To the Barricades or the Blackboard: Bioethical Activism and the “Stance of Neutrality”
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KeywordsBioethics Activism Neutrality Sexual orientation Gender identity Heteronormativity Biopower
Margaret Thatcher, the former British prime minister famously dismissed a meeting with a group of medical royal college leaders as “a mere trade union delegation.” This was, of course, an affront to their professional status and dignity. It also provided a brutal lesson in the boundaries of professional authority in the eyes of government when what might be termed the “stance of neutrality” strays, perhaps unintentionally, into the political arena (however misguided the PM of the time might have been in her perceptions).
In their editorial in this edition, Dawson and colleagues (2018) have posited the view that bioethics cannot stand by in a neutral “academic stance” when it is confronted by abuses of human rights. They therefore question the concept of a “neutral stance” as an accepted norm in bioethics, largely derived from the academic Socratic tradition of even-handed enquiry and normative standards.
In the last editorial in this journal (Ashby and Morrell 2018), we commented on the positioning of bioethicists in the wider scientific world and questioned whether they were sometimes embedded in the subject they were commenting on and therefore in some way no longer neutral. Dawson et al. now open up another important dimension of the “gaze” of the bioethicist: the academic activist. This role has the potential to generate conflicts for bioethicists themselves and their various audiences. The problem is that without a clear boundary between academic analysis and political engagement, the field risks losing its authority, primarily with governments and regulators, but also with other members of the academy and wider society.
A non-political and dispassionate stance in bioethics gives the field a certain detached authority that is usually endorsed by governments and regulatory bodies. This is certainly the case with normative medical and health professional ethics, with particular regard to the codes of practice. These engender moral authority and, by setting clear standards and boundaries of practice and conduct, represent lines in the sand that can be respected by nearly all parties.
The problem of neutrality comes into sharp focus at the hazy intersection between normative ethics and ethics as a field of argumentation. In this sense ethics is really no different to politics. The very reason that there is the subject at all is essentially because there is substantial disagreement about many ethical issues within the professions themselves, as well as more broadly in most societies. The normative ethics codes do, nonetheless, represent broad agreement about key bottom lines and principles that enjoy a very high level of international agreement. It is largely from this normative area that ethics and ethicists derive their authority, and it is this consensus and acceptance that is potentially under threat if it becomes conflated with ethics as an engaged political force.
It is probably therefore desirable for ethics as activism to be clearly separated off from the academic discipline itself and its normative consensus standards. If academic neutrality is lost and the subject of ethics and bioethics is directly used in politically contentious debates, the credibility of bioethicists to defend the standards they hold dear is also potentially compromised. Dawson and colleagues (2018) are certainly entitled to criticize, for instance, the treatment of asylum seekers in Australia, and one would imagine that most workers engaged in bioethical inquiry there and around the world would support them. This necessary protest does, however, need to be badged as such and differentiated from their academic canons. It is commonly seen and accepted that, over many years, groups of academics and professionals have written public condemnations of human rights abuses in the form of letters and advertisements. This “segregated” form of activism protects the body of academic work and scientific endeavour from itself being embroiled in the political process. However the problem remains that much of bioethics itself is contestable and indeed the field is full of dialectical difference. There is therefore no pure scientific canon in bioethics that can be ring-fenced off from the contested political arena.
This journal thrives on exploring difference from many viewpoints using diverse methodologies. It takes part, of its very nature, in a larger ongoing global conversation and this we would certainly vigorously defend. Perhaps the best that can be done is to clearly label what is derived from academic endeavour and what is opinion. To that end we try to maintain this signposting and transparency in the editorial process and by our ready willingness to publish editorials and commentary pieces that are clear about their polemical intent.
Symposium: Sex, Gender, and the Body
In this issue the journal’s commitment to diverse, multi-perspectival scholarship can be seen through a symposium drawn from seven unsolicited manuscripts that serendipitously converged around issues relating to Sex, Gender, and the Body. Together these articles highlight the ways in which normativity surrounding sex, gender, and sexuality leads to policing of the bodies, identities, and experiences of individuals and communities—be they LGBTQI, cisgendered, or otherwise.
A number of these articles address the ways in which heteronormative ideas embodied by healthcare systems can impact upon access and utilization of healthcare services. Through their empirical study with fifty-five LGBT+ individuals in Turkey Keleş, Kavas, and Yalım (2018) highlight the way experiences of stigmatizing and segregating discourses impact on the capacity of LGBTQI individuals to utilize healthcare services. Also addressing access to and experiences of healthcare services, Burrow and colleagues (2018) draw on phenomenological interviews with queer birthing women in rural Nova Scotia to characterize the intersectional oppressions that that result from structurally embedded heteronormative and homophobic healthcare practices and policies. Finally, Johann Go (2018) in his analysis of arguments for public funding of gender reassignment surgery points to the moralistic biases inherent in the controversy stirred up by a procedure that is demonstrably effective, evidence-based, clinically indicated, and cost effective. Each of these three articles ultimately alerts us to the ways in which structural violence that compounds the oppression and inequities borne by already marginalized groups can result from heteronormatively charged healthcare policies and practices.
In a further exploration of normativity surrounding sex and embodiment, two articles address requests for female genital surgery and the ways in which clinicians respond to the moral dilemmas such requests entail. Spriggs and Gillam (2018) in their qualitative study of clinician’s responses to requests for labiaplasty from under-eighteens, problematize commonly drawn distinctions between genitalia characterized as structurally “problematic” or “diseased” and that deemed structurally “normal,” as well as distinctions between “functional” and “appearance” concerns. They question the ethical relevance of such fuzzy distinctions and argue for a broader conception of health that includes relief of psychological distress and not just physical abnormality. Similarly, Saleh, Friesen, and Ades (2018) point to the consideration of mental and social well-being as arguments in favour of re-infibulation. They highlight the conflicting ethical values at play when responding to a request to re-infibulate and argue for a case-specific approach. Each of these articles ultimately (though not explicitly) raises familiar questions about the concept of autonomy and the arguably misguided belief that individuals can ever be truly independent of their webs of social and cultural relations. Can requests to re-infibulate or to “normalize” labia ever be independent of the social norms surrounding female bodies? And if not, what moral weight ought we to attach to an individual’s wishes?
In addition to problematizing individualistic notions of autonomy these cases raise questions regarding the broader social implications of interventions that seek to alleviate individual distress rather than addressing sources of distress at a structural level. One example that has recently been the subject of extensive debate in Australia—preimplantation sex selection—clearly captures this tension between individual and social goods. While some scholars have argued that procreative beneficence demands that we select traits, including sex, which will allow a future child to have the best possible life (Savulescu 2004), others highlight both the societal and individual level injustices that would result from such an approach (Hendl 2017). In the case of selection for or against embryos with intersex characteristics these tensions are particularly stark. While the challenges faced by intersex individuals arguably legitimize arguments from procreative beneficence for non-selection, such decisions may reinforce flawed understandings of sex as binary, perpetuate stigma, and further entrench the marginalized status of intersex individuals.
A number of articles in this symposium address the issue of intersexed bodies directly. Cresti, Nave, and Lala (2018) discuss possible approaches to sex assignment of babies born with intersex characteristics. They address both naturalistic and epistemological objections to the expansion of sex categories and argue for a delay in sex and gender attribution or at the very least provisional sex and gender assignment that privileges the autonomy and future well-being of the child rather than heteronormative bodies. This article is complemented by a timely editorial by Morgan Carpenter (2018) exploring processes of normalization and othering of intersex bodies and identities in Australia and a commissioned article by Karkazis and Carpenter (2018) addressing recent changes to regulation of female testosterone levels in sport. These articles draw attention to themes that pervade the rest of this symposium—the surveillance and regulation of bodies by medical, governmental, and sporting authorities. In what are arguably displays of biopower (Lemke 2011), such authorities regulate bodies at multiple levels, controlling the normative ideals to which the body’s appearance must conform, their legal and social status or identity, and the nature and range of experiences within which they may participate.
These articles are all particularly timely in the current political climate in which increasing progress towards the codification of the rights of LGBTQI individuals in some political arenas is matched by apparent regression and tightening of controls over expressions of sexuality and gender identity in others. Such actions prompt a return to the question with which this editorial began—what ought the role of bioethicists be in confronting unjust political discourse and public policy?
- Burrow, S., L. Goldberg, J. Searle, and M. Aston. 2018. Vulnerability, harm, and compromised ethics revealed by the experiences of queer birthing women in rural healthcare. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9882-5
- Cahill, S.R., and H.J. Makadon. 2017. If they don’t count us, we don’t count: Trump administration rolls back sexual orientation and gender identity data collection. LGBT Health 4(3). https://doi.org/10.1089/lgbt.2017.0073
- Carpenter, M. 2018. The “normalization” of intersex bodies and “othering” of intersex identities in Australia. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9855-8
- Cresti, M., E. Nave, and R. Lala. 2018. Intersexual births: The epistemology of sex and ethics of sex assignment. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9880-7
- Danon, L.M. 2018. Intersex activists in Israel: Their achievements and the obstacles they face. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9877-2.
- Dawson, A., C.F.C. Jordens, P. Macneill, and D. Zion. 2018. Bioethics and the myth of neutrality. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9885-2
- French, R. 2018. What is the good of it—Ethical controls of human subject health research? Curtin University Annual Ethics Lecture. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9883-4
- Go, J.J. 2018. Should gender reassignment surgery be publicly funded? Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9881-6.
- Karkazis, K., and M. Carpenter. 2018. Impossible “choices”: The inherent harms of regulating women’s testosterone in sport. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9876-3
- Keles, Ş., M.V. Kavas, and N.Y. Yalım. 2018. LGBT+ individuals’ perceptions of healthcare services in Turkey: A cross-sectional qualitative study. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9874-5
- Lemke, T. 2011. Biopolitics: An advanced introduction. Translated by E.F. Trump. New York and London: New York University Press.Google Scholar
- National Center for Gender Equality. 2018. Trump’s record of action against transgender people. https://transequality.org/the-discrimination-administration. Accessed November 26, 2018.
- Saleh, M., P. Friesen, and V. Ades. 2018. On female genital cutting: Factors to be considered when confronted with a request to re-infibulate. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9875-4
- Savulescu, J. 2004. Procreative beneficence: Why we should select the best children. Bioethics 15(5–6): 413–426.Google Scholar
- Spriggs, M., and L. Gillam. 2018. “I don’t see that as a medical problem”: Clinicians’ attitudes and responses to requests for cosmetic genital surgery by adolescents. Journal of Bioethical Inquiry 15(4). https://doi.org/10.1007/s11673-018-9878-1