultureor even the seeds of one. One sub-group,the deaf, has a separate culturefromthe hearing, and they arefightingfor its recognitionand preservation, as well as for their right to continue makingtheir own culture(Sacks 1988). Disabled people do have both knowledgeand ways of knowing that are not available to the able-bodied.Although ultimatelyI hope that disabled people'sknowledgewill be integratedinto the cultureas a whole, I suspect that a culturewhich fearsand denigratesthe real body would rathersilence this knowledge than make the changes necessaryto absorbit. It may have to be nurturedand cultivatedseparatelywhile the able-bodiedcultureis transformedenough to receive and integrate it. THE KNOWLEDGE AND HOW IT IS SILENCED OF DISABLEDPEOPLE

In my second yearof illness, I was readingan article about the psychological and philosophicalrelationshipof mind to body. When the authorpainted a rosypictureof the experienceof being embodied,I was outragedat the presumptionof the writerto speakfor everyonefroma healthy body. I decided I didn't want to hear anythingabout the body from anyone who was not physically disabled.Beforethat moment, it had not occurredto me that there was a world of experience from which I was shut out while I was able-bodied. Not only do physically disabled people have experiences which are not available to the able-bodied, they are in a better position to transcendcultural mythologies about the body, because they cannotdo things that the able-bodiedfeel they mustdo in orderto be happy, "normal"and sane. For

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example, paraplegicsand quadriplegicshave revolutionarythings to teach about the possibilitiesof sexualitywhich contradictpatriarchalculture'sobsession with the genitals (Bullardand Knight 1981). Some people can have orgasmsin any part of their bodies where they feel touch. One man said he never knew how good sex could be until he lost the feeling in his genitals. Few able-bodiedpeople know these things, and, to my knowledge, no one has explored their implicationsfor the able-bodied. If disabledpeople were truly heard, an explosion of knowledgeof the human body and psyche would take place. We have access to realmsof experience that our culturehas not tapped (even for medical science, which takes relatively little interest in people's experienceof their bodies). Like women's particularknowledge, which comes from access to experiencesmost men do not have, disabledpeople's knowledge is dismissedas trivial, complaining, mundane (or bizarre),less thanthat of the dominant group. The cognitive authority(Addelson 1983) of medicine plays an important role in distortingand silencing the knowledgeof the disabled. Medical professionalshave been given the power to describeand validate everyone'sexperienceof the body. If you go to doctorswith symptomsthey cannot observe directlyor verifyindependentlyof what you tell them, such as pain or weakness or numbnessor dizzinessor difficultyconcentrating,and if they cannot find an objectively observablecause of those symptoms,you are likely to be told that there is "nothingwrongwith you," no matterhow you feel. Unless you are very lucky in your doctors, no matterhow trustworthyand responsible you were consideredto be beforeyou startedsayingyou were ill, yourexperiencewill be invalidated.13 Otherpeople are the authoritieson the reality of your experience of your body. When you are very ill, you desperatelyneed medicalvalidationof yourexperience, not only for economic reasons(insuranceclaims, pensions, welfare and disabilitybenefits all depend upon official diagnosis), but also for social and psychologicalreasons.People with unrecognizedillnessesare often abandoned by their friends and families.14 Because almost everyone accepts the cognitive authorityof medicine, the personwhose bodily experience is radically differentfrommedicaldescriptionsof her/his condition is invalidatedas a knower. Eitheryou decide to hide your experience, or you are socially isolated with it by being labelled mentally ill15or dishonest. In both cases you are silenced. Even when your experience is recognizedby medicine, it is often re-describedin waysthat are inaccuratefromyourstandpoint.The objectivelyobservablecondition of yourbody maybe used to determinethe severityof your pain, for instance, regardlessof yourown reportsof it. Forexample, until recently, relativelyfew doctorswere willing to acknowledgethat severe phantom limb pain can persistfor months or even yearsafteran amputation.The accumulatedexperienceof doctorswho were themselvesamputeeshas begun

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to legitimizethe other patients' reports(Madruga1979). When you are forced to realizethat other people have more social authority than you do to describe your experience of your own body, your confidence in yourself and your relationship to reality is radicallyundermined. What can you know if you cannot know that you are experiencingsuffering or joy; what can you communicate to people who don't believe you know even this?16Most people will censorwhat they tell or say nothing ratherthan expose themselves repeatedlyto such deeply felt invalidation. They are silenced by fear and confusion. The processis familiarfromour understanding of how women are silenced in and by patriarchalculture. One final caution:As with women's"specialknowledge,"there is a danger of sentimentalizingdisabledpeople'sknowledgeand abilities and keeping us "other"by doing so. We need to bringthis knowledgeinto the cultureand to transformthe cultureand society so that everyone can receive and make use of it, so that it can be fully integrated, along with disabledpeople, into a sharedsocial life. CONCLUSION

I have tried to introducethe readerto the rich varietyof intellectual and political issuesthat are raisedby experiencesof physicaldisability.Confronting these issues has increasedmy appreciationof the insights that feminist theory already offers into cultural attitudes about the body and the many forms of social oppression. Feministshave been challenging medicine's authority for many yearsnow, but not, I think, as radicallyas we would if we knew what disabledpeople have to tell. I look forwardto the developmentof a full feminist theoryof disability.17We need a theoryof disabilityfor the liberationof both disabledand able-bodiedpeople, since the theoryof disability is also the theory of the oppressionof the body by a society and its culture.

NOTES * Many thanks to KathyGose, Joyce Frazee,MaryBarnes,BarbaraBeach, Elliott Gose and Gordon Renwick for helping me to think about these questions, and to MaureenAshfield for helping me to researchthem. Thanks also to the editorsof this issue, VirginiaWarren,and two anonymousreviewersfor their work on editing an earlierversion of the paper. 1. ItzhakPerlman, when asked in a recent CBC interview about the problemsof the disabled, said disabledpeople have two problems:the fact that the worldis not madefor people with any weaknessesbut for supermenand the attitudesof able-bodiedpeople. 2. An excellent descriptionof this last issue as it confrontsthe deaf is found in Sacks 1988. 3. See Matthews 1983; Hannaford1985; Rooney and Israel(eds.) 1985, esp. the articlesby Jill Weiss, Charlynn Toews, MyraRosenfield, and Susan Russell;and, for a doctor'stheories, Kleinman 1988. 4. We also need a feminist theory of mental disability, but I will not be discussingmental disabilityin this essay.

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5. In a recent article in Signs, Linda Alcoff arguesthat we should define "woman"thus: "womanis a position from which a feminist politics can emerge ratherthan a set of attributes that are 'objectively identifiable.'" (Alcoff 1988, 435). I think a similarapproachmay be the best one for defining "disability." 6. For example, Pelvic InflammatoryDisease causes severe prolonged disability in some women. These women often have to enduremedical diagnosesof psychologicalillness and the skepticismof family and friends, in addition to having to live with chronic severe pain. See Moore 1985. 7. Feminismhas challenged the distributionof responsibilityfor providingsuch resourcesas childcare and protection from family violence. Increasinglymany people who once thought of these as family or personalconcerns now think of them as social responsibilities. 8. Some people save me that troubleby teling me I am fine and walking away. Of course, people also encounterdifficultieswith answering"How are you?"duringand aftercrises, such as separationfrom a partner,death of a loved one, or a nervousbreakdown.There is a temporary alienation fromwhat is consideredordinarysharedexperience. In disability,the alienation lasts longer, often for a lifetime, and, in my experience, it is more profound. 9. The idealizationof the body is clearlyrelatedin complex ways to the economic processes of a consumersociety. Since it pre-datedcapitalism, we know that capitalismdid not cause it, but it is undeniable that idealizationnow generates tremendousprofits and that the quest for profit demandsthe reinforcementof idealizationand the constant development of new ideals. 10. SusanGriffin, in a characteristicallyhonest and insightfulpassage,describesan encounter with the fear that makes it hard to identify with disabledpeople. See Griffin 1982, 648-649. 11. Thanks to Joyce Frazeefor pointing this out to me. 12. When Simone de Beauvoirusesthis termto elucidatemen'sview of women (and women's view of ourselves), she emphasizesthat Man is consideredessential, Woman inessential;Man is the Subject, Woman the Other (de Beauvoir1952, xvi). SusanGriffinexpandsupon this idea by showing how we project rejected aspectsof ourselvesonto groupsof people who are designated the Other (Griffin 1981). 13. Manywomen with M.S. have lived throughthis nightmarein the earlystagesof their illness. Although this happensto men too, women'sexperienceof the body, like women'sexperience generally, is more likely to be invalidated (Hannaford1985). 14. Accounts of the experienceof relativelyunknown,newly-discovered,or hard-to-diagnose diseasesand conditions confirm this. See, for example, Jeffreys1982, for the storyof an experience of Chronic FatigueSyndrome,which is more common in women than in men. 15. Frequentlypeople with undiagnosedillnesses are sent by their doctors to psychiatrists, who cannot help and maysend them backto their doctorssayingthey mustbe physicallyill. This can leave patients in a dangerousmedical and social limbo. Sometimesthey commit suicide because of it (Ramsay1986). Psychiatristswho know enough about living with physical illness or disabilityto help someone cope with it are rare. 16. For more discussionof this subject, see Zaner 1983 and Rawlinson 1983. 17. At this stage of the disabilityrights movement, it is impossibleto anticipate everything that a full feminist theory will include, just as it would have been impossibleto predict in 1970 the presentstate of feminist theory of mothering.Nevertheless, we can see that besidesdealing morefully with the issuesI have raisedhere, an adequatefeminist theoryof disabilitywill examine all the ways in which disabilityis sociallyconstructed;it will explain the interactionof disability with gender, race and class position; it will examine every aspectof the cognitive authority of medicine and science over our experiences of our bodies; it will discuss the relationshipof technology to disability;it will question the belief that disabledlives are not worth living or preservingwhen it is implied in our theorizingabout abortionand euthanasia;it will give us a detailed vision of the full integrationof disabledpeople in society, and it will proposepracticalpolitical strategiesfor the liberationof disabledpeople and the liberationof the able-bodiedfrom the social oppressionof their bodies.

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Madruga,Lenor. 1979. One stepat a time. Toronto: McGraw-Hill. Matthews, Gwyneth Ferguson. 1983. Voicesfrom the shadows:Womenwith disabilities speakout. Toronto: Women's EducationalPress. Moore, Maureen. 1985. Coping with pelvic inflammatorydisease. In Women and Disability.FrancesRooney and Pat Israel,eds. Resourcesfor Feminist Research14(1). Newsweek. 1988. Reading God's mind. June 13. 56-59. Ramsay,A. Melvin. 1986. Postviralfatiguesyndrome,thesagaof RoyalFreedisease. London: Gower Medical Publishing. Rawlinson, MaryC. 1983. The facticity of illness and the appropriationof health. In Phenomenology in a pluralistic context.William L. McBrideand Calvin O. Schrag, eds. Albany: SUNY Press. as experienceand instituRich, Adrienne. 1976. Of womanborn:Motherhood tion. New York:W.W. Norton. Rooney, Francesand Pat Israel,eds. 1985. Womenanddisability.Resources for FeministResearch14(1). Sacks, Oliver. 1988. The revolution of the deaf. The New YorkReviewof Books,June 2, 23-28. Shaul, Susan L. and Jane Elder Bogle. 1981. Body image and the woman with a disability.In Sexualityandphysicaldisability.David G. Bullardand Susan E. Knight, eds. St. Louis:C.V. Mosby. Sherwin, Susan. 1984-85. A feminist approachto ethics. DalhousieReview 64(4):704-713. Sherwin, Susan. 1987. Feminist ethics and in vitro fertilization.In Science, morality and feminist theory. Marsha Hanen and Kai Nielsen, eds. Calgary:The University of CalgaryPress. Sontag, Susan. 1977. Illnessas metaphor.New York:Random House. U.N. Decade of Disabled Persons 1983-1992. 1983. Worldprogramme of action concerningdisabledpersons.New York:United Nations. Whitbeck, Caroline. Afterwordto the maternalinstinct. In Mothering:Essays in feminist theory. Joyce Trebilcot, ed. Totowa: Rowman and Allanheld. Zaner,RichardM. 1983. Flirtationsor engagement?Prolegomenonto a phiin a pluralistic context.William L. losophyof medicine. In Phenomenology McBrideand Calvin O. Schrag, eds. Albany: SUNY Press.

Re-visioning Clinical Research: Gender and the Ethics of ExperimentalDesign SUE V. ROSSER

Since modernmedicineis basedsubstantiallyin clinicalmedicalresearch,the flawsand ethicalproblemsthatarisein thisresearchas it is conceivedandpracticed in the UnitedStatesarelikelyto be reflectedto someextentin currentmedicineand its practice.This paperexploressome of the ways in whichclinicalresearchhas sufferedfroman androcentric focusin its choiceanddefinitionof problemsstudied, and in designand interpretation methods used of experiments,and approaches theoriesand conclusionsdrawnfrom the research.Some examplesof re-visioned researchhint at solutionsto the ethicaldilemmascreatedby thisbiasedfocus; an increasednumberof feministsinvolvedin clinicalresearchmayprovideavenuesfor additionalchangesthatwouldlead to improvedhealthcarefor all.

INTRODUCTION

Since the practice of modem medicine depends heavily on clinical research, flaws and ethical problems in this research are likely to result in poorerhealth care and inequity in the medical treatmentof disadvantaged groups.The firstpurposeof this paperis to exploresome ways in which clinical researchhas been impairedand compromisedby an androcentricfocus in its choice and definition of problemsstudied, approachesand methods used, and theories and conclusionsdrawn.1Second, I shall describesome attempts to correct this biased focus and envision furtherimprovementthroughfeminist perspectivesand approaches. In scientific research, it is rarelyadmitted that data have been gathered and interpretedfrom a particularperspective. Since scientific researchcenters on the physicaland naturalworld, it is presumed"objective;"therefore, the termperspectivedoes not applyto it. However, the decisions, either conscious or unconscious, regardingwhat questionsare asked, who is allowed to do the asking, what informationis collected, and who interpretsthat information create a particularvantage point from which the knowledgeor truth is perceived. Hypatiavol. 4, no. 2 (Summer1989) ? by Sue V. Rosser

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Historiansof science, particularlyThomas Kuhn (1970) and his followers, have pointed out that scientific theories are not objective and value-freebut are paradigmsthat reflect the historicaland social context in which they are conceived. In our culture, the institutionalizedpower, authority,and domination of men frequently result in acceptance of the male world view or androcentrismas the norm. Recognizingthe influence of this androcentric perspective is particularlydifficult for scientists because of their traditional belief in the objectivity of science which makesit difficultfor them to admit that they actuallyhold any perspectiveswhich may influence their data, approaches, and theories. Feminist philosophersof science (Fee 1981; 1982; Haraway1978; Hein 1981; Keller 1982) have describedthe specific ways in which the very objectivity said to be characteristicof scientific knowledgeand the dichotomybetween subject and object are, in fact, male ways of relating to the world, which specifically exclude women. Researchhas also become a masculine province in its choice and definition of problemsstudied,methodsand experimental subjectsused, and interpretationand applicationof experimentalresults. Revealing the distortions in clinical research that emanate from the androcentricbiases uncovers points at which a feminist ethics might influence this research. Feminist scientists (Bleier 1984; Birke 1986; Holmes 1981) and philosphers(Fee 1983) have called for more people-orientedand patient-centeredresearchwhich wouldbe likely to providebetter health care for all. OF PROBLEMS STUDIED CHOICEAND DEFINITION

With the expense of sophisticatedequipment, maintenanceof laboratory animalsand facilities, and salariesfor qualifiedtechnicians and researchers, virtuallyno medical researchis undertakentodaywithout Federalor foundation support. Gone are the days when individualshad laboratoriesin their homes or made significantdiscoveriesworkingin isolation using homemade equipment. In fiscal 1987, the National Institutesof Health (NIH) funded approximately$6.1 billion of research(ScienceandGovernmentReport1988). Privatefoundationsand state governmentsfundeda smallerportionof the reIndicators1987). search (NSF Scienceand Engineering The choice of problemsfor studyin medicalresearchis substantiallydetermined by a national agendathat defineswhat is worthyof study, i.e. funding. As Marxist(Zimmerman1980), African-American(McLeod1987) and feminist critics (Hubbard1983) of scientificresearchhave pointed out, the scientific researchthat is undertakenreflectsthe societal bias towardsthe powerful who are overwhelminglywhite, middle/upperclass, and male in the United States. Obviously, the membersof Congresswho appropriatethe funds for

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NIH and other Federal agencies are overwhelminglywhite, middle/upper class, and male; they are more likely to vote funds for researchwhich they view as beneficial to health needs, as defined from their perspective. It may be arguedthat actualprioritiesfor medicalresearchand allocations of fundsarenot set by membersof Congressbut by leadersin medicalresearch who are employeesof NIH or other Federalagenciesor who arebroughtin as consultants.Unfortunatelythe same descriptors-white, middle/upperclass, and male-must be used to characterizethe individualsin the theoreticaland decision-makingpositions within the medical hierarchyand scientific establishment. Women are lackingeven at the level of the peer reviewcommittee, which is how NIH determineswhich of the competitive proposalssubmittedby researchersin a given area are funded. In the ten year interval 1975-1984, women went from 16.9 percent of NIH peer review committee membersto only 17.9 percent;duringthis time, the total numberof membersnearlydoubled from 733 to 1,264 (Filner 1986). Becausethe percentageof women postdoctoralfellows increasedby 32 percentduringthe sametime period, it seems likely that qualifiedwomen were available, but not used. I believe that the resultsof having a huge preponderanceof male leaders setting the prioritiesfor medical researchhave definite effects on the choice and definition of problemsfor research: 1) Hypothesesarenot formulatedto focus on genderas a crucialpartof the question being asked. Since it is clear that many diseaseshave differentfrequencies (heart disease, lupus), symptoms (gonorrhea), or complications (most sexually transmitteddiseases) in the two sexes, scientists should routinely considerand test for differencesor lack of differencesbasedon gender in any hypothesisbeing tested. Forexample, when exploringthe metabolism of a particulardrug,one shouldroutinelyrun tests in both malesand females. Two dramatic,widelypublicizedrecent examplesdemonstratethat sex differences are not routinelyconsideredas partof the questionasked. In a longitudinal study of the effects of cholesterol lowering drugs, gender differences werenot tested since the drugwas tested on 3,806 men and no women (Hamilton 1985). In a similartest of the effectsof aspirinon cardiovascular disease, which is now used widely by the pharmaceuticalindustryto support"taking one aspirin each day to prevent heart attacks,"no females were included. (SteeringCommittee of the PhysiciansHealth StudyResearchGroup 1988). 2) Some diseases which affect both sexes are defined as male diseases. Heart disease is the best exampleof a diseasethat has been so designatedbecause of the fact that heart diseaseoccursmore frequentlyin men at younger ages than women. Therefore, most of the fundingfor heart diseasehas been appropriatedfor researchon predisposingfactorsfor the disease(such as cholesterollevel, lack of exercise, stress,smoking,and weight) usingwhite, middle-aged, middle-classmales.

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This "male disease"designation has resultedin very little researchbeing directedtowardshigh risk groupsof women. Heart disease is a leading cause of death in older women (Kirschstein1985) who live an averageof 8 years longer than men (Boston Women's Health Book Collective 1984). It is also frequentin poor black women who have had severalchildren (Manley et al, 1985). Virtually no research has explored predisposing factors for these groupswho fall outside the disease definition establishedfrom an androcentric perspective.Recent data indicate that the designationof AIDS as a disease of male homosexualsand drugusershas led researchersand health care practitioners to fail to understandthe etiology and diagnosis of AIDS in women (Norwood 1988). 3) Researchon conditions specific to females receives low priority,funding, and prestige. Some examples include dysmenorrhea,incontinency in older women, and nutrition in post-menopausalwomen. Effectsof exercise level and durationupon alleviation of menstrualdiscomfortand length and amount of exposureto VDTs that have resultedin the "clusterpregnancies" of women giving birth to deformedbabies in certain industrieshave also received low priority. In contrast, significantamountsof time and money are expendedupon clinical researchon women'sbodies in connection with other aspectsof reproduction.In this centuryup until the 1970sconsiderableattention was devoted to the development of devices for females ratherthan for males (Cowan 1980; Dreifus 1978). Furthermore,substantial clinical researchhas resultedin increasingmedicalizationand control of pregnancy,labor, and childbirth. Feministshave critiqued(Ehrenreichand English 1978; Holmes 1981) the conversion of a normal, natural process controlled by women into a clinical, and often surgical, procedurecontrolled by men. More recently, the new reproductivetechnologies such as amniocentesis, in vitrofertilization, and artificial inseminationhave become a majorfocus as means are sought to overcome infertility. Feminists (Arditti et al, 1984; Corea and Ince 1987; Corea et al 1987) have warnedof the extent to which these technologies place pressureupon women to producethe "perfect"child while placing control in the hands of the male medical establishment. These examples suggestthat considerableresourcesand attention are devoted to women'shealth issueswhen those issuesaredirectlyrelatedto men's interest in controlling productionof children. Contraceptiveresearchmay permit men to have sexual pleasurewithout the productionof children; research on infertility, pregnancy, and childbirth has allowed men to assert more control over the productionof more "perfect"childrenand over an aspect of women's lives over which they previouslyheld less power. 4) Suggestionsof fruitfulquestionsfor researchbasedon the personalexperience of women have also been ignored. In the health care area, women have often reported(and acceptedamongthemselves)experiencesthat could not be documentedby scientific experimentsor were not acceptedas valid by

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the researchersof the day. Fordecades, dysmenorrheawas attributedby most health care researchersand practitionersto psychologicalor social factorsdespite the reportsfrom an overwhelmingnumberof women that these were monthly experiences in their lives. Only after prostaglandinswere "discovered" was there widespreadacceptance among the male medical establishment that this experience reportedby women had a biological component (Kirschstein1985). These four types of bias raiseethical issues:Health care practitionersmust treat the majorityof the population, which is female, based on information gatheredfrom clinical researchin which drugsmay not have been tested on females, in which the etiology of the disease in women has not been studied and in which women's experience has been ignored. APPROACHES AND METHODS

1) The scientific communityhas often failed to include females in animal studies in basic research as well as in clinical researchunless the research centered on controlling the productionof children. The reasonsfor the exclusion (cleaner data from males due to lack of interferencefrom estrus or menstrualcycles, fear of inducingfetal deformitiesin pregnantsubjects, and higher incidence of some diseasesin males) are practicalwhen viewed froma financial standpoint. However, the exclusion resultsin drugsthat have not been adequatelytested in women subjectsbeforebeing marketedand lack of informationabout the etiology of some diseasesin women. 2) Using the male as the experimentalsubject not only ignores the fact that femalesmayresponddifferentlyto the variabletested, it may also lead to less accuratemodelseven in the male. Modelswhich moreaccuratelysimulate functioningcomplex biologicalsystemsmaybe derivedfromusingfemale rats as subjects in experiments. Women scientists such as Joan Hoffman have questionedthe traditionof using male rats or primatesas subjects.With the exception of insulin and the hormonesof the female reproductivecycle, traditional endocrinological theory assumedthat most of the 20-odd human hormones are kept constant in level in both males and females. Thus, the male of the species, whetherrodentor primate,was chosen as the experimental subjectbecauseof his noncyclicity. However, new techniquesof measuring blood hormone levels have demonstratedepisodic, rather than steady, patternsof secretion of virtuallyall hormonesin both males and females. As Hoffman points out, the rhythmic cycle of hormone secretion as also portrayedin the cycling female rat appearsto be a more accuratemodel for the secretion of most hormones (Hoffman 1982). 3) When females have been used as experimentalsubjects,often they are treated as not fully human. In his attempts to investigate the side effects (Goldzieheret al, 1971a) nervousnessand depression(Goldzieheret al, 1971b)

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attributable to oral contraceptives, Goldzieher gave dummy pills to 76 women who sought treatment at a San Antonio clinic to prevent further pregnancies.None of the women was told that she was participatingin research or receiving placebos (Veatch 1971; Cowan 1980). The women in Goldzieher'sstudy were primarilypoor, multiparous,Mexican Americans. Researchthat raisessimilar issuesabout the ethics of informedconsent was carriedout on poor PuertoRican women duringthe initial phasesof testing the effectivenessof the pill as a contraceptive (Zimmerman1980). Frequentlyit is difficult to determinewhether these women are treatedas less than human becauseof their genderor whether race and class are more significant variables. From the Tuskegee Syphilis Experimentin which the effects of untreatedsyphilis were studied in 399 men over a period of forty years (Jones 1981), it is clear that men who are black and poor may not receive appropriatetreatment or informationabout the experiment in which they are participating.Feministscholars(Dill 1983; Ruzek1988) have begun to explore the extent to which gender, race and class become complex, interlockingpolitical variablesthat mayaffect access to and qualityof healthcare. 4) Currentclinical researchsets up a distance between the observerand the human object being studied. Several feminist philosophers(Keller 1985; Hein 1981; Haraway1978; Harding1986) have characterizedthis distancing as an androcentricapproach.Distance between the observerand experimental subject may be more comfortablefor men who are rearedto feel more comfortablewith autonomyand distance (Keller 1985) than for women who tend to value relationshipand interdependency(Gilligan 1982). 5) Using only the methods traditionalto a particulardiscipline may result in limited approaches that fail to reveal sufficient information about the problembeing explored. This may be a particulardifficultyfor researchsurrounding medical problems of pregnancy, childbirth, menstruation, and menopausefor which the methods of one discipline are clearly inadequate. Methods which cross disciplinaryboundariesor include combinations of methods traditionallyused in separatefields may provide more appropriate approaches.For example, if the topic of researchis occupationalexposures that present a risk to the pregnantwoman working in a plant where toxic chemicals are manufactured,a combinationof methods traditionallyused in social science researchwith methodsfrequentlyused in biologyand chemistry may be the best approach.Checking the chromosomesof any miscarriedfetuses, chemical analysisof placentaeafterbirth, ApgarScoresof the babiesat birth, and blood samplesof the newbornsto determinetrace amountsof the toxic chemicals would be appropriatebiological and chemical methods used to gatherdata about the problem. In depth interviewswith women to discuss how they are feeling and any irregularitiesthey detect duringeach month of the pregnancy,or evaluation using weekly written questionnairesregarding the pregnancyprogressare methods more traditionallyused in the social sciences for problemsof this sort.

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Jean Hamilton has called for interactivemodels that drawon both the social and naturalsciences to explain complex problems: Particularlyfor understandinghuman, gender-relatedhealth, we need more interactiveand contextual models that address the actual complexity of the phenomenon that is the subject of explanation. One example is the need for more phenomenological definitionsof symptoms,along with increasedrecognition that psychology, behavioralstudies, and sociology are among the 'basic sciences' for health research.Researchon heart disease is one example of a field where it is recognized that both psychologicalstressand behaviorssuch as eating and cigarette smoking influence the onset and naturalcourseof a disease process. (1985, IV-62). Perhapsmore women holding decision-makingpositions in designingand funding clinical researchwould result in more interdisciplinaryresearchto study issuesof women'shealth care such as menstruation,pregnancy,childbirth, lactation, and menopause.Those complex phenomenafall outsidethe rangeof methodsof studyprovidedby a sole discipline. The interdisciplinary approachesdevelopedto solve these problemsmight then be appliedto other complexproblemsto benefit all health care consumers,both male and female. THEORIES AND CONCLUSIONSDRAWNFROMTHERESEARCH

The rationalewhich is traditionallypresentedin supportof the "objective" methods is that they prevent bias. Emphasisupon traditionaldisciplinaryapproachesthat are quantitative and maintain the distance between observer and experimentalsubjectsupposedlyremovesthe biasof the researcher.Ironically, to the extent that these "objective"approachesare in fact synonymous with a masculine approachto the world, they may introducebias. Specifically, androcentricbias may permeate the theories and conclusions drawn from the researchin several ways: 1) First, theories may be presentedin androcentriclanguage.Much feminist scholarshiphas focussedon problemsof sexism in languageand the extent to which patriarchal language has excluded and limited women. (Thome 1979; Lakoff1975; Kramaraeand Treichler 1986). Sexist language is a symptomof underlyingsexism, but languagealso shapesour concepts and providesthe frameworkthroughwhich we expressour ideas. The awareness of sexism and the limitationsof a patriarchallanguagethat feministresearchers have might allow them to describetheir observationsin less gender-biased terms. An awarenessof languageshould aid experimentersin avoidingthe use of terms such as "tomboyism"(Money and Erhardt1972), "aggression"and

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"hysteria"that reflect assumptionsaboutsex-appropriatebehavior(Hamilton 1985) that permeate behavioraldescriptionsin clinical research.Once the bias in the terminologyis exposed, the next step is to askwhetherthat terminology leads to a constraintor bias in the theory itself. 2) An androcentricperspectivemay lead to formulatingtheoriesand conclusions drawnfrom medical researchto supportthe statusquo of inequality for women and other oppressedgroups. Building upon their awarenessof these biases, women scientists have critiquedthe studies of brain-hormone interaction (Bleier 1984) for their biological determinism used to justify women's socially inferiorposition. Bleier has repeatedlywarnedagainst extrapolatingfrom one species to another in biochemicalas well as behavioral traits.Perhapsmale researchersare less likely to see flawsin and questionbiologically deterministictheories that provide scientific justificationfor men's superiorstatus in society because they as men gain social power and status fromsuch theories. Researchersfromoutside the mainstream(women for example) are much more likely to be critical of such theories since they lose powerfrom those theories. In orderto eliminate bias, the communityof scientists undertakingclinical researchneeds to include individualsfrom backgroundsof as much varietyand diversityas possiblewith regardto race, class, gender, and sexual preference(Rosser 1988). Only then is it less likely that the perspectiveof one groupwill bias researchdesign, approaches,subjects, and interpretations. HINTS OF RE-VISIONING

Some changes in clinical researchhave come aboutbecauseof the recognition of flawsand ethical problemsfor women discussedin this paper.Some of the changes are the result of critiquesmade by feminists and women scientists; some of the changes have been initiated by men. The rise of the women's health movement in the 1970's encouraged women to questionestablishedmedicalauthority,take responsibilityfor their own bodies (Boston Women's Health Book Collective 1984; Cowan 1980) and expressnew demandsfor clinical researchand for access to health care. Feminist demandshave led to increasedavailabilityof health related information to women consumers.Litigation and federalaffirmativeaction programshave resulted in an increasefrom about 6% to about 40% of women medical students from 1960 to the present (Altekruseand Rosserin press). Consumercomplaintsand suggestionshave fosteredminorreformsin obstetrical care. The decor, ambiance, and regimensof birthingfacilities have improved to providepersonaland psychologicalsupportfor the mother and to promote infant-parentbonding. However, concurrentwith modest obstetrical modifications in hospitals, nurse midwives in most states have felt the backlashof professionaleffortsto control their practice and licensurestatus

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(Altekruseand Rosserin press). Effortsto increasethe understandingof the biology of birth and translatethat knowledge into clinical care expressedas acceptable infant mortalityrates remain inadequate. 2) Guidelineshave been developedthat requireany researchprojectthat is Federallyfundedto insurehumane treatmentof human subjectsand fully informedconsent. The impetusfor the formationof the National Commission for the Protectionof HumanSubjectsof Biomedicaland BehavioralResearch was the revelation of the abuses of human subjectsduring the Nuremberg War CrimesTrials and the TuskegeeSyphilis Experiments(Belmont Report 1975). However, the attention drawn by men such as Veatch (1971) to unethical issues surroundingthe testing of oral contraceptives in women helped to insurethat women, especiallypregnantwomen, were given particular consideration in the papers forming the basis of the Belmont Report (Levine 1978). 3) In recent yearsU.S. governmentagencies have shown increasedsensitivity to clinical researchsurroundingwomen'shealth issuesand the difficult ethical issues of including women in pharmacologicalresearch.The Public Health Service (PHS) Task Force on Women's Health Issueswas commissioned to aid the PHS "asthe agencyworkswithin its areasof jurisdictionand expertise to improve the health and well-being of women in the United States" (U.S. Department of Health and Human Services 1985). In her insightful commissionedpaper "Avoiding Methodologicaland Policy-Making Biases in Gender-RelatedHealth Research"for the Report to the Task Force, Jean Hamilton makes strong recommendations: PHS consensus-developmentconference on "Gender-related Methodsfor Health Research"(for the developmentof guidelines) should be held. . . . The feasibilityof includingwomen in certain types of researchneeds to be reexamined. ... A numberof workinggroupsshouldbe formed:A working-group to reconsiderthe difficultethical issuesof includingwomen in pharmacologicalresearch(e.g., extra-protectionfor women as research subjects, versus other means for informedconsent) .. A working-groupto identifyand to considermechanisms to enhance the kind of multi-center,collaborative or clinicalresearchcenterstudiesthat would be most efficient in advancing our understandingof women and their health ... A working groupor committee to considerwaysto fostersubject-selection in a way that allows for an examination of possible age, sex, and hormonal status effects. (Hamilton 1985, IV-63-64) 4) Some attempts at patient involvement in researchdesign and implementation have provideda mechanismto shorten the distance between the observerand subjectsobserved. ElizabethFee describesan account of occu-

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pational health researchin an Italian factory: Priorto 1969, occupationalhealth researchwas done by specialists who would be asked by managementto investigate a potential problemin the factory. .... The procedurewas rigorouslyobjective, the resultswere submittedto management. The workerswere the individualizedand passiveobjectsof this kind of research. In 1969, however, when workers'committees were establishedin the factories,they refusedto allow this type of investigation . .. Occupationalhealth specialistshad to discuss the ideas and proceduresof researchwith workers' assemblies and see their "objective" expertise measured against the "subjective"experience of the workers.The mutual validation of data took place by testing in terms of the workers'experience of reality and not simply by statistical methods; the subjectivityof the workers'experience was involved at each level in the definition of the problem, the method of research, and the evaluation of solutions. Their collective experience was understoodto be much more than the statisticalcombinationof individualdata;the workershad become the active subjectsof research, involved in the production, evaluation, and uses of the knowledge relating to their own experience. (1983, 24)2

CONCLUSION

Replacing the androcentrismin the practice of medical researchand the androcentricbias in the questionsasked, methodsused, theoriesand conclusions drawnfrom data gatheredwith a feminist approachrepresentsa major change with profoundethical implications.LyndaBirke, a feministscientist, suggeststhat feminismwill change science and medicinefromresearchthat is oppressiveto women and potentiallydestructiveto all towardsliberationand improvementfor everyone. Perhaps this discussion of creating a feminist science seems hopelessly utopian. Perhaps.But feminism is, above all else, about wanting and workingfor change, change towardsa better society in which women of all kinds are not devalued, or oppressed in any way. Working for change has to include changing science, which not only perpetuatesour oppression at present, but threatensalso to destroyhumanityand all the other species with whom we share this earth. (1986, 171).

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I have described some hints of the re-visioning of clinical research, promptedby liberationmovementsof the 1970s and 1980s, that have made health care somewhatless elitist, morehumane, and moreaccessibleto all. If a strongerfeministpresencewere to be felt in design and interpretationof research,who knowswhat additionalimprovementsmight occur?Boundby my own trainingin traditionalscience, I wearthe blindersprovidedby the society to individualsof my class, race, and gender in the late-1980s. How can those of us, living with the currentreality, visualizethe new realitythat can come about by the changes we are beginning? SuzetteHaden Elgin in her futuristicnovel NativeTonguedescribesthe impossibilityof envisioning the new reality: "Perceivethis . .. there was only one reasonfor the Encoding Project, really, other than just the joy of it. The hypothesis was that if we put the projectinto effect it wouldchange reality." "Go on." "Well . . . you weren't taking that hypothesis seriously. I was."

"We were." "No. No, you weren't. Becauseall yourplanswerebasedon the old reality. The one before the change." "ButNazareth,how can you plan for a new realitywhen you don't have the remotest idea what it would be like?" Aquina demandedindignantly. "That'snot possible!" "Precisely,"said Nazareth. "We have no science for that. We have pseudo-sciences,in which we extrapolatefor reality that wouldbe nothing morethan a minorvariationon the one we have . . . but the science of actual reality change has not

yet been even proposed,much less formalized."(1984, 294)

NOTES 1. Numerousfeminist scientists (Keller 1982, 1985; Bleier 1984, 1986) and historiansand philosophers of science (Hein 1981; Fee 1981, 1982; Haraway 1978) have documented an androcentricbias in scientific research. 2. This example challenges more than the quality of informationgarneredby objective research methods in which distance is maintainedbetween the observerand the subject. It also raisesquestionsaddressedpartiallyby the BelmontReport(1975) regardingthe ethics of "double blind" experiments:Why shouldn't individualswhose health may be affected have a right to know what is being done for them and why? Is it ethical to give one groupof individualsa placebo if the drugbeing tested is likely to cure a health problemthey have or if withholding the drug will exacerbate the health problem?It also raises the more radical idea of subject in-

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volvement in experimentaldesign and interpretation:Shouldn't the subjectsbe involved in defining what the problemis and the best approachesto solving the problem? REFERENCES

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Kramarae,Cheris and Paul Treichler. 1986. A feministdictionary.London: PandoraPress. Kuhn, Thomas S. 1970. The structureof scientificrevolutions.(2nd ed.). Chicago: The University of Chicago Press. Lakoff, Robin. 1975. Languageand woman'splace. New York:Harperand Row Publishers,Inc. Levine, Robert J. 1986. Ethicsand regulationof clinicalresearch.(2nd ed.). Baltimore:Urban and Schwarzenberg. Levine, RobertJ. 1978. The natureand definition of informedconsent. The BelmontReport:Ethicalprinciplesandguidelinesfor theprotectionof human subjectsof research.Appendix. 1. (DHEW PublicationNo. OS 78-0013) 3-1-91. A cross-cultural comparison.WashingMcLeod, S. 1987. Scientificcolonialism: ton, DC: Smithsonian Institution Press. Manley, Audrey, Jane Lin-Fu, Magdalena Miranda, Alan Noonan, and Tanya Parker.1985. Special health concernsof ethnic minoritywomen in Women'shealth. Reportof thepublichealthservicetaskforceon women's healthissues.Washington, DC: U.S. Departmentof Health and Human Services. Money, John and Anke Erhardt.1972. Man and woman,boy and girl. Baltimore:Johns Hopkins University Press. National Science Foundation. 1986. Reporton womenandminoritiesin science and engineering.Washington, DC, NSF. National Science Foundation science and engineering indicators. 1987. Washington, DC (NSB-1, Appendix Table 4-10). Norwood, Chris. 1988. Alarmingrise in deaths.Ms. July, 65-67. Rosser, Sue V. 1988. Good science: Can it ever be gender-free?Women's Forum11 (1), 13-19. StudiesInternational is powerful,butso areraceand Ruzek,Sheryl. 1988. Women'shealth:sisterhood class. Keynote addressdeliveredat SoutheastWomen's Studies Association Annual Conference, February27 at University of North Carolina-Chapel Hill. Scienceandgovernmentreport.1988.Washington,D.C. March1, 18(4):1.Steering Committee of the Physician'sHealth Study ResearchGroup. 1988. reportoffindingsfromtheaspirincomponentof the Specialreport:Preliminary ongoingphysician'shealthstudy.New EnglandJoural of Medicine 318, 4, 262-264. Thome, Barrie. 1979. Claimingverbalspace:Women,speechand languagein collegeclassrooms.Paperpresentedat the ResearchConferenceon Educational Environmentsand the UndergraduateWomen, September13-15, Wellesley, MA: Wellesley College. U.S. Departmentof Health and HumanServices. 1985. Women'shealth:Report of the PublicHealth ServiceTask Force on Women'sIssues. vol. 2. Washington, D.C.: Public Health Service.

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Veatch, RobertM. 1971. Experimental pregnancy.HastingsCenter report. 1: 2-3. Zimmerman,B. et al. 1980. People'sscience. In Scienceand Liberation,Rita Arditti, Pat Brennan, and Steven Cavrak, (eds.). Boston: South End Press, (299-319).

An Ethical ProblemConcerning Recent TherapeuticResearch on BreastCancer DON MARQUIS

The surgicaltreatmentof breastcancerhaschangedin recentyears.Analysisof theresearchthatled to thesechangesyieldsapparently goodarguments for all of the women. The research Therewas (2) (1) very great for yielded benefits following: no otherway of obtainingthesebenefits.(3) Thisresearchviolatedthefundamental rightsof the womenwho wereresearchsubjects.This sets a problemfor ethicsat many levels.

Breastcancer is a scourgeamong women. One in fourteenwill get breast cancerduringher lifetime. Each year 100,000 cases of breastcancer are diagnosed in the United States and 30,000 deaths are attributedto the disease (DeVita et al. 1985, 1119). Even though surgeryfor earlybreastcancer is often curative, women with breastcancer are often forcedinto continued contact with the medical profession.Chemotherapyor hormonal therapyafter apparentlysuccessfulsurgeryis often advisable.Chemotherapyfor breastcancer where there is clinical evidence of spreadbeyond adjoininglymphnodes is not curative, but can produce remission. Sometimes multiple remissions can be producedwith successive,differentchemotherapeuticregimens.Radiation therapyfor advanced disease is often beneficial. Doctorshave at least three moralduties to women with breastcancer. One obligation is to offer their patients what is, in their professionaljudgment, the best treatment or treatments. This duty clearly entails a corresponding patient right: a right to best medical care by one's doctor. This has been called "the therapeuticobligation" (Marquis1983, 42; Gifford 1986, 348). Respectfor a patient'sright of informedconsent is anotherdutyof doctors. All persons have the right to refuse invasive medical treatment. Although there are disagreementsconcerningthe basisof this right, one securefoundation appearsto be the right of all competent adults to refuse the voluntary touching or invasion of their bodies. Not only medicalintrusion,but also domestic violence, rape, and physicalsexualharassmentfall within the scope of this fundamentaland indisputableright. Hypatiavol. 4, no. 2 (Summer1989) ? by Don Marquis

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This right is particularlyimportantin the context of breastcancer. Except in unusualsituationsthe right to refusemedicalcare is only of theoreticalimportancewhen treatmentis curativeand refusalmeans death or seriousdisability. However, a clinical oncologist may be able to offer a woman with breastcancer a choice of chemotherapiesin which differentprobabilitiesof response are balanced against different toxicities associatedwith the treatments. In the case of surgeryfor breast cancer, there has been controversy concerningwhich surgicalprocedureproducesthe best probabilityof diseasefree survival. When there are different degrees of disfigurationassociated with the surgeriesand no consensus among medical researchersconcerning which surgeryis best, the right of informedchoice among alternativesis of great importance. This right imposessome positive obligationson doctors. The right to informedconsent is meaninglessunless a physicianexplains fairlyand with as little bias as possible the treatmentoptions that are available. Accordingly, this right entails a doctor'spositive duty to provide a good deal of information. Risks and benefits must be covered. Perhapsthe evidence supporting each alternativemustbe discussed.Arguably,a doctoreven has an obligation to presentthe opinions of other specialistswho hold differentviews concerning recommendedtreatment. The point of all of this is clear:since a woman has the right to control her own body, she has the right, not just to refuseto sign some consent form, but to as meaningfuland as informeda choice as possible concerningher treatmentfor breastcancer (Katz1978; Robinson 1972). Doctors' third moral duty is to pursuean active programof researchinto the causes, prevention, treatment, and cure of breastcancer. In contrastto the therapeuticobligation, this is not an obligationof each individualdoctor. Not all doctors have the duty to engage in research.However, the medical professionas a whole, with society'scooperation,has an obligationto pursue this task. The well-being of all women is the moralbasisfor this social duty. This will be referredto as "the researchobligation." Recent researchinto the surgicaltreatmentof breastcancer involves considerationof all three duties becausethe researchnecessarilyinvolves women who were actuallybeing treatedfor breastcancer. Whether observanceof all three of these duties was possiblein recent breastcancerresearchraisesissues of fundamentalimportancefor feminists. MASTECTOMY AND CONVENTIONAL RANDOMIZATION

For many years in this country the Halsted radical mastectomywas the standardtreatmentfor earlybreastcancer. This surgeryinvolved removalof the entire breast surroundingthe malignant lump, removal of the lymph nodes underthe armon that side, and removalof the pectoralmusclesunderneath the cancerousbreast. This disfiguringsurgerycould lead to swellingof

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the upperarm and to difficultieswith moving that arm. Such radicalsurgery was justified on the groundsthat cancer cells might have startedto spread throughthe lymphaticsystemfrom the original lump. Hence, removalof as much tissue as possible was necessaryin order to maximizethe chances of "getting it all." For various reasons during the 1960s, controversydeveloped within the medicalcommunityconcerningwhether the length of survivalwithout clinical evidence of recurrenceof the cancer (called "disease-freesurvival")would be as good with less extensive surgery. In particular,the issue concerned whether simple mastectomy, in which only the breastcontaining the tumor was removedbut in which the pectoralmusclesimmediatelyunderthe breast were preserved,yielded a disease-freesurvivalrate that was as good as that of the Halsted radicalmastectomy. In 1971, BernardFisherand his colleagues began a study to resolve this issue (Fisheret al. 1985b). Fisher'sstudywas a randomizedclinical trial. A diagramwill aid in understandingits nature (see Figure1). Patientswho participatedin this studyhad potentially curablebreastcancer1 (Step 1), were asked by their doctors to be in this study (Step 2), and consentedto participate(Step 3). Patientsconsentedto have the surgerythat they receiveddeterminedby a randomizingdevice (Step 4). This means that whether a particularpatient in the study received a radicalmastectomyor a simple mastectomywas neither chosen by her doctor, nor chosen by the patient. It was determinedby some randomizingdevice, such as the flip of a fair coin. Many surgeonswould be much more comfortable(as physicians)participating in a nonrandomizedstudy in which the outcomes of patients whose surgeonsbelieved radical mastectomywould be best were comparedto the outcomes of patients whose surgeonsbelieved simple mastectomywould be best (Taylor 1984, 1365). And undoubtedlymany patients would have been more comfortableparticipatingin a study in which they had chosen either the more or less extensive surgeryaftera chance to weigh and to discusseach alternative. Nevertheless, the community of medical scientists and statisticians believes that neither of these designswould yield reliableresults.They believe that this randomizedclinical trial of radical vs. simple mastectomy providedthe only way of deciding whether disease-freesurvivalafter simple mastectomywas as good as disease-freesurvivalafter radicalmastectomy. This attitude is not restrictedto breastcancer. In the United States randomizedclinical trialsare ordinarilyrequiredby the Foodand DrugAdministration before a new drug can be released. Differentlydesigned studies can yield data that suggestgreaterefficacy, of course;however, unless the situation is exceptional, most medicalscientistswill not regarda claim concerning the effectivenessof treatment in any area of medicine as establishedunless that claim is confirmedby at least one, and possiblymore than one, random-

FIGURE 1 CONVENTIONAL RANDOMIZED TRIAL RADICALMASTECTOMY VS. SIMPLE MASTE

STEPS 1

2

3

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izedstudy (Byar1979; Sacks, Chalmers,and Smith 1982; Vaisrub1985; Angell 1984). The reasonsthat supportthis virtualconsensusappearcompelling.Neglect of the randomizedclinical trialrequirementin the past has resultedin the use of ineffective treatments (Chalmers 1967; Sacks, Chalmers, and Smith 1982). Furthermore,there seem to be many problemswith non-randomized designs for comparingradicaland simple mastectomy. Suppose in the early 1970s one group of patients who received radical mastectomiesbecausetheir doctorsbelieved that procedurewas best for them was comparedto another groupof patients who received simple mastectomy becausetheir doctorsbelieved that procedurewas best for them. Can the disease-free survival of the two groups be compared to establishthe relative efficaciesof the procedures? This design wouldyield decisive resultsonly if all the factorsthat arecorrelated with outcome are evenly distributed between the two groups. This would requireheroic and accuratedocumentationeffortson a huge groupof patients (Gifford1986). It also presupposesthat all the factorsthat are correlated with outcome in women who alreadyhave breast cancer are known. This presuppositionis known to be false. Finally, there is some reason for thinking that a worse outcome in the early 1970s would be correlatedwith being chosen by one's physician for radicalratherthan simple mastectomy. After all, if a surgeon'sclinical judgmentsuggestedthat some particularpatient had a worseprognosis,he or she wouldbe likely to recommendthe more radicalsurgery.This design, which accordsso well with a doctor'stherapeutic obligation, would not yield reliableresults, which conflicts with doctors'research obligation. A design comparingpatients receiving simple mastectomyto patients receiving radicalmastectomyin which the groupsare determinedby patients' free informedchoice is subjectto almostthe samedifficulties.The samplesize would have to be huge and the data collecting heroic and accurate.There is some reasonto think that patients might choose the more radicalsurgerybecause they react to nonverbalcommunicationfrom their doctorsconcerning the seriousnessof their disease. If this were so, the studywould be biased. If many surgeonsbelieved it might be biased (and they wouldhave), then they wouldcontinue to do radicalmastectomiesno matterwhat the studyshowed. Accordingly, researchdesigned in this way, although it accordswell with a doctor'sobligation to respect the right of informedconsent, would also not yield resultshelpful to women. Compare a randomizeddesign to these other designs. As a result of randomization,all factors, known and unknown,that might bias the resultsare themselvesrandomlydistributed.Therefore,the largerthe sampleof patients studied, the less likely it is that the resultswill be biased. Statisticianshave developed waysof calculatingthe size of the sampleneeded to have any spe-

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cificdegreeof confidencein the resultswithout knowingthe biasingfactorsor the degreeof bias.Therefore,thereappearto be goodreasonsforaccepting the viewsof medicalresearchers obthat, unlessveryspecialcircumstances the clinical is randomized the trial we reliable method for have estain, only tablishingthatone treatmentis betterthanorasgoodasanother.Thisis why a randomized studywasconductedto answerthe question:is radicalmastecan tomy unnecessarily disfiguring operation? Not onlydoesFisher'sstudydesignseemsuperior,it alsoseemsnot to have interfered with doctors'othermoralduties.If surgeonsbelievethat thereis no goodmedicalreasonto chooseone surgery overanother,then theyhave not violatedtheirtherapeutic obligationto theirpatientsby askingthemto If a patient'sconsentto have her treatmentdeteracceptrandomization. minedrandomlyis as freeandinformedas possible,then the dutyto respect informedconsenthas not been violated. Thisstudyalsofulfilleddoctors'researchobligations.One thousandseven hundredsixtyfive patientswereenrolledin this studyof radicalmastectomy vs. simplemastectomy.Ten yearresultsshowno betterdisease-free survival with radicalmastectomythan with simplemastectomy(Fisher1985b).Becausemanywomenhave been sparedunnecessarily deformingsurgerythis studyhas been trulybeneficial. Anotherstudywassuggested bydatathatemergedin the 1970's.Somesurgeonswonderedwhetherornot goodresultscouldbe obtainedin earlybreast cancerif only the tumorand a smallsurrounding marginof breastwereremovedandthe breastwaspreserved. this Although technicallyis called"segmentalmastectomy," almosteveryone,includingdoctors,calls it "lumpectomy."As a consequence,Fisherandhis colleaguesbegananotherrandomizedclinicaltrialto comparedisease-free survivalof lumpectomy eitherwith or withoutradiationtherapyto simplemastectomy(Fisheret al. 1985a). The designof this studywasbasicallythe sameas the designof the earlier studyexceptthat threetreatmentswerecomparedinsteadof two. Patients withearlybreastcancerwereaskedto givetheirinformedconsentto be randomizedto receiveeitherlumpectomy with radiationtherapyor to receive withoutradiationtherapyor to receivea simplemastectomy. lumpectomy in thisstudywasso slowthatthe studycouldnot be completed Enrollment as designed(Fisheret al. 1985a;Ellenberg1984).It is not difficultto understandwhythiswasso. No doubtwomenwereunwillingto consentto having the issueof whetheror not theirbreastswouldbe amputated decidedby the equivalentof the flipof a coin. Plainlywe havethe beginningsof a problem. On the one hand, apparently exist for the view that convincingarguments onlya randomized studyis reliableenoughto establishwhetheror not simple is excessivelymutilating.2 On the otherhand,sucha studycould mastectomy not be completedbecause,apparently, consentcouldnot be obtained.

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THE NATUREOFTHEPRERANDOMIZED DESIGN

When Fisher'steam realizedthat their conventionally randomizedstudy could not be completed, they adopted a prerandomizeddesign. A diagram will help explain how prerandomizationis differentfrom conventional ranis domization(see Figure2). The reasonthis design is called 'prerandomized' In consent a conventionthat randomization(Step 3) occursbefore (Step 5). ally randomizeddesign, by contrast, randomizationoccursafterconsent is obtained (Compare Figure 1). In this prerandomizeddesign doctors decide which patientsshall participatein the studybeforeaskingthem to participate (Step 2). They then call the statisticianto have their patient randomizedto a treatment(Step 3) without yet having askedher for consent (Step 5). After doctors learn from the statistician the treatment to which the patient has been assignedby randomization(Step 4), they thenask her for consent (Step 5). Prerandomization'sproponents believe that prerandomizedpatients should feel more comfortable consenting to be on the study because they know what treatmentthey wouldbe getting when they consent. They believe that doctorswill feel more comfortableaskingpatients to participatefor the same reason. As a consequence, a prerandomizedstudy is supposedto enroll more rapidlythan a conventionally randomizedstudy (Zelen 1979). Of course, patients have the right to decline the treatmentto which they were randomized(Step 6). In a study such as this one, surelysome will. It seems reasonableto supposethat patients who decline will preferto receive one of the other treatmentson the study. If any patients decline the treatment to which they were randomized,then the groupof patients who were randomlyassignedto a particulartreatment(Step 4) will be differentfromthe group of patients who actually receivethat particulartreatment (Step 7). Considerfor examplea patient randomlyassignedto simplemastectomy.The randomassignmenttakes place beforethe doctor discussesthe studywith the patient. Supposethat patient preferslumpectomywithout radiationtherapy. If so when askedfor informedconsent to participatein the trialby receivinga simplemastectomy,she maydecline and maychoose lumpectomywithout radiation therapy,as she has the right to do. Hence, that patient will be in the grouprandomlyassignedto mastectomy,but in the groupthat receiveslumpectomy without radiation therapy. Plainly this disparitymay occur with any treatmentgroup. Therefore, when the resultsof a prerandomizedstudy are evaluated, there is a choice that does not exist in a conventionally randomized study. The disease-free survival of patients who actually receiveeach treatmentcan be comparedor the disease-freesurvivalof patients who are randomlyassignedto each treatment can be compared. Which comparison should be made? Intuitively, it might seem that one should comparethe groupsactuallyreceiving different treatments. After all, the main purposeof doing this re-

FIGURE2 CLINICALTRIAL PRERANDOMIZED

TREATMENT RANDOMLY ASSIGNED

-

LUMPECTOMY WITH RADIATION

INF CON REQ

LUMPECTOMY W/O RADIATION

INFO CON REQ

~~~~~\ ~SIMPLE SIMPLE MASTECTOMY

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searchis to find out whether patientswho receive simplemastectomydo better than patients who receive lumpectomyeither with or without radiation. In spite of these considerations, there appearsto be a decisive argument against this method of evaluation. Membershipin the groupof patients enrolled in this study who actuallyreceivea particulartreatmentis determined in part by patient choice. The more the treatmentsto which patients have been randomlyassignedare refused,the more patient choice will determine the composition of the treatment groups.The reasonsfor women's choices may be correlatedwith the outcome of their diseases.Forexample, presumably women will be inclined to choose the more mutilatingsurgerythe more seriousthey believe their disease is. If this belief has any basis in reality, the resultsof the studywill be biased. Indeed, the problemwith a prerandomized design in which outcomes of each groupreceivingeach treatment are compared is basically the same as the problemwith an entirely nonrandomized design in which the groupsthat are comparedare determinedentirelyby patient choice. And, our earlierdiscussionshowed that this latterdesign could not yield reliable results. Thereforein orderto preservethe scientific virtuesof randomization,the groupsrandomlyassigned to each treatment must be comparedeven when they include patients who received one of the other treatments.A mastectomy groupso constitutedwill contain women who actuallyreceivedlumpectomies (See Figure2). This dilutes the powerof the study, that is, the capacity of a given sample size of patients to reflect a differencein treatmentefficacy if there really is one. Becauseof this dilution effect, the largerthe percentage of refusals,the largerthe samplehas to be to retain the powerof the study. Even a 15%refusalrate entails that the samplesize necessaryto complete the studywill have to be twice the samplesizeof the correspondingconventionally randomizedstudy (Ellenberg1984, 1405). This characteristicof prerandomizedclinical trials makes them less efficient and, consequently, more difficult to complete.3 THE ETHICSOF PRERANDOMIZATION

It is easy to understandwhy surgeonsmight feel more comfortableasking their patients to participatein a prerandomizedstudy than in a conventionally randomizedstudy. In a prerandomizedstudy they can approachpatients with a particulartreatment;in a conventionally randomizedstudy, they approachpatients with what must seem to be a gamblingdevice. Patients may feel more comfortableconsenting to be on a prerandomizedstudy, for when they consent, they know what treatmentthey would receive. Consenting to conventional randomizationis consenting to uncertainty.In short, the doctor-patient interaction in a prerandomizedstudy seems to mimic a purely therapeuticinteraction instead of an interactioncharacterizedby chance.

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Reflection on the ethics of the doctor-patientinteraction in a prerandomized trial suggestsa differentunderstandingof the context of prerandomization. Although a surgeon can approacha patient with a particulartreatment, this treatmentcannot be a therapeuticrecommendation.The doctor did not choose that treatment as best for the patient; the surgery"recommended" was determined solely by a randomizingdevice. A doctor who would like to recommenda particulartherapyto a patient becausehe or she believes it therapeuticallysuperiorcould not ethically participatein the trial. In such a situation, had the randomizingdevice selected another treatment, the surgeonwould have been in the position of recommendinga treatment believed to be inferior.This violates the therapeuticobligation. Accordingly, physicianswho are ethical and who participatein a prerandomizedtrial must destroyin their conversationwith patients exactly what may make both doctors and patients comfortable:the appearanceof a therapeuticrecommendation. Unless doctorsdo that, patients may easily mistakea recommendation based on chance for a recommendationbased on therapeuticjudgment. Of course, each woman facing surgeryfor breastcancerhas the right of informed consent and all that is entailed by that right, whatever her doctor shouldrecommend.In a purelytherapeuticcontext, manywomen, no doubt, would decide to take their doctors'advice. After all, many chose their doctors because they have confidence in them. In addition, most women who have just learned they have breast cancer feel weak and vulnerable. However, in the context of a prerandomizedtrial, informedconsent becomes even more significantbecause the physicianswho participatein the trial, if ethical, won't have a particulartherapeuticrecommendation.Women in the studycan choose any of the three treatmentswithout the pressureof rejecting an authority figure'stherapeutic recommendation. Because the treatment they are offered was actually chosen at random, their physician, if ethical, can have no therapeuticreasonfor recommendingit. Thereforepatients on this trialwouldhave a good deal morefreedomthan in the usualpurelytherapeutic situation to decline the treatmentthey were offered.They can choose the treatment with which they are most comfortableunder the assumption that there is no good reason to believe that any treatmentinvolves a therapeutic disadvantage.All this makes clear that although the prerandomized situationmight seem to mimic the purelytherapeuticcontext, randomization must be explicitly recognized by both doctor and patient as central to a prerandomizedclinical trial. In view of this, how can one explain how the prerandomized versionof the lumpectomyvs. simple mastectomystudy actuallydid enroll enough women to be completed, although the conventionally randomizedversion did not? One possibleexplanation is that doctorswere more comfortableapproaching patients when a prerandomizeddesign for the trial was used because the prerandomizedcontext mimicsthe purelytherapeuticcontext. The argument

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in the above paragraphestablishedthat physicians in prerandomizedtrials have a duty to ensure that patients understandthat treatment was chosen randomly. Therefore, this explanation succeeds only if physicians violated that duty. Another possible explanation is that women were more willing to participatewhen they were told outrightwhat treatmentthey would receive. However, if women were unwilling to accept having the retention of their breastdeterminedby a randomizingdevice in a conventionally randomized study, it is difficultto understandwhy they wouldaccept the very same thing in a prerandomizedstudy unless their physicianshad failed to explain clearly the nature of the study. Furthermore,a significantpercentageof refusalsto accept the treatment to which patients are randomlyassigned in a prerandomizedstudy requiresthat the sample size of a prerandomizedstudy be increased as comparedwith the sample of the correspondingconventionally randomizedstudy. Therefore, the prerandomizedstudy should have been moredifficultto complete than the conventionallyrandomizedstudy. Hence, the issue becomes:is there any explanationof the successof the prerandomizedmastectomyvs. lumpectomytrial, given the failureof the conventionally randomizedversion of the trial, that is compatiblewith the assumptionthat the trial was conducted ethically? SOMEPOSSIBLE EXPLANATIONS

SusanEllenberg,in a discussionof some ethical concernsregardingprerandomization,has offeredwhat amountsto a possibleexplanationof the success of this prerandomizedbreastcancer study. Knowledgeby the physician of the assignedtreatmentallows conscious or subconscioustailoring of the study presentation to predisposethe patient to accept the assignedtherapy.If the patient has been assignedto standardtherapy, the physician may stressthe experimentalnatureof the new therapy,its potential risks, and the possibilitythat the new therapymay be worse than the standardone. If the patient has been assigned to the experimentaltherapy,the physicianmay stressthe unsatisfactorytrackrecordof the standardtherapyand the promising earlierstudiesthat indicatedthat the experimentaltherapy may be an improvement.The physicianmay gloss over or even omit the informationthat treatmenthas been chosen by a random mechanism and imply to the patient that the assigned therapyhas been individuallyselected for the patient (Ellenberg1984, 1406-1407). If doctors in the mastectomy-lumpectomytrial behaved as Ellenbergsuggests they may have behaved, then they violated their patients'right of informed

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consent.Thosepatientswouldhave been deceitfullymanipulated into beto which that treatment were lieving any they randomlyassignedwas, in theirphysicians' view, therapeutically superior.If Ellenberg's possibleexplanationis the actualexplanationof the successof thistrial,thenthe trialwas unethical. Arethereotherpossibleexplanations forthe successof thisprerandomized trial?Therearesomeempiricaldataconcerningthisstudythatareilluminating:Taylor(1984)did a studyto discoverwhyphysicianshadnot beensuccessfulin enrollingpatientson the conventionally randomized versionof this citedsuchreasonsas (1) study.Physicianswho returnedher questionnaires the studyinterfered with the traditionaldoctor-patient relationship,(2) informedconsentwasdifficultto obtain,(3) physicianshad difficultytelling patientstheydidnot knowwhichsurgicaloptionwasbetter,(4) somephysiciansbelievedtheyalreadyknewwhichtreatment wasbetter,(5) somephysiciansbelievedthey wouldbe personallyresponsible forpatientsrandomized to a treatmentthatturnedout to be worse,and(6) somephysicians believed that the researchprotocolwastoo inflexible. Supposethese accountsdo explainwhy the conventionallyrandomized versionof the trialfailed.Wouldprerandomization havecausedthesephysicians'concernsto be reducedif the prerandomized versionof the trialwere conductedethically?Let us considertheseexplanations in order. Does prerandomization result in less interferencewith the traditional "Doctorknowsbest"doctor-patientrelationship? In both designsthe patient'srightof informedconsententailsthatphysicianshavea dutyto admit makeintheydon'tknowwhichtreatmentis better.Doesprerandomization formedconsenteasierto obtainfor the ethicalphysician?Everything a patientmustunderstand forgenuineinformedconsentin a conventionally randomizedtrialmustalsobe understood in the prerandomized version.Indeed, is moredifficultto explain.Physicians whohavedifficulty prerandomization to do not know which is better arenot aided admitting patientsthey option since have an to make that admission by prerandomization they obligation whicheverdesignis used.Physicians whobelievethatone treatmentis better thanthe otherhave a dutynot to enrollpatientson the trialwhetherconIf they do, they have violated ventionallyrandomizedor prerandomized. theirtherapeuticobligation.A feelingof guiltassociatedwithpatientsrandomizedto the treatmenteventuallyshownto be worsecouldoccurin connectionwith bothdesigns.The researchprotocolwasno moreinflexiblein the conventionallyrandomized designthan in the prerandomized design. Therefore,if the six reasonsofferedin the Taylorarticlearesufficientto exrandomized versionof the lumpectomy plainthe failureof the conventionally vs. mastectomystudy,they are also sufficientto explainwhy the prerandomizedversionwouldfail if it wereethicallyconducted.Sincethe prerandomizedversiondidnot fail, if the Taylorexplanationis complete,then the

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prerandomizedversion of the trial must not have been conducted ethically. Is there another way of explaininghow prerandomizationcould have been both ethical and successful?Ellenberg(1984, 1408) has suggestedthat conventional randomizationmay fail "becausepatients are reluctantto agree to accept an unknown regimen." If so, prerandomizationmay improvethe acceptance rate, since with this design patients know, when asked, what treatment they will receive. This explanation, however, does not seem to explain what actually occurredin the lumpectomyvs. mastectomystudy. Many conventionally randomizedstudiesare completed in medicine. This suggeststhat patientsare, in general,willing to accept an unknownregimen. What would account for the unwillingness of women to accept an unknown regimen in this particular study?The obvious answer in this case is that because the surgeriesbeing compared had such different, permanent consequences for one's body, women were unwilling to be randomizedto a therapythey viewed as much less desirablein the absenceof their physicians'belief that less desirabletreatment offereda therapeuticadvantage.Ellenberg'sconjectureboth "explains too much" and neglects the obvious explanation. Is there any other possible explanation for the success of this prerandomizedstudy?Appelbaumand his colleagues (1987) have studiedinformed consent in randomizedclinical trialsand have identifieda "therapeuticmisconception:" patients will read consent forms, sign them, and still believe that the treatmentthey are receivingwas chosen for them becausetheir doctor thought it best. The therapeuticmisconception can easily explain why patients accepted prerandomization.However, whenever the therapeutic misconception is present, obviouslygenuine informedconsent has not been achieved. Hence, Appelbaum'sresults can explain why prerandomization succeededin this case only on the condition that doctors'duties to their patients were violated. Susan Ellenberg has argued that because of the major problems with shouldbe considereda last resortmeasprerandomization,"prerandomization ure" (Ellenberg1984, 1408). Prerandomizationwas a last resortmeasurein the lumpectomyvs. mastectomystudy. However, if the analysisup to this point is correct, we cannot explain how the conventionallyrandomizedtrial failed while the prerandomizedversion of the trial both succeeded and was conducted in accordancewith generallyaccepted ethical standards.Put another way, when prerandomizationwas used as a last resortin this case, we cannot explain how it could have been simultaneouslyboth successfuland ethical. The absenceof such an explanationmustbe contrastedwith the ease of explaininghow prerandomizationcould succeedif not conductedethically: prerandomizedcontexts misleadingly mimic purely therapeutic contexts. This supportsa considerablystrongerconclusionthan Ellenberg's:the prerandomizedlumpectomyvs. mastectomystudy violated generallyaccepted, and apparentlyeasily defensible, standardsof medical ethics.

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CONCLUSION Before concluding that the mastectomy-lumpectomytrial was patently unethical, a look at the resultsof that trial are in order.The trial established that when both lumpectomygroupswere combined, disease-freesurvivalafter mastectomywas no better than disease-freesurvival after lumpectomy. The trial also establishedthat disease-freesurvivalafterlumpectomywith radiation was better than after mastectomy (Fisher et al. 1985a). These are wonderfulresults!It means that most of those 100,000 women each year diagnosedwith breastcancer can choose less disfiguringsurgeryknowing they are not reducingtheir chances of survival.Furthermore,we have apparently good reasonsfor believing that there was no other way to get these results. Accordingly,one might want to arguethat the beneficialresultsof this study for women utterly submergethe ethical concerns discussedin this essay. Tempting as this argumentis, it is subject to substantialdifficulties.The fundamentalright of women to control their own bodies seems fundamental, not only to the ethics of women's health care, but also to the wrongnessof rape, domestic violence, and physical sexual harassment. Accordingly, it does not seem to be the sortof rightwe wouldwant to tamperwith underany circumstancesin a systemof ethics responsiveto feminist concerns. In addition, tamperingwith the right of patients to control their own bodies might be thought to justifymedicalpaternalismfor fully competentpatients in some cases. Many medical ethicists would regardthat price as too greatto pay. Finally, most contemporaryethical theoristswoulddefendthe view that fundamental rights overridesocial benefits. Indeed, they might arguethat what it meansto say that a right is fundamentalis that considerationsof social benefit cannot override it. Analysis of this recent therapeuticresearchon breast cancer appearsto yield the conclusion that obtainingthe extraordinarilyvaluableresultsof this studyand protecting the rightsof women are incompatible.Since there also appearto be compelling argumentsfor giving up neither the benefits of this studynor the rightsof women, this essayleaves us with a problem,not a solution. Resolution of this problembased upon the resourcesof feminist ethics or feminist critiquesof science or perhapsother approachesto ethical theory requiresan analysisfar beyond the scope of this essay.

NOTES MarySpratt, Ron Stephens, Janet Levy, Jane Henney and Ace Allen madehelpfulcomments on an earlierdraftof this essay. Helen BequaertHolmes' detailed comments on an even earlier draftwere exceptionally helpful. Janice Doores and Cynthia Hodges did the word processing.I wish to thank them all. 1. Potentiallycurablebreastcanceris cancerthat is not so faradvancedthat cure is impossible.

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2. This point is stated conservatively.The resultsof a nonrandomizedstudywould probably not have been acceptedby surgeons,most of whom were taughtthe virtuesof the Halstedprocedure. Furthermore,a nonrandomizedstudy that falselyshowed that lumpectomyproducedas good survivalas mastectomywould have tragicconsequencesfor women if accepted. 3. For a more detailed discussionof this efficiency problemsee Ellenberg(1984).

REFERENCES

Angell, Marcia. 1984, Patient preferencesin randomizedclinical trials. New EnglandJournalof Medicine310 (21): 1385-1387. Appelbaum, Paul S., Loren H. Roth, Charles W. Lidz, Paul Benson, and William Winslade. 1987. Falsehopes and best data:Consent to research and the therapeuticmisconception.HastingsCenterReport17 (2): 20-24. Byar, David P. 1979. The necessity and justificationof randomizedclinical trials. In Controversiesin cancer:Designof trialsand treatment.Henri J. Tagnon and MauriceStaquet, eds. New York:Masson. Chalmers,Thomas. 1967. The ethics of randomizationas a decision-making technique and the problemof informedconsent. Reportof the 14thConference of CardiovascularTrainingGrant ProgramDirectors.Bethesda, Maryland:National Heart Institute. DeVita, Vincent T. Jr., Samuel Hellman, and Steven A. Rosenberg. 1985. Cancer,principlesandpracticeof oncology.Philadelphia:J. P. Lippencott Company. Ellenberg,Susan. 1984. Randomizationdesigns in comparativeclinical trials. New EnglandJournalof Medicine310 (21): 1404-1408. Fisher,Berard, MadelineBauer,RichardMargolese,et. al. 1985a. Five-year resultsof a randomizedclinical trialcomparingtotal mastectomyand segmental mastectomywith or without radiationin the treatmentof breast cancer. New EnglandJournalof Medicine312 (11): 665-673. Fisher, Berard, Carol Redmond, Edwin R. Fisher, et. al. 1985b. Ten-year results of a randomizedtrial comparing radical mastectomy and total mastectomywith or without radiation.New EnglandJournalof Medicine 312 (11): 674-681. Gifford,Fred. 1986. The conflict between randomizedclinical trialsand the therapeutic obligation. The Journalof Medicineand Philosophy11 (4): 347-366. Katz,Jay. 1978. Informedconsent in therapeuticrelationships:Lawand ethics. In Encyclopedia of bioethics.WarrenT. Reich, ed. Glencoe: The Free Press. Marquis,Don. 1986. An argumentthat all prerandomizedclinical trials are unethical. TheJournalof Medicineand Philosophy11 (4): 367-384. Marquis,Don. 1983. Leavingtherapyto chance: An impassein the ethics of randomizedclinical trials. HastingsCenterReport13 (4): 40-47.

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Robinson, Spotswood. 1972. Canterburyvs. Spence. U. S. Court of Appeals, District of Columbia Circuit. 464 FederalReporter, 2nd Series, 772. Sacks, Henry, Thomas Chalmers,and HarrySmith. 1982. Randomizedversus historicalcontrolsfor clinical trials. TheAmericanJournalof Medicine 72: 233-240. Taylor, KathrynM., RichardG. Margolese,and Colin L. Soskolne. 1984. Physicians' reasons for not entering eligible patients in a randomized clinical trialof surgeryfor breastcancer. New EnglandJournalof Medicine 310 (21): 1363-1367. Vaisrub,N. 1985. Manuscriptreview from a statistician'sviewpoint. Journal of theAmericanMedicalAssociation253 (2): 3145-3147. Zelen, Marvin. 1979. A new designfor randomizedtrials.New EnglandJournal of Medicine300 (22): 1242-1245. Zelen, Marvin. 1977. Statistical options in clinical trials. Seminarsin Oncology4 (2): 441-446.

Can Clinical Research Be Both Ethical and Scientific? A Commentaryinspiredby Rosserand Marquis HELENBEQUAERTHOLMES

Problemswithclinicalresearchthatcreateconflictsbetweendoctors'therapeutic and researchobligations may be fueledby a rigidview of scienceas determiner of clinicaltritruth,a heavyrelianceon statistics,and certainfeaturesof randomized als. I suggestsomecreative,feministapproaches to suchresearchand exploreways to providechoicefor patientsand to use valuesin directingboththerapyandscience - to enhancethe effectivenessof each.

Both Rosserand Marquispoint out problemswith medicalresearchon human subjectsthat may resultin unfairtreatmentof women and/orresultsthat have questionabletruth value. To me their papersraise the question:can a clinical studybe both ethical and scientific at the same time? I shall explore this questionfrom a feminist perspective,using feministvalues and recognizing that one major goal of feminism is to eliminate oppression (Sherwin 1989, 70). The oppressedhere is the patient: any sick or disabledperson. (Even the wealthy sick are oppressedthrough the pronouncedinequalityof the doctor-patientrelationship.) One paradoxis that, although the goal of medical researchis to alleviatethe sufferingof this oppressedgroup, such research sometimescontributesto their suffering. Clinical researchmay use subjectswho have been oppressedin other ways (besidesbeing patients). Inner city teaching hospitalsmay use poor and minorities;ethnic groupsmay be selected for use becauseof a higher genetic or environmentalfrequencyof certain diseases;women maybe used in a variety of techniquessometimescalled "alternativeassistedreproduction."In this final case, wealthy women often finance their doctors'clinical experiments; nevertheless,they are membersof at least two oppressedgroups:biologicalfemales and patients. In this essay, afterdefining "ethical"and "scientific,"I considerthe use of statistics and randomizedclinical trials as means of finding "truth."I shall suggest some feminist approachesto questions which these raise and shall Hypatiavol. 4, no. 2 (Summer1989)? by HelenBequaertHolmes

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propose issues to consider in setting up experimentaldesigns that would be ethically acceptable to feminists. SOME(ARBITRARY)DEFINITIONS

An ethicalaction, of course, is one done in a right way for a good end. For "right"and "good"we all have common understandings,fromclassicaltheories of ethics, or from "principles"found in medical ethics texts, or fromvalues highlightedby feminist ethics theorists, but mostly fromsimple intuition wherebywe usuallyrecognizea "right"action or a "good"person. (But I believe that the trulyhardcases- in case studiesor stressingour daily livesmay have no really ethical solutions.) To be less vague: drawingupon nonfeministethics, I define an action (in this case clinical research)as "ethical"if it is just, is beneficent, and respects autonomy.Drawingupon the insightsof feministethics, I amplifythis definition by proposingthat clinical researchis ethical if it respectsall humanseven if female, poor, or of color - fully, allows them to make informed choices,1 and at the same time caresfor them, recognizestheir place in relationshipsthat are vital partsof their lives, and is situation-and context-sensitive. Since authentic ethicists and authentic feminists would behave this way, I consider the adjectives "ethical" and "feminist"equivalent. It was tempting to change the title of this essay, in imitation of Longino (1988) in the first Feminism& Science issue of Hypatia,to "Can Clinical ResearchBe Feminist?" A scientificapproachis one that attemptsto obtain knowledgeof the natural world;arbitrarilyI posit that a studyis "scientific"if it revealstruth about natureand that it is good for a studyto be scientific. Specifically,in the case of medical research, a study should give us accurate information about whethera given drugcan cure a given disease, a given surgicaltreatmentcan correct a given problem, and so forth. However, judgmentsabout accuracyand truth present a formidableproblem. Only humanbeings can makesuch judgmentsand no humansarefree of biases. Let us look at a simpleexample. A certainchemical solution has been heated to a certaintemperature.We mayagreethat there is a "true"temperature of that solution and that, among arbitrarysystems, we shall take centigradeas our scale. However, when my lab partnerand I in analyticalchemistry read the thermometer,we recorddifferentvalues. I was taught in freshman chemistryto put my eye level with the meniscusof the mercurywhen readinga thermometer,and she was not. We are both white, middle-class, and female (a common sociologicalbackground)and we both want to turn in beautifulgraphson our lab reportsand get A's (a common goal), yet we read differenttemperaturesbecauseof little differencesin our pasts. Modem automatic devices determine temperatureelectronically, but human judgmentis

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still involved in setting standards.Scientists accept arbitraryconventions; they then assume (perhapserroneously)that all other scientists accept the same ones. (I am not raisingthe questionhere of whether "temperature" exists only in the human imagination.) If even a true temperatureeludes us, how much moredifficultit is to agree whether a given treatmentor medication"cures"a disease. With its marvelous mechanismsof recovery, the human body can often heal itself without treatmentor in spite of a distinctlyharmfultreatment.Many sick people survived bleedingby leeches in the 1700s, even though we now know that each lost drop of blood lowered their chance of recovery. Furthermore,scientists'search for truth is limited by their senses and distorted by their belief systems.2However, to proceed I must assumethat appropriatestudiescan help us to fathomthe mysteriesof natureand to become more effective healers. STATISTICS

Modem scientistsuse statisticiansas arbitersof truth. In field hospitalsduring World War II no one experimentedto see whetherpenicillin wouldwork -say, by giving it to only half the gunshot patients. Penicillin obviously stoppedinfections and saved lives. No statisticianwas needed to declaresignificance. But nowadays most new "breakthroughs"in medicine - new drugs, new surgical procedures- may alleviate some symptoms,slow the progressof a disease, stave off the moment of death, or lead to a few moresurvivors. Is the old treatment better than the new? Is surgerybetter than a drug?It is not immediatelyclear. One must define "success"for each experiment. Does survival count as success if it is survival-confined-to-bed,or survival-with-pain?After success is defined, one must consider what to do with the figuresobtained. The researchergoes to the statistician,as to the oracleat Delphi, with the data. After applying the appropriateformula, the statistician tells whether the researcher's"null hypothesis"has not been falsifiedat the 5% level of significance, and hence is accepted. Let's use a specific example. One null hypothesis might be that, after breastcancer surgery,radiationplus chemotherapy(therapyA) providesbetter disease-freesurvivalthan chemotherapyalone (therapyB). Of course, if everyonewith the first treatmentwere still alive and half of the second group weredead, there wouldbe no need for statistics(except that statisticaltesting is expected of every scientist). If tests with the data give a 95% likelihood that therapyA is better, the hypothesis is accepted. However there still is a 5%chance that therapyA was reallyno betterthan therapyB, in which case a "type two" errorhas been committed. On the other hand, if the statistics did not quite make the 5% cut-off level, the hypothesis would be rejected:

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then, if therapyA had actuallybeen betterthan therapyB, a "typeone" error would have been committed (Levine 1988, 190; Ratcliffeand Gonzalez-delValle 1988, 386). The statisticalthresholdcan be crossedby a very slight change in results. On a recent NOVA television show, "Do Scientists Cheat?"(NOVA 1988, 6), Dr. MartinShapirodescribeda hypotheticalexperimentwith 80 cancer patients, 40 getting treatment,40 with none (the controls). He displayedresults that showedno statisticallysignificanteffect of the treatment.However, if one treated patient who died were omitted from the tally, significance would be found. Some very acceptablereasonscould be found to decide not to count a particularpatient - maybeshe did not get quite the full courseof the drug?Perhapsher cancer had alreadybegun to metastasize?Perhapsshe wasn't in the same age group as the rest? If the treatmentREALLYworks, omitting such a patient would be ethical,to avoid committinga type one error, to make a helpful treatmentavailable to futurepatients. On the other hand, the treatment might NOT really be better. The omission would be unethical if the scientist'smotivationwas simplyto get anotherpublishedpaper (it's almost impossibleto publish"non-significant"results)or to continue getting researchfunds from the pharmaceuticalfirm that providesthe drug. ETHICSAND THERANDOMIZED CLINICALTRIAL

The United States Food and DrugAdministrationtries to control the introduction of new drugs, requiring(after animal experimentation)phase I studieson healthy volunteersto determinetoxicity, and phase II studieson sick people to determine efficacy (Levine 1988, 6; Silverman 1985, 151). Next, in phase III, should come studies to determine the "truth" about whether a new treatmentis actuallymore effective than the old treatmentor better than no treatmentat all. The randomizedclinical trial (RCT) is consideredto be the best way to determine this for medical and surgicaltreatments.3However, since each person(with the possibleexception of identical twins) is unique, no method of randomizationcan be perfect. Each person is physiologicallyunique - having a unique set of genes, unique life experiences, and unique combinationsof previousinfectionsand medicalinterventions. Thus each collection of people receiving the same treatment in an RCT is heterogenous. A double-blindstudy (in which neither patient-subjectsnor those who record resultsknow who gets the treatmentand who does not) should increase the likelihood that resultswill be "true,"becausesome biases (that a drugreally works, that certain side effects are trivial, etc.) are, in theory, eliminated. Also, a double-blindexperimentis supposedto mitigatethe "placebo effect." People who receive dummypills often improvein health - even participants who know that the pill they take has a 50-50 chance of being a

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dummy.There is a psychologicalbenefit in believing that one is actuallybeing treated. My view, after being given short shrift so often by doctors too busyto listen to all my questionsin an annualcheckup, is that a patient in an RCT would get such positive emotional vibes in being in the center of attention - with people eagerly recordingdata about bodily functions - that health would, of course, improve.However, the placeboeffect is viewed negatively and sometimes considereddangerous:investigatorstalk about eliminating it (Levine 1985 and 1988, 204). Marquis(1989) comparesthe pre-randomizedexperimentaldesign (where the cancer patient is told which treatment alternative she'll get before she agreesto participate)with simple randomization(where patient is told what the different treatments are and agrees to be in a trial, not knowing which she'll get). He points out that, when a largepercentageof potential subjectsrejectsparticipationin each such type of study, there may be no results to help women in the future. But if physicianswho enroll patients in such trials actually have preferredtreatmentsand have not communicated these preferencesto their patients, then the therapeuticobligation has vanished. Marquisleaves us with a tangled paradox.Three points may help untangle it. 1) If there were a verymuch better treatment,it wouldcome to light without the randomizedtrial (a treatment, say, effective on estrogen-dependent cancersas well as others;one effectiveon metastasized cancers;one effectivein low and high dosages,etc.). But when we cannot see for ourselvesand mustgo to Delphi to learnwhich is better, then there mustbe little differencebetween treatments.In such a case, the problemsof poorrecruitmentto the experiment and of truefranknessbetweendoctorand patientwouldnot matterso much. 2) Both the randomizedand the pre-randomizeddesigns (with informed consent) should indeed be commendedas waysof treatingpatientsas full human personsand unique individuals,but they don't go far enough. Patients should be encouraged to consider (and their choices should be respected) such mattersas the following: a) Meaningof a worthwhilelife. How productivedo I want to be in continuing my life? What obligations do I have to people in close relationships?If I become bedriddenor crippled, would this be viewed as an opportunityor as an unbearable burdenby others? b) Views on pain and suffering.Is longevity an end in itself? If I have to take huge dosagesof pain-killers,has the real me been destroyed? How much longevity counterbalances how much suffering? c) Altruism. If I participatein an experiment, how much am I willing to sufferto benefit others, if it will not benefit

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me? Can a belief that I am doing somethingfor othershelp me to endurepain?Will participationin an experimentgive more meaning to my life by giving a special meaning to my death? Veatch (1987b) has argued: A rationalpersonmay not want to maximizehis or her medical well-beingat the expense of somethingelse the personvalues . . . Many of the standardconcepts of modem medicine are called into question. There is no longerany such thing as a "medicallyindicated"treatment. (Veatch 1987b, 2) 3) Clinical experimentsprovideopportunitiesfor doctorsto develop into caring persons - perhaps the injection that medicine needs most. They could startby being honest with patients and by admittingtheir own biases, worries,uncertainties, and lack of knowledge. Let us look at an imaginaryscenario: A breastcancer patient is told after lumpectomythat there are three therapies being evaluatedby medical science. These treatments,she is told, have been chosen by physiciansexpert in treating cancer, and an experimentto comparethem has been designedwith the advice of formerand currentpatients (Rosser 1989). She may choose any of the three, a completely free choice. Her doctor explains that all three are helpful in prolonging disease-freesurvival,but no treatmentguaranteesit. This experimenthas been set up to determinewhetherone treatmentis somewhatbetterthan the other two. She may decide rightnow to get the decision over with; she may ask her doctor to flip a coin, or she maydo some readingand/ortalk with people during the next week. If she chooses the last, she is encouragedto ask questions of membersof the local breastcancer supportgroup.The groupincludedformerpatients, at least one who has had each treatment.The doctorgives her a handout with the phone numberof the cancer supportgroup, a list of readings availablein the local public library,and a note admittingher to the hospital librarywhere the librarianhas a special file of appropriatearticles. The doctor appearsrelaxed and encouragesquestions. Should the patient askwhat treatmentREALLYis best, he or she respondshonestly. (An ethical doctor would not agree to participatein the experimentif he or she thought that one of the treatments was seriously inferior.) A response might be, "Frankly,I think that treatmentx maybe somewhatbetterbecause... "Or, "I'dpreferyou to choose treatmenty becausewe haven't recently (or the national project hasn't) had many women choose y - it would provide useful informationto help women in the future." If the patient insists, "Youchoose for me," the doctor does indeed choose, or says, "I'dpreferyou to be in the experiment."He then pulls a slip out of an envelope, and says "I've assignedyou randomly, and you'll be in the . . . group. Will you accept that?"

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The patient would be permittedto change her treatmentchoice, afterfurther readingor afterexperiencingside effects, even in the middleof therapy. She may leave suggestionsin a suggestionbox - anonymouslyif she wishes -and she is invited to attend meetings of the researchteam. In this scenario patients have the opportunityto exercise some control over their therapy;the placeboeffect is encouragedand usedto promotehealing; patientsare also allowedto turnback responsibilityto the doctor. (In my view, patientsshouldbe permittedbut never forcedto become informeddecision-makers,i.e., mini-experts,on every ill that besets their bodies.) But at present this scenariowould seldom be feasible. First, it would be difficult to recruit enough subjects to get statistical significance when increments of "success"will likely be tiny. Second, even if doctorswere to cooperate, such a trial could be conducted only where there were patient supportgroupsand appropriatelibraryfacilities. However, I present it to give specific examples of desirablefactors to include when feministsdesign clinical experiments. OTHERS'CONCERNSABOUTRCTs

Although most clinical researchersclaim that the randomizedclinical trial is "the most reliablemethod of evaluatingthe efficacyof therapies"(Byaret al 1976) or the "gold standard"(Levine 1988, 211), some disagree(Rosner 1987). For example, Weinstein (1974) and others suggestconsideringindividual patient preferencesand using adaptivedesignsthat make use of information obtained duringthe investigation, therebyexposingfewerpatients to an inferiortreatment. Veatch (1983 and 1987a) has proposedwhat he calls the semi-randomized clinical trial which he claims is both scientificallyand ethically superior.In this schema, patients are recruitedfor a trialof, let us say, a new therapyversus the standardtherapy. After a randomizationprocedure,each is assigned to one or the other therapy.At this point patientsmayreject the assignment, opting for the other treatment. Some patients may preferstandardtherapy; others, something new. The patients assigned to the new treatment but choosing the standardare then asked if the researchermay follow the course of their therapy. Fromthis schema, five groupsnow exist: those who prefer not to be followed;those assignedto standardtherapyand acceptingit; those assigned to new therapy and accepting it; those assignedto standardwho choose new instead, and those assignedto new who choose standard.The resultsof therapyin the last fourgroupsare then studiedover what is probablya courseof severalyears,to determinelong-termeffects. (In most clinical trials wherepatientsare given a choice to opt out of randomization,they are offered only standardtreatmentand the resultsof their treatmentare not studied.Or, as describedby Marquis(1989, nn; alsoConn 1974, 1067), they areconsidered to be in the groupto which they were randomized,regardlessof treatment.)

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Similaritiesbetween Veatch's schema and my hypothetical breast-cancer scenarioabove are obvious. Veatch admitsthat more subjectswill need to be recruitedto have largeenough groups(statisticallyspeaking)in all categories. However, he claims that this design is superiorscientificallybecauseone can make more statisticalcomparisons:those who choose a therapyvs those who do not; everyone getting standardtherapyvs everyone getting the new, etc. He points to resultsfrom the Boston Inter-HospitalLiver Group'sstudy of therapeuticportacavalanastomosis.Those who were randomizedto surgery but insistedon medical treatmentdid better than those randomizedto medical treatment(Veatch 1987a, 133; Conn 1974, 1067). Perhapssome people are in tune with their bodies and use some sort of "sixthsense"in reactingto proposedtreatments.Can we use the placebo effect to enhance healing, and let those moved to use the misfortuneof their illness to help futurepatients be the ones who join clinical trials? Using the typical "principles"languageof mainstreambioethics, Veatch gives ethical justificationfor the semi-randomizedclinical trial. Arguments for good experimentaldesignare, he claims,argumentsfrombeneficence,i.e., designsto give more benefitsand lowercosts to futurepatientsand society. Just as the right of patients to consent (based on autonomy) cannot be overriddenby considerationof good researchdesign (beneficence), so the right of a least well-off group to be benefitted (basedon justice) cannot be overriddenon beneficence grounds(Veatch 1987a, 132). Veatch has been challenged by other mainstreambioethicists. Lebacqz (1983) claims that a disadvantagedgroupmaybe harmedby being allowedto choose a new "treatment,"becausethe languageused in experimentaldesign is often deceptive. Something called "therapy"or "treatment"may actually be a "nonvalidatedintervention."But, in my view, moreharmis done when a patient is assignedto such a nonvalidatedintervention. Accurate language in consent forms is necessary,whatever the researchdesign. Accordingto Gordonand Fletcher(1983, 23) "behavioraland psychologic factorscan show strongcorrelationswith the endpoints. . . commonlyused to evaluatetreatment."Thereforethey query,"Howcan one interpretapparent differencesin outcome when the assignmentof patients between treatment groupsbeing comparedis a consequenceof the behaviorof either the patient or the physician?"They conclude that semi-randomizationis UNin JUST, both for Lebacqz'sreason(above) and because"semi-randomization . will the interestof some penalizesthe chances that. eventuallyall prosper more."But, if Gordon and Fisherpermitinformedconsent, semi-randomization merelyallowsresearchersto collect dataon patientswho opt out of their assignedtreatment- which should increasethe chances that all will prosper more.

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A FEMINIST ANALYSIS

Feministsconcerned about properconduct of clinical trialscan adaptand benefit fromVeatch's ideas. Let'scleanse his competing-principleslanguage, in which one principle "overrides"another. In this mainstreamparlance, "beneficence"as a principle usuallyranks lower in the hierarchybecause it has a utilitarian taint, whereas "justice" and "autonomy" have higher Kantiancredentials. Now for a feminist wording:A woman coming into the "health"care system is a unique individualpsychologicallyand physically.Partof her identity and thus part of her health and well-being, however, is in her network of close and distant relationships.Forexample, she may be concernedover the disruptionher illnesswill have on others;she maybe worriedaboutinfectious transmissionto her childrenor about a genetic susceptibilityin her children. Thus a doctor who offersher a true choice about participatingin an experiment for the good of futurepatientsrespectsher complicatednetworkof relationships without needing to understandit. Consideringa person as more than just a body is a cornerstoneof healing. Experimentalresultsmay be better at predictinghealing if all participantsin all groupsin an experimentare free to do what they wish (as much as possible, given their illnesses). All membersof each treatmentgroupmust benefit in well-being. Veatch recently (1988, 7), without the usuallanguageof principles,argues in similarvein. A patient, he says, mayhave a rationalnonmedicalreasonfor choosing one treatmentover another, even if doctorsdo not know which is better, and even if the other treatmentmay providea statisticallysignificant longer survivalthan the ones chosen by the patient. A patient'schoice may be based on "specialconcerns, interests, fears, or life positions." However, as feministswe must be sensitive to all formsof oppression,and the semi-randomizeddesign is elitist in some ways. We must accept those people who have blind faith in the medicalprofessionand not try to convert them to our agnosticism. Some people may be too sick, too weary, or too scaredto weigh choices. Even the highly educatedmust not be forced. Processing informationmay be too difficultfor some and too stressfulfor others. Any feminist theory of clinical experimentationmust take into account the variousvulnerabilitiesof patients. Since science is alwaysbiased as practiced (Longino 1987; Ratcliffe and Gonzalez-del-Valle1988),4 researchersplanning experimentsshould try to recognizeand remove biaseswhere possibleand should try to consciouslyexploit bias toward acceptable values. For example, we can decide to be accountable to women and all sick persons, as Longino suggests: If we recognize. . . that knowledge is shapedby the assumptions, values and interestsof a cultureand that, within limits,

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one can choose one's culture, . . . we can choose to whom, socially and politically, we are accountablein our pursuit[of scientific understanding].(Longino 1987, 61) SOMEHARD CASES

So far we have discussedexperimentsinvolving rational adults and have pointed out some circumstancesin which they should not be expected to be full participantsin decision-making.The mentally retardedand patients in comas are never able to be full participants,and a feminist theory must be able to incorporatethese persons. Children are another such group. Let us give a feminist analysisof an experimentcurrentlyunderwayin northeastThailand, the poorestpartof that land (McBride1988). These childrenhave significantlylow levels of zinc and vitamin A in their blood. Each of these deficiencies lowersresistanceto disease. Moreover,low levels of zinc impairgrowthand also prevent vitamin A fromfunctioning- and low levels of vitamin A cause night blindness. The children have been divided into four groups:zinc alone, vitamin A alone, both nutrients,neither nutrient. They will be tested on their susceptibilityto infections. "The study may also help resolve the controversyover whether the U.S. diet is adequatein zinc and vitamin A" (McBride 1988, 11). One unethical aspect of this studyis that a vulnerablepopulationof thirdworldchildren is used to settle a first-worldscientific controversy.Second, it is unlikely that the groupwith no treatmentwill benefit in any way. Inclusion of such a groupcannot be justifiedby sayingthat, if there were no experiment, all children would be untreated.Given what we alreadyknow, some treatmentfor all must be providedso that everyonemay benefit fromparticipation. How wouldfeministsdesign such an experiment?First,the childrenthemselves shouldbe involved in some way in designingand implementingthe experiment.Their creativitycould be stimulated,despitepovertyand illiteracy. Perhapseach child could choose two friends, each to be in a differentgroup. One groupwould receive a moderate(non-toxic) amountof zinc with a trace of vitamin A; the second, moderatevitamin A and a trace of zinc; the third, moderateamountsof both zinc and vitamin A. Resultsfromthis experiment might answerthe questionwhetherone shouldmaximizezinc or vitaminA in a food sourceto be grownlocally. Childrenin the experimentand childrenin the futurewould benefit. All participatingchildren could truthfullybe told that the specialfoodsthey weregetting wouldhelp them to see betterat dusk. They could even be taught a simple test to use themselves to check their black-and-whitevision.

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CONCLUSION

Do feministswant clinical experiments?I think we do, although my "yes" is not a hearty one. For example, we want contraceptivesthat are saferand moreeffective than ones currentlyavailable;differencesin both safetyand efficacy are likely to be subtleand thus mustbe tested statisticallyafterwell-designed experiments. I have tried to indicate problemswith current randomizedclinical trials and to give some specific examples of solutions that might be acceptableto feminists. Rosser (1989) sees some hopeful trendsin modem clinical experiments; some mainstreambioethicists such as Veatch (1987b and 1988) urge overt attention to values in "scientific"medicine. Ratcliffeand Gonzalez-delValle (1988) claim that truly "rigorous"research requires the researcher to have a consciously held, wellthought-out, and coherent ethical frameworkto guide his or her choices during every phase of the researchprocess .... Value-explicitresearchclearlyrequiressystematicexposureto, reflection upon, and practice in the application of ethical frameworks.(389) Feministscientists, physicians,and philosophersneed to work together to make scientific medicine both more "scientific"and more "ethical"at the same time. If medicine is to help the people who need it most, science and ethics mustmerge. Authentic science and authentic ethics maybe unattainable absolutes,but for a close approachto those absolutesI believe that each needs the other. Science and ethics, at the least, will have a synergisticeffect on each other and should enhance each other's effectiveness. NOTES 1. n extremely importantissue for feminists is informedconsent. Although space does not permitsuch a discussionhere, it shouldbe includedin any feministanalysisof the ethics of clinical experiments.Feministsneed to considerin depth questionsabouttiming and language,about what is trueconsent, abouthow much patientsneed to understand,and aboutwhetherdemanding consent can be harmfulor hazardousto health (Loftusand Fries 1971). Rosner (1987) provides a concise overview of diverse views on these and other issues in informedconsent. 2. One excellent example of belief systemsoperatingin clinical science is the predictionof many in vitro fertilization(IVF) clinic directorsthat, once the technique is "perfected,"the success of IVFwill be better than nature(Andrewset al 1986, 852). Desireto confirmthis belief has led to questionabledefinitions of success, elimination of some patients fromstatistics, and a selective use of the earlier literatureabout "natural"rates of conception. 3. See Chalmers (1981), Marquis (1989), or Rosner (1987) for lucid arguments to this effect. For comprehensivediscussionsof many points about ethics and reliabilityof RCTs see Levine (1988), Rosner (1987), and Silverman (1985). 4. Longino (1987) cited herein is but one exampleof the manyexcellent feministanalysesof the sourcesand types of distortionand bias in scientific experimentation.The readeris referred to the November 1987 issueof the Newsletteron FeminismandPhilosophy and its literatureover-

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view/bibliographyon pages 20-24; also to the two issuesof Hypatiaon Feminism& Science Volume 2 (3) 1987 and Volume 3 (1) 1988 - and the bibliographyon pages 145-155 in the latter issue.

REFERENCES

Andrews, MasonC., Suheil J. Muasher,Donald L. Levy, HowardW. Jones, Jr., JairoE. Garcia, Zev Rosenwaks,GeorgeannaS. Jones, and Anibal A. Acosta. 1986. An analysisof the obstetricoutcome of 125 consecutive pregnancies conceived in vitro and resulting in 100 deliveries. AmericanJournalof Obstetricsand Gynecology154:848-854. Byar, David P., Richard M. Simon, William T. Friedewald, James J. Schlesselman, David L. DeMets, Jonas H. Ellenberg,Mitchell H. Gail and James H. Ware. 1976. Randomizedclinical trials: Perspectiveson some recent ideas. New EnglandJournalof Medicine295:74-80. Chalmers, T.C. 1981. The clinical trial. MilbankMemorialFund Quarterly 59:325-339. Conn, Harold0. 1974. Therapeuticportacavalanastomosis:To shunt or not to shunt. Gastroenterology 67:1065-1073. Gordon, RobertS., and John C. Fletcher. 1983. Can strictrandomizationbe ethically acceptable?ClinicalResearch31 (1):23-25. Kopelmann,Loretta. 1983. Randomizedclinical trials, consent and the therapeutic relationship.ClinicalResearch31 (1):1-11. Lebacqz,Karen. 1983. Justice, choice, and the languageof research.Clinical Research31, (1):26-27. Levine, RobertJ. 1985. The use of placebosin randomizedclinical trials.IRB 7 (2):1-4. Levine, RobertJ. 1988. Ethicsand regulationof clinicalresearch.New Haven: Yale University Press, 2nd ed. Loftus,ElizabethF., and JamesF. Fries. 1979. Informedconsent may be hazardousto health. Science204:11. Longino,Helen E. 1987. Can therebe a feministscience?Hypatia2 (3):51-64. Marquis,Don. 1989. An ethical problemconcerningrecent therapeuticresearch on breastcancer. Hypatia4 (2): 140-155. McBride,Judy. 1988. Asian childrenmayquell nutritionalcontroversy.AgriculturalResearchFebruary:11. NOVA. 1988, October 25. Do scientists cheat? Boston:WGBS. Ratcliffe, John W., and Amalia Gonzalez-del-Valle.1988. Rigor in healthrelated research:Toward an expanded conceptualization.International Journalof HealthServices18 (3):361-392. Rosner, Fred. 1987. The ethics of randomizedclinical trials. The American Journalof Medicine82:283-290.

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Rosser,Sue V. 1989. Re-visioningclinical research- genderand the ethics of experimentaldesign. Hypatia4 (2): 125-139. Sherwin, Susan. 1989. Medical and feminist ethics: Two different approachesto contextual ethics. Hypatia4 (2): 57-72. A guidedstep into the Silverman, William A. 1985. Humanexperimentation: unknown.Oxford:Oxford University Press. Veatch, Robert. 1983. Justice and research design: The case for a semirandomizationclinical trial. ClinicalResearch31 (1):12-22. Veatch, Robert M. 1987a. The patient as partner: A theory of humanethics.Bloomington:IndianaUniversity Press. experimentation Robert M. 1987b. Emphasis on values prompting a change in Veatch, medical practice. KennedyInstituteof EthicsNewsletter1 (9):1-2. Veatch, Robert M. 1988. Should I enroll in a randomizedclinical trial?A critical commentary.IRB 10 (5):7-8. Weinstein, Milton C. 1974. Allocation of subjectsin medical experiments. New EnglandJournalof Medicine291:1278-1285.

What Setting Limits May Mean A FeministCritique of Daniel Callahan'sSettingLimits NORA K. BELL

thesisthatagebe a In Setting Limits, DanielCallahanadvancestheprovocative to theelderly. to kinds services in decisions allocate certain health of limitingfactor at available one discovers that there are data, However,whenone looks manymore elderlywomenthanthereareelderlymen, and theseolderwomenarepoorer,more apt to livealone, and less likelyto haveinformalsocialandpersonalsupportsthan theirmalecounterparts. Olderwomen,therefore,willmaketheheaviestdemandon healthcareresources.If agewereto becomea limitingfactor,as Dr. Callahansuggestsit should,thelimitsthatwillbe set arelimitsthatwillaffectwomenmoredrastically than they affect men. This review essay examinesthe implicationsof Callahan'sthesisfor elderlywomen.

In his recent and controversialbook, SettingLimits,Daniel Callahan has put forth a provocativethesis: that "intergenerationalequity"might require us to rethinksome of the traditionalgoals of medicine as they affectcare that is providedto the elderly. Specifically,Callahan suggeststhat the increasing numbersof the elderly, coupled with medicine's increasedtechnological capabilities, create the potential within medicine for "an unending medical struggleagainstaging and death"that is, perhaps,not properlyone of medicine's "deepestends" or goals. As Callahan states, his "firstand most fundamental"purposein writing SettingLimitsis to: stimulatea public discussionof the futureof health care for the aged. .... My approachwill not generallybe a pleasing one. It puts to one side the kind of relentless optimism that has been the mainstay of medcal advancement and its economic underpinning.It rejects the conceit that we can have anything we want if we put our minds to it and are willing to pay for it. ... This book, by contrast, is a call for limits, . . . for a willingness to ask once again how we might creatively Hypatiavol. 4, no. 2 (Summer1989) ? by NormaK. Bell

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and honorablyaccept aging and death when we become old, not alwaysstruggleto overcome them. (1987, 23-24) On its face, Callahan'saim in this book is one for which I have a greatdeal of sympathy. I have been present in the ICU when a ninety-two year old woman with terminalmetastaticcance isintubatedrepeatedlyeach time she extubatesherself. I have arguedin favorof the "validity" of giving effect to a living will that was executed in a state other than the one in which the elderly patient finds herselfhospitalized.I, myself, have arguedthat the prolongation of life, or the forestallingof death, can be a "falsegoal"of medicine. I agree that one's quality of life is not necessarilya function of the length of one's life, and I, too, worryabout "creepingmedical immortality." But I am more worriedabout setting involuntarylimits. If age becomes a limiting factor, as Dr. Callahan suggestsit should, apart from the obvious consequencesto which manybeforeme have taken objection, there is yet another consequencethat I feel mustnot be overlooked.The limits that will be set will be limits that affect women more drasticallythan they affect men. The so-called "frontier"of old age extends endlesslyfor many more women than it does men. My objective in writing this essay, therefore, is to examine the implications of Callahan'sthesis for elderly women. THEENDSOFAGING RECONSTRUCTING

The elderly are currently the heaviest users of health services, and the greatbulk of those servicesis spent in "forestallingdeath"and in "warehousing"personsuntil their deaths. In fact, these facts representpartof the challenge society would face in setting limits. When one looks closely at the data, however, what one very quicklydiscovers is that there are manymoreelderlywomen than there areelderlymen, and these older women are poorer, more apt to live alone, and less likely to have informalsocial and personalsupportsthan their male counterparts.Furthermore, a disproportionatenumberof nursinghome patients are women. Older women, therefore, are more likely to make the heaviest demand on health care resources.1 Relying on data supportingthe above, albeit with hardlyany emphasison how the data speak to gender-relatedissues, Callahan moves to his second agendain SettingLimits,namely, proposing"a differentway of providingcare than is commonly considered:that of using age as a specific criterionfor the allocation and limitation of health care" (1987, 23). In this section of his book Callahan "reconstructsthe ends of aging"and advanceshis thesis that age should be a limiting factor in the provisionof health services:that upon reachingthe end of a "naturallife span"furthermedical interventionshould be acknowledgedas inappropriate.

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Callahanproposesa new conception of life and the naturalend of one's life in old age, a conception that focuseson the fact that one's life on the whole has had numerousand bountifulexperienceswhose richness in old age now suggestscompleteness. Such a conception (or definition) of life makes no evaluative claims about the experiences by which one's life is so defined. definition Rather, Callahan is offeringwhat he considersto be a biographical of life; there comes a time when the biographyis complete, even though there might be many more pages one could write. Forthe lifelong readerthere will still be manyold booksnot read, and a constant streamof new books to be read. For the painter, there will be an infinite numberof furtherpossibilities, as there will be for one who enjoys investing in the stock market, understandingnatue, watching scientific and other knowledgebeing discovered,growinga garden,observingthe sunset, enjoying music, and taking walks. In that sense, however, life's possibilitieswill never be exhausted;. . . Yet even if we will lose such possibilitiesby death in old age, we will on the whole alreadyhave had ample time to know the pleasuresof such things (Callahan 1987, 67). Callahan insists that "[t]he pattern I want to note is a familiarone in most cultures,includingour own: the belief that death at the end of a long and full life is not an evil, that indeed there is somethingfitting and orderlyabout it" (65). The naturalend to a long and full life, i.e. the correlativeto the "natural life span," is what he calls a "tolerabledeath": (1) a death that occurs when one has accomplishedmost of what life has to offer, (2) a death that occurswhen one has fulfilledone's obligationsto all those to whom one has responsibilities,and (3) a death that no longer offendsor engendersrage and despairat human finitude (66). ForCallahan, the end of the agingprocessis not properlyspent, therefore, "warring"againstthe diseasesthat accompanylongevity. The goal of geriatric medicine is not to seek new ways to predictor prevent late-onset genetic death as a function of state-of-the-art disease;it is not to define "premature" medicine at any given moment; it is not to seek "justa little longerlife";it is not to practice opportunisticmedicine or to imagine medicine as providing the fountainof youth. Rather, so that one mayexperiencethe naturalend of a life, the goal is to put aside the alluresthat medicine offersfor staving off old age. On Callahan'sview, society should seek to impose limits on health carefor the elderlyso that the richnessand fullnessof old age aren'tlost, and so that old age isn't villified by our fight against it. OLD AGE IN NEW TIMES

Although Callahan'sanalysesof social purposeand age, "naturallife span" and "tolerabledeath", and the obligationsof the young to the very old (and

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the old to the young and to the future)are themselvesphilosophicallyengaging, and although one could focus on the argumentshe advancesfor giving up certain of medicine's "belovedideas," it is more to the point to examine the questionhe poses when he articulateshis final goal in urgingthat society set limits on the provision of medical care to the aged. The question, as he framesit, is: "Whatwould it mean in practiceto have a health policy for the agd of the kind that I propose?"(1987, 23) Unfortunately, serious problems underlie what Callahan ultimately suggests as his answer, problemsthat, despite his compassionateand thoughtful insight, redoundnegatively against his thesis. In "Old Age in New Times" (the final chapterof SettingLimits),Callahan arguesfor moving beyond the decade-oldagendaof anti-ageismto his newer agenda. Callahan is not deeply worriedabout anti-ageistplatformsof health care reformthat were basedon analysesof the "troubledand horriblelot" of the elderly(Butler, 1975); he acknowledgesthat there maystill be itemsfrom that agendathat need to be addressed(althoughhe doesn't tell us what they are). However, he sees the focus on abusesand "unmetbasic needs" of the elderlyas outmoded, as leadingus to seek to extend the outerboundsof medicine's capabilites.Rather, what Callahanwants the readerto adopt as a new focus is capturedin his distinction between tragedy,outrageand sadness: It is a tragedywhen life ends prematurelyeven though it is possible to save that life, and when old age is full of burdens even though resourcesare available to relieve them. It is an outragewhen, throughselfishness,discrimination,or culpable indifference, the elderly are denied what they need and deserve. But it is only a sadness,an ineradicablepartof life itself, when aftera long and full life a personages and dies. ... It is wise to want to banish the tragedyand the outrage, but not the sadness. (1987, 204) As Callahan himself argues,on the very next page, one must seek to discer the properends of medicine and of aging "in a largermoral and social context" (205). Yet it is preciselythat caveat that Callahanseemsto have ignored. Setting limits on health care provisionin the waysthat Callahansuggests may in some cases still be properlydescribedas a "tragedy"and an "outrage.' OR TRAGICDEATHS? TOLERABLE

Nowhere in the final chaptersof SettingLimitsdoes Callahan take note of the implicationsof his thesis for women, or of the special plight of women among the aged (except to mention that women are burdenedmore than men in being caregiversfor sick and agingparents).Nowhere does he discuss

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whether there might be differencesin the definition of "naturallife span"or one's perception of a "tolerable death" that are gender-relative.Nowhere does he discussthe fact that the limits he suggestsimposingmay have tragic consequencesfor women. On my view, however, these are the very consequencesof setting limits that need to be examinedmore carefully.In what follows, I would like to offer such an examinationby lookingmoreclosely at Callahan'sthree-partdefinition of what counts as a tolerabledeath. First:a tolerabledeathis one thatoccurswhenan individualhas accomplished mostof what life has to offer. Callahan'sbiographicaldefinition of life fails to take adequatenote of the differencesin the biographiesof men and women. To believe that it is desirable to adopt the use of an age standardsuggeststhat a woman'slife shouldbe viewed as completed earlier in her biological chronologythan it actually is, that is, when procreation,childrearing,housekeepingand the maintainingof conjugalrelationshipsare complete. The argumentin favorof believing that there is an appropriatetime in a person'sbiographyfor claimingthat her life could be consideredfull strikes me as advancing recognizedforms of male bias: both a general devaluationof women'sconcernsand an indifferenceto a woman's"lifepossibilities" apartfrom herabasementinto moreservilepositions. I couldn't agree that one's life from a certain point to that is not (That say forwardmight not be worth living or might itself be intolerable.) Why shouldn'tone believe, as JamesChildress(1984) has suggested,that the use of an age standardseems to symbolizea willingness on our part to abandonolder female personsand exclude them from communalcare?2Furthermore,as Childressseems to believe, the use of an age criterionfor determining how to allocate health care resourcesseems to manifestsociety'sperception that youth is valuable and advanced age, particularlyadvancedfemale age, has less worth. The testimony of older persons, especially older women, who professto believe that they arewilling, and maybeeven morally obliged, to let a youngerperson (say, a child or a grandchild)live in their stead is less evidence in favor of accepting the argumentthan it is evidence confirmingsociety'sdevaluationof olderpersonsand advancingage. Besides, willingness on the part of some older persons to elect to forego certain resourcesor experiences in favor of giving them to youngerpersonsdoes not imply that a standard for accomplishing that should be imposed.Unless Childress'claim aboutthe use of an age criterionis true, i.e., unlesswe really do believe that youth is more valuable, why should it be obvious that we should prefer to limit resources to older persons in favor of allocating to younger persons?Why shouldn't we believe that electing such a standard makeswomen'sdeaths premature?Why isn't it obvious that women'sold age is full of burdens?Is it obvious that there aren't resourcesavailableto relieve them?

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Callahan'sbiographicaldefinitionof life seemsto measurea person'slife by the notion of a "rangeof experiences"without takingnote of any qualitative measure of those experiences. This understandingof measuringone's life seems counterintuitive.It doesn't seem enough to say that the rangeof a person's experiences, or the rangeof her exposureto resources,is greaterin virtue of her having lived longer. Surely the quality of those experiencesor of those resourcescolors them in a way that cannot be ignored.Forthat reason, it seems culpableindifferenceto fail to count the qualityof those experiences as significant. Insofar as women have historically been disadvantagedwith respect to their achievements, their interests, their economic, social and political status, and their sexuality,manywouldarguethat the qualityof their life experiences has been so low that with respectto the firstcriterionof what counts as a tolerabledeath, Callahan'sdefinition begs the question. This bringsme to the second part of Callahan'sdefinition: A tolerabledeathis one thatoccurswhenone hasfulfilledone'sobligations to all thoseto whomone has responsibilities. Women are beginning to enter the paid laborforce in substantialnumbers, but in spite of their economic emergence,women continue to be in disadvantagedpositions in the marketplace both in termsof the wagesthey command and the jobs open to them. As human capital, women are valued less highly than men (Bergmann, 1986). This can be viewed as a naturalconsequenceof the fact that "[i]nthe past, women's place in the economy was an assignmentto sole responsibilityfor the care of the children, and to houseworkand other worksthat could efficiently be combined in the home with child care. Men were given sole responsibility for earning money, and exempted from taking a share in "women'swork' " (Bergmann,1986, 7). The importanceassignedto earning money, among other things, helped contribute to devaluing "women's work."Reskin and Hartmann(1986) and others delineate some of the kinds of workthat have been so devalued, among them: caringwork(child care and work(all those tasksinvolved in purnursingcare, for example), consumption kin work and services), (tasksinvolved in keepingup with famchasinggoods and ily birthdays,weddings, funerals, simply "keeping in touch"), invisible work(housework,cooking, sewing, washing, ironing, for example). A further indicationof the lack of value attached to such workis found in the fact child that governmentand industryhave been slow to move to "industrialize" care and housework, making it even harder for women (especially single mothers) to compete effectively in the job market (Bergmann1986, 275298).3 Becauseof the value attachedto providingfor anotherfinancially,women's responsibilitiesto others continue in largepart to be describedas consisting in caringwork, kin work, consumptionworkand other formsof so-called"in-

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visible work."It is easy to imaginesomeone arguingthat a womanwho is single, or who outlives her spouse, or whose children are independenthas outlived her usefulnessand her obligations. Furthermore,because women live longer than men and have been in the work force a shorterperiod of time than men, and hence have contributedless to public fundsand have limited provisionsof their own for their old age, women could also be perceivedas undeservedlyrequiringmore in the way of others' responsibilitiesto them. As the largestand poorestpopulationof the elderly, it is women who will make the heaviest demandson public monies for health care. It is the older womanwho will have the greatestneed for increasedsocial and nonfinancial formsof support.It is she who will be society'sgreatestburden,and it is she for whom limits will be set. This "largersocial and moralcontext" is of vast importancein evaluating the thesis in SettingLimits.Setting limits is much more complex than it appearson the surface.Forhis part, Callahan acknowledgesthat an age standardhas "symbolicsignificance"when its use is coloredby its context or by the rationalearticulatedfor its use (1987, 169). He also acknowledgesthat death is a tragedyand an outrageif it comes on the heels of one's having been denied what one needs throughdiscriminationor indifference(1987, 204). A deathis tolerablewhenit no longeroffendsor engendersrageand despair. Of course, I don't pretendto believe that Callahan is interestedin dealing women out. If anything, his argumentis one that I have heardmanyso-called senior citizens expressalmost as eloquently themselves. And I do agree that we have to be sensible about utilizingmedical resources,especially in cases wherethey aren'tlikely to benefit the recipientor alteran inevitablybadoutcome. I acknowledgethat we are fast approachinga time in our historywhen the largestsegmentof our population,our largestspecialinterestlobby, if you will, is the aging and the elderly. However, I can't agree with Callahan's claim that the age standardwhich he offers would have a use transformed from its present use, a use that "affirms"and does not denigrate old age (1987, 170). On the contrary,I want to arguethat there is tremendoussymbolicsignificance for women in adoptingan age standard,a significancethat derivesfrom and is colored by woman'ssocial and moral history. Honoringa "naturallife span"could mean believing that a naturallife normally ends in the mid-70s (the life expectancy for males), and in accepting that age standard,Callahan-stylepolicy makersmight adopt measuresthat precludewomen from receiving essential servicesat the ends of our (longer) lives. Among the items left over from the "old"antiageismagenda, the widespreadproblemof elder abuse and neglect should generateoutrage. A Universityof Massachusettsstudysuggeststhat there are six times as many cases of abuse of the elderly as are actually reported(ElderAbuse 1988). Abuse,

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neglect, and exploitation includefailing to providethe ill and the fragilewith minimal medical care, medication, and hospitalization. In a book of this scope, one wonderswhy this problemisn't given more prominence. Again because of their numbers,women constitute the majorityof those affected by abuse and neglect. When I worryabout setting limits, I worry about the attitudesengenderedby promulgationof the belief that there is an age beyond which one is getting more than her fair share. Callahan'sargumentseems to rest on the presumptionthat there is little value in providingcertain health services to personswho have reached the end of full and naturallives. I protest that presumptionbecause 'naturallife span' and 'tolerabledeath' are not genderneutral. Providinghealth services to the very old has been devalued, in partbecausemedical intervention can dehumanizethe naturalend to one's natural life span. I wonder if that absence of value is not also due in large measureto the fact that there are few male competitors for these services. Couldn't we believe that, like other items in women'ssocial history, when men move to evaluatesomethingthat is peculiarlythe province of women, it then becomes devalued? Given this social and moral context, woman'sold age is not affirmedby setting limits; it is made invisible. Given this context, the deaths of older women will engenderrage and despair.Given this context, appealingto an age standardwill make the deaths of women prematurein the fullest sense of the word. Not only will their deathsbe sad, they will be a tragedyand an outrage.

NOTES I am especiallygratefulto my colleagueFerdinandSchoeman for the manyhelpfulsuggestions he made about variousaspectsof this discussion. 1. Older women now outnumberolder men three to two. This representsa dramaticincrease from 1960, when the ratio of elderly men to elderly women was five to four. Furthermore,the ratio changes markedlywith increasedage. The 1984 census found only 40 men for every 100 women at age 85, but 81 men for every 100 women between the ages of 65 and 69. By the year 2050, the projectedlife expectancyfor femaleswill reach 83.6 yearsas contrastedwith a life expectancy for males of 79.8 years. The gender ratios are importantfor the furtherreason that they indicate that more women than men will be living alone in old age. Although more than one-third of all elderlydisabled men living in their communitieswere caredfor by their wives, only one in ten elderlydisabled women were cared for by their husbands(Special Committee on Aging, 1985). An obvious concern, and the concern that underliesCallahan'sinterest in examining medicine's goals for an aging society, is that the projectedincreasein the size of the olderpopulation impliescorrelativeincreasesin the demandfor health careresourcesand the provisionof services to the elderly. In addition, elderly personsare more likely than other adults to be poor. Moreover,the economic statisticsare especiallygrimfor elderlywomen. Accordingto a study publishedin 1985 by the United States Senate's Special Committee on Aging, of those persons between the ages of 65 and 69, white males had a median income of $12,180 per year as comparedto a median income of $5,599 for elderlywomen. Becausethey live longerthan their male counterparts,elderly women averagea longer period of retirementthan elderlymen and must,

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therefore,relyon privateand publicsourcesof income longerthan elderlymen. Not surprisingly, nearly three-quartersof the populationof the elderly poor are women (1985, 2). Although at presentonly aboutfive percent of the elderlylive in nursinghomes, close to seventy-five percent of all nursinghome residentshave no spouseand are institutionalizedbecause they have health problemsthat significantlylimit their ability to care for themselves. Not surprisingly,a disproportionatenumber(74.6 percent) of nursinghome patientsare veryold, white, female, and without spouse (Special Committee on Aging, 1985). The economic implicationsof an aging populationare obvious. If limits are not set, Callahan predictsthat health care expendituresfor the elderlywill exceed $200 billion by the year 2000. By 2040, he predictsthat pension and health programswill accountfor 14.5 percentof the GNP and 60.4 percent of the Federalbudget, respectively(1987, 228). 2. Childress does not make this argument with respect to older women in particular.He makes it with respect to all older persons. 3. Furthermore,some social changes designed to benefit women economicallyhave actually workedto their detriment. "No-faultdivorce looked like a civilized way for equal adultsto deal with maritalincompatibility.[Yet]its implementationhas cut adriftmillions of middle-agedand elderlyhousewiveswho had every right to believe they had been guaranteeda comfortablehome for life. Well-meaningeffortsto reformwelfarefailedmiserablyto lead single mothersout of poverty" (Bergmann1986, 300).

REFERENCES

1983. US Senate SpecialCommitteeon AgaingAmerica:Trendsandprojections. with AARP). Washington, DC. Aging (in conjunction Americain transition:An agingsociety. 1985. US Senate Special Committee on Aging. Washington, DC. 99-B. A profileof olderAmericans- 1986. AmericanAssociationof RetiredPersons. Washington, DC. Bergmann, Barbara. 1986. The economicemergenceof women. New York: Basic Books. Butler,R.N. 1975. Why survive?Beingold in America.New York:Harperand Row.

Callahan, Daniel. 1987. Settinglimits:Medicalgoalsin an agingsociety.New York:Simon & Schuster. Childress,JamesF. 1984. Ensuringcare, respect, and fairnessfor the elderly. The HastingsCenterReport14(5): 27-31. Day, Alice T. 1984. Who cares?Demographictrends challenge family care for the elderly. PopulationsTrendsand PublicPolicy. Washington, DC: PopulationReference Bureau,Inc. Elderabusereportsaregrowingin SC. 1988. TheState.Columbia,SC. June5. Long term care: A review of the evidence. 1986. University of Minnesota, School of Public Health: Division of Health Services. May, William. 1982. Who cares for the elderly?The HastingsCenterReport 12(6): 31-37.

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of thepopulationof the US by age, sex and race: 1983-2080. WashProjections ington, DC: US Bureauof the Census. Series P-25, 952. Reskin, Barbaraand H. Hartmann, eds. 1986. Women'swork, men's work. Washington, DC: National Academy Press. Waldo, Daniel and H. Lazenby. 1984. Demographic characteristics and health care use and expenditures by the aged in the US: 1977-1984. HealthCare FinancingReview6(1).

The Politics of Communities A Review of H. TristramEngelhardtJr.'sThe Foundations of Bioethics CHRISTINEOVERALL

ThisreviewessayexaminesH. TristramEngelhardt, Jr.'s The Foundationsof text in mainstream biomedical ethics.It foBioethics, a contemporary nonfeminist cusesupona centralconcept,Engelhardt's ideaof themoralcommunityandargues thatthemostseriousproblemin thebookis itsfailureto takeaccountof thepolitical andsocialstructuresof moralcommunities,structureswhichdeeplyaffectissuesin biomedicalethics.

H. TristramEngelhardt,Jr.'sThe Foundationsof Bioethics1 providesan instructive example of the nonfeminist nature of contemporarymainstream workin biomedicalethics. It illustratesthe errorof attemptingto engagewith biomedicalissuesin a social and political vacuum, that is, without a feminist analysisof the human context in which some groupsof personshave more power and resourcesthan others. Engelhardtoverestimatesthe existence of genuinelyfree choice, underestimatesthe role of acculturation,and virtually ignoresthe existence of oppressionand coercion. ForEngelhardt,apparently, a personis white, non-disabled,neither a child nor elderly, and male. Those who fail to fall into that categoryare simply invisible. Although he acknowledgesa general principle of beneficence, according to which "[t]he goal of moral action is the achievement of goods and the avoidanceof harms"(86), Engelhardttakesthe liberalview that it is not possible to establishor justifyany one particularview of the good or the good life (45), or any particularorderingof goodsand harms(86). Hence, wherethere is disagreementabout the good, the only alternativeto a forceableresolution is to arriveat agreementvia a method set out in the very natureof ethics itself. Basedon respectfor the freedomof the moralagents involved (45), this method rules out the use of unconsented-toforce againstmoral agents, and requiresthe utmostrespectfor the autonomyof persons.It constitutesa secular ethic and defines the generaldomain of the peaceablesociety. The peaceablesociety also, he points out, embracesany numberof particularmoralcommunities.A communityis "a voluntaryassociationof individuHypatiavol. 4, no. 2 (Summer1989)? by ChristineOverall

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als througha common concrete view of the good" (49). It is, I would argue, the responsibilityof ethicists to ask questions about what real communities are like;2 that is, we should be concernedabout the politics of communities. But Engelhardt'smoralcommunitiesturn out to have little semblanceto actual communities, and their relationships are self-defeatinglyrelativistic. They arediscussedin a misleadinglyneutralfashion, that is, divorcedfroman awarenessof the actual compositionof communitiesand of the materialconditions which define communities and the relationshipsamong their members. Eachof us in North America may belong to severaldifferentcommunities, whether national, regional, or local, or defined by racial, ethnic, religious, class, or employmentaffiliations.Although there may be morallysignificant differencesin how we came to belong to each of these, in most cases, I believe, we were not coerced into becoming communitymembers.Yet we do not necessarilyshare with all or even with any of our putative communities very much of a "commonconcrete view of the good." Indeed, some aspectof a person'sconception of the good may well conflict with partof the conception of the good held by one of her communities;so we can at best, perhaps, hope that there will be a significantoverlap between our conception of the good and those of our moral communities. If, therefore,we are to rely on a conception of the good to define a moral communitywe must think very carefullyaboutwhat is meant when that conception is said to be shared.The community is, presumably,the sum of its members,so the communityconception of the good is in one way the sum of its members'conceptions of the good. But it is worth noting that in this respect not all membersof a communityare createdequal. Fromthe perspective of some newcomers,it must appearthat those who got there firstdefined the community good to suit themselves and have been enforcing it ever since. What is interestingabout many moralcommunitiesis that, althoughsome of their membersmay in some sense have chosen to join them, it is not the case that just anyonemay choose to join. Engelhardtclaims that one may " 'shop'for intellectual and moralinsightsfromvariousreligiousand cultural 'traditions'" (52), and he appearsto assumethat one may likewise shop for new communities, abandoningone's old communityif it no longer satisfies. In fact, he is extraordinarilyoptimistic about individuals'freedomwith respect to their communities:"One can, in many circumstances,choose other friends, colleagues, patients, physicians, or HMO. One can even disown one's parentsor children, or adopt children. One can emigrateor move to a new social groupwith which one has more substantialagreement"(75). But it is not the case that all of us freelyand equallychose the communities of which we are a member.How much choice of communitiesis possessedby the Iranian, the Pole, or the Guatamalan?How much "shopping"for an in-

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tellectual or moraltraditionis availableto most personsin the worldas it actually exists? How many women, in particular,can disown their parentsor children, emigrate, or move to a new social group? In some contexts, of course, it is good that one cannot become part of a communitymerelyby choosing it: we wouldnot want to permitpeople to become, let's say, doctorsor civil servantsor universityprofessorsjust by virtue of choosing to be a doctor, civil servant, or universityprofessor.But it can also be problematicinsofaras the communitiesof doctors, civil servants,and universityprofessorscan themselveschoose, on the basisof some conception of the good, to barsome personsfrom membershipin their respectivegroups for reasons quite unrelated to their qualificationsfor joining them. Those who got there first-usually the white, heterosexual, non-disabled, adult males-function as gate-keeperswho determine not only the community's conception of the good, but also who else can join them. According to Engelhardt,individualsare not morallyobligatedto belong to any community(ies) in particular,and have the right to refuseto participate in any particular community (42). Indeed, "there are a number of equallydefensible,but quite different,moralperspectives"(20). But if that is the case, it no longerseemspossibleto rationallychoose one's moralcommunity. "Equallydefensible"turs out to mean "equallyindefensible."The only way to evaluate a particularcommunity (other than just comparingits conception of the good to one's own, which is as indefensibleas any other) is in regardto whether it respectsthe autonomyof its membersand does not impose its conception of the good on other communities.And presumablywith referenceto this autonomycriterion,manycommunitiesare morallyacceptable. Thus, Engelhardt'sassumptionof the equality of moral communities reduces feminism and feminist ethics to just one moral system among many, having no claimsover traditionalsystemsto priorityor greaterinsight. By implication, feminist analyses of the family, of childcare, poverty, violence, sexualabuse, housing, healthcare,job access, and so on, have no moremoral authoritythan those of non-feminists. But if I choose to join the moralcommunity of feminists rather than the conservative moral community of R.E.A.L. Women ("RealisticEqualActive for Life"), it is not just becauseI think that the feminist community respects autonomy better than does R.E.A.L. Women. The inadequacyof Engelhardt'sconcept of communityis obvious:Respect for autonomy provides at most a necessarybut not a sufficientcriterion for the evaluation of a community that I am consideringjoining. For not all moralcommunitiesare morallyequal. At the very least there may well be rational grounds, apart from the respect-for-autonomycriterion, for rejecting membershipin certain moral communities. For example, there may be rational grounds,apartfroma concern for autonomy,for rejectingmembership

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in the communityof Jehovah'sWitnesses, the communityof white supremacists, or the community of pornographyproducers.These rational grounds have to do at least in part with the truth value of central beliefs of the community members,and with the acceptabilityof their key values. A commitment to feminist ethics precludesthe relativisticacceptanceof the equalityof all moral communities. Although Engelhardtlists the devout Southern Baptist, the Texan deist, and the homosexual San Franciscoatheist as examplesof communitymembers (50-51), he shows no awarenessof the particularconstraintsand demandsthat each of these individualswill experience by virtue of their community membership.Is the southernBaptistblack or white? How does being gay prevent access by the San Franciscoatheist to the privilegesof heterosexuality?How will being female affect what jobs are available to the Texan deist, and the salarythat she can earn?Such questionsseem not to occur to of Engelhardt.In fact, there are no referencesin the whole of TheFoundations Bioethicseven to the phenomena of racismor sexism, let alone to classism, 3 heterosexism, ageism, or ableism. Yet they are surelyrelevantto the health care issueswith which he is concerned. One's race, sex, class, sexualorientation, age, and disabilities have very powerful implications both for one's health care needs and for one's access to health care services. But according to Engelhardt,the only salient characteristicsof a community memberare self-consciousness,rationality, freedomto choose, and possessionof a sense of moralconcern (105). Although he states baldlythat "[n]otall humansare equal,"the chief humandifferencehe appearsto recognizeis the variationsin competence which differentiate fetuses, children, "competent adults"and "mentallyretardedadults"(104). The failure even to mention major systems of oppressioncannot be excused on the groundsthat the book examinesthe "foundations"of bioethics, since oppressivesystems are part of the foundationsof human association. Nor can the book's silence on oppressionbe excused as just an oversight. Instead,close readingof this book suggeststhat it is a partof the veryfabricof Engelhardt'smoraldiscourse.Forexample, within the book can be found the following extraordinaryclaims: (1) that except within a specific community (with all the relativistic implicationsof that exception) it cannot be shown that it is good to pay for abortionand contraceptionfor the indigent (72); (2) that there is a "fundamentalright,"foundedupon the principleof autonomy, to have access to "pornographyproducedby consenting others" (94), and that the sale of pornography,like the practiceof prostitution,is a "victimless crime" (140); (3) that children, insofaras they "fail to go out and support themselves on their own," are partiallyowned by their parents (129), who may legitimatelychoose for their children "not simply to achieve their best interests,but also in orderto control and direct their lives" (281); (4) that "a prospectivefather'soffer to pay the costs of an abortionshouldprevent a suit

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for childsupportif the fatheris not the husbandof the mother"(220); (5) who thatif she livesout herlife withina traditional society,an "individual" hasbeensubjectedto femalegenitalmutilation"maywithgreatlikelihoodbe (288);and(6) that it is morallyperpleasedwith havingbeencircumcised" missibleto sell one'sbodilyorgans(365). It is possibleto producemanyothersuchexamplesfromthisbook.Lestit be thoughtunfairto takesuchclaimsoutof context,it shouldbe pointedout limitedperspective withinEngelhardt's thattheyareembedded uponpersons in moralcommunities.Personsandonlypersons,he says,areself-conscious, rational,ableto engagein praiseandblame,andworthyof praiseandblame fromotherhumanbeingswholackthese (p. 107);theymustbe distinguished and are thereforenot persons.But, havingmadethe admitcharacteristics tedlysignificantdistinctionbetweenpersons(whetherhumanor not) and leapsto the conclusion non-persons(whetherhumanor not), Engelhardt that personsandonly personshave moralstandingwithinmoralcommunities.Thatis, onlypersonspossessautonomy(108);onlypersonscanandneed to be respected(114-115);only personscan definetheirown best interests (109); andonly personscan be the judgesof the significanceof harmsand benefits(114). thatpersonshavethisoverridI foundno furtherarguments forsupposing need not be respected, moral or for that status, ing supposing non-persons cannotdefinetheirown interests,andareunableto judgethe significance of harmsandbenefits,evenforthemselves.Giventhe tremendous statusof personswithinEngelhardt's moralworld,then, it is hardlysurprising thatchildrenandfetusescan be owned,organscanbe sold,andanimalsarenot entitled to respect.Buta moralperspective suchas thisshouldbe regarded with who until were with classed veryrecently profoundsuspicionby women, childrenandlunaticsandnot regarded asbeingfullpersons.To treatthe perdifferenceas the mostimportantindicationof relativemoral son/non-person statusnot onlypermitsandjustifiesabuseof animalsandchildren,it alsoprovidesscantprotectionforthosewhosepersonstatusis in doubtorhasonlyrecentlybeen awarded. A furtherresultof Engelhardt's for oppressionand domination disregard withinmoralcommunities is his ageismandableism.ForEngelhardt, deathis to beingveryoldorverydisabled.On the topicof dispreferable indisputably abilityhe says,"[t]heuseof geneticcounseling,prenataldiagnosis,andabortionwherenecessaryin orderto avoidthe birthof a defectivechildcanreflect an exemplarycommitmentof beneficenceto the childrenone wishesto have"(p. 227). At the veryleast,theseremarks deservecondemnation for theirinsensitivityto the experiences,needs,andfeelingsof olderanddisabledindividuals. Theyalsooverlookboththe degreeto whichthe challenges of ageanddisabilitymaybe eitherincreasedor diminishedby changingthe socialconditionsin whichthe elderlyanddisabledmustlive, andthe wayin

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which pejorativeattitudestowardsage and disabilitymay worsenthe experience of those conditions. When all non-personsare demoted to the ranksof the less-deserving,the burdenof proof then rests on those who would wish to protect and care for them. Thus, Engelhardtfinds it necessaryto seek groundsto justifyassigning any rightsat all to infants, the "profoundlymentallyretarded,"and "the very senile," includingeven the right to be "protectedfrombeing killed at whim" (p. 116). Insteadof placing the burdenof proofon those who would wish to harm, the assumptionis that it is morallypermissibleto kill, mutilate, or inflict pain on non-persons unless reasonscan be offered to prevent it. And those reasonsoften turn out to be difficult, and in some cases even impossible, for Engelhardtto find. What emerges from this analysis of The Foundationsof Bioethicsis that moralcommunitiesare not, or not necessarily,benign, cosy groupingswhere each of us can find an ethical home. Communitiescan and do oppressboth their own membersand those who do not belong. Moreover,ethical systems such as that of Engelhardtwhich appearnot to take account of oppression may in fact serve to reinforce it through the failure to recognizepower and dominationdifferentialsand throughthe denial of materialand social conditions in which some people must strugglefor what others take for granted. Of course, moralcommunitiesdo not have to be that way. Humanbeings arejust as able to love and care aboutothersas to harmand oppressthem (for both are learnedbehaviors), and we can have caringconnections with other communitymembersand with those who are not membersof our moralcommunity. Whatever the nature of these relationships,however, it is essential for bioethicists to examine them, and to be mindfulof the social context in which issues in biomedical ethics are generated and sustained. In other words, the ethical analysis of health care problemsnecessitates an understandingof the politics of communities. NOTES 1. All page numbersin this review essay referto Engelhardt(1986). I am gratefulto Jocelyn Downie, whose unpublished1986 paper, "The Foundationsof BiomedicalEthics"firstdrew my attention to The Foundationsof Bioethicsand affordedme the opportunityto reflecton the issues it raises. I also wish to thank editor Helen BequaertHolmes and the anonymousreviewersof Hypatiafor their helpful comments. 2. A good example maybe found in IrisMarionYoung'spaper,"The Idealof Communityand the Politics of Difference,"which also includesextensive referencesto the substantialliterature on communities. 3. Although Engelhardtdiscussesrecent controversiesas to whetherhomosexualityshouldbe consideredto be a disease (e.g., pp. 161 and 378), there is no evidence that he recognizesthe institution of heterosexualityas an oppressivesocial system.

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REFERENCES

Engelhardt,H. Tristram,Jr. 1986. Thefoundationof bioethics.New York:Oxford. Young, IrisMarion. 1986. The ideal of communityand the politics of difference. SocialTheoryand Practice12 (1):1-26.

Book Reviews

Women and Moral Theory. Editedby EVA FEDERKITTAYand DIANA T. MEYERS.Totowa, N.J.: Rowman & Littlefield, 1987. ShirleyWagner This significantcollection of essayswas assembledfrompaperspresentedat a 1985 conference on Women and MoralTheory, held at the State University of New York at Stonybrook. The conference was inspired by Carol Gilligan's book, In A DifferentVoice (1982), a book that has alreadyinfluenced and is continuing to stimulatedebate on the importanceof gender in moral reasoningand in moral theory. A short introductoryessay by the editors sets out the rationale for the structureof the collection. There are foursections. PartI, GenderDifference and Morality:The EmpiricalBase, is Gilligan's setting essay. Part II, The TraditionalRoots of an Ethics of Responsibility,contains three essays, only one of which directlyrelatesto Gilligan'sresearch.The thirdpart, Aspects of MoralDeliberation, is the core of the collection. Eight essaysdebate the major philosophicalissues involving the care/responsibilityand justice perspectives. PartIV, BeyondMoralTheory:Political and LegalImplicationsof Difference, contains four essayswhich apply the ethics of care/responsibilityto political and legal issues. In her essay, Gilligan reviews the researchleading to her conclusion that there are two clearly defined moral perspectiveswhich she labeled the care and justice perspectives. She questions the construction of moral development theory because the moral thinking of girls and women, now shown to be frequentlyat odds with that of boys and men, was not examined in establishing either the meaning or the measurementof moral judgment within contemporarypsychology. Her dominant question becomes: Can existing moral theory be modified to incorporatethe care perspectiveor must a new comprehensive moral theory be constructed?Gilligan maintains the latter becausethe care perspectiveand the justice perspectiverepresenttwo different modes of approachingmoral dilemmas. Several of the authorsin this collection share Gilligan'sview. In particular, Virginia Held and MarilynFriedmanexplore the philosophicalimplications of Gilligan'sresearchfor existing moraltheory. Their articlesreflectthe conclusions of other feminist philosopherswho have arguedthat epistemology, metaphysics,methodology, and philosophy of science will all need to Permissionto reprinta bookreviewfromthisselectionmaybe obtainedonlyfromtheauthor.

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undergo reconstruction in terms of theory if they are to fully incorporate other realities and claim universality. Gilligan's belief in the necessity of the reconstructionof moral theory is predicatedon the fundamentallydifferentassumptionsin the justice and care perspectives.She sees the two perspectivesas built on differentconceptions of the self, noting that the key concepts of autonomyand (universal)principles are importantto the justice perspectivebut minimal in the care perspective. Several essays specificallyaddressquestions related to these perceived distinctions but suggestthat the concepts central to the care perspectiveare compatiblewith those used in the justice perspective. The essaysby ThomasHill and Diana Meyersfocusparticularlyon whether the concept of autonomyin relationshipto the self is necessarilyat odds with the careperspective.Forboth of these philosophers,autonomyis an essential concept in any comprehensive moral theory. Hill's article examines some philosophicalmeaningsof autonomyto demonstratethat they arecompatible with the careperspective.Meyersmaintainsthat matureadherents,who take into considerationboth their own interestsand those of others, are, in fact acting as autonomousindividuals. The concept of autonomy has been significant to feminism. By arguing that women have self-interestsand have the right to become autonomousbeings, feministshave pressedfor the reformof institutionsthat limit women's abilitiesto develop as autonomousselves. Recognizingthis, I am as reluctant as Hill and Meyersto give up the concept in any comprehensivemoraltheory. However, I agree with Gilligan that many women makingmoral decisions do not operateas autonomousindividualsas that term is commonlyunderstood.They seldom abstracttheir own self-interestsfrom the interestsof others. Nor would these women use the languageof autonomyand self-interest in descriptionsof their decision-making. In her article, Seyla Benhabibprovidesa much fullerunderstandingof the relationalself. She also questionsthe possibilityof incorporatingthe justice and careperspectivesinto a single comprehensivemoraltheory. Some philosophershave suggestedthat the justice mode of reasoningis more appropriate to the publicspherewhile the ethics of care/responsibilityis moreappropriate to the privatesphere. Benhabibis rightlywaryof this attempt at resolution, recognizingthe ways in which this can continue to silence women's moral voice. She cautionsthat, unlessthe ethics of care/responsibilityis given equal weight with that of rights, it may be used to politically oppresswomen. As Virginia Held also notes, the existence of separatepublic and private sphereswith justice seen as the moralgoal in the public spherehas not been beneficial to women whose lives have been lived primarilyin the private sphere. The principlesof the public spherehave not been appliedto the private sphere. Additionally, while men have benefittedfromthe ethics of care and responsibilitybecausewomen considerthe interestsof the men they are

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in relationshipto when making moral decisions, women's interestsare seldom given equal considerationby men. The three articles by Ruddick, Katzensteinand Laitin, and Hasse discuss how the care/responsibilityperspectivemight be appliedin the publicsphere. An excellent exampleof a policy studyis the Hasseessay. Using the legal system as a concrete example, Hasse elaboratesthe institutional impediments that will make it difficultto fully incorporatethe care perspectivein the public sphere. Since legal languageand legal reasoningare heavily imbuedwith the languageof rights, it is no surprisethat the existing systemwould find it difficult to incorporatethe care perspective. Hasse, however, seems to suggest that this difficultypresentsa valid reasonfor not attemptingto modify the currentlegal reasoningwith concers raisedby an ethics of responsibility. Hasse does not give consideration to the benefits that might be gained from the applicationof the ethics of responsibilityto the legal system. This weakensher conclusions. She also underminesher workin the last paragraph when she notes that she has not addressedwhetheran ethics of responsibility exists. This statement raises, in my mind, the possibilitythat she has been unable to give the care/responsibilityperspectivethe carefulconsiderationit deserves. As in all edited collections, coherence and unity is a problem.In my opinion, Sharon Meagher,who summarizedmost of the articles,did an excellent job. However, some essays only tangentially address the issues raised by Gilligan. In other articles,the reiterationof the Kohlbergand Gilligan theses approaches redundancy. Seeing how different authors interpret Gilligan's findings is not a sufficientreason for the editors to permit this. The richness of the essays in this collection offersso many questions for considerationand reflection that a review essay cannot possiblytouch upon all of them. The readerlooking for resolutionof particularissueswill not find it. The issuesthat must be addressedto revise or reconstructmoraltheory to include the moralrealityof women are well representedhere; the book is essential to anyone who addressesmoral issues. In the Patient's Best Interest, by SUE FISHER,RutgersUniversity Press, New Brunswick,NJ, 1986. EllenDorsch Sue Fisheraccomplishestwo importanttasks in her book, In the Patient's BestInterest.First,her findingsprovidesupportto feminist health care activists who alreadyare awareof the effect that a capitalist,physician-dominated health care systemhas on the qualityand type of health carewomen receive. Second, she gives credibilityto the belief that there is roomfor valuesand advocacy in research.

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Fisherdid this in the context of a six-yearstudyof the interactionsbetween physiciansand patients in two medicalsettings. She spent the firsttwo years of her researchin the Departmentof ReproductiveMedicine (Oncology subspecialty) in an urban,west coast, teaching hospital. Outpatientgynecologic care was deliveredin two clinical settings: 1) the facultyclinic where professors of reproductiveoncology providedcare primarilyto patients referredby communityphysicians,and 2) the communityclinic where residentssaw patients, mostly indigent, underthe supervisionof faculty. Here she audio and video taped conversationsabout possible hysterectomies,with particularinterestin how, and which, patientswerecounseledto "geta pelvic clean out." The last four years were spent in the Department of Family Practice in a teachinghospital in a rural,southeasternstate. Insteadof hysterectomies,the preventive screening test, the Pap smear, was the topic of study. By reviewingthe videos and transcripts,she found recurrentpatternsthat characterizedthe content and structureof these medical interactions. Her findings included: 1) the status that is given to physiciansgreatlyinfluences patients'willingnessto take advice, 2) informationis powerand sharingthat informationis perceivedas a weakeningof power, 3) the scientific and medical informationgiven to patients is as value-ladenas "soft"data, and 4) male dominance plays an importantpart in how female patients make decisions. This research substantiatesmuch that has alreadybeen written about the doctor-patientrelationship (Waitzkin 1983; Boston Women's Health Book Collective 1984). Fisher'sgoal in this study was "to see how these medical decisions were reachedbetween the participantsin the two hospitalsettingsand to studythe ways in which the decision-makingprocessreflectedand sustainedsocioculturalfactors"(p. 5). She uses the metaphorof a web to weave the findingsof her researchinto the more general economic, political, and policy arrangements of our health care system and society in general. In the final chapter she takes her specific findings and puts them into this web, aligning herself with Starr (1982), Terris (1986), Waitzkin (1983), and Scully (1980), amongothers. She discussesthe effectsof a capitalistand sexist society on the deliveryof medical care to women. Doctors control access to the profession and to care; they define illness, and they determine how medicine will be practiced.(Todaymanydoctorsarguethat reimbursementmechanisms,quality assuranceprograms,etc. determine the practice of medicine more than they do.) Our greaterand greaterreliance on medicaltechnology reflectsthe push for corporateprofitability,while medical education stressesthe use of this technology, sparkingphysician interest in technological solutions to all medical problems. Fisher'sresearchrevealshow these systemictrendsinfluencethe actualdelivery of care and decision-making. The urban teaching hospital implemented a system where low income women generallywere referredto the

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communityclinic, while insured,wealthierwomen were referredto the faculty clinic. Although maintaining that their advice was based on statistics and most likely believing this, doctorsusuallyadvisedolder women to have hysterectomies,even when the masswas benign and the chance of developing a malignancywas no greaterthan in the general population. To those women uninterested in having any or more children, unable to have children, not married,or who may have needed to rely on the state for financial assistance, the physicians told them that they no longer "needed" their uteruses;they may as well have them taken out. In studyingdecision makingabout pap smears,Fisheragain found that societal biases influence the low priorityplaced on preventive care. In 1977, only two percent of the money spent on health care in the US was spent on prevention. Health insuranceplans usuallydo not pay for preventive care; thus many women minimizethe frequencywith which they have this test. In addition, pap smearsare not money makersfor doctors;they take time, and many patients prefernot to undressand undergoa pelvic exam. Fisherobserved that doctors often neglected to offer a pap smear during a physical exam, especially to older women, unless they asked for the test. With the current administration encouraging competition in health care delivery, some doctorshave found that pleasingpatientstakespriorityover good medical practice-especially when the test is not a moneymakeranyway. Fisheroffersa few options or directionsfor social change. Firstshe advocates putting medicine back in the public domain. Like Waitzkin, she suggests that a national health care system, not a national insuranceplan, provides the only comprehensive approachto restructuringthe entire system: i.e., prevention, treatmentand education. Second, she stressesthe need for the public to become more involved in the design of the systemand eventually to take control of it. If the publicdoes not, she predictsthat corporateinterests, alreadydeeply involved in the US health care system, will become the controllingforce. Then, health care decisionswill be basedon profitability, not need. Finally, Fisherreiteratesthe tactic long advocatedby the women'shealth care movement-"to become active and remainactive, to organize,to educate, to politicize, and to become and remainadvocates, breakingdown the myths and structuresthat bind women" (p. 175). Fisheraids this movement by makingher importantfindingsavailableto academics.But these findings need to be made accessible to community and health activists also. Fisher must be encouragedto write in less academic languageand publish in the popularpress. This will providesupportto women who have alreadyexperienced discrimination within the medical system. And most importantly, Fisherwill reach a largeraudience where she will help "to breakdown the myths and structuresthat bind women."

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REFERENCES

Boston Women's Health Book Collective. 1984. Our bodies,ourselves,New York:Simon and Schuster. Scully, Diane. 1980. Men who controlwomen'sbodies.Boston: Houghton Mifflin. Starr, Paul. 1982. The socialtransformation of Americanmedicine.New York: Basic Books. Terris,Milton. 1986. Towarda national medicalcaresystem:II. The historical background.Journalof PublicHealthPolicy7(3): 291-295. Waitzkin, Howard B. 1983. The secondsickness:Contradictions of capitalist healthcare. New York:The Free Press. The Regulation of Sexuality: Experiencesof Family Planning Workers. By CAROLEJOFFE.Philadelphia:Temple University Press. Hardcover1986; paperback,1988. The Tentative Pregnancy: Prenatal Diagnosis and the Future of Motherhood. By BARBARA KATZ ROTHMAN. Hardcover:New York:Viking, 1986; paperback:New York:Penguin, 1987. KathrynPyneAddelson Less than a decade ago, mainstreamphilosophicaldiscussionsof the moral problemof abortion assumeda division between questions of public policy and personalchoice. Policy and choice were analyzedin termsof a conflict of rights between fetus and woman. Mainstreamtextbooks still take this approach-they reprintthe same "classicdiscussions"that are supposedto clarify concepts and argumentsand train studentsto make rationaldecisions. In contrast, many feminist scholarshave taken abortionto be a partof a larger networkof moralproblemsof reproduction.These feministshave begunmaking new ethical theories, and they have arguedthat "clarifyingconcepts"is political work in which scholarand teacherdefine other people'sexperience. These two books offer tremendoussupportfor this new feminist viewpoint throughfield studies that show moral experience in the processof being defined. But at the same time, they show that feministpolitics and theorymust be much more complicated and radical than we ever thought when we so bravelybegan. CaroleJoffe'sbook is basedon researchdone in the late 1970s, with abortion and contraceptioncounselorsin a family planning clinic. It capturesa moment in history in which the earlybirth control movementswere finding their full fruit in familyplanning servicesand legalizedabortion-a moment when feminists from the Second Wave were still having their impact. Barbara Katz Rothman's book is tuned towardthe reproductivefuture and a

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medicalizationof reproductionthat was undreamedof when the American MedicalAssociation firstdrove the midwivesout of business.She studiedgenetic counselorsand pregnantwomen facing decisionson prenataldiagnosis, with abortion a possibility if the fetus was diagnosedas "defective." Both booksgive us new waysto see the connections of abortionwith other issuesof sexualityand reproductionand with state and patriarchalcontrol. at a familyplanningclinic ("Urban")in a Joffedid participant-observation and contraceptioncounselorswithin the on abortion Northeastcity, focusing "in the highly complex situationof mediatingbeclinic. These workerswere tween the public worldof bureaucraticallyprovided'services'and the private worldof people'ssexual behavior"(4). In this cruciallocation, policy meets personal,abstractconflicts in feminist ideologybecome all too concrete, and abortion is inextricablyconnected with other issues of sexuality, reproduction, and the family. "Urban"was an affiliateof a large, national familyplanning organization. It offereda numberof services, includingpregnancytesting, contraception, abortion, and sterilizationservices, as well as routine gynecologicalcare, genetic and infertilitycounseling, and educationprograms;there was also a special clinic for teenagersreceivingcontraceptivesand abortion.Twelve counselors worked in either contraception or abortion service (including teen counseling). Although they explainedmedicalmattersand proceduresto clients, their core view was that they facilitated decisions by offeringsympathetic aid to clients in sorting through the moral and social problemsthat were at issue in their lives. The style was "quasi-therapeutic" (58). I find three themes in Joffe'sstudyof particularinterestfor feministphilosophy and feminist ethics: the strugglesover the definitions of contraception and abortion;the ambiguitiesin abortionpolitics as the counselorscame to modify and complicate their own feminist stances on reproductivechoice, and the need for a languagethat can framethe deeply complex moral concems in sexuality and reproduction. Strugglesover the definition concerned meaning in action. Joffesays that one major theme that characterizedcontraceptive work at Urban was the counselors'effortto claim a social as well as a medicalmeaningfor contraception (61). Joffesaysthat the very presenceof both physiciansand counselors at familyplanning clinics conveys one core ambiguityof abortion:it is taken to be both a medical procedureand an emotional experience (and, I would say, a moralone) (104). The economic realities(the medicalproceduresproduced the largestshare of clinic income), the pay scales, and relationships with outside agencies supportedthe medical definition. At the same time, againstthese powerfulforces, the counselors(and other workers)were able to affect the definition. In discussingabortion choices, counselorsfelt it was essential to discuss sex, family, and life plans. Doing this was verydifficultwithin the limitations

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of clinic schedules, and so they used strategiesof "slowdowns"and "secret caseloads"to overcome the limitations of clinic-scheduledwork (88ff). In "slowdowns,"the counselortook extra time as needed, despite the fact that clients waited and supervisorsdisapproved.In "secretcaseloads,"a counselor encouragedneedy clients to returnwithout charge, and without mediationby the clinic office. After much pressureby counselorsand their superiors,Urban eventually opened a counseling clinic, thereby institutionalizingand legitimatingthe secret caseloads,and officiallybroadeningthe definitionsof abortionand contraception. I find a moral in this story for feminist intellectualsand activists. It cautions us againstspeakingglibly aboutdefinitionsas simpleproductsof the patriarchy or the medical establishment. It also displays feminist politics at work, not in the "interestgroup"realmwhere abortionlegislation is fought over but in a juncturewhere public meets private. In the arena of "pro-choicevs pro-life"abortionpolitics, feminists often use a simplified,"reproductiverights"rhetoric.Joffesaysthat the counselors came to see abortiondifferentlyas a result of their work. One counselorremarked," ... aftergetting involved in counseling. .. you face the realityof it. It isn't so easy to be a parlorroom advocate"(114-15). Their experiences led to a social critique-in some cases abortionis a convenience within a society based on expediency. The counselors objected to being part of the conveniencing, particularlywith "repeaters." Of course, all along some feminist intellectualsand activistshave criticized the reproductiverights rhetoric. What I find importantin Joffe'sresearchis that she tells us about some women'sexperience as they test that rhetoricin feminist use. This is importantfor feminist ethics as well. Philosophytextbooks deal with moraldecisions in the abstract-the standardones are suited to hypotheticaldilemmas.However the counselors'moraljudgmentwas very much tied to context-choice in a context of relationshipand social options ratherthan decision out of weighing principles.Joffe says, . . .the reasonsfor the abortion-the youth of the aborter,a failed marriage,a fetus known to be deformed-all inevitably shaped counselors'emotional responsesto it. And since most of the reasonsclients gave struckcounselorsas reasonable-in fact, quite compelling-counselors were able, undermost circumstances, to proceed with a view of abortion as "sad but necessary"and "the best of availablealternatives"(115). The counselorswere concerned with abortion and contraceptivechoice for action, not with abstractjudgmenton the rightsor wrongs.They workedat facilitating choices. Joffe'sworkallowsus to criticizeCarolGilligan, who workedout her ethics of care and relationshipby interviewingindividualwomen about their abor-

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tion experiences. The result is that the ethics remainsat the personallevel, without a way to discussfeminist politics. The "universalethic of care"that marksGilligan's highest stage is abstract, not groundedin historical situations. To analyzethat highest stage requiresthat we use carefullychosen field studies of women in action, not simply interviews with individuals about their interior lives. Joffe'sstudy offersus a beginning. Joffe'sresearchitself is an act of feminist politics because she shows both the institutional means by which sexuality is controlled and some of the means by which feminists may modify that control. She says, ... it is not clear what contoursthe strugglefor a new sexual moralitywill have .... It is very likely, however, that front-line workersin the fields of reproductionand sexualitywill play an importantrole in this task. Already, in institutions such as Urban, the responsesof counselorsappearto be prefiguringnew understandings about sexualityitself and the role of state-sponsoredinstitutions in facilitating sexual decisions. In the finest sense of the word, I think it correct to view the activities of these counselorsas subversive(165). BarbaraKatzRothman'sbook is basedon her field observation(in the early 1980s) in genetic counseling sessions, and on interviewswith genetic counselorsand with 120 pregnantwomen who had facedthe option of prenataldiagnosis (17). These women wanted the children they were carrying.If they chose amniocentesis, the procedurecould rarelytake place before the sixteenth week of the pregnancy,with resultsreceivedfourweeks later. If abortion was the option chosen at that time, it was a difficult, late abortion in which labor was induced. LikeJoffe'scounselors,the genetic counselorsmadegreateffortsto be neutral in their counseling. The presupposition is that ideally each woman should be given the informationavailable and allowed to examine options and futuresfrom all sides: After that, she ought to reach her own decision. The premises (among counselors and philosophers)are that informationis usuallya good thing, a morallyneutralthing; informationis needed to make the moraldecision; makingone's own decisions is good. In her studyof these women's experiences, Rothman raises questions that shake these premises and shake the foundationsof philosophicalethics and "valuesclarification." She says, "Refusingamniocentesisis turningawayfrom the value of choice, and even more profoundly, turning away from the value of information" (84). Amniocentesis is a relativelynew technique. The technician insertsa needle through the woman's abdomen into the amniotic sac to withdraw amniotic fluid-the dangerof the needle hitting the placentaor fetus is less-

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ened by using sonography (ultrasoundimaging). From a medical point of view, the disadvantagesare discomfortor pain, risk of infection, slightly increasedriskof miscarriage,and unknownrisksfromultrasoundexposureduring the sonogram.The medical reasonfor the technology is that many fetal genetic conditions can be diagnosedthrough laboratoryexaminationof the fluid. The conditions include sickle-cell anemia and Tay Sachs disease, neural tube defects (including spina bifida), and chromosomaldisorders(includingDown Syndrome).At present,few of these conditionscan be treated prenatally,and only a few afterbirth. That is, medically, a positive diagnosis for any of the conditions indicates abortion. One main part of the amniocentesisdecision involves "weighingrisksof the procedure against risks of fetal diseases, defects and disorders."But, Rothmansays, to speakof weighingrisksagainsteach other is overly simplistic. The meanings,and not just the probabilities of... risksmust be consideredby each woman, for herselfand her family.The meaning of disabilityis not the same to all people, nor are all disabilitiesthe same. Most of us know too little aboutdisabilities to fully understandtheir meaning in our children'slives (250). The meaning of the pregnancy loss is also different for different people. Rothman says, The riskof miscarriagefromthe procedureis one concern. But morefundamentally,the potential for pregnancyloss, through abortion, is built right into amniocentesis. Terminating a wanted pregnancyat twenty weeks is a profoundlywrenching, painfulexperience. The potential for such a terminationcasts its shadowback over the entire firsthalf of the pregnancy,creating the "tentative pregnancy"(250). Some mothersspoke of "suspendedanimation,"of "a sense of unreality,"of "tryingto deny the reality of the pregnancyto myselfbecauseof fear of bad results"(103). Rothman arguesthat one of the ways that the definition of childbearing has changed is in the direction of separation.One striking separationhas made the fetus an independentpatient for medicine. For millennia women were the sourcesof knowledgeon when a pregnancyexisted, when the baby quickened, and so on. Now (Rothman says) the mother becomes invisible. She becomes"the maternalenvironment,"and fetal medicine is "anew frontier." There is ample evidence for Rothman'sclaim-for example, in a recent New YorkTimesarticle on fetal surgery,the mother wasn't mentioned at all

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until nearly the end, and then only to say that medically,fetal surgeryposed an "acceptablerisk"for her (TheNew YorkTimes,TuesdayAugust 16, 1988). Another separationis that of motherfromfetusduring"the tentative pregnancy." There are marksof the separation-women who plan on amniocentesis tend to "go public"about the pregnancylater than other women; they feel fetal movement later and they begin wearingmaternityclothes later, on the whole. Rothmansaysthat realityhas been turnedon its head by the technology. "Ratherthan moving fromcomplete attachment (duringpregnancy) through the separation that only just begins at birth, this technology demandsthat we begin with separationand distancing. Only afteran acceptable judgment has been declared, only after the fetus is deemed worthy of keeping, is attachment to begin." The technology assumeswomen's experience parallelsmen's (114). Complexities of feminist reproductive politics are evident throughout Rothman'sbook. Some women avoidedgenetic counselingbecauseit is irrelevant "to those who believe life is alwaysworthwhile"(63). Otherswho had amnio with a firstpregnancyfound that motherhoodchangedthem so that it became questionablewhether they could make a decision to abort a "defective fetus"(74). Others found that their familycould handle a "specialproblems child" with love and unity-including a Down Syndromechild. One woman'samniocentesisresultsshowedno genetic problems,but her daughter "hashad other health problemsand we've learnedthat we can indeed handle these problemsand continue to thrive as a healthy family(74). Hearingother women speak tremendouslycomplicatesfeminist reproductivepolitics-simple "pro-lifevs. pro-choice"distinctions collapse. Rothman emphasizesthe problems with the new procedures,though of course they have been seen as a godsend by many women. At times, she seems to be carpingat counselors.Her examplesof their incomplete"neutrality" and their failureto be non-directivepale beside her own "guidelinesfor personal decision making" in the book's appendix: "Announce the pregnancy" (254); "do not ask to lear the sex of the fetus" (256). But at root, her philosophical/feministpoint is altogether valid: we must examine our premisethat informationand informeddecision are unquestionablegoods to pursue.She says, We do not even have a languageof moralitythat allows us to talk about the moral nature of information itself. Moral questions, as we generallyphraseit, come with the problems of what to do with information... but whetheror not to enter into the decision-makingprocessitself is not widely recognized as a moral dilemma (83). In their role as researchers,by the questionsthey ask and the methodsthey use, Joffeand Rothman also exercisean authoritythat needs to be examined,

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of course. But whateverits flaws, their field researchallowsus to get closer to seeing moral concepts in the processof being defined. Their books give us a better idea of what differentwomen take to be importantmoralquestionsin reproductiveethics and so help us see directionsthat feminist ethics should take. They keep us on the course of preservingthe subversivein our own work.

Notes on Contributors

KATHRYN PYNE ADDELSON is Professorof Philosophyand Directorof the Programin the History of the Sciences at Smith College. She has been active in grassrootspolitics and is currentlyon the boardsof the LeverettVillage Co-op and the RattlesnakeGutterLandTrust. She has publisheda number of articlesin feministphilosophyand is currentlycompletinga book manuscripton feminist ethics and issuesof sexuality and reproduction. NORA KIZERBELLis currentlyChair of the Departmentof Philosophyat the Universityof South Carolina. An Associate Professorof Philosophy,she also holds adjunctProfessorshipsin the USC Schools of Medicine and Public Health and is residentethicist at Richland MemorialHospital in Columbia. She eared her doctorateat the Universityof North Carolina.The authorof numerousarticles in bioethics and social and political philosophy, she has consulted throughoutthe Southeast on issues affecting health care delivery and health policy. She was an EXXONFellowin Ethicsand Medicineat Baylor College of Medicine in summer1985. ELLENDORSCH is an independenthealth planning and policy consultant workingprimarilyin Vermont. Her most recent workincludesa reporton the statusof prenatalcare in Vermont, plus programdevelopmentin familyplanning and materal and child health. As partof a contract with Planned Parenthood of Northern New England, she is developing opportunities for PPNNE to workwith familyplanning organizationsin developingcountries. Her chapter on Heart Disease was recently published in OurselvesGrowing Older,a book for midlife and older women. She is a health activist, particularly working in the areasof access to care, abortionrights and community health. SARA T. FRYis Associate Professorat the Universityof Marylandat Baltimore. She has authoredarticlesin biomedicalethics and nursingethics. She is co-author of Case Studiesin NursingEthicsand is currentlyworkingon a book on the protection of privacyin health care. She teaches coursesin the philosophyof science, epistemology, and health care ethics. HELENBEQUAERTHOLMEShas a Ph.D. in genetics and is currentlyan Associate Fellow at the Institute for Advanced Study in the Humanitiesat

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the University of Massachusetts.She was a co-editor of BirthControland and The Custom-MadeChild? ControllingBirth:Women-Centered Perspectives She Women-Centered writes about and researchesfeminist techPerspectives. nology assessmentand ethical analysisof reproductivetechnologies. PAUL LAURITZENis Assistant Professorof ReligiousStudies at John Carroll Universityin Cleveland, Ohio. He is currentlyworkingon a studyof the relation between contemporaryfeminist and religiousapproachesto moral theory. His article, "Reflectionson the Nether World:Some Problemsfor a Feminist Ethic of Care and Compassion" is forthcoming in the journal, Soundings. DON MARQUIS receivedhis Ph.D. fromIndianaUniversityand is Associate Professorof Philosophyat the University of Kansas,Lawrence,Kansas. His primaryresearcharea is medical ethics. Most of his recent publications have been concerned with the ethics of experimentationin medicine. CHRISTINE OVERALLis Associate Professorof Philosophyand Queen's National Scholar at Queen's University, Kingston, Ontario. She is the author of Ethicsand HumanReproduction: A FeministAnalysis(Unwin Hyman, 1987), and co-editor, with LorraineCode and Sheila Mullett, of FeministPerspectives:Philosophical Essayson Methodand Morals(University of Toronto Press, 1988). She is currentlyediting an anthology, to be publishedby Toronto Women's Press,entitled The Futureof HumanReproduction, and is writing a book called Women,Sexuality,and FeministTheory. LAURA M. PURDY received her Ph.D. from StanfordUniversity. She is Associate Professorat Wells College, and for 1988-89 holds the IrwinChair at Hamilton College. Her researchis mainly in appliedethics and feminism, and she is completing a book on equal rightsfor childrententatively entitled LiberatedChildren,LostChildren? SUE V. ROSSER is a Director of Women's Studies at the University of South Carolinaat Columbiaand Associate Professorof PreventiveMedicine and CommunityHealth in the Medical School. She received her Ph.D. degree in Zoology from the University of Wisconsin-Madison and taught in the women's studies programthere. She has edited collections and written extensively on the theoretical and appliedproblemsof women and science, includingthe booksTeachingAboutScienceandHealthfroma FeministPerspective:A PracticalGuideand FeminismWithintheScienceandHealthCareProfessions:OvercomingResistance. SUSAN SHERWIN is Associate Professorof Philosophyat DalhousieUniversity, Halifax, Nova Scotia. After too many yearsin administrativework,

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she is now tryingto devote herselfto her principalacademicinterestsin feminist ethics and health care ethics; she has publishedseveralarticles in these areasand is currentlyworkingon a book on feminist medical ethics. BETTYA. SICHELis Professorof Philosophyof Educationat Long Island University, C. W. Post Campus, Brookville,New York. She holds a Ph.D. from New York University and has publishedin such journalsas Philosophy and Phenomenological Research,EducationalTheory,andJournalof MoralEducation. Her recent book, published by Temple University Press, is entitled MoralEducation:Ideals,Community,and Character. SHIRLEYWAGNER is an Associate Professorof Political Science, Chair of the Social Science Department,and Coordinatorof the newly createdFreshman FoundationYearat FitchburgState College in Massachusetts.She is a memberof Eastem SWIP and is currentlyworkingon a book on the judicial philosophyof SandraDay O'Connor. MARGARET URBAN WALKER is Associate Professorof Philosophy at FordhamUniversity. She has published articles on normative ethics and moral agency, and is developing a fully relationalethic of responsibilityfor vulnerable,attachedand situatedmoralagents. She teaches ethics, Wittgenstein and feminist philosophy. VIRGINIA WARREN is an Associate Professorof Philosophyat Chapman College. She serveson a hospital ethics committee, and has taught seminars for health care professionalsat local hospitals. She wrote the guidelines for non-sexist language for the American Philosophical Association, and has published articles on ethics, Kierkegaard,and masochism. Her current research topics include autonomy, worldhunger, and elitism in higher education. SUSAN WENDELLis Assistant Professorof Philosophyand Women'sStudand ies at Simon FraserUniversity. She and David Copp edited Pornography on discrimiarticles has 1983. She Prometheus Books, Censorship, published nation, equality of opportunity,pornography,and liberal feminism.

Announcements

Callfor papers:The Journalof AestheticsandArt Criticisminvites submissions for a special issue on "Feminismand TraditionalAesthetics." Contributions that offer feminist perspectives,critiques,and explorationsof any of the elements of historicalor contemporaryaesthetic theoryand philosophyof artare welcome. Inquiriesand submissions(in duplicate, name on a detachabletitle page) may be directed to either of the guest co-editors:(1) ProfessorPeggy Brand, Philosophy Dept., The Ohio State University, 230 North Oval Mall, Columbus,Ohio, 43210-1365; or (2) ProfessorCarolynKorsmeyer,Philosophy Department, Baldy Hall, SUNY at Buffalo, Buffalo, New York, 14260. Deadline for submissionsis January15, 1990. Genderand Educationis a new journalthat aids the distributionand exchange of feminist researchand ideas in the multidisciplinary,internationalarea of education. Since it is the policy of the journalto establisha forumfor discussion and debate about gender in education, articlesthat examine the experiences of boys and men as well as girls and women are welcome. Each issueof Genderand Educationcontains independentlyrefereedarticles and a Viewpoints section with shorter contributionsthat are more polemical in tone. There is also a book review section. A special issue is publishedonce a year. The special issue in Volume 1 (1989) is entitled 'Anti-racism,Gender and Education'.The special issue in Volume 2 (1990) will be on the topic 'Equal OpportunityPolicies'. Contributionsto this new journalare actively sought. Please send four copies of your manuscriptto the Editor:Dr. June Pervis, School of Social and HistoricalStudies, PortsmouthP01 3AS, United Kingdom. All submissionswill be seen anonymouslyby two referees.Each article should be accompaniedby a summaryof 100-150 wordson a separatesheet. Books for review should also be sent to June Pervis. Genderand Educationis publishedthree times a year, in March,June, and October. Subscriptionrate: one year (one volume) ?58.00, post free. Individualsreceivingthe journalat a private addressfor their own use may subscribeat a 50% discount (i.e. ?29.00) under the terms of the PersonalSubscriptionPlan. Callfor papers:Papersare soughtfor an anthologyof CriticalFeministEssaysin the Historyof WesternPhilosophyto be publishedby the SUNY press in its "FeministPhilosophy"Series. The anthology will have two parts:one addressingancient Greek philosophy;and the other, modem philosophy. Papers for the first part should focus on some aspect of Plato's or Aristotle's work. Papersfor the second part should focus on some aspect of Cartesian

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philosophyor Hobbes', Locke's,Hume's, Mill's, Rousseau's,Kant's,Hegel's, Marx'sand Nietzche's work. Critical overviews of a philosophicalfield or trendsand their developmentsduringthe two periodsarealso welcome. Send proposals,draftsand inquiriesto: Bat-Ami Bar On Departmentof Philosophy, SUNY College at Oswego, Oswego, NY 13126. The Institutefor Women's Policy Research(IWPR) is a recently formedindependentnonprofitresearchinstitute dedicatedto conductingand disseminating researchthat informspublic policy debates affecting women. IWPR seeks to bridgethe communicationgap between scholarlyresearchers,state and federalpolicymakers,and advocates. In it first year, IWPR has focused on economic justice issuesaffectingwomen (welfarereform,familyand medical leave, and child care). Projectedareasof researchincludehealth care and internationalrelations. In all its work, IWPR seeks to addressissuesof ethnicity, race, and class as well as gender by recognizingthe full diversityof women'ssituations. For furtherinformation,contact: Institutefor Women's Policy Research, 1400 20th Street, NW Suite 104, Washington, DC 20036. (202) 785-5100. Callfor Papers:SUNY Pressannouncesa new book publicationseriesRadical SocialandPoliticalTheory.The editorsseek new, controversial,and outstanding worksof radicalsocial and political theory, workswhich challenge existing societal structures.Manuscriptswhich extend morefamiliarradicalideologies such as Marxism,feminism, civil disobedience,and black liberation,as well as worksdeveloping new bodies of thought and practicein areassuch as ecology, greenpolitics, liberationtheology, and deconstructionarewelcome. The following are of particularinterest: * Analyses of currentsocial problemsfroma radicalperspective,e.g., economic development, AIDS, gender violence, and political power * Unmasking the cultures of domination in the family, the media, the workplace,leisure, sexuality, art, and spirituality. * Studies in particularlyAmerican radicalism:What are the fundamental contradictionsof contemporaryAmerican society? What are the radicalresourcesof our own culture and politics? All inquiriesabout the series and all manuscriptsand book proposalsshould be sent to: Peggy Gifford, Editor, SUNY Press, State University Plaza, Albany, NY 12246-0001. The GustavusMyersCenterfor theStudyof HumanRightsin theUnitedStatesis requestingnominationsfor books publishedin 1988 (will also considerbooks publishedearlier).The Center was foundedto continue the researchinto tolerance in the United States inauguratedby GustavusMyersin his Historyof

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Bigotryin the UnitedStates.The specific purposeof the Center is to identify, reward,and publicizeoutstandingbooks about all kinds of intolerancein the United States. Winners will be announcedon December 10, HumanRights Day. FirstPrizecarrieswith it a $1000 cash award.Address:ProfessorJames R. Bennett, Director,GustavusMyersCenter, KH234, Universityof Arkansas, Fayetteville, AR 72701, (501) 575-4301, 442-4600. Call for Papers.Bioethicswelcomes the submissionof papersfor publication. Papersmay deal with any aspect of ethical issuesraisedby medicine and the biological sciences, and may be written from any disciplinaryperspective, whether law, sociology, economics, philosophy,medicine, etc. They should be written without unnecessarilytechnical language, in a form that can be understoodby an internationaland interdisciplinaryreadership.All papers submittedwill be acknowledgedand if they fall within the scope of the journal and meet minimalstandards,will be sent anonymouslyto referees.A decision on publicationwill be given within three months of receipt, and published within six months of acceptance. Contributorsare asked to send three copies of their paper, preparedso that, after removal of the title page, the author'sidentity is not apparent. The copies will not be returned.Papersshouldbe sent, preferablyby air mail, to: Helga Kuhse and Peter Singer, Editors, Bioethics,Centre for Human Bioethics, Monash University, Clayton, Vic., Australia3168. Societyfor Womenin Philosophy.For informationon membershipin regional divisions which include programannouncementand a subscriptionto the national SWIP Newsletter, as well as a subscriptionto Hypatia,contact: PacificSWIP:Executive SecretaryRita Manning, UC San Jose State, San Jose, CA 95192. TreasurerRuth Doell, San Francisco State University, Dept. of BiologicalScience, 1600 HallowayAve., San Francisco,CA 94132. MidwestSWIP:Executive SecretaryRuth Ginzberg,Dept. of Philosophy, Wellesley College, Wellesley, MA 02181. TreasurerCarol Van Kirk, Philosophy Dept., Ohio University, Athens, OH 45701. EasternSWIP: Executive Secretary Libby Potter, Dept. of Philosophy, Haverford College, Haverford, PA 19041. Co-Executive SecretaryJoan Ringelheim, Apt. la, 150 W. 74th St., New York, NY 10023. Treasurer Jana Sawicki, Dept. of Philosophy, Univ. of Maine, Orono, ME 04469. The Societyfor thePhilosophy of Sex andLoveannouncesa call for papersto be at the two presented following meetings: with the American Philosophical Eastern December Association, Division, 1989; and with the APA, Central 1990. be on Division, April any issue within the philosophyof Papersmay love and sex. Twelve to thirteen pages maximum, excluding footnotes; standardspacingand margins.Preparefor blind reviewing,puttingname and

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affiliationonly on cover letter. Send two neat and clean copies of the paper, and return postage if desired. Deadlines: EasternDivision, April 15, 1989; Central Division, September1, 1989. Send to: ProfessorAlan Soble, Philosophy Dept., University of New Orleans, New Orleans, LA 70148 (504-2866257). Newsletteris sponsoredby the APA Committee The Feminismand Philosophy on the Status of Women in Philosophy. Its purposeis to publishinformation about the status of women in philosophyand to make more widely available the resourcesof feminist philosophy. The Newsletterwill contain discussions of recent developmentsin feminist philosophyand relatedwork in other disciplines. It will include literatureoverviewsand book reviews, suggestionsfor eliminatinggenderbias in the traditionalphilosophycurriculum,and reflections on feminist pedagogy. It will also keep the professioninformedabout the work of the Committee on the Status of Women in Philosophy. The Newsletterwill provide a forumfor queriesand informaldiscussionsof topics relevantto feminist philosophyand also to the statusof women in the profession. The editor invites contributionsto the Newsletter. Scheduleof Topics: September 1, 1989; Topic: Feminismand Aesthetics;editors: LaurieShrage and Nancy Tuana; deadline for submissionof manuscripts:May 1, 1989. February1, 1990; Topic: Open Issue: all topics welcome; editor: Nancy Tuana; deadline for submissionof manuscripts:October 1, 1989. May 1, 1990; Topic: Feminismand MoralTheory;editors: Betty Sichel and Nancy Tuana; deadline for submissionof manuscripts:January1, 1990. editors:KarenJ. September 1, 1990; Topic: Feminismand the environment; Warrenand Nancy Tuana; deadline for submissionof manuscripts:May 1, 1990. SubmissionGuidelines: All submissionsmust be limited to ten manuscriptpages and must follow the APA guidelines for gender neutral language (APA Proceedings).Essays should be submitted in duplicate with the author'sname only on the title page for the anonymousreviewingprocess. Manuscriptsmust be typed double-spacedand referencesmustfollow Chicago Manualstyle. Pleasesend articles, comments, suggestions,and all other communicationsand inquiriesto: Nancy Tuana, Arts and Humanities,JO 3.1, University of Texas at Dallas, Richardson,TX 75083-0688.

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The Societyfor theStudyof WomenPhilosophers was foundedin Dec., 1987 at the annualconferenceof the AmericanPhilosophicalAssociation. The Society is open to women and men from all disciplinesand is constitutedaround the following purposes: 1. The firstpurposeof the Society for the Studyof Women Philosophersis to create and sustaina "Republicof Letters,"in which women are both citizens and sovereigns.To that end, we shall commemoratewomen philosophersof the past as well as of the presentby engagingtheir texts, whether criticallyor appreciatively,in a dialogicalinterchange. In this way, both we and our sistersfrom the past can also become interlocutorsfor our sisters in the future. 2. The second purposeof our Society is to examine the natureof philosophy, specificallyin light of women'scontributionsto the discipline. Thus, papers are welcome which reflect on the methodologyand style of women philosophers themselves, or which compare the texts of women with those of men. 3. Furthermore,since philosophicalmethod may be distinguishedfromphilosophical understanding,it is possible that philosophical understanding could be reachedin a varietyof ways. The Society, therefore,will also explore the natureof philosophyby comparingthe worksof women philosopherswith those of women thinkersof other types, such as poets, mystics, novelists or biographers. We thus hope to enlarge and enrigh the resources of everyone who is concerned with the central and most basic questions of human life. The following people will serve on the Executiveboardfor 1988-90: Veda Cobb-Stevens, University of Lowell; Linda Lopez McAlister, University of South Florida; Elizabeth Kamarck Minnich, Scripps College; Petra von Morstein,Universityof Calgary;BeverlySchlack Randles,EmpireState College; MargaretSimons, University of Southern University; Cecile Tougas, University of Lowell. Anyone who would like to become a memberplease send name, address, and institutional affiliation along with a check for $10.00 to cover dues for the calendaryear to: Beverly Schlack Randles, 311 JeffersonSt., Saratoga Springs, NY 12866. Call for Papers:SOCIETY FOR THE STUDY OF WOMEN PHILOSOPHERS.The next conferenceof the Society for the Studyof Women Philosopherswill be held in conjunction with the meeting of the American Philosophical Association, Eastern Division (Atlanta, GA), December, 27-30, 1989. Papers are welcomed on the following topics: 1) any aspect of the thought of a woman philosopher (where "philosopher"is traditionallydefined); 2) other women thinkers (e.g., poets, novelists, diarists,mystics);3)

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the natureof philosophyspecificallyin light of women'scontributionto the history of thought. Papersshould be no longer than 15 pages, double spaced. Since they will be anonymouslyreviewed, please attach two cover sheets. On the first, put the title and your name, addressand social securitynumber.On the second, put the title and yoursocial securitynumberonly. Send six copies of the paper to: Linda Lopez McAlister, Women's Studies Program,University of South Florida,SOC 107, Tampa, FL 33620. Deadline for receipt of papers: September 1, 1989.

SubmissionGuidelines Hypatiasolicits paperson all topics in feministphilosophy.We regularlypublish generalissuesas well as special issueson a single topic, or comprisingthe proceedingsof a conference in feminist philosophy. All papersshould conform to Hypatiastyle using the Author/Datesystemof citing references(see the ChicagoManualof Style). Papersshould be submittedin duplicatewith the author'sname on the title pageonly for the anonymousreviewingprocess. EcologicalFeminism.This special issueof Hypatiawill focuson a wide rangeof philosophical issues germane to ecological feminism. Suggestionsof topics that might be developed include the following: 1. The natureand desirability/undesirability of ecologicalfeminism(e.g. for feminist theory, environmental ethics, the science of ecology, environmentalism,or developmentpolicies). 2. Challenges of ecofeminism to environmental ethics, particularlyto deep ecology and animal liberationism. 3. The relevance of ecofeminismto the analysisand solution of pressing environmental issues (e.g. deforestationand forestry,potable water, species preservation,naturalresourceconservationand use, sustainable agriculture,food production and consumption, domestic pets, wildlife, use of animals in experimentation). 4. Ecofeminismand history (e.g. the historiesof Wester philosophy,of environmentalproblems,of imperialistaggression). 5. Ecofeministpolitics, global activism, and the peace movement. 6. Ecofeminism,post-modernism,and critical theory. 7. Ecofeminismand bioregionalism. 8. Ecofeminismand the conception of nature. 9. Ecofeministspirituality. 10. Ecofeministart and aesthetics. 11. Ecofeminismand science, technology, and industry. 12. Ecofeminismand women in development. Papersshouldbe submittedin duplicateto the guesteditor:KarenJ. Warren, Department of Philosophy, MacalesterCollege, 1600 Grand Avenue, St. Paul, Minnesota, 55105 (612) 696-6172. (Pleaseput yourand addresson a detachabletitle pageonly. If you wish returnof the manuscript,include a self-addressed,stampedenvelope with your submission).Deadline: March 15, 1990.

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The HypatiaBook Review Section aims at increasingthe visibility and readership of books in feminist philosophy. At present, three general book review guidelineshave been developed: 1. To promote dialogue between books, reviewersare asked to discuss, when possible, more than one book in feminist philosophy. Several books might be clustered around a theme, or a single book might be highlightedand its relationto other books in feministphilosophymight be mentioned in brief. 2. Book reviewersare askedto discussthe majorclaims of the book(s) reviewed and to present the reviewer'sown reflections. 3. Book reviews will be either Short Reviews or Review Essays: ShortReviewswill be two to three text pages, that is, three to fourtyped double-spacedpages in length. ReviewEssayswill be approximatelyeight to twelve text pages, or ten to twenty typed double-spacedpages in length. Books which will be the subjectof Review Essaysshouldbe proposedin advanceto the Book Review Editor. For furtherinformation,contact the HypatiaBook Review Editor:Jeffner Allen, Departmentof Philosophy, SUNY Binghamton, Binghamton, New York 13901.

Back IssuesAvailable

Volume1, Number1, Spring1986 Antigone'sDilemma:A Problemin PoliticalMembership,by ValerieA Hartouni,Women Wider,How Philosophersin the Ancient GreekWorld;Donningthe Mantle,by Kathleen ManyFeministsDoes It Take to Makea Joke?:Sexist HumorandWhat'sWrongwith It, by MerrieBergmann,The Politicsof Self-Respect:A FeministPerspective,by DianaT. Meyers,PreparingThe Wayfor a FeministPraxis,by AndreaNye, RomanticLove, Altruism, and Self-Respect,by Kathryn PaulyMorgan,OppressionandResistance;Fry'sPolitics and Reality,by ClaudiaCard,Comment/Reply,by LauraM. Purdyand NancyTuana Volume1, Number2, Fall 1986 Motherhoodand Sexuality, edited by Ann Ferguson,Motherhoodand Sexuality:Some FeministQuestions,by Ann Ferguson,Foucaultand Feminism:Towardsa Politicsof DifContraChodorowandDinnerstein,byJanice ference,byJanaSawicki,FemaleFriendship: Raymond,Woman:Revealedor Reveiled?,by CynthiaA. Freeland,The FeministSexuality Debate:Ethicsand Politics,by CherylH. Cohen,Feminismand Motherhood:O'Brien vs. Beauvoir,by ReyesLazaro,PossessivePower,by JanetFarrell-Smith, The Futureof Mothering:ReproductiveTechnologyand FeministTheory, by Ann Donchin,Should a FeministChoose a Marriage-Like Pelationship?,by Marjorie Weinzweig Volume2, Number1, Winter 1987 ConnectionsandGuilt, by SharonBishop,WrongRights,by Elizabeth Wolgast,Througha GlassDarkly:Paradigms of Equalityandthe Searchfora Woman'sJurisprudence, by Linda J. Krieger,Is EqualityEnough?,by Gale S. Baker,The Logicof SpecialRights,by Paul Green, PregnancyLEave, ComparableWorth, and Concepts of Equality,by Marjorie Weinzweig,Women, Welfareand the Politicsof Need Interpretation,by NancyFraser, The FeministStandpoint:A Matterof Language,by TerryWinant,BodiesandSouls/Sex, Sin and the Sensesin Patriarchy: A Studyin AppliedDualism,by SheilaRuth,Improper Behavior:ImperativeforCivilization,by Elizabeth Janeway,The New Men'sStudies:From FeministTheoryto GenderScholarship,by HarryBrod Volume2, Number2, Summer,1987 and Loving Perception,by MariaLugones,Sex-Role Playfulness,"World"-Travelling, and Degradation,byJudith Stereotypesin Medicine,by MaryB. Mahowald,Pornography M. Hill, Do Good FeministsCompete?,by VictoriaDavion,A (Qualified)Defenseof Liberalism,by SusanWendell,The Unit of Language,byAndreaNye, The Lookin Sartreand Rich, by JulienS. Murphy,How Bad is Rape?,by H. E. Baber,On Conflictsand Differences Among Women, by LuisaMuraro,The Politics of Women'sStudiesand Men's Women'sStudies?,by Studies,by MaryLibertin,Does ManningMen'sStudiesEmasculate HarryBrod,Celibacyand Its Implicationsfor Autonomy,by CandaceWatson Volume2, Number3, Fall, 1987 FeministScholarshipin the Sciences:WhereAre We Now andWhen Can We Expecta TheoreticalBreakthrough?, by SueV. Rosser,The MethodQuestion,by SandraHarding, The Gender/ScienceSystem:or is Sex to Genderas Natureis to Science?,by EvelynFox Keller,Can ThereBe a FeministScience?,by HelenE. Longino,Le sujetde la scienceest-il sexue?/Isthe Subjectof Science Sexed?by LuceIrigaray,translatedby CarolMastrangelo Bove,UncoveringGynocentricScience, by RuthGinzberg, JustifyingFeministSocial Sci-

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Traence, by LindaAlcoff,John Deweyand EvelynFoxKeller:A SharedEpistemological dition, by LisaHeldke Volume3, Number1, Spring,1988 Introduction,by NancyTuana,Science, Facts,and Feminism,by RuthHubbard,ModelPotter,The WeakerSeed:The Sexist Bias ing the GenderPoliticsin Science, by Elizabeth of ReproductiveTheory,by NancyTuana,The Importanceof FeministCritiquefor ConSyntemporaryCell Biology,by The BiologyandGenderStudyGroup,The Premenstrual N. Zita,Womenand the Mismeasure of drome:Dis-easingthe FemaleCycle, byJacquelyn Thought,by JudithGenova,Dreamingthe Future,by HilaryRose,FeministPerspectives ImberandNancyTuana,ReviewEssay/ACriticalAnalysisof Sanon Science, by Barbara N. Zita draHarding'sThe ScienceQuestionin Feminism,by Jacquelyn Volume3, Number2, Summer,1988 Dyke Methods,by JoyceTrebilcot,Recipesfor TheoryMaking,by LisaHeldke,Working TogetherAcrossDifference:Some Considerations,by UmaNarayan,DoesWomen'sLiberationImplyChildren'sLiberation,by LauraM. Purdy,Womanas Metaphor,by Eva FederKittay, Anarchic Thinking, by Gail Stenstad,Poems, by Uma Narayan,Poetic Politics:How the AmazonsTook the Acropolis,byJeffnerAUen,ReviewSymposium:FeWithoutIndimaleFriendship: SeparationsandContinua,by ClaudiaCard,Individuality vidualism:Review of JaniceRaymond'sA Passionfor Friends,by MarilynFriedman,Response,byJaniceG. Raymond,Forum:WelfareCutsand the Ascendanceof MarketPatriOn Nancy Fraser's"Women,Welfareand archy,by MarilynFriedman,Comment/Reply: the Politics of Need Interpretation,by BruceM. Landesman,DesperatelySeekingApproval:The Importanceof DistinguishingBetweenApprovaland Recognition,by Linda TimmelDuchamp,Competition,Recognition,and Approval-Seeking, by VictoriaDavion, BookReviews:Genderand History:The Limitsof Social Theoryin the Age of the Family, by LindaNicholson(KathrynS. Russel),Philosophyand FeministThinking,by Jean Grimshaw (ane Duran),LesbianPhilosophy:Explorations,by JeffnerAllen, Sexes et parentes, by LuceIrigaray(EleanorH. Kuykendall),Intercourse,by AndreaDworkin(MelindaVadas),Women'sWaysof Knowing:The Developmentof Self, Voice andMind,by andJillMattuckTarule Clinchy,NancyRuleGoldberger, MaryFieldBelenky,BlythMcVicker (MonicaHolland) Volume3, Number3, Winter, 1989 A. Introduction,by NancyFraser,Two Interviewswith Simonede Beauvoir,by Margaret SorSimons,Introductionto "SorcererLove,"by LuceIrigaray,by EleanorH. Kuykendall, cererLove:A Readingof Plato'sSymposium, by LuceIrigaray,The HiddenHost:Irigaray and Diotimaat Plato'sSymposium, by AndreaNye, "Essentially Speaking":LuceIrigaray's and FrenchFeminism: Languageof Essence,by DianaJ. Fuss, LacanianPsychoanalysis Towardan AdequatePoliticalPsychology,by DorothyLeland,The BodyPoliticsof Julia PhallocraticEnds",by Kristeva,by JudithButler,Introductionto Kofman's"Rousseau's KelNancyJ. Holland,Rousseau'sPhallocraticEnds,by SarahKofman,Comment/Reply: ler'sGender/ScienceSystem:Is the Philosophyof Science to Scienceas Science is to Nature?,by Kely Oliver,The Gender/ScienceSystem:Responseto KellyOliver, by Evelyn FoxKeller,DoingJusticeto Rights,by CarlWellman,A Replyto CarlWellman,by ElizabethWolgast,Book Reviews:Feminismand Methodology,by SandraHarding,Women's the LiberalArts Curriculum,by MarilynR. Schuster Placein the Academy:Transforming and SusanR. VanDyne

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Volume4, Number1, Spring,1989 Some Remarkson Exploringthe Historyof Womenin Philosophy,by LindaLopezMcAlister,A ChristianMartyrin Reverse:Hypatia:370-415A.D., by UrsuleMolinaro,Educating for Silence:RenaissanceWomenand the LanguageArts, byJoanGibson,The Three Princesses,by BeatriceH. Zedler,Anne ViscountessConway:A SeventeenthCenturyRationalist,by JaneDuran,DamarisCudworthMasham:A SeventeenthCenturyFeminist Philosopher,by LoisFrankel,Anna Doyle Wheeler:Philosopher,Socialist,Feminist,by McFadden,EvolutionaryTheoryin the Social Philosophyof CharlottePerkins Margaret Gilman,by MaureenL. Egan,EdithStein'sPhilosophyof Womanandof Women'sEducaOn Not Teachingthe Historyof Philosophy,by Mary tion, by MaryCatharine Baseheart, EllenWaithe,Does MarriageRequirea Head?Some HistoricalArguments,by LindaA. Bell,ReviewSymposium:FeministArcheology:UncoveringWomen'sPhilosophicalHistory, by MaryAnne Warren,On A Historyof Women Philosophers,Vol. I, by R.M. Dancy, Book Reviews:The Concept of Woman, by Sr. PrudenceAllen, SarahGrimke: Letterson the Equalityof the Sexes and OtherEssays,editedby Elizabeth Ann Bartlett Backissueseach: $10/indiv. and $20/insti. JournalsManager,IndianaUniversityPress, 10th and MortonStreets, Bloomington,IN 47405.

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