Saturday, April 22, 2006

Killing the Black Body, by Dorothy Roberts

My mentor suggested this book as a "relief" after I finished reading Beauchamp & Childress's Principles of Biomedical Ethics. I've written elsewhere about why I might need "relief" after reading B&C. Roberts certainly offered a challenge to the dominant mode of bioethics (as represented by B&C, whose work is not just the standard read, but the gold standard), but perhaps not challenging enough.

If you're not up on why people might challenge the standard read, the short version is that it is heavily invested in moral reasoning that privileges autonomy or maximizing choice. In Beauchamp and Childress's case, even though their bioethical principles include justice, beneficence, and non-maleficence as well as autonomy, when you read through their chapters on the three other principles, the other principles are defined in terms of autonomy. So, their definition of distributive justice is a distribution that mitigates inequities for which one is not responsible (which one didn't choose). Their definition of maleficence is anything that impinges on the freely chosen life plan of another. Obligations of beneficence are optional when they involve more than minimal inconvenience.

So, ever since the Nuremburg trials, the understandable and admirable goal of various proposed or enforced laws, policies, professional ethics statements, and so on is to protect or maximize the autonomy of the individual chooser. Never again should non-consensual medical procedures be performed; never again should doctors lie or coerce; never again should the search for knowledge justify cruelty. All well and good.

Now, this interest in personal autonomy has channeled the discussion of reproductive liberty into a certain predictable course. When one speaks of reproductive liberty and whether and how it should be abridged by the state, one assumes certain things about reproduction: that it is an activity undertaken by an agent whose choices and life plans must be honored even by those who may not agree with her choices and plans. That which is good, reproductively speaking, is that which enables the agent to make better, more informed choices, or to carry out those choices more effectively and efficiently. Distributive injustice occurs when technologies and information exist, but are not available to a certain chooser because of the selfishness, paternalism, or economic policies of people or nations. (So, even though IVF produces waste embryos, it is good because it helps couples realize a particular goal; failing to offer pre-natal diagnostic tests is a paternalistic refusal to allow a woman to make a choice about the course of her pregnancy; etc.)

Roberts does not challenge autonomy as a pre-eminent value of bioethics; she challenges how the standard read ignores the racial dimension inherent in the discourse of reproductive liberty. She traces the history of reproduction among African-Americans, highlighting how reproductive liberty has been an elusive dream for Black women. (I'll use Robert's self-designation for the rest of this review.) Under slavery, their wombs and the fruit thereof were the property of their masters; Margaret Sanger, late in her career, joined with eugenicists to plant clinics in predominantly black and immigrant areas (Roberts wants to believe that Sanger's motives remained pure, though, despite her evil bedfellows); welfare reform proposals often seek to limit the "irresponsible" fertility of minority women; doctors who treat infertile Black women often push adoption rather than referring them to a reproductive endocrinologist; even members of the early Black Panther movement instructed Black women that it was their duty to reproduce for the sake of the race--no liberty to be had, even in the fight for liberty.

She challenges both classic pro-choice discourse as well as pro-life discourse. Pointing to one practice for disciplining pregnant slaves--digging a hole in the ground just large enough for her belly, so that she could be whipped without damaging the valuable commodity in her womb--she suggests that any discourse which seeks to protect a fetus at the expense of its mother's choices participates in this slave-holding mentality. (I cannot agree with this as a blanket statement, but it is certainly a provocative read on, for example, laws that seek to criminalize prenatal drug use among minority women.) Yet she also suggests that pro-choice activists focus too much on securing birth control and abortion services for minority women, at the expense of efforts to secure pre-natal care and funding for child assistance programs. They assume, in other words, that offering liberty and justice to Black women means offering them ways to have fewer children, not more. When economic reality forces women to choose between food and childbearing, Roberts suggests that offering access to abortion is not enough. The economic reality must be changed, so that the woman can have real choices.

In the end, however, her constructive proposals fail to offer anything new, save a powerful read of the history of reproduction as influenced by racism. Her analysis of the ways in which poor and minority women are overlooked or ignored (and even demonized) in many discussions of distributive justice is convincing. If one is committed to maximizing autonomy as *the* appropriate goal of justice (distributive and otherwise), one will appreciate her challenge to give greater attention to maximizing the autonomy of minority and low-income women. One may wonder how on earth the government is supposed to finance this autonomy-maximization (which necessitates, for example, infertility treatment for any who might want it, including the destitute). But one will have no serious objection to her basic argument: if autonomy is to be protected at all, it must be protected for Black women.

If one would like to hear a more serious challenge to the role of autonomy in the pursuit of the justice, the common good, or individual happiness, it's not here.


JoVE said...

Very interesting. I think I agree with you about autonomy needing to be knocked off top spot in the values chain. In the US, autonomy seems to be even more politically privileged than elsewhere. Or it seems so for those of us who are elsewhere.

I stll think that one of the problems is one central to liberal political thought, which is based on an understanding of the individual as wholly independent. Carol Pateman's The Sexual Contract is a very good critique of this, explaining how even the male head of household who supposedly embodies this ideal is not wholly independent but dependent on a wife to deal with the messiness of life, thus allowing him to be in the public world as an independent individual.

when you get to reproductive ethics, the difficulty is the inherent inseparability of the woman and the fetus/child. In a discourse dominated by the autonomous individual, you have to deny/privilege either the mother or the child to be able to talk about the issues at all.

there are also various levels to reproductive choice issues which you hint at. One is the legal ability of a woman to choose a procedure (IVF, abortion, birth control, etc). One is the existence of REAL choices (economic hardship, etc being important here). And another is whether as a society we can place limits on how much of our collective resources we will spend on providing certain procedures (different depending on the way you finance healthcare).

Of course, in the latter case, you get into a broader healthcare debate about priorities and choices in healthcare provision in general. A debate which I think is significantly skewed by the fact that no one will think the health care system is working until we have immortality, eternal youth, and a complete abscence of illness. Clearly an unreasonable wish list.

Sarah said...

". . . no one will think the health care system is working until we have immortality, eternal youth, and a complete abscence of illness."

*Snort* Oh, how right you are!