A summary of the philosophical literature on trust.

The power of new medical technologies, the cultural authority of physicians, and the gendered power dynamics of many patient-physician relationships can all inhibit women's reproductive freedom. Often these factors interfere with women's ability to trust themselves to choose and act in ways that are consistent with their own goals and values. In this book Carolyn McLeod introduces to the reproductive ethics literature the idea that in reproductive health care women's self-trust can be undermined in ways that threaten their autonomy. Understanding (...) the importance of self-trust for autonomy, McLeod argues, is crucial to understanding the limits on women's reproductive freedom. -/- McLeod brings feminist insights in philosophical moral psychology to reproductive ethics, and to health-care ethics more broadly. She identifies the social environments in which self-trust is formed and encouraged. She also shows how women's experiences of reproductive health care can enrich our understanding of self-trust and autonomy as philosophical concepts. The book's theoretical components are grounded in women's concrete experiences. The cases discussed, which involve miscarriage, infertility treatment, and prenatal diagnosis, show that what many women feel toward themselves in reproductive contexts is analogous to what we feel toward others when we trust or distrust them. -/- McLeod also discusses what health-care providers can do to minimize the barriers to women's self-trust in reproductive health care, and why they have a duty to do so as part of their larger duty to respect patient autonomy. (shrink)

Some bioethicists argue that conscientious objectors in health care should have to justify themselves, just as objectors in the military do. They should have to provide reasons that explain why they should be exempt from offering the services that they find offensive. There are two versions of this view in the literature, each giving different standards of justification. We show these views are each either too permissive (i.e. would result in problematic exemptions based on conscience) or too restrictive (i.e. would (...) produce problematic denials of exemption). We then develop a middle ground position that we believe better combines respect for the conscience of healthcare professionals with concern for the duties that they owe to patients. Our claim, in short, is that insofar as objectors should have to justify themselves, they should have to do it according to the standard that we defend rather than according to the standards that others have developed. (shrink)

Conscience in Reproductive Health Care responds to the growing worldwide trend of health care professionals conscientiously refusing to provide abortions and similar reproductive health services in countries where these services are legal and professionally accepted. Carolyn McLeod argues that conscientious objectors in health care should prioritize the interests of patients in receiving care over their own interest in acting on their conscience. She defends this "prioritizing approach" to conscientious objection over the more popular "compromise approach" without downplaying the importance of (...) health care professionals having a conscience or the moral complexity of their conscientious refusals. McLeod's central argument is that health care professionals who are gatekeepers of services such as abortions are fiduciaries for their patients and for the public they are licensed to serve. As such, they owe a duty of loyalty to these beneficiaries and should give primacy to their beneficiaries' interests in accessing care. This conclusion is informed by what McLeod believes is morally at stake for the main parties to the conflicts generated by conscientious refusals: the objector and the patient. What is at stake, according to McLeod, depends on the relevant socio-political context, but typically includes the objector's integrity and the patient's interest in avoiding harm. (shrink)

Whether in vitro fertilization is medically necessary determines, in many jurisdictions, whether it ought to be funded through public health insurance. This is certainly the case in Canada, where the Canada Health Act requires that provinces pay for all medically necessary health care services. Debate raged recently in Ontario, my own province, over whether IVF should be deemed medically necessary and therefore covered under Ontario’s Health Insurance Plan. Advocates for public funding insisted that Ontario, along with most other provinces in (...) Canada, was behind the times in not having such funding, given how many governments around the world, including most European... (shrink)

Some accounts of the fiduciary relationship place trust and autonomy at odds with one another, so that trusting a fiduciary to act on one’s behalf reduces one’s ability to be autonomous. In this chapter, we critique this view of the fiduciary relationship (particularly bilateral instances of this relationship) using contemporary work on autonomy and ‘relational autonomy’. Theories of relational autonomy emphasize the role that interpersonal trust and social relationships play in supporting or hampering one’s ability to act autonomously. We argue (...) that fiduciary relationships, understood through the lens of relational autonomy, can provide a means of enhancing, rather than diminishing, beneficiaries’ autonomy. (shrink)

This paper addresses the likely impact on women of being denied emergency contraception (EC) by pharmacists who conscientiously refuse to provide it. A common view—defended by Elizabeth Fenton and Loren Lomasky, among others—is that these refusals inconvenience rather than harm women so long as the women can easily get EC somewhere else nearby. I argue from a feminist perspective that the refusals harm women even when they can easily get EC somewhere else nearby.

The process of adopting a child is “not for the faint of heart.” This is what we were told the first time we, as a couple, began this process. Part of the challenge lies in fulfilling the licensing requirements for adoption, which, beyond the usual home study, can include mandatory participation in parenting classes. The question naturally arises for many people who are subjected to these requirements whether they are morally justified. We tackle this question in this paper. In our (...) view, while strong reasons exist in favour of licensing adoptive parents, these reasons support the licensing not only of adoptive parents, but of all or some subset of so-called “natural” parents as well. We therefore conclude that the status quo with respect to parental licensing, according to which only adoptive parents need to be licensed, is morally unjustified. (shrink)

Now that stem cell scientists are clamouring for human eggs for cloning-based stem cell research, there is vigorous debate about the ethics of paying women for their eggs. Generally speaking, some claim that women should be paid a fair wage for their reproductive labour or tissues, while others argue against the further commodification of reproductive labour or tissues and worry about voluntariness among potential egg providers. Siding mainly with those who believe that women should be financially compensated for providing eggs (...) for research, the new stem cell guidelines of the International Society for Stem Cell Research (ISSCR) legitimise both reimbursement of direct expenses and financial compensation for many women who supply eggs for research. In this paper, the authors do not attempt to resolve the thorny issue of whether payment for eggs used in human embryonic stem cell research is ethically legitimate. Rather, they want to show specifically that the ISSCR recommended payment practices are deeply flawed and, more generally, that all payment schemes that aim to avoid undue inducement of women risk the global exploitation of economically disadvantaged women. (shrink)

Some stem cell researchers believe that it is easier to derive human embryonic stem cells from fresh rather than frozen embryos and they have had in vitro fertilization (IVF) clinicians invite their infertility patients to donate their fresh embryos for research use. These embryos include those that are deemed 'suitable for transfer' (i.e. to the woman's uterus) and those deemed unsuitable in this regard. This paper focuses on fresh embryos deemed suitable for transfer - hereafter 'fresh embryos'- which IVF patients (...) have good reason not to donate. We explain why donating them to research is not in the self-interests specifically of female IVF patients. Next, we consider the other-regarding interests of these patients and conclude that while fresh embryo donation may serve those interests, it does so at unnecessary cost to patients' self-interests. Lastly, we review some of the potential barriers to the autonomous donation of fresh embryos to research and highlight the risk that female IVF patients invited to donate these embryos will misunderstand key aspects of the donation decision, be coerced to donate, or be exploited in the consent process. On the basis of our analysis, we conclude that patients should not be asked to donate their fresh embryos to stem cell research. (shrink)

The status quo on parental licensing in most Western jurisdictions is that licensing is required in the case of adoption but not in the case of assisted or unassisted biological reproduction. To have a child via adoption, one must fulfill licensing requirements, which, beyond the usual home study, can include mandatory participation in parenting classes. One is exempt from these requirements, however, if one has a child via biological reproduction, including assisted reproduction involving donor gametes or a contract pregnancy. In (...) an earlier paper, we challenged this system of parental licensing by showing that arguments in favour of it do not succeed. One argument we failed to consider, however, is that prospective biological parents have a right to reproduce that protects them against the sort of state interference that is involved in parental licensing. According to this argument, because prospective adoptive parents do not exercise a similar right when attempting to become parents, they are not similarly protected. In this paper, we argue that this reproductive rights argument, like other arguments in favour of the status quo on parental licensing, is flawed. We also question whether people in fact have a right to reproduce, and in doing so distinguish this right from others that we think are legitimate, including a right to become a parent and a right to bodily autonomy. (shrink)

This book concerns the ethics of having children through adoption or technologically-assisted reproduction. Some people who choose between these methods struggle between them. Others do not agonize in this way, perhaps because they have a profound desire for a genetic link to the child(ren) they will parent and so prefer assisted reproduction, they view adoption as the only morally decent choice in an overcrowded world, or for some other reason. This book critically examines moral choices that involve each of these (...) ways of making or expanding families with children. The contributors discuss how adoption and assisted reproduction are morally distinct from one another, but also emphasize how they are morally similar, given that both are forms of family‐making. (shrink)

One understanding of conscience dominates bioethical discussion about conscience. On this view, to have a conscience is to be compelled to act in accordance with one’s own moral values for the sake of one’s “integrity,” where integrity is understood as inner or psychological unity. Conscience is deemed valuable because it promotes this quality. In this paper, I describe the dominant view, attempt to show that it is flawed, and sketch a positive alternative to it. In my opinion, conscience often fails (...) to promote inner unity (regardless of the degree of inner unity we have in mind); acting with a conscience leaves many people broken rather than unified. A better view about the value of conscience is that having a conscience encourages morally responsible agency. My goal is to prove that this alternative explains better what it means to value conscience in health care and the extent to which we ought to value it. (shrink)

This paper comes out of a panel honoring the work of Anne Donchin (1940-2014), which took place at the 2016 Congress of the International Network on Feminist Approaches to Bioethics (FAB) in Edinburgh. My general aim is to highlight the contributions Anne made to feminist bioethics, and to feminist reproductive ethics in particular. My more specific aim, however, is to have a kind of conversation with Anne, through her work, about whether reproductive justice could demand insurance coverage for in vitro (...) fertilization. I quote liberally from Anne’s work for this purpose, but also to shower the reader with her words, reminding those of us who knew her well what a wonderful colleague she was. (shrink)

Currently, the preferred accommodation for conscientious objection to abortion in medicine is to allow the objector to refuse to accede to the patient’s request so long as the objector refers the patient to a physician who performs abortions. The referral part of this arrangement is controversial, however. Pro-life advocates claim that referrals make objectors complicit in the performance of acts that they, the objectors, find morally offensive. I argue that the referral requirement is justifiable, although not in the way that (...) people usually assume that it is. (shrink)

The article aims to distinguish autonomy from integrity. I claim that integrity is different from a form of autonomy at least, but that integrity and autonomy overlap considerably. Integrity itself is a form of autonomy: what ethicists call ‘moral autonomy.’ (They tend to distinguish between personal and moral autonomy.) Autonomy is the genus, one might say, with integrity (i.e., moral autonomy) and personal autonomy being species of it.

Infertility can be an agonizing experience, especially for women. And, much of the agony has to do with luck: with how unlucky one is in being infertile, and in how much luck is involved in determining whether one can weather the storm of infertility and perhaps have a child in the end. We argue that bad luck associated with being infertile is often bad moral luck for women. The infertile woman often blames herself or is blamed by others for what (...) is happening to her, even when she cannot control or prevent what is happening to her. She has simply had bad luck. We focus on the self-blame of infertile women and show how it stems from pro-natalism that targets women. We also argue that overall for women, regret is a better moral response to infertility than self-blame. (shrink)

A peer commentary on an AJOB article by Kyle Fritz called "Unjustified Asymmetry: Positive Claims of Conscience and Heartbeat Bills.".

The introduction to a special issue of the journal Bioethics that we edited.

A model policy for conscientious objection in medicine.

The Hague Conference on Private International Law currently has a Parentage/Surrogacy Project, which evaluates the legal status of children in cross-border situations, including situations involving international contract pregnancy. Should a convention focusing on international contract pregnancy emerge from this project, it will need to be consistent with the Hague convention on Intercountry Adoption. The latter convention prohibits adoptions unless, among other things, ‘the competent authorities of the receiving State have determined that the prospective adoptive parents are eligible and suited to (...) adopt’. Included in it, therefore, is a parental vetting or licensing requirement. In our view, a similar requirement must also appear in any Hague Convention on international contract pregnancy if the two conventions are to be ethically consistent with one another. In particular, there should be a licensing requirement in such a convention for at least some of the prospective parents in contract pregnancy arrangements. We consider several arguments against this conclusion, and argue that none of them is successful. (shrink)

Self-protection seems to be negatively correlated with integrity on the standard conception of that virtue. To be self-protective is to lose some of our integrity. In this paper, I pursue the somewhat unlikely claim that a certain amount of self-protection is consistent with integrity and is even required by it in many circumstances.

Currently, the preferred accommodation for conscientious objection to abortion in medicine is to allow the objector to refuse to accede to the patient’s request so long as the objector refers the patient to a physician who performs abortions. The referral part of this arrangement is controversial, however. Pro-life advocates claim that referrals make objectors complicit in the performance of acts that they, the objectors, find morally offensive. McLeod argues that the referral requirement is justifiable, although not in the way that (...) people usually assume. (shrink)

An overview of the philosophical and bioethics literature on conscientious refusals by health care professionals to provide abortion and contraceptive services.

The feminist literature against the commodification of embryos in human embryo research includes an argument to the effect that embryos are “intimately connected” to persons, or morally inalienable from them. We explore why embryos might be inalienable to persons and why feminists might find this view appealing. But, ultimately, as feminists, we reject this view because it is inconsistent with full respect for women's reproductive autonomy and with a feminist conception of persons as relational, embodied beings. Overall, feminists should avoid (...) claims about embryos’ being inalienable to persons in arguments for or against the commodification of human embryos. (shrink)

Philosophical theories about parental licensing tend to pay insufficient attention to forms of discrimination that may be inherent in, or result from, a system of parental licensing. By situating these theories in relation to the status quo on parental licensing, we aim to show how many of them reinforce what philosophers have called “biologism”: the privileging of families formed through biological reproduction over families formed in other ways. Much of our discussion focuses on biologism, although we also touch on other (...) forms of discrimination that parental licensing can cause or exacerbate, such as classism, sexism, homophobia, racism, and ableism. We firmly believe that any adequate proposal in favour of parental licensing must take worries about discrimination seriously. Unfortunately, most philosophical proposals fail to do so. (shrink)

This article aims to lay out the ‘for money’ and ‘for dignity’ arguments that feminist ethicists have given about the reproductive labour women perform in providing oocytes or in getting pregnant for others. Feminist arguments about the morality of these two practices overlap significantly because, from a feminist perspective, the morally relevant facts about them are quite similar. Still, there are dissimilarities, stemming from the obvious fact that one practice involves giving up oocytes while the other involves giving up a (...) baby after a pregnancy. Some arguments by feminists reflect this core difference, in that they apply specifically to one practice but not to the other. The article highlights when the relevance of a particular argument differs for these different reproductive practices. (shrink)

Public attention on embryo research has never been greater. Modern reproductive medicine technology and the use of embryos to generate stem cells ensure that this will continue to be a topic of debate and research across many disciplines. This multidisciplinary book explores the concept of a 'healthy' embryo, its implications on the health of children and adults, and how perceptions of what constitutes child and adult health influence the concept of embryo 'health'. The concept of human embryo health is considered (...) from preconception to pre-implantation genetic diagnosis to recent foetal surgical approaches. Burgeoning capacities in both genetic and reproductive science and their clinical implications have catalysed the necessity to explore the concept of a 'healthy' embryo. The authors are from five countries and 13 disciplines in the social sciences, humanities, biological sciences and medicine, ensuring that the book has a broad coverage and approach. (shrink)

With the cure rate for many pediatric malignancies now between 70% and 90%, infertility becomes an increasingly important issue. Strategies for preserving fertility in girls and adolescent women occur in two distinct phases. The first phase includes oophorectomy and cryopreservation of ovarian cortex slices or individual oocytes; ultrasound-guided needle aspiration of oocytes, with or without in vitro maturation, followed by cryopreservation; and ovarian autografting to a distant site. The second phase occurs if the woman chooses to pursue pregnancy, and includes (...) IVM of the oocytes, followed by in vitro fertilization and transfer of any created embryos to the woman's uterus. For ovarian autografting, the woman would undergo menotropin ovarian stimulation and retrieval of matured oocytes. The ethical challenges with each of these phases are many of fertility preservation and include issues of informed choice. The lack of proven benefit with these strategies and the associated potential physical and psychological harms require careful attention to the key elements of informed choice, which include decisional capacity, disclosure, understanding and voluntariness, and to the benefits of in-depth counseling to promote free and informed choice at a time that is emotionally difficult for the decision makers. (shrink)

A review of Holly Fernandez Lynch's book Conflicts of Conscience in Medicine (MIT Press, 2008).

The Hague Conference on Private International Law is currently considering the development of a Hague Convention on international contract pregnancy. Recently, the Permanent Bureau of the conference published A Preliminary Report on the Issues Arising from International Surrogacy Arrangements . There, it acknowledges that overlap may exist in the proper regulation of international adoption and international contract pregnancy . The report states that “some of the techniques employed by the 1993 Convention [on Protection of Children and Co-operation in Respect of (...) Intercountry Adoption] may be of relevance to international .. (shrink)

To a large extent, what we do and the circumstances we find ourselves in are beyond our control. Yet this fact presents a problem for the common view that we can be held responsible only for what we have direct control over. If we have control over very little, if anything at all, then to what extent can we be held responsible? A typical response by feminist philosophers is to accept the absence of control—or in other words, the presence of (...) luck—but to insist that responsibility remains often enough. According to this view, where there is luck, there can also be responsibility. At the same time, feminists accept, of course, that where there is luck, there may not be responsibility. In general, like other philosophers, feminists have a complicated understanding of the relationship between luck and responsibility. In this chapter, we aim to describe how their understanding flows out of their feminist commitments and also what avenues there are for future research on luck and responsibility in feminist philosophy. Avenues that concern luck without responsibility are our central concern. (shrink)

I want to get both personal and philosophical in this piece. I want to reflect on how my relationship with Sue Sherwin has fostered my own relational autonomy. At the same time, I want to discuss what theories of relational autonomy, like Sue's, add to the bioethics literature on autonomy. With this second objective, I hope to begin clearing up some confusion that I see in this literature about the nature of relational autonomy.Sue was my PhD supervisor, but more than (...) that, she has been my mentor and my role model. I doubt I would still be part of the discipline of philosophy if it weren't for Sue. I came to Dalhousie University as a PhD student in 1995 with a burning love for philosophy but an intense dislike for... (shrink)

Letter to editor of the Hastings Center Report on R. Kukla’s “Conscientious Autonomy: Displacing Decisions in Health Care” (HCR 35(2), 2005: 34-44).

The main aims of the paper are to explain how objectification admits of degrees and why a significant portion of the objectification of women in contemporary Western society - objectification that contributes to their oppression - is what I call "partial objectification." To acknowledge the full range of objectification in women's lives, feminists need a theory of how objectification can be degreed. They need to be able to say that women can be both bosom and legitimate job candidate, both breeder (...) and health care patient, both sex object and intimate partner. (shrink)

An introduction to a special issue of Bioethics edited by McLeod and called Understanding and Protecting Reproductive Autonomy.

The reproductive rights of women have been a central topic in feminist bioethics. The focus has been predominantly on the right not to reproduce, and so not to be subject to pronatalist social forces that make motherhood compulsory for women. That is the case despite many women and other members of marginalized groups experiencing anti-natalism, or in other words, social pressure to avoid biological reproduction. For these groups, the right to reproduce is as important, if not more important, than the (...) right not to reproduce. This chapter concentrates on the right to reproduce and considers what form it should take in feminist bioethics. The main claim of the chapter is that feminists should ground the right in the need to protect marginalized groups from anti-natalism. (shrink)

A review of Transformative Motherhood: On Giving and Getting in a Consumer Culture, edited by L. Layne (NYU Press, 1999).

A review of Louis Charland's paper, "Cynthia's Dilemma: Consenting to Heroin Prescription," American Journal of Bioethics 2(2), 2002: 37-47.

The central concerns of Hutchison’s paper are the under-representation and unequal pay of women in surgery and the role that subtle gender biases play in explaining these phenomena. My comments focus on how well executed and important this work is and also why we need more of it to fully understand the gravity of the situation for women in surgery and how it compares with similar situations for women in other fields.