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Health, in terms of physical, mental, social, and spiritual aspects of the human body, has been further nuanced by raising issues related to gender. Gender is a fundamental and instrumental principle in determining the nature of bioethics debate and inﬂuencing the premises and justiﬁcations about permissibility of biomedical technologies and their alteration of the (gendered) body. This research paper discusses the historical background and major topics on gender in bioethics debates such as reproductive health, abortion, female genital mutilation, gender and disaster bioethics, and gender-based violence and health care ethics. This research paper illustrates the link between health and human rights for improving gender inequalities globally and the importance of gender in bioethics debate.
Gender and health are inextricably linked. Gender is a complex identity of a person and is constituted by multiple ontologies. In the following research paper, gender is explored through a health lens in bioethical debate. In the following chapter on gender in bioethical debate, gender refers to the “social elaboration of a biological difference between male and female into two distinct kinds of people, men and women (Crosthwaite in Kuhse and Singer 2013, p. 158) and in particular, differences that exist in experiences of and perceptions towards bioethical issues. This research paper will explore gender-related topics in bioethics and provide an overview of historical and contemporary debate.
History And Background: Bioethics: The Origin
The ﬁeld of bioethics seeks to address inequalities and disparities that may exist as a result of the impact of scientiﬁc and/or medical technologies on individuals and/or groups of individuals. Gender is an important aspect because it is an area vulnerable to preexisting tensions and divisions of an individual’s gender status and their role in society. Moreover, the development of genderspeciﬁc scientiﬁc and/or medical technologies results in and shapes debate on the bioethical aspects of, for example, reproductive techniques.
The nature of bioethics, then, is an inquiry into the discourse of the human condition and evaluates the social and cultural context of who is involved. Gender, thus, has developed as an important aspect of what to look for when considering the advent and implication of new ways of affecting our bodies, and society.
From a traditional perspective of examining the doctor-patient relationship, bioethics changed course when new healthcare opportunities created new dynamics and relationships between members of society. For example, a woman who undergoes in vitro fertilization (IVF), in some cases, produces a child that is not genetically related to her. This has fundamentally altered the nature of some societal and biological relationships and in order to be thoroughly analyzed for its ethical implications requires attention to gender inﬂuences. The ﬁrst part of this research paper will look at the emergence of gender in bioethics through the discourse of feminism, and the latter part of this research paper will provide an overview of gender and reproductive ethics.
Feminism And Bioethics
Bioethics has been criticized to some extent for ignoring the importance of feminism. Susan Wolf (1996) has pointed out that the cause for overlooking feminism in bioethics debate stemmed from the ontological nature of bioethics at its origin, rather than a direct rejection of a feminist understanding of the body and healthcare. Feminist theory and its embrace of the concept of gender transpired during the 1970s – at a similar period in time to the emergence of bioethics. Thus, as both gender and bioethics were establishing their respective discourses, they remained quite distinct from each other. In fact, the identiﬁcation of gender as something other than the determination of biological sex had only originated in 1955 when sexologist John Money introduced the notion of gender as a role that is part of society. There was then a two-tiered process in gender becoming accepted and recognized in bioethical debate, namely, that gender needed to become embodied in its new holistic understanding as symbolizing an individual’s role in society and ﬁnally for bioethics to break away from its positivist structure and reliance on deriving bioethical arguments from abstract ethical principles. While both of these steps are still in process, there is sufﬁcient situating of gender in feminism and society in bioethics to attempt to account for gender issues related to bioethical debate.
Feminism and bioethic aims to expose “how imbalances of power in the sex-gender system play themselves out in medical practice and in the theory surrounding the practice” (Lindemann-Nelson 2000). Nelson also criticizes feminist bioethics for insufﬁcient contributions to bioethical theory and for concentrating efforts in the area of reproductive health, resulting in other areas of bioethics needing critique of gender bias (ibid). Wolf further argues that feminist engagement with bioethics will serve to reconstruct “the work of bioethics, including by expanding the subjects of concern, shifting the ﬁeld’s epistemology, and changing its analytic methods” (Wolf 1996).
The feminist movement has created historical societal changes regarding the rights of women, and aims to achieve equal political, economic, cultural, personal, and social rights for women. In this sense, feminist agenda includes achieving reproductive rights for women such as access to contraception and abortion. However, in a global context, feminist critique has been challenged and criticized for prioritizing the perspectives of Western women, and thus increasing the extent of marginalized women in other areas of the world, especially societies where advocating women’s rights can mean threats to life. Later movements of feminism are including leaders of thought from nonwhite backgrounds.
The Female Body In Clinical Medicine
Although the following sections expose bioethical issues related to gender, the female body undergoes peculiar transformations in each of the different contexts. These range from being silenced in the sense of the lack of space for female perspectives or the personiﬁcation of the female body as a “mother” in embryology or objectiﬁed in terms of her body when considering practices used to control a woman such as female genital mutilation and gender-based violence.
The way we structure our concept of the body has implications for clinical medicine, and these implications originate from even the most fundamental – conceptual and theoretical – of levels. For example, Edmund Pellegrino (2008, p. 309) points out that “Man’s most daring creations promise to annihilate him as a person unless he can decide who he is and what his existence is for and where it should lead.” Pellegrino argues that the current context of medicine – one whereby the boundaries between life and death are no longer ﬁxed points (Lizza 2009, p. 1) – requires us to re-examine our understanding of the body, or at least the lens it is viewed through fearing that the impact of a description about the body that is considered as neutral and value free will forego a conscientious and responsible analysis of society.
The implicit reference in Pellegrino’s observations is that without a conscientious and evaluative analysis of the way that medicine uses the body for its action both our bodies and our societies may suffer. Furthermore, it implies that how we treat the body reﬂects our society, a premise from which Foucault (1973) established his conception of ethics. The human condition is not merely experienced, it is enacted; a “good” society, body, ethic, or medicine is not discoverable but is practiced (Foucault 1973), or alternatively, our understanding of the human condition is formed through practice discourses. Such discourses that have focused on gender in bioethics have been lacking and only undertaking speciﬁc focuses such as surrounding reproductive medical practices means that we produce a certain kind of body.
In contemporary practices, although gender aspects are being recognized in bioethical debates, the body is considered as a neutral object in anatomical and medical discourses. Bioethical debate is therefore instrumental in developing the gender relations of the body in biomedical practice. Alasdair MacIntyre (2001) in Dependent, Rational Animals grounded a virtue-based theory of ethics, revived from Aristotelian moral philosophy, in a biological understanding of who we are as human beings, and individual members of society. MacIntyre engaged with texts from both ethics and biology, and developed an approach that looked at the underpinnings of the tensions we are currently facing concerning our moral practices, or how we are to ethically treat another person, especially persons who are marginalized due to differences such as gender. An aspect of this formed the central tenant of Dependent, Rational Animals, where MacIntyre argued that we cannot distinguish between independence and dependence. We are necessarily both independent and dependent, and the growth of morality is contingent on how we view others and learn from our social relationships. We must recognize gender and the vulnerability, which occurs in the presence of gender in certain social and medical conditions. MacIntyre argues that we are physical, biological beings and ethics is part of this nature. This role of our biology in forming our condition, our morality – and human ﬂourishing – is what MacIntyre (2001) called a “metaphysical biology.” Thus ethics and biology are not mutually exclusive and when we talk about gender we are also referring to the metaethical realities of the lived experiences of individuals. This research paper now proceeds to discuss certain cases of gender in bioethics debate.
Reproductive Health And Technologies
Feminist bioethics and the emergence of greater reproductive choices led to enhanced debates about the medicalization and the commodiﬁcation of women’s bodies, namely, to increase freedom of choice and negate oppression and control of a woman’s body by male members of society. Women’s bodies gained scrutiny and it began to be understood that the body is gendered. Furthermore, the way the body is shaped in clinical medicine, as so far discussed, has a signiﬁcant impact on bioethics debate that emerges from analyzing the relationship between the body and medical technologies. A major part of bioethics debate grounded in gender is on reproductive health; the promotion of rights for women to access healthcare globally is an essential part but also the assumptions and choices that take place following the gendered body. In Reproductive Genetics, Gender, and the Body: ”Please Doctor, May I have a Normal Baby,” Elizabeth Ettorre (2000) argued that the continuation of privileging a mechanistic view of the body constructs a “limited view of the body” and “the way reproductive genetics operates tends to hide the fact that what may appear as ‘defective genes’ is a result of a body’s interaction not only with the environment but also gendered social practices valorized by difference as well as rigid deﬁnitions of health and illness.”
In this sense, selective abortion is a practice that has emerged from the ability to detect the gender of the fetus via ultrasound. Female speciﬁc abortion is selected due to the undesirability of having a daughter in certain societies. India is where the problem is most at large and population census surveys show evidence that aborting a female fetus is signiﬁcantly impacting on society. There is an extreme deﬁcit of young girls compared to young boys across various states in India. Female speciﬁc abortion is the result of “preexisting discriminatory practices that have extremely deep historical roots” (Patel 2007, p. 17). Thus, although it may be the case that abortion is permitted in a society, opting for an abortion based on the gender of the fetus is viewed as ethically wrong because it creates and continues gender inequality.
Gender selection, however, is not a new practice. Prior to medical technologies such as ultrasound and accessibility to abortion in healthcare facilities, female infanticide took place at birth. Thus, the issue has been at stake over generations and has been shaped by developing medical technologies and new healthcare policies. As a result gender is being placed under a new light and raising further issues in bioethics debate. Globally, “travelling cultures” (Ahmad 2014) mean that societies where this phenomenon was not previously present are being faced with the ethical issue of terminating a pregnancy on the basis of gender for cultural reasons within different normative frameworks. In the UK, for example, in areas where there are high risks that gender-selective abortion may occur, ultrasound testing for gender is not permitted. This again raises ethical issues regarding health justice and discrimination. But it also highlights the intersection between health and human rights in tackling gender inequalities.
The act of termination of pregnancy, or more precisely, the debate about the moral permissibility of legalizing abortion as a medical intervention, is a pivotal example in raising the importance of gender in bioethics. Using the dominant lens for viewing the human body, the biological meaning of termination (prior to 8 weeks gestation) refers to the cessation of a particular embryonic development. During this early stage of pregnancy, embryos either fail to develop or (in over a third of pregnancies) are aborted due to an anomaly (Wilcox et al. 1988). In such cases, the human body undergoing the pregnancy, and subsequently the loss of the pregnancy, is passive and although obviously female is gender neutral. The gender aspects such as social determinants of health and vulnerabilities to circumstances that increase the risk of a miscarriage are bracketed from the description of the pregnancy cessation.
The (clinical) act of termination, however, is a deliberate interaction with embryonic development intended to prevent the presence not of the unborn but of the “born.” The embryo is not desired because it represents the becoming of a new individual member of one’s own family, society, cultural, and/or religious group. Consequently, because the embryo is fundamentally more than the aforementioned biological meaning of pregnancy (and termination), movements in the provision of women’s healthcare have seen the legislation of termination in particular countries advocate the choice and autonomy of the pregnant woman. Furthermore, the Roe versus Wade case (410 U.S. 113 1973) changed “choice” into “right.” A woman now had the constitutional right to terminate her pregnancy (Steinbock 1992, p. 43).
As Mary Boyle (2014) in Rethinking Abortion: Psychology, Gender and the Law, women (in the UK) have been able to have abortions legally for over 30 years yet abortion has rarely been considered as anything other than a health issue. There is a nulliﬁcation of gender roles in the act of termination of pregnancy. In other words, it is only in extreme and difﬁcult cases that circumstances related to gender in society are contextualized in the health setting, most primarily to ﬂesh out premises that the ethics of abortion debate is grounded in. For example, abortion to save the mother’s life is a common argument and moral, religious, and legal justiﬁcation in many societies. Yet, interestingly, the woman is not yet a mother, thus her gender is surpassed by an identity that is prescribed and imposed on certain expectations related to her gender in her society – a woman is synonymous with being a mother. Her identity as a woman, who is also a patient, and suffering from a medical condition, where her own life is under threat, is merged with the existence of the embryo/fetus. In this example of gender in bioethics, it is important to note that recognition of the rights of a woman does not necessarily entail that gender is sufﬁciently treated.
Gender inequalities lead to unsafe and illegal practices of abortion plus increased rates of maternal mortality as a result of abortion-related deaths. Malawi, for example, has one of the highest mortality rates in the world – 24 % of maternal rates are attributed to unsafe abortion. Overall, out of 44 million abortions that are estimated to be carried out each year, a little under half of these are undertaken unsafely (Sedgh et al. 2007). Even in countries where abortion is legal, it may only be legal under certain circumstances such as if the physical life of the woman is at stake, or with the signed consent and permission of a male member of the woman’s family. A further clause is that stigma and lack of conﬁdentiality such as in South Africa may draw women to seek unsafe abortions outside of the clinical setting.
Female Genital Mutilation
Female genital mutilation (FGM) is the ritualistic removal of some or all of the external female genitalia. As it is practiced as a cultural practice, FGM is performed by a traditional circumciser, which is typically not sterilized, and without anesthesia, and usually by an elder female member of the community. Although FGM is illegal in most of the countries where it is prevalent, concentrated in 27 African countries as well as Iraqi Kurdistan, the Middle East, and Asia, poor enforcement of the law results in the continuation of the practice. Human rights activist Waris Darie, for example, reﬂects on Djibouti and the difﬁculties in reducing FGM practice as it being impossible to imprison 90 % of the population. Nigeria is the latest country to criminalize FGM and this is a signiﬁcant milestone. However, regulation of the practice and prosecution is difﬁcult. Even in the UK, where there are an estimated 103,000 women and young girls living with FGM, there has only been one prosecution.
Furthermore, FGM is symbolic of the underlying tenets of the societies that consider it essential for maintaining the purity of a young girl and ensuring a high bride price and future marriage proposal. Failure for a young girl to be circumcised, which can occur at any age from a few days after birth to puberty, can lead to severe consequences such as the girl becoming ostracized from her family, and likewise, the family from their community, as well as increasing the risk of violence and harm toward the uncircumcised girl.
FGM highlights gender inequalities in a society and the consequences for health of individuals who are vulnerable due to their gender. FGM has primarily been treated as a social and cultural issue, and sometimes argued in a religious context, and thus has been marginalized from healthcare discourses. However, the increase of multiculturalism from increasingly globalized societies in Western countries has rejuvenated the FGM debate in a bioethical rhetoric. FGM raises questions about cultural (and religious) pluralism in ethics, and boundaries and limitations of cultural and moral relativism. The appearance of patients in Western healthcare settings who have undergone or at risk of FGM has led to development of guidelines for healthcare professionals regarding protocols on disclosure and reporting. In turn, this has called for a greater implementation of bioethics and human rights related to health in medical education.
The UK case involved a medical doctor. Dhanuson Dharmasena, an obstetrics and gynecology registrar, was accused of reconstructing a patient’s FGM during a procedure that involved resuturing a scar following childbirth. Earlier this year, Dharmasena was acquitted and proved that the procedure had been undertaken for clinical motivations. However, his case raises issues that medical practitioners – and fundamentally, medical educators – cannot ignore. During Dharmasena’s court case, he was asked if he had read the guidelines issued by the Royal College of Obstetrics and Gynecology on FGM. He said that he had not. His admission reﬂects the divide between clinical and cultural issues throughout the entire systematization of medical knowledge.
Medical practitioners play an important role in the protection of individuals in society. But when cultural practices such as FGM prompt grave human rights concerns, the situation can be complex. It takes a great deal of conﬁdence to navigate different cultural dialogues – and the very notion of culture is very difﬁcult to integrate into the sterilized, neutral vocabulary of medicalized descriptions of our human condition. FGM poses signiﬁcant challenges to the ways that bioethical debate must function and the topics it needs to address to be relevant for the individuals who are subject to health injustice on the basis of gender.
Gender And Disaster Bioethics
Gender and health are inextricably linked in the context of disasters and are a representative example of gender in the context of global bioethics. Disasters are a social phenomenon and social processes become more visible in times of crisis. This means that societal, cultural, and religious norms and values are evident in the nature of a disaster and shape the needs and risk of affected individuals. Gender is an organizing principle in society, and thus disasters are not gender neutral. Working within a disaster is representative of the society during “peace” times. Humanitarian guidelines must account for the values within society, which poses difﬁculty when working from a position of neutrality and needing to advocate pluralism. Furthermore, gender is under recognized in terms of its impact. Triage and disaster recovery may be at risk of minimizing the importance of gender. The typology of a disaster affected by gender includes the following categories: exposure to risk, risk perception, preparedness behavior, warning communication and response, physical impacts, emergency response, recovery, and reconstruction.
Gender offers us a conceptual challenge by way of requiring recognition of our own values in different circumstances and contexts where gender may be treated in ways very different to our own values. The status of women is one of the most contentious issues related to gender, which has signiﬁcant impacts during disasters. However, before the effects of gender on disasters are described, there must also be reﬂection on how humanitarian actors are to manage situations when faced with ethical or human rights conﬂicts. For example, a humanitarian worker practicing in a society where the right to freedom is not fulﬁlled in ways that a woman from a Western country may be accustomed to will need to be aware of how they frame a woman who is required to wear certain clothing such as a headscarf. Is this a mask of oppression or an enactment of honor? This is an example of a normative question that infuses the gaze of the humanitarian worker toward a member of the society that they are assisting with.
The disaster phase remains even after the initial threat of the disaster has ceased. The recent earthquake in Nepal, for example, produced over 100 tremors and a second earthquake of 7.0 magnitude 2 weeks after the initial devastating earthquake. In addition, the social issues brought to the surface continue during the psychological reaction to the disaster and the reconstruction of the respective society/societies.
A recent study from Iran concluded that different aspects of a disaster were manifested through different aspects of gender. In the context of recent earthquakes in Iran, it was described that a woman is present in society in different ways, namely, as an individual who experiences the disaster, as a member of a family, and as part of a community (Nakhaei et al. 2015). Using these themes, Nakhaei et al. were able to identify key needs of Iranian women affected by the earthquakes. By linking the status of gender within the Iranian context, an appropriate disaster response could be tailored. A major concern of affected women was to be resettled into a permanent home, which reﬂected the status of the woman in the family structure as needing to mediate the changes that occurred in their family including separation and loss of male family members. This poses practical challenges for a woman’s everyday life in a society where liberty is restricted based on gender as well as the emotional impact of the bereavement and reorganization of family life. Finding ways to recover from a disaster may be at odds with the ideas of progression and modernity that humanitarian workers have as their ideals and markers of a functioning society. This gap in perception and goals for planning needs addressing. Often it can lead to an uncomfortable prescription of imposing normative values or realigning gender roles and requirements onto a foundation that is not sustainable.
Positive social transformation related to gender is possible in the context of disaster settings. The Nepalese civil war conﬂict offers a long-standing example. Traditionally Nepalese widows were required to wear a white sari. However, following an armed conﬂict over 10 years between 1996 and 2006 and over 15,000 deaths, many women became widows. During the postconﬂict era, widows challenged the centuries-old entrenched belief system surrounding the status of women and resisted the practice of the White Sari (Yadav 2015). Here the multiplicity of disaster is witnessed. The context of a conﬂict became the site in the social transformation from a form of gender discrimination to gender equality.
Gender-Based Violence And Healthcare Ethics
In a recent statement, Major General Patrick Cammaert, former UN Peacekeeping Commander, said, “It is now more dangerous to be a woman than a soldier in modern conﬂict.” In addition to violence reﬂecting societal statuses, prejudice, and lack of human rights from a perspective of gender, sexual violence is increasingly appearing as a military strategy as a “weapon of war.” During 2013, psychological aid and support in the aftermath of sexual violence by UN humanitarian agencies was provided to 38,000 people. In Lebanon, home to the largest number of Syrian refugees, postrape treatment was provided from 17 hospitals and primary health care centers. On average, during 2013, 75 people each month who had experienced sexual violence during the Syrian conﬂict accessed UN services in the Za-atari refugee camp in Jordan. The fear of sexual violence is also a driving force for refugee exodus – women and children are ﬂeeing conﬂict regions where they fear they are at risk of being victims of sexual violence.
Despite the documented cases of sexual violence during the Syrian conﬂict, the International Independent Commission of Inquiry on the Syrian Arab Republic (March, 2013) found that “direct accounts of sexual violence continue to be sought from victims and eyewitnesses. It remains immensely difﬁcult to collect ﬁrst-hand accounts due to a culture of silence that prevents reporting.” Thus, a gendered effect of sexual violence also extends to the aftermath of the trauma via the phenomenon of nondisclosure.
Disclosure of sexual violence is especially risky for women who are situated in predominantly patriarchal and religious societies in both times of peace and conﬂict. Remaining silent fosters a host of gender-determined strategies. Silence can enable the maintenance of family relationships and social cohesion among a backdrop of socially constructed shame for being a victim of sexual violence. Sexual violence victims are also vulnerable to other related gender-based violence such as honor killings if their trauma is revealed due to strong stigmas and sensitivities regarding sexual violence. Furthermore, during conﬂict, with family members dispersed and people internally displaced, there is a limitation of trustful objects thus the environment for safe disclosure is far removed.
The disclosure of sexual violence in the humanitarian context is also problematic. Sharing of sexual violence trauma by a woman to a male elder is problematic across many cultural contexts. The nature of the sexual violence as a “weapon of war” also particularizes gender further. Women are targeted because their role in society symbolizes collective aspects such as bearing families and creating new life. This is at odds with the tyranny of war. Thus rape is a “deliberate strategy to undermine community bond and weaken resistance to aggression” (Swiss and Giller 1993). Whatever happens to a woman in war is also an attack on the male members of her family. In this sense, it can be added that “since rape in war affects not only the individual but also the family and community to which the survivor belongs, the restoration of social and community bonds is central to the process of healing and must be addressed within the speciﬁc cultural setting” (ibid). The characteristics that render women vulnerable and at risk during conﬂict also represent key features for the recovery of herself and her society.
Justice is also a signiﬁcant aspect for the purpose of disclosure. Women who were victims of sexual violence may play a role in criminal proceedings against war atrocities. For some women, being part of a justice process will be the ﬁrst time in their lives where their voice is validated and recognized to contain the value and worth of a human being. The future of the society may also be dependent on a woman’s ability to disclose her testimony – a reﬂection on the Bosnian women who were victims of rape as a “weapon of war,” for example, is that “there will be no justice, unless women are part of that justice” (Hoefgen 1999).
On March 19, 2015, a 28-year-old woman, Farkhunda (Afghans traditionally use one name), was brutally murdered during daylight in the center of Kabul, Afghanistan. A mob quickly gathered on hearing a verbal accusation by a local man from a shrine where Farkhunda taught religious scriptures that she had burnt the Holy Quran. Farkhunda was beaten to death, burnt, and her body dumped in a river. This incident has revived the discourses related to gender and women’s rights in Afghanistan. However, this individual incident cannot be isolated from the disaster of conﬂict that several generations of Afghans have known.
Rona Popal, Executive Director of the USA-based Afghan Coalition, issued the following statement during an interview about Farkhunda’s murder: “What happened in Kabul, Afghanistan is all due to 35 years of wars in Afghanistan. Wars completely destroyed our religion and culture of Afghanistan. More than 80 % of Afghans have mental problems. They see every day people are being killed in front of them in pieces so people have no feeling toward each other and to their community.” Importantly, the pallbearers for Farkhunda’s funeral were all women. As women are not permitted to attend funerals in Afghanistan, this was a signiﬁcant sign of shifting values in gender rights and roles. Gender is a concept permeable to societal events and narratives.
Gender is an important aspect of bioethics debate and recognition of the gendered body is vital for human rights. However, gender has struggled to gain its place in bioethics debate and at present it is still neglected. With the increase of bioethical issues in societal and public forums and with further academic research, however, the importance of gender will increase. Major topics in bioethics that are related to gender have been discussed in this research paper, although not exhaustively. This served as an introduction to the role of gender in bioethics debate.
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