## 1. The Development of Feminist Bioethics


### 1.1 Introduction



Bioethics is the hybrid discipline that attends to the ethical
implications of developments in the life sciences, especially
biomedical research and practice, public health, the delivery of
healthcare services, and the socio-ethical impacts of technology.
Since it first emerged as a distinct approach in applied philosophy,
bioethics has blossomed into a substantial interdisciplinary field,
drawing on a highly diverse range of scholarship, including
philosophy, theology, law, medicine, and the biological sciences, and
increasingly turning to the social sciences and humanities.



Chronicles of bioethics tend to argue that it originated as a response
to two main factors. First, medical developments in the mid-twentieth
century raised issues beyond the limits of conventional medical
ethics' focus on intraprofessional conduct and the
physician-patient dyad. Second, this period also saw growing
recognition of historical atrocities in medical research (such as the
experimentation on inmates of concentration and extermination camps
during the Nazi Third Reich that led directly to the Nuremberg
Doctors' Trial and, indirectly, to the first set of research
ethics guidelines in the Nuremberg Code of 1947). But this narrative,
while not wrong, omits the broader political and intellectual context
of the milieu within which bioethics developed. The 1960s saw social
transformation in many parts of the world, and in its early days at
least, bioethics' focus on those who might be harmed by medical
practice reflected these social and cultural changes. Like many young
disciplines, it has also been open to a wide range of theoretical and
methodological approaches. This may be one reason why feminist
bioethics was able to develop rapidly and strongly as a distinctive
sub-field within it.


### 1.2 Emergence and early days



The roots of feminist bioethics can be found in both feminist activism
and feminist theory. In the early years of second wave feminism, the
women's healthcare movement identified many areas where
women's interests were severely neglected. While feminist
*activism* identified problematic areas and mobilized protest,
the *academic* critique provided a theoretical framework to
show that mainstream biomedicine and bioethics are fundamentally
gendered in ways that affect both how the life sciences are researched
and implemented *and* how this research and practice are
ethically analyzed. In other words, feminists were saying that not
only does bioethics give too little attention to gender-specific
disparities in healthcare research and treatment, but that the
gendered perspective from which mainstream bioethics identifies
morally troubling issues and their ethically salient features makes it
unable (or much less likely) to account adequately for certain
injustices, biases or harms in any given scenario (Tong 1997; Sherwin
2008; Scully et al. 2010).



In its earliest phase, feminist bioethics focused on topics that were
patently being neglected by the mainstream. Inevitably, these were
areas that could traditionally be seen as "women's
issues": anything to do with reproduction, including abortion
and the assisted reproductive technologies (ARTs) emerging at that
time, but also the exclusion of women from medical research, the role
of psychiatry and its treatment of women, and the increasing
medicalization and commodification of women's bodies. These
perspectives cast new light on even well-examined terrain. For
example, although ethical issues within clinical research have been
exhaustively mapped out, it took feminist analyses to highlight that
the routine exclusion of women from clinical research, on the grounds
that the "anomalies" of female physiology generate
unreliable data, was ethically problematic (Sherwin 1994; Baylis &
Halperin 2012; Baylis & Ballantyne 2016).



Pioneering work included a ground-breaking anthology, *Feminist
Perspectives in Medical Ethics* (Holmes & Purdy 1992), and the
first monograph treatment of feminist bioethical theory, Susan
Sherwin's *No Longer Patient: Feminist Ethics and Health
Care*, (Sherwin 1992). A major milestone was the publication of
Rosemary Tong's, *Feminist Approaches to Bioethics:
Theoretical Reflections and Practical Applications* (Tong 1997).
In 1993, the International Network on Feminist Approaches to Bioethics
(FAB) was founded and since 1996 has held its own biennial Congress in
association with the World Congress on Bioethics. To further the
development of feminist bioethics, in 2007 FAB established its own
journal, the *International Journal of Feminist Approaches to
Bioethics* (*IJFAB*). From the outset, *IJFAB* has
been committed to expanding the field of bioethics to include a wide
range of areas relevant to women's healthcare and related
research.



However, it is important to realize that feminist bioethics is
characterized less by the areas that it addresses or ethical theories
that it draws on, than by its particular approach to ethical analysis.
The combination of attention to practical issues, distinctive
conceptual commitments, and the explicit ethical-political goal of
achieving equality and justice for women is the hallmark of feminist
bioethics. The following sections will first identify the feminist
perspectives on ontology and epistemology that are foundational to
this approach; show how these commitments shape feminist approaches to
bioethical analyses; and then outline two areas of theory, care ethics
and relational autonomy, that have been developed within feminist
bioethics and have also enriched theoretical bioethics more generally.
Finally, this entry considers the future of feminist bioethics in the
twenty-first century.


## 2. Foundational Feminist Perspectives


### 2.1 Ontology



Feminist philosophy favors a moral ontology that contrasts sharply
with that of traditional moral philosophy. In a now well-rehearsed
critique, feminists argue that the model of the agential subject used
in mainstream moral and political thought reflects rather too closely
the gendered social and political environment in which it was first
devised (Mackenzie & Stoljar 2000). This model identifies the self
as a singular, isolated locus of consciousness, with little account
given to either the particularities of the body or the familial and
community contexts within which moral agents operate except where
embodiment and social embeddedness are thought to compromise moral
agency. Feminist moral theory has long argued that this picture is
flawed, and in the end, ethically treacherous, because it leaves out
many features of human life that are essential to genuine moral
selfhood and agency. Mainstream theory was (and often still is)
devised by the most privileged members of societies in which privilege
is distributed according to sex and class. Feminist theory notes that
this has resulted in the perspectives and experiences of men being
mistaken for universals, and the perspectives and experiences of women
(shaped by the biological fact of female embodiment and the social
fact of subordinate status) being dismissed. In the nonideal world,
moral subjects *are* embodied beings, and the particularities
of their bodies are morally relevant; they are also linked to known
and unknown others through dependencies and responsibilities that are
often unchosen; and these connections to other persons are asymmetric
as a rule rather than exceptionally. This moral ontology gives a more
accurate depiction of reality and is therefore a more theoretically
useful model.



It is only fair to acknowledge that contemporary moral and political
philosophy has engaged to some extent with these critiques from
feminists and others, and as a result some would now consider this to
be a caricature of its views. Nevertheless, it is still relatively
rare to see nonfeminist applied ethics, including bioethics,
describing moral subjects and agents in explicitly socially embedded
and embodied terms.


### 2.2 Epistemology



The dominant form of epistemology within feminist bioethics is
similarly social. The knowledge to which individuals have access is
collectively generated, maintained, circulated and conveyed, and the
moral subject of feminist bioethics therefore has epistemic resources
that differ markedly from those available to the traditional singular
self. Moreover, gendered social identities have the effect of shaping
the epistemic resources that are available to the inhabitants of those
identities (Harding 1991; Wylie 2003). The situated epistemic
resources of marginalized social identities will differ from those of
more powerful groups, and vice versa. Beyond an awareness of the
situated nature of knowledge, feminist standpoint epistemology
presents the stronger claim that marginalized identities have a unique
epistemic insight into the specific effects of power maldistribution
(Hartsock 1983; Grasswick 2004; Harding 2009; Intemann 2010; see also
SEP entries by Anderson on
 feminist epistemology
 and Grasswick on
 feminist social epistemology).



Social positioning also determines whether the knowledge a person has
is considered credible by members of her own or other groups. Gendered
or otherwise biased social and political structures generate skewed
distributions of epistemic authority, leading to a variety of forms of
epistemic injustice--an idea that has been developed in many
theoretical directions and widely disseminated through moral and
political philosophy (Fricker 2007; Code 2014; Dotson 2014; Pohlhaus
2017; Grasswick 2018). In summary, where traditional epistemology
looks at how individuals acquire and use information, from a feminist
perspective the center of attention shifts to the social and political
structures within which knowledge is created and maintained, and
epistemic injustice can occur. Epistemic injustice refers to the
unfair ways in which the knowledge of individuals who belong to
socially marginalized and stigmatized groups is treated. The most
commonly described forms or families of epistemic injustice are
testimonial and hermeneutical. Testimonial injustice describes those
situations where a person's identity results in their statements
being ignored or disbelieved: a relevant example would be the vaginal
mesh scandal, in which women's claims of pain and injury were
disregarded (O'Neill 2021). Hermeneutical injustice on the other
hand occurs when a person's or group's knowledge is
excluded from the collective epistemic resources (the things
"everyone knows") because their knowledge is dismissed as
unimportant or irrelevant. An example here would be the overall lack
of data about pregnant women's responses to common medication
because of their historical exclusion from clinical research. This
exclusion was justified on ethical grounds (the protection of the
supposedly vulnerable woman and foetus), but the ethical evaluation
was based on unjustified sexist assumptions.



Feminist epistemology therefore drives a re-examination of how ethical
issues are perceived and described, whose experiences are afforded
credibility, how (and by whom) an issue is defined as
"moral" in the first place, and how consensus on what
constitutes a robust ethical evaluation is shaped by the social
organization of epistemic authority.


## 3. Feminist Approaches to Bioethical Analysis



These foundational feminist perspectives on *ontology* and
*epistemology* provide the key theoretical orientations for
feminist bioethics. Ethical analyses need to account for how real
moral agents are formed and behave, combined with a more critical
understanding of the social, political, and other forces that shape
the experiences, knowledge, and judgments of differently situated
people. These priorities lie behind the critique of mainstream
bioethics' tendency to favor ideal theory and to work from a set
of highly abstract principles, its isolation of moral problems from
their context, and its neglect of, or lack of interest in, the
perspectives of subordinated social groups.



This background means that feminist approaches to bioethical analyses
tend to share characteristic features. These include attention to
power dynamics and social context; the use of empirical data to inform
theory; the weight given to relationality and care, and to the moral
significance of embodiment and materiality; and greater openness to
and incorporation of marginalized perspectives.


### 3.1 Power dynamics and social context



In all societies we know of, human relationships are shaped by
arrangements of social and political power that favor men and enable
the oppression of women in a variety of ways, both covert and overt.
Feminist bioethics looks at the micro-, meso-, and macro-level
organizations of power in the moral difficulties that are encountered
within healthcare and research. The examination of these power
relations not only provides a gendered reframing of bioethics'
traditional clinical focus, for example by considering how paternalism
in the doctor-patient dyad works differently according to the sex of
each, but also provides a broader insight into the structural
underpinnings of seemingly isolated instances of moral wrong. In doing
so, feminist bioethics extends in two dimensions beyond what is
conventionally considered to fall within the confines of healthcare:
to the previously unnoticed small-scale microaggressions (Freeman
& Stewart 2019), and at the other end of the scale to the global
economic structures that maintain entrenched patterns of social and
political domination over women's lives. Feminist bioethicists
also go beyond the analysis of sex and gender to consider how the
distribution of power plays out across other categories of race,
sexual orientation, disability, age, and so on.



These broader analyses were a key factor in feminist bioethics'
interest in the social determinants of health and in their
understanding that structural social inequities are fundamental to
generating differentials in people's health, anticipating by
some years the concerns of public health ethics articulated since the
mid-2000s. Feminist authors, for example, have highlighted that the
distribution of political and economic power is visible in the way
that public health processes focus on the *effects* of social
marginalization and exclusion but pay less attention to the underlying
causes (Rogers 2006; Baylis, Kenny, & Sherwin 2008).


### 3.2 Use of situated empirical and experiential knowledge



Feminism is based on the observation that a person's experience
is sexed and gendered and will differ in important ways depending on
whether that person is biologically male or female, or lives as a man
or a woman. And because the organization of power is also gendered,
the issue of whose perspectives matter (or are noticed at all) will
reflect the needs and demands of the most powerful. Feminist analyses
are therefore sensitive to the stratifications that make it unlikely
that we (whoever we are) have an overarching view of even the most
familiar situations. For bioethics, this limitation is compounded by
its focus on life science and biomedical innovation, and on
technologies and practices that have yet to establish themselves in
everyday life. As an example, the growth of assisted reproductive
technologies very obviously demanded new forms of health policy and
governance. Less obviously, it also generated new professional and
private identities and behaviors linked to being a parent, child, or
sibling, novel forms of families (such as same-sex couples with
genetically related children), and rapidly evolving relationships
between legislation and private life (Baylis & McLeod 2014).



The experiential basis of feminism and the novelty of the practices
that bioethics deals with both lead to the conclusion that normative
judgments should be based in what Margaret Walker famously referred to
as "the actual moral and social orders", i.e., knowledge
of *what is actually going on* rather than assumptions about
*how we think things might be* (Walker 1998). Where that
knowledge is not available it must be acquired. So, although much of
bioethics took an empirical turn in the early 2000s, feminist
bioethics has a particularly strong orientation towards the use of
empirical methods to anchor any descriptive and normative claims in
the realities of natural, social, political, and institutional worlds.
There is also a leaning towards qualitative methods of inquiry to
capture morally salient differences that track not only with sex and
gender, but also with class, ethnicity, sexuality, and so on. As a
result, some feminist bioethicists are involved in developing
empirical methodologies to provide appropriate material for normative
reasoning, while others work on clarifying the always problematic
relationship between empirical data and normative conclusions (Scully
2016).


### 3.3 Importance of the body and embodiment



Women's lives are shaped by the materiality of having/being a
body that deviates from the male norm. Feminist theory recognizes the
political and moral importance of the body, and part of feminist
bioethics' central criticism of mainstream bioethics is that as
well as being abstract and decontextualized, it also reflects a
disembodied view of moral life. This in turn creates an obliviousness
to the moral significance of embodied particularity. Medical science
has a long history of dismissing the female body as
"anomalous", and because it also tends to equate anomaly
with pathology, it has an equally long history of pathologizing
women's bodies. Early feminist bioethicists, including Susan
Bordo (1993) and Mary Mahowald (1993), published work examining
medical and cultural attitudes toward women's bodies.
Subsequently, an influential strand of work within feminist bioethics
has moved from the moral consideration of the normatively *sexed
and gendered* body to reflecting more generally on what is means
to have/be an anomalous body, including raced and disabled bodies,
intersex bodies, or bodies that are of nonstandard shape or size
(Reiheld 2015; Dolezal 2015; MacKay 2017). Some of the most
interesting work in this area takes a phenomenological approach to the
experiences of pregnancy, lesbian or transgender embodiment, and
disability or illness. Susan Wendell's *The Rejected
Body* (1996) was an early instance of a large body of feminist
bioethical writing that relates to disability.


### 3.4 Listening to marginalized voices



Feminist bioethics is distinctive in the emphasis it places on
recognizing the historical and continuing exclusion of minority
viewpoints as a form of epistemic injustice in which the knowledge of
marginalized groups is kept out of mainstream bioethics. From early
on, feminist bioethics looked beyond the marginalization of sex and
gender to other forms of exclusion, and sought to identify how power
relations interacting with minority statuses can perpetuate moral
harms in research, clinical care, and public health. The dismissal of
the experiences and perspectives of women, Black, or disabled people
is now increasingly acknowledged in bioethics. However, feminist
analyses also illuminate relevant examples of damaging exclusions that
fall outside the boundaries of familiar minority categories or
protected characteristics. These include the suppression of
"anomalous" knowledge that is assumed to be distorted by
mental illness (Bluhm 2011; Thachuk 2011) and the silence within
mainstream bioethics about the role of low-paid care workers in
healthcare. They have also drawn connections between epistemic
injustice and feminist work on microaggressions experienced by
patients in clinical settings (Buchman et al. 2017; Freeman &
Stewart 2019).


### 3.5 Political commitment/activism



A final characteristic of feminist bioethics that draws together all
the other distinctive features is its political commitment. While
feminist bioethics, like feminist ethics more broadly, is an academic
discipline, it originated in and alongside a social-political movement
with the aims of global justice and equality for women. Feminist
theory has always attempted to connect the personal with the
political. In the context of ethics, this means something more than
just expanding the ethical frame of reference beyond person to person
interactions to the institutional or societal scale; it means an
understanding that individual and interpersonal issues are
fundamentally shaped by broader socio-political forces. Hence,
feminist bioethics always has a perspective that pushes beyond the
straightforward characterization of a moral concern in medicine or
life sciences, and even beyond examining why it has arisen. A feminist
approach to bioethics pushes towards identifying and catalyzing social
and political change to create better lives for women.


## 4. Feminist Contributions to Bioethics Theory



The distinctive analytic toolkit of feminist bioethics has made
significant theoretical contributions to bioethical thinking. Its
close relationship with feminism as a political movement has made
feminist bioethics highly critical of philosophical bioethics'
usual privileging of ideal theory (in the sense of being based around
the kind of world we would *like* to have) and of the search
for universalizable principles. Both these approaches tend to increase
the appeal of abstraction more, making it harder to see the world as
it is, with persisting inequality and discrimination, and so obscure
the need for radical change and especially for realistic ways to
achieve it. Feminist ethics has responded through the production of
its own conceptual contributions to broader ethical theory. The most
significant and best known of these are the ethics of care/care
 ethics[1]
 and the concept of relational autonomy.


### 4.1 Ethic of care/care ethics



The idea that care could form the basis of a distinct approach to
ethical theory took shape after the publication of psychologist Carol
Gilligan's now-famous work on gender-based differences in moral
evaluation, *In a Different Voice* (1982). Drawing on empirical
data Gilligan attempted to show that patterns of moral reasoning that
prioritize care practices, chosen and unchosen relationships, and the
acknowledgment of mutual responsibilities are more characteristic of
women, while alternative modes focusing on justice, rights, and the
elaboration of overarching moral principles are more likely to be used
by men. Subsequent commentators, including some feminist bioethics,
have been highly critical of Gilligan's conclusions. Some, for
example, have complained about her own use of stereotypical gendered
norms in her work. Others are skeptical of the supposedly rigidly
*gendered* distribution of care versus justice-based ethics,
suggesting that the difference is linked not to gender per se but to
the experience of being socially and politically marginalized, and
therefore more likely to turn to the relational networks of community
for support than to institutional justice-based systems (see, e.g.,
Cortese 1990). Other areas of continuing debate are whether the ethic
of care counts as a form of virtue ethics, or whether conversely it
only appears so because it cannot be neatly slotted within the
traditional taxonomies of ethical theory (Halwani 2003; Groenhout
2014; Sander-Staudt 2006).



Nevertheless, the basic idea of the importance of care has given rise
to an extraordinarily rich body of work within feminist thought (Held
2006; Gary 2022) and has had considerable influence beyond. By
differentiating between various understandings of care and by paying
attention to the moral subtleties of relational bonds, the ethics of
care exposes problems and suggests approaches that are overlooked by
justice-oriented frameworks. Unsurprisingly, the ethics of care has
proven to be especially appealing in biomedicine and public health,
fields where the notion of "caring for" is central
(although often unexamined). In many ways, however, the value of the
ethic of care lies less in the centrality of care as a practice than
in its ability to challenge the conventional understanding that
dependence relationships are restricted to specific circumstances
(such as infancy or illness) rather than something in which all of us
are embedded at all points of our lives. In particular, care ethicists
highlight the fact that relationships involving care are often
unchosen and always unbalanced. Moreover, by reframing care as
dependency work, ethicists such as Kittay (1999) and Kittay and Feder
(2003) demonstrate the ubiquity of dependency in the form of dependent
interactions in communities that do not involve obvious care
practices. Positioning unbalanced relations as the norm rather than
the exception contrasts starkly with the view of ethical theories in
which normal social and moral life consists mainly of reciprocal,
negotiated relationships between equals and dependence is invariably
undesirable if not outright pathological.



A longstanding criticism of the ethic of care is its potential naivety
about those care relationships that are themselves exploitative or
unjust. Further, it has been attacked for lacking a robust political
perspective that can adequately account for and unsettle larger-scale
patterns of domination and oppression affecting women. In response,
some authors have visibly extended the ethic of care's reach to
include structural, systemic, and global issues (Carse & Lindemann
Nelson 1996; Ruddick 1989; Noddings 2002; Held 2006). Joan
Tronto's *Moral Boundaries: A Political Argument for an Ethic
of Care* (1993) was an early attempt to craft a political theory
integrating the practice of care into the organization of life in a
democratic and pluralistic society, as was the anthology
*Socializing Care* edited by Hamington and Miller (2006).



Others have teased out the connections between care and associated
moral concepts such as dependence, agency, and autonomy. An example is
a growing body of recent work on vulnerability as a useful moral
concept (Hurst 2008; Mackenzie, Rogers, & Dodds 2014; Luna 2014,
2019; Miller 2020). The terminology of "vulnerable
groups", to denote people who are collectively more likely to
suffer disadvantage, harm, or exploitation in research or other
contexts, is key to many aspects of research ethics especially
informed consent, and increasingly appears in public health ethics
too. However, this use of vulnerability tends not to examine the
forces that lead to the existence of vulnerable groups in the first
place. By contrast, feminist authors pay close attention to the way
that social and political circumstances can generate or exacerbate
vulnerabilities. One example is provided by the intrinsic biological
vulnerability of extreme old age: the extent to which it is
experienced as problematic is heavily influenced by other factors such
as poverty, lack of secure housing and healthcare, and social
isolation. Furthermore, a population's vulnerability to famine
may be the result of climate change (Macklin 2012; Reiheld 2016).


### 4.2 Relationality and relational autonomy



Feminist bioethics' approach to care is grounded in its
relational ontology, that is the claim that the self is constituted
through relationships, as discussed earlier. As Annette Baier
wrote,



> 
> 
> A person, perhaps, is best seen as one who was long enough dependent
> upon other persons to acquire the essential arts of personhood.
> Persons essentially are *second* persons, who grow up with
> other persons. (Baier 1985: 84)
> 
> 
> 



This theoretical basis in turn underpins the moral significance of
relationality, and the responsibilities and obligations of
relationships, particularly in the context of healthcare. These
relationships arise between patient and healthcare providers, patients
and families, and include more novel forms such as those between a
gamete or embryo donor, and the children that result (Sherwin &
Stockdale 2017).



A relational model of the self sees individuals as inextricably
connected in an enduring network of familial, community, and wider
connections that create and sustain them as persons. Feminism's
relational view of the self provides the basis for a distinctive view
of the autonomous self, called relational autonomy, in which autonomy
is not a property of a person but is effected through the networks of
interaction that make up social life (Donchin 2000; Mackenzie &
Stoljar 2000). Relational autonomy considers a person's capacity
for self-determination to be dependent on the
connections--personal and institutional--that come into
play, and whether these foster or constrain autonomous action depends
on the detail of precisely how they operate in the given situation.
This view is in stark contrast to moral philosophy's traditional
formulation of personal autonomy as the individual's capacity to
act as an independent decision-maker, uncontaminated by any influence
from or concerns about other agents. Ethical analyses based on this
ideal generally omit as irrelevant the particularities of
intrafamilial relationships, as well as the wider context of
institutional power relationships and social dynamics that influence
patient options, and the medical research priorities that shape
them.



Relational autonomy is not simply a statement about practicalities
(that we need others in order to realize our choices), but a claim
that the internal capacity to be self-determining is itself a result
of early experiences in family and community that provide us with the
tools to reflect on how we want our lives to go and how to make that
happen. According to relational autonomy theorists, autonomy is not a
property possessed by all competent adults, but a developmental
achievement that requires social cooperation and supportive
institutions. The crucial point is that feminism's critique is
not that the traditional concept of autonomy is unachievable because
people are constrained from exercising authentic autonomy due to their
social entanglements. Rather, it is that this model is just
fundamentally *wrong*, because it is exactly that network of
relationships that provides the conditions of possibility for
self-determination and self-actualization in the first place. Autonomy
is inherently produced through relationships, not compromised by
them.



Respect for the autonomy of the individual patient or research subject
is a core principle of bioethics, underpinning informed consent and
patient choice. Indeed, mainstream bioethics and medical ethics have
sometimes been accused of effectively reducing autonomy to informed
consent and the ability of a patient to select between a limited set
of clinical options. From a feminist point of view, a more adequate
conceptualization of autonomy must take into account the entirety of
the relational context. Combined with feminist theory's focus on
the power structures of systems and institutions, relational autonomy
pushes beyond the analysis of interpersonal constraints on patient
autonomy (e.g., the authority differential between patient and
healthcare provider) to consider the effects of larger scale
structures and environments, and of social norms and pressures. For
example, Carolyn Ells uses a Foucauldian analysis to argue that the
standard depiction of patient choice relies on a false model that
treats them as if they existed outside the relations of power that in
fact are diffused throughout society, and to consider the implications
of a relational model of autonomy for the practice of patient-centered
care (Ells 2003; Ells et al. 2011).



While accepting that the principle of respect for autonomy has been
essential to the protection of individual liberty, including the
liberty of women, feminist bioethics has considerable reservations
about its relevance to socially disempowered groups for whom the
possibilities of self-determination are always constrained by
material, social, and political factors (Gibson 2019). Serene Khader
(2020) has expressed concern that relational autonomy theorists
implicitly hold that autonomy can only be achieved in ideal
conditions, which in reality means never. Other feminists have
examined how autonomy can be constrained by features that are less
obviously a product of power relationships or oppressive social
environments. McLeod (2002) has used examples from reproductive
medicine to show that encounters with healthcare providers can
undermine a woman's self-trust, thereby threatening her
autonomy. Meanwhile, feminist attention to the moral relevance of
embodied experience has identified trauma, abuse, inexperience,
impairment or illness, and relational responses to these states, as
potentially compromising autonomy (Donchin 2000; Brison 2001; Goering
2009; Scully 2010; McDonald 2018).


## 5. Feminist Contributions to Thematic Areas


### 5.1 Reproduction, reproductive medicine, and assisted reproductive technologies



Many people assume that bioethics is feminist when it addresses
"women's issues", such as pregnancy or menopause.
The roots of this misperception can be traced both to the
discipline's origins in women's health activism, and the
fact that many feminists were drawn into the field by their interest
in the burgeoning technologies of assisted reproduction in the 1990s
and 2000s. Reproductive issues are seen as "feminist"
simply because both biologically and socially they tend to affect
women more than men. And in practice, the first decades of feminist
bioethics were dominated by writing on contraception and abortion, and
the medicalization of pregnancy and childbirth. There was a particular
focus on how societies in general and healthcare in particular should
respond to the industrialized growth of assisted reproductive
technologies (ARTs) (in vitro fertilization, surrogate pregnancy, egg
and embryo donation, artificial insemination by donor). This has been
extended to more recent techniques such as mitochondrial transfer,
techniques of selective reproduction (prenatal testing, diagnosis, and
screening; preimplantation genetic diagnosis; preconception testing;
and genome editing), and the ability to generate, test, and manipulate
embryos ex vivo (e.g., Wolf 1996; Gupta 2000; Rapp 2000; Shanley 2001;
Kukla 2005; Mullin 2005; Harwood 2007; McLeod 2009; Baylis 2013;
Baylis & McLeod 2014).



This work on reproduction is identifiably feminist not simply because
it addresses issues that are of greater salience to women, but because
it reflects the characteristic features of feminist bioethical
approaches discussed earlier. It starts from the experiential
perspective of women, and it consciously examines the systemic and
interpersonal power differentials that determine how these
technologies were developed, delivered, and experienced. A feminist
framework enables a *different kind* of ethical evaluation of
the practices of reproductive medicine and ARTs than mainstream
bioethics can provide. A key insight is that because women bear a
disproportionate share of the associated risks and burdens, new
reproductive technologies are not gender neutral, a fact frequently
ignored in debates about the ethics of assisted reproduction. Thus,
feminist work highlights the potential that research into and use of
these technologies holds for issues such as the exploitation of
women's bodies and body tissues (Turkmendag 2022), the unequal
distribution of the physical and psychological burdens of fertility
treatments between women and men, the impact of ARTs on women's
career plans, and many others (Dickenson 2013; Ballantyne 2014).



Some feminist ethicists have also attempted to place reproductive
ethics in the wider context of both social expectations of maternity
and parenthood, and the accepted norms of the human body. There are
concerns that the fertility industry has a vested interest in
reinforcing a set of social expectations that women will do (and pay)
anything to have children and will turn to whatever technology is on
offer if they have difficulty conceiving due to a medical condition or
simply because of their age (Warren 1988; Parks 1999). Similarly, the
availability of testing and screening technologies, and potentially of
genomic editing, exerts pressure on women (and men) to produce only
"perfect" children (Rothman 1986 [1993]; Rapp 2000; Mills
2015; de Melo-Martin 2017). Alongside the health benefits they
may offer, these technologies may increase the stigma experienced by
disabled children and their families and exacerbate social
inequalities. Many of these issues overlap with others known to
disproportionately affect women, such as the impact of caregiving
responsibilities and the effect of particular economic policies on
socially marginalized groups, while some feminist bioethicists draw
parallels between the ways that both the female body and the disabled
body are seen as deviations from the (nondisabled, male) norm of human
embodiment (Scully 2022).



Feminist bioethics has also contributed to the ethical analysis of the
use of reproductive tissues for research or to circumvent infertility.
Insight into the routes through which eggs, embryos, and other
reproductive material flow into and circulate in contemporary medicine
and research raises questions about the potential exploitation of
women and women's bodily tissue. Examples of this include
groundbreaking work by Donna Dickenson (2007) on property and
ownership of the body and body parts, and by Catherine Waldby, Robert
Mitchell and Melinda Cooper on the global economy of reproductive
tissues (Waldby & Mitchell 2006; Cooper & Waldby 2014). One of
the key issues raised by these discussions is how to recognize when
women (and others) are being exploited as producers of bodily material
for research in the increasingly common situations where the research
takes place in the context of medical treatment, such as for
infertility.


### 5.2 Practices of care



Feminist ethics' theoretical contribution to the ethic of care
was discussed in section 4. This section considers feminist
bioethics' critical examination of the practices of health and
other forms of care. Mainstream bioethics rarely focuses on care as a
core ethical practice, and when it does, it generally fails to
distinguish between the different types of care performed by nurses,
personal care assistants, care workers and others, and fails to
highlight the economic and political invisibility of the unpaid care
work provided by family members (Parks 2003).



For bioethics, care ethics focuses primarily on relationships in the
clinical setting or the home, and on the micro level of interactions
between individual caregiver or healthcare professional and care
recipient. Feminist care ethics notes that the mundane labor of care
is low status and poorly paid, and (not unrelatedly) strongly
gendered, and justifications for the limits to medical and social care
services provided by state or by commercial providers often assume
that the primary responsibility for the care of dependent family
members is most naturally shouldered by women. Not least because of
this, the caring aspect of medicine is often dismissed as
"housekeeping" and compared unfavorably to heroic
biomedical interventions or the "crisis issues" that
dominate bioethical discussion.



Fresh interest in the moral structure of caregiving has been generated
by two particular developments--one technical, the other social.
First, novel assisted reproductive technologies including egg and
embryo donation and mitochondrial transfer have led to the emergence
of new family forms and structures (Cutas & Chan 2012; Hudson
2020). Relatedly, other authors note that the increasing
technologization of medicine, combined with changes in work patterns
and expectations, makes it harder to integrate care for family members
with the demands of modern workplaces and practices. They critically
examine the ambiguous consequences for women, and for the recipients
of care, of the replacement of traditional care practices by
technology, for example by care robots (Parks 2010; Gary 2021) or
other forms of artificial intelligence (Vallor 2011).



Second, demographic changes mean that nations of the Global North are
experiencing the aging of their populations with a concomitant
increased demand for both medical and social care (Holstein 2013).
Combined with the economic and political forces shrinking health and
welfare public services, these demographic changes in many parts of
the world mean that care responsibilities are shifting away from state
provision and back onto families, thereby reinforcing traditional
family structures in which women are the main providers of care
(Noddings 2002). A significant amount of feminist work examines the
organization of familial versus societal care responsibilities. In
this vein feminist bioethicists such as Rosemarie Tong (2009) and
Monique Lanoix (2013) have written on the discriminatory impact on
women of long-term care work, including the ethics of the national and
international arrangements of care for children, elderly, and
chronically ill people. Globalization has fostered an explosion in
international migrant care work, in which women move from poorer to
richer countries to provide care for children and elderly or disabled
and chronically ill people. Such transnational displacement of care
provision mainly affects women from socially marginalized groups and
has enduring and complex consequences for them, their families, and
their countries of origin (Weir 2008; Eckenwiler 2011, 2013).



Moving beyond practices that are readily identifiable in conventional
terms as care, there is also a focus of work within feminist bioethics
on the broader role of the family in decision-making about individuals
in clinical and public health contexts (Lindemann et al. 2019).
Conflict or ambiguities in care responsibilities become most visible
in high profile cases about end-of-life care, but there is growing
awareness of the need for an overall more robust theoretical framework
to encompass a broader understanding of the moral significance of
families. Finally, other recent work illustrates the expansion in
scope and scale of the application of care ethics, including care in
global pandemics (Gary & Berlinger 2020), the concept of caring
institutions (Bourgault 2020), care on a geopolitical scale (Robinson
2011; Vaittinen et al. 2019), and care as environmental responsibility
(Laugier 2015).


### 5.3 Disability and other non-standard embodiments



Biomedicine's view of the female body as a troublesome deviation
from a standard male norm has rarely been questioned by mainstream
scholars. Not surprisingly, feminist bioethics has taken a more
skeptical approach to the categorization of normal and abnormal
bodies, and has developed a rich exploration of what it means
bioethically to have or to be a "non-standard" body,
whether by virtue of sex, gender, age, race, class, or disability.
Engaging with the work of disability scholars, for example, feminist
bioethicists have critically examined the way the impaired body is
construed. They have gone beyond some well-trodden bioethical issues
in the regulation of technologies to prevent, cure, or ameliorate
disability, producing a body of theoretical work on, for example, the
social and cultural expectations of normality and the norms of
dependency and vulnerability (Fine & Asch 1988; Kittay 1999; Wong
2002; Tremain 2005; Scully 2008, 2014; Hall 2011; Ho 2011; Reynolds
& Silvers 2017).



Other feminist bioethicists have reflected on the more general
classification of non-standard embodiments as pathologies, and the
questions of autonomy and choice that such medicalization raises
(Purdy 2001, 2006; Garry 2001; Zeiler & Kall 2014). The
pathologization of the obese body and fat stigma have been extensively
discussed (Reiheld 2015, 2020; Guidry-Grimes & Victor 2012;
Strings 2015; MacKay 2017). There is also a growing body of work on
related issues concerning transgendered (Draper & Evans 2006;
Nelson 2016) and intersex embodiment (Holmes 2008; Feder 2014); see
also below.


### 5.4 Mental health and illness



Given that women who voice unorthodox opinions have frequently been
called "mad", it is not surprising that feminist bioethics
has also given considerable attention to women's experiences of
mental illness and psychiatry (Martin 2001; Chesler 1972 [2005]).
Feminist analyses have examined the way that gender stereotypes of
women as hysterical or overemotional contribute to the women's
own accounts of symptoms, distress, or unusual perceptions being
dismissed (Potter 2019). These examples are more complex than they
appear. There is compelling evidence that gender stereotyping
contributes to women being disproportionately diagnosed with mental
disorders such as depression, but it is also true that the oppression
experienced by women (and other marginalized groups) can in fact
generate higher levels of mental distress (Stoppard 2000; Bluhm 2011;
Nicki 2016; Shaw & Proctor 2005; Ussher 2018; McDonald 2018). The
operations of epistemic and institutional power help to explain how
sexist bias can lead to women's accounts of their experience,
including mental states, being either dismissed as trivial or
pathologized as symptoms of mental illness (see Martin 2001; Hansen et
al. 2011; also Harbin 2022). The impact of such epistemic injustice on
women in mental health and psychiatric contexts can be severe (e.g.,
Bueter 2019; Crichton et al. 2017), in the extreme leading to
involuntary psychiatric treatment (Tseris et al. 2022).


## 6. Continuing Evolution



As new themes in bioethics arise, feminist bioethics continues to
offer distinctive approaches and insights, by responding to technical
developments, expanding into topics traditionally excluded from
mainstream bioethics, and incorporating conceptual work originating
elsewhere in feminist thought.


### 6.1 Responding to new biomedical technologies and practices



A recent development in reproductive medicine is mitochondrial
replacement, the replacing of "faulty" with
"healthy" mitochondria (the subcellular structures
responsible for energy production) to prevent the transmission of
genetic disease. Alongside the issues raised by mainstream ethical
analysis, feminist bioethicists have noted the potential exploitation
of women as providers of eggs (and therefore mitochondria) for
research and treatment, just as they have for the global economy of
other reproductive tissues (Baylis 2013; Dickenson 2013). Similar
concerns are raised about the fact that research into emerging
reproductive technologies, such as genome editing and epigenetics, and
any treatments to which such research ultimately leads, have a much
greater impact on women than on men (Scott 2022). The development of
uterus transplants for infertility raises important moral questions
about the safety and efficacy of an experimental technique that
affects only women (Flynn & Ramji 2019; Lotz 2021). Meanwhile,
authors such as Ruby Catsanos and colleagues (2013) highlight the
often neglected point that the development of uterus transplantation,
as of many other reproductive technologies, inevitably uses
women's bodies as means to the end of perfecting the
procedure.



A growing number of bioethicists are now publishing on what are
broadly referred to as data ethics, digital ethics, or AI ethics. All
areas of healthcare are rapidly adopting a variety of technologies
that make use of artificial intelligence (AI), machine learning (ML),
and/or some form of automated decision-making. The technologies are
promoted on the basis that they are faster, more accurate, and bring
greater consistency and objectivity to medical practices and services,
as well as possibly offering more cost-effective ways to provide these
services to remote or under-resourced areas, thereby increasing global
equality. AI applications in healthcare include those that
specifically target women's health, such as AI systems that
analyze radiological imagery in diagnosing breast and cervical cancer
or predict disease progression from clinical data. Meanwhile a growing
market of direct to consumer AI-based products and apps claim to
empower users, such as pregnant women, through the provision of health
information (Gross et al. 2021; Paton 2022). These claims have been
challenged by some feminist bioethicists who see instead just another
instance of the control and surveillance of women's bodies.



Furthermore there are serious concerns about the overhyping of AI on
the basis of poor quality data, shaky evidence, and oversimplification
of the real-life settings in which AI-powered devices will be applied
(Wang et al. 2019; Carter et al. 2020). More specifically of interest
to a feminist critique, against the claims that computer-driven
processes are better and fairer because they are
"uncontaminated" by human fallibilities, it is becoming
clear that AI has a tendency to build existing injustices into novel
digital systems (D'Ignazio & Klein 2020; Wellner &
Rothman 2020). This may be due to the biased nature of the data on
which systems are trained. One obvious way in which this can happen is
if AI healthcare technologies use data derived largely or exclusively
from men (Larrazabal et al. 2020). Health data are heavily affected by
long-standing social, cultural, and institutional biases, which means
that algorithms based on these data will perpetuate or even exacerbate
existing gender and health disparities--for example, the lack of
data on women's physiology inevitably means that AI-based
predictions of pharmaceutical side effects are potentially very
inaccurate. The problem may also lie with the algorithm itself (i.e.,
the data may be adequate but what the algorithm does with the data is
not), or more fundamentally, it might flow from the social or
political assumptions around which the entire process has been
constructed, such as beliefs about the lifestyles and behavior of the
women taking a particular medication (Ho 2022).



Feminist critics have long pointed out that for any technology, the
specifically gendered distribution of practices and obligations can
turn what appears to be superficially beneficial into something more
ambiguous. For example, the expansion of AI health monitoring in the
home has been presented as means of reducing the burden on caregivers
(who are often women) and enhancing the autonomy of disabled or older
people. Nevertheless, the expectation that family members will adopt
AI-supported care may simply set up new burdens of cost or complexity
in the management of care, place emotional or other pressures on
family members (for example, if employers expect their employees to
put surveillance in place instead of offering flexible working hours),
and disrupt familial care relationships (Entwistle et al. 2014; Ho
2019).



From a feminist perspective, creating a genuinely ethical AI requires
thinking beyond the issues of a particular technological application
or abstract notions of "algorithmic fairness", in order to
take into account the context within which AI is being developed and
deployed in real-life healthcare. A global contextualization should
also ensure that AI healthcare solutions do not draw data solely from,
or use algorithms designed to focus on, the concerns of richer and
more powerful sectors of the community, neglecting the needs of poorer
sectors and exacerbating health disparities.


### 6.2 Expanding the limits of disciplinary interest



A second evolutionary pathway has continued feminist bioethics'
history of pushing at the boundaries of what is considered
"proper" bioethics. For example, since the early 2000s,
public health ethics have become a recognized part of mainstream
bioethics, yet many of the concerns of public health ethics were
anticipated by feminist health care movements at least a couple of
decades earlier. Feminist approaches are centrally concerned with
justice and equality, and the role of power relations--primarily,
but not solely, gendered power relations--in the generation of
inequity. In the context of public health, feminist analyses are
attentive to the connections between gender, health, and population
health inequities overall, but also look at how the social and
political distortions of power affect all the processes of public
health (Rogers 2006: 351), from policy making through to program
delivery (Baylis, Kenny, & Sherwin 2008).



In addition, a growing number of feminist bioethicists are moving
towards topics that have not been associated conventionally with
biomedicine but that nevertheless have powerful indirect effects on
human health. Some authors have developed a specifically feminist
bioethics of food consumption and production (Rawlinson & Ward
2016; Rawlinson 2019) in relation to ideas about vulnerability,
ecological dependence, and global justice (Gilson 2015; Reiheld 2016),
and have analyzed changes in agricultural and food production
practices through the lens of power and gender dynamics (Di Chiro
2017; Gilson & Kenehan 2019; Littig 2017; Wichterich 2015).



Some recent feminist work has taken these concerns beyond an
exclusively human focus. It understands "bio" to encompass
all aspects of the living world, in line with a longstanding
ecofeminist view that environmental damage reflects patriarchy and
male domination (Agarwal 1992; Plumwood 1993; see Elmhirst 2018 for a
recent overview of the field). There is a growing emphasis on the
consequences of environmental damage and climate change for humans and
the biosphere overall (Dwyer 2013; Whyte & Cuomo 2016; Zoloth
2017; Buckingham & Le Masson 2017; Bee & Park 2022). Some of
these areas have benefited from strong cross-fertilization between
feminist bioethics and feminist science and technology studies (STS),
with scholars working productively around the borders between the
two.


### 6.3 Incorporating theoretical developments



Feminist bioethics continues to change under the influence of ongoing
conceptual work in feminist and mainstream philosophy. One notable
development over the last quarter century is the rise of
intersectionality. First formally articulated by Kimberle
Crenshaw in 1989, intersectionality suggests that when identities or
social groupings intersect, they do so in ways that generate novel
experiences that are not reducible to the sum of individual categories
(Crenshaw 1989; Hill Collins & Bilge 2016). A disabled woman, for
example, will face some unique barriers to adequate healthcare that
would not be encountered by either a disabled man or a non-disabled
woman; these would be barriers that do not track neatly according to
sex and disability, but reflect the interaction of both. For any
theorists of justice and equality, including bioethicists, the
intersectionalities of sex, gender, race, class, sexual orientation,
and so on, should be illuminating. Although not yet widely
disseminated throughout mainstream bioethics, intersectionality has
been taken up with enthusiasm by feminist bioethics for its ability to
generate powerful analyses of the ways in which social
identities--the particularities of who one is and how one is
positioned in society--affect health and healthcare.



Feminist bioethics is also responding to developments in the
conceptualization of sex and gender. Thinking about the meaning of
being a woman has always been of interest to feminism, for obvious
reasons, but this engagement has been given new life by contemporary
activity in the areas of gender identification and reassignment. Given
the role that biomedicine and the pharmaceutical industry continue to
play here, it is unsurprising that bioethicists are exploring the
controversies around clinical interventions in the management of
intersex persons and in gender reassignment, for example. Feminist
bioethicists have described the barriers to effective healthcare
encountered by both transwomen and transmen, including practical
issues such as lack of privacy in healthcare settings, as well as lack
of knowledge and discriminatory attitudes on the part of healthcare
providers (Harbin et al. 2012; Freeman 2018; Drouillard 2021).
Intersex individuals encounter related issues (Feder 2014). The social
and biological nature of women's identity is currently a highly
fraught area of feminist theory and activism, with some concerned to
ensure that any framework of rights that takes account of gender
self-definition and reassignment continues to protect the rights and
needs of cis or natal women (Nelson 2016).



Feminist bioethics has always had an international feel to it,
reflecting not just the commonality of women's shared experience
but also an awareness of the global economic and political systems
that generate locally specific instances of injustice to women and
other marginalized groups. In this vein, feminist bioethicists have
considered the health needs of people living in economically
disadvantaged areas, the skewed distribution of health research and
care resources across societies and the world, and the global
dominance of western, highly technologized medicine that often diverts
resources from more basic healthcare services. Other authors examine
the impact on women of international health policy, including formal
instruments such as the UNESCO Declaration on Universal Norms on
Bioethics (Rawlinson & Donchin 2005).



However, during the final decade of the twentieth century it became
clear throughout the women's movement that the sense of global
commonality through shared experience might be thinner than it seemed.
Black women and women of color, Indigenous women, and others protested
the exclusion of their own histories and perspectives from feminist
thinking and activism - including feminist bioethics (Mohanty 2003).
Most recently, bioethicists have responded to calls for the
decolonization of bioethical research and teaching (Obasogie &
Darnovsky 2018; Richardson 2019; Shahvisi 2019). Decolonization
describes the awareness that the past 500 or so years of human history
have been shaped by colonial power and that coloniality continues to
structure our systems of knowledge to this day. Arianne Shahvisi
describes decolonization as



> 
> 
> the systematic uncovering, announcing and destabilizing of coloniality
> in the topics of study, methodologies, training and culture ....
> (Shahvisi 2022, 351).
> 
> 
> 



She argues that as a normative discipline, feminist bioethics has a
particular obligation not just to note and examine the gendered,
racialized, and geographical patterns of suffering that result from
coloniality, but also to end them (Shahvisi 2022). Feminist approaches
that take into account the particularity of women's experience
and that are sensitive to the effects of local and global power
dynamics are therefore well-placed to lead bioethics beyond treating
the concerns of the global South as a set of distant issues (Diniz
& Velez 2001; De Castro 2001; Khader 2013; Ganguli-Mitra
2021). While decolonization generates deep tensions within the academy
as a whole, the willingness to face the theoretical, professional, and
political tensions that result is part of the critical and avowedly
*self*-critical nature of feminist bioethics.


## 7. The Future of Feminist Bioethics



Feminist bioethics arose originally out of women's responses to
the inadequacies of mainstream bioethics, one of which was perceived
to be its lack of radical edge, or perhaps better, its political
timidity. Like any movement with progressive goals, feminist bioethics
in some sense aims to put itself out of business: it wants to see the
criticisms it presents to the mainstream acknowledged and the defects
remedied. Feminist approaches work to transform the bioethical labor
going on at the heart of the discipline, and indeed many of its
insights have been absorbed into the mainstream. Examples include the
so-called empirical turn in bioethics and a recognition of structural
inequities in healthcare. But this kind of success is always
double-edged, and many feminist bioethicists will have felt irritation
at the amnesia (or willful ignorance) of mainstream bioethics about
the source of these vital insights. More seriously, there is a danger
that the power and perceptiveness of feminist critique will dissipate
as (or if) it loses its outsider status.



Nevertheless, while the incorporation of feminist ideas may have
smudged the line between mainstream and feminist bioethics, any
assimilation of feminist ideas into mainstream bioethics is restricted
to its theoretical and methodological approaches and largely excludes
the specific goals of fostering gender and social justice. Beyond the
academy, recent social and political developments, ranging from the
erosion of reproductive autonomy in the overturning of *Roe v.
Wade* in June 2022, to the gendered impact of the global COVID-19
pandemic, have been salutary lessons in the precarity of feminist
gains in the wider world.



Feminist bioethics continues to develop in response to medical and
life science research on the one hand, and developments in philosophy
and social theory on the other. It also reflects the establishment of
new fields of inquiry, such as AI ethics, and the disruption of old
disciplinary boundaries. In this respect it is not so different from
mainstream bioethics overall. What makes it distinctively feminist is
the underlying commitment to the political goal of identifying
practices that harm and disadvantage women, grounded in the conviction
that this will produce a better and fairer world not just for women,
but for everyone.