Women, Medicine, Ethics and the Law

Susan Sherwin, Barbara Parish

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351746021
• Edition: 1
• Topic: Sciences sociales
• Subtopic: Sociologie

This title was first published in 2002: A collection of articles focused on women within a general study of medicine, ethics and the law. Topics covered include: areas where the institutions of medicine, ethics and the law intersect in women's reproductive and sexual lives; the impact of legal policies and dominant ethical beliefs on many aspects of women's health; and the health practices and policies of bioethics and health law. The editors recognise that it is important not to lose sight of social differences other than gender, such as race, ethnicity, class, age, sexuality, religion, level of physical and mental ability, and family relationships. In their approach they seek to consider the lives and experiences of women as primary. Hence, they focus on the question of how women's encounters with the health-care system are structured by gender and other socially significant dimensions of their lives (rather than the question of how women differ from the male "norm").

[1]

Gender and Culture in the Globalization of Bioethics

Christine E. Gudorf^*

In the last four decades, the field of western bioethics has broadened from its original focus on physician-patient issues (hence the name change from medical ethics) in three general areas: a tremendous expansion of issues involving both new technologies and research norms, as well as the challenges to both prevailing principles and practices from the women’s movement.¹

The latest challenge to the field of bioethics arises within the globalization of the field, and includes issues such as the shifting of technology from rich to poor nations, the health care brain-drain from poor to rich nations,² as well as the challenges to bioethic principles from both non-European cultures and the growing crisis of environmental degradation caused by overconsumption and overpopulation.

This paper will address two specific challenges to bioethics within the globalization process: 1) female circumcision, and 2) the role of health care personnel in fertility reduction. Both issues involve challenges to existing understandings of bioethics, affect largely female populations, and are highly charged religious issues in much of the world. Furthermore, there are dramatic implications in these issues for the future of American bioethics.

I FEMALE CIRCUMCISION

Until fairly recently, relatively few persons outside affected nations had much knowledge of the various practices encompassed by the term female circumcision.³ Individual Christian missionaries usually deplored the practice when they came into contact with it in the nineteenth century.⁴ However, ignorance prevailed until international organizations, most notably UNICEF and the World Health Organization (WHO), began in the early 1980s to advocate the abolition of what was called “female genital mutilation,” and women’s groups around the world (in affected as well as unaffected nations) began publicizing the practices grouped under the term.⁵

The two bioethical principles relevant to female circumcision are beneficence, or a ban on maleficence (based on the pledge in the Hippocratic oath to do no harm) and informed consent. Female circumcision practices vary according to the age of the girl at the time of circumcision.⁶ Most African cultures practicing female circumcision place it within puberty rituals,⁷ though the Beja and the Beni Amir tribes of Sudan historically circumcised girls of seven to forty days old.⁸ But the age of circumcision for girls in Africa seems to be dropping. Descriptions of groups of newly circumcised girls often report ages from four to nine years old, and in some groups the surgery is done on girls who are only twenty-four months old.⁹ Very seldom are adults the subjects of female circumcision.¹⁰ Normally, parents are the guardians of minor children, so informed consent for intervention in the health of a child must be obtained from the parent. In the case of female circumcision, mothers, usually with the tacit consent of fathers, arrange for the circumcision, often with the help and sometimes the prompting of both maternal and paternal grandmothers who, in many cultures undergoing modernization today, tend to have more loyalty to traditional cultural and religious practices.¹¹ Female circumcision, then, does not formally violate the principle of informed consent, since it is the guardian of the child (a guardian who herself likely underwent the same surgery as a girl) who arranges the surgery. It is more difficult to conclude that female circumcision does not violate the principle of beneficence.

This principle insists that any harm inflicted on patients be both temporary and outweighed by future health benefit. Different socio-religious cultures have different explanations of the benefits and necessity of female circumcision, depending upon both the type of procedure locally done and the cultural understandings of gender and sexuality.¹² Female circumcision is the term used to describe at least three different surgical procedures. The most simple is the removal of the clitoral hood, sometimes along with a piece of the labia minora (the inner lips of the vulva).¹³ This form is appropriately called female circumcision, since the hood of the clitoris is the analogue of the foreskin of the male penis.¹⁴ However, this mild form is clearly the least practiced form in the contemporary world.¹⁵ The intermediate form is a clitoridectomy, or excision of the entire clitoris, hood, glans and shaft, sometimes along with some or all of the labia minora.¹⁶ The most extreme form of female circumcision is genital infibulation, often called pharaonic circumcision in Africa, and includes a clitoridectomy as well as the excision of the labia minora and as much as possible of the labia majora.¹⁷ As a part of this last form of circumcision, the edges of skin on either side of the labia are stitched together, leaving a straw or wood splinter to hold open a one-centimeter passage for urine and menstrual flow, after which the girl’s legs are tied together for three or four weeks.¹⁸

The resulting health dangers from female circumcision depend upon both the type of circumcision done, and the degree of sanitation within the surgical situation. Female genital surgeries outside urban areas are performed either by female midwives, most of whom learned their trade from mothers or grandmothers, or by male barbers or priests, none of whom have much knowledge of antisepsis.¹⁹ In the cities, some circumcisors have some medical training, but few circumcisions involve anesthesia or sterile conditions.²⁰ The most immediate health dangers are infection, hemorrhage, and tetanus.²¹ Few reliable statistics exist on mortality or sickness following circumcision, despite the fact that experts estimate there are 84 to 200 million living women who have undergone one of these procedures, usually under appalling conditions.²² Deaths following circumcisions are attributed to everything from hostile spirits to bad humors in the blood. In those who survive both the procedure itself and the infections which commonly follow, there can be two different kinds of damage. One is the damage to the woman’s health, and the other is the reduced ability to enjoy sex.

The first type of damage is more or less limited to the pharaonic circumcisions.²³ Women with pharaonic circumcisions experience extreme pain from vaginal intercourse since it involves the erect penis tearing through scar tissue.²⁴ Studies show that new husbands require as long as two to twelve weeks and alcoholic fortification to achieve full vaginal entry.²⁵ Doctors tell stories of frustrated men plagued with impotence as a result of weeks, months, and even years of trying to penetrate the scar tissue, and who finally secretly bring their wives to a doctor, who breaks scalpels and scissors cutting through.²⁶ Moreover, every new tear heals, leaving thickened scar tissue which is re-torn with succeeding intercourse.²⁷

Further damage to a woman’s health arises from medical complications with childbirth. Scar tissue is not nearly so elastic as normal skin, and thus will tear and bleed much more extensively, often delaying second stage labor.²⁸ But pharaonic circumcision is also a health risk apart from sex and childbirth. Pharaonically circumcised women take fifteen to forty minutes to void their bladders, leaving residual urine and menstrual flow trapped behind the barrier of scar tissue to become a site of both vaginal and urinary tract infections.²⁹ There is also a strong link between pharaonic circumcision and high Acquired Immunodeficiency Syndrome (AIDS) transmission rates in parts of Africa.³⁰ This is due not only to the inevitable scar tissue tears in vaginal intercourse that allow HTV+ semen access to the female’s blood system,³¹ but also to the fact that many couples avoid the problems wrought by pharaonic circumcision on vaginal sex by shifting to anal sex,³² which also poses high risks of HIV+ transmission. In addition, the more severe forms of pharaonic circumcision can remove so much skin, and even muscle, from the area around the crotch that free movement of lower extremities is permanently impeded;...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Series Preface
• Introduction
• 1 Christine E. Gudorf (1996), ‘Gender and Culture in the Globalization of Bioethics’, Saint Louis University Public Law Review, 15, pp. 331–51.
• 2 Bonnie Kettel (1996), ‘Women, Health and the Environment’, Social Science & Medicine, 42, pp. 1367–79.
• 3 Rebecca J. Cook (1993), ‘International Human Rights and Women’s Reproductive Health’, Studies in Family Planning, 24, pp. 73–86.
• 4 George F. Brown and Ellen H. Moskowitz (1997), ‘Moral and Policy Issues in Long-Acting Contraception’, Annual Review of Public Health, 18, pp. 379–400.
• 5 Catriona Mackenzie (1992), ‘Abortion and Embodiment’, Australasian Journal of Philosophy, 70, pp. 136–55.
• 6 Abby Lippman (1991), ‘Prenatal Genetic Testing and Screening: Constructing Needs and Reinforcing Inequities’, American Journal of Law and Medicine, 17, pp. 15–50.
• 7 Robert H. Blank (1993), ‘Maternal–Fetal Relationship: The Courts and Social Policy’, The Journal of Legal Medicine, 14, pp. 73–92.
• 8 Linda LeMoncheck (1996), ‘Philosophy, Gender Politics, and In Vitro Fertilization: A Feminist Ethic of Reproductive Healthcare’, The Journal of Clinical Ethics, 1, pp. 160–76.
• 9 Elizabeth S. Anderson (1990), ‘Is Women’s Labor a Commodity?’, Philosophy & Public Affairs, 19, pp. 71–92.
• 10 Judith Mosoff (1995), ‘Motherhood, Madness, and Law’, University of Toronto Law Journal, 45, pp. 107–42.
• 11 Alice Domurat Dreger (1998), ‘ “Ambiguous Sex” - or Ambivalent Medicine? Ethical Issues in the Treatment of Intersexuality’, Hastings Center Report, 28, pp. 24–35.
• 12 Karen L. Baird (1999), ‘The New NIH and FDA Medical Research Policies: Targeting Gender, Promoting Justice’, Journal of Health Politics, Policy and Law, 24, pp. 531–65.
• 13 Kirsti Malterud (1999), ‘The (Gendered) Construction of Diagnosis Interpretation of Medical Signs in Women Patients’, Theoretical Medicine and Bioethics, 20, pp. 275–86.
• 14 Lisa S. Parker (1995), ‘Breast Cancer Genetic Screening and Critical Bioethics’ Gaze’, The Journal of Medicine and Philosophy, 20, pp. 313–37.
• 16 Kathleen Marie Dixon (1994), Oppressive Limits: Callahan’s Foundation Myth’, The Journal of Medicine and Philosophy, 19, pp. 613–37.
• 17 Kathryn Pauly Morgan (1991), ‘Women and the Knife: Cosmetic Surgery and the Colonization of Women’s Bodies’, Hypatia, 6, pp. 25–53.
• 18 Susan Wendell (1989), ‘Toward a Feminist Theory of Disability’, Hypatia, 4, pp. 104–24.
• 19 Nancy S. Jecker (1993), ‘Privacy Beliefs and the Violent Family: Extending the Ethical Argument for Physician Intervention’, JAMA, 269, pp. 776–80.
• 20 Sally Zierler and Nancy Krieger (1997), ‘Refraining Women’s Risk: Social Inequalities and HIV Infection’, Annual Review of Public Health, 18, pp. 401–36.
• Name Index