from Hypatia Volume 14, Number 2

"Fatal Practices": A Feminist Analysis of Physician-Assisted Suicide and Euthanasia

DIANE RAYMOND

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In this essay, I examine the arguments against physician-assisted suicide (PAS) Susan Wolf offers in her essay, "Gender, Feminism, and Death: Physician-Assisted Suicide and Euthanasia." I argue that Wolf's analysis of PAS, while timely and instructive in many ways, does not require that feminists reject policy approaches that might permit PAS. The essay concludes with reflections on the relationship between feminism and questions of agency, especially women's agency.

Susan M. Wolf's "Gender, Feminism, and Death: Physician-Assisted Suicide and Euthanasia" (1996) makes an important contribution not only to the popular and academic debate on physician-assisted suicide (PAS) and euthanasia but also to the growing body of writing by feminists in the area of bioethics.¹ Wolf notes the "new levels of intensity" (1996, 282) both proponents and opponents bring to this arena, and she notes the issue's uncontroversial practical significance as states decide whether to legalize PAS and/or other forms of euthanasia. Since Wolf's essay was published, the U.S. Supreme Court took up the assisted suicide issue. As predicted, the Court (in Washington v. Glucksberg and Vacco v. Quill) ruled equivocally in returning the question to the states. That decision, while consistent with the Court's federalist inclinations, obviously offers little legal, much less moral, guidance. Writing for a unanimous Court, Chief Justice Rehnquist affirmed the Court's temporizing: "our holding permits this debate to continue, as it should in a democratic society" (in Garrow 1997, 4). Oregon, having revoted its "Death with Dignity Act" in 1997, is currently the only state to permit PAS.

In this essay, I want to examine critically Wolf's argument against PAS. While I suspect that she and I agree far more than we disagree, this essay deliberately sharpens and foregrounds our differences as a strategy by which to interrogate some of her criticisms of PAS. Like Wolf, I will not rehearse the standard moral arguments for and against suicide and euthanasia. My goal here is not primarily to challenge Wolf's motivating claim that PAS ought not to be endorsed as social policy, though such a challenge follows from some of the arguments I make here. Further, like Wolf, I take as a given that "attending to gender and feminist concerns in analyzing these problems is no longer optional" (Wolf 1996, 287). Instead, my intention is to complexify feminist philosophical approaches to the practice of PAS as currently understood and in light of its present and persistent popularity.² Given Wolf's and my shared commitment to feminist theory and practice, to highlight our disagreements contributes, I hope, both to a more nuanced dialogue between feminism and bioethics and to richer conversations within feminism itself. Indeed, this essay may serve as a corrective to feminist approaches to bioethics that have tended to neglect the ways by which feminism's interventions in the applied realm might reshape it.

This essay is structured around three sections. In the first section, I expand on Wolf's discussion of medical practice to examine briefly typical pedagogical approaches to the issue of PAS; that discussion will help to ground my later recommendations. Next, I consider Wolf's argument against PAS, emphasizing the value assumptions underlying her position. Finally, I explore what alternative strategies and policies on PAS a feminist analysis might justify. The essay concludes with reflections on feminism and moral agency, a topic central not only to medical ethics (often veiled under topics like paternalism, informed consent, and competence) but also to much of feminist theory.

Though this essay presupposes a feminist perspective, I aim here to address the widest possible audience of feminist scholars, practitioners, and policy-makers. My current feminist vision, as will become clearer, tends towards a hybrid, pragmatic feminism rather than to a loyalty to any traditional feminist orthodoxy. The local character of my feminism and its attention to multiple aspects of identity and power should not be confused with any naive version of relativism. Indeed, my rejection of certain articulations of feminism will emerge over the course of this essay's argument. Similarly, hybrid feminism's specificity at first glance challenges policy-making's generality; yet, as I shall suggest, while this local feminism eschews simplistic policy positions, it does not preclude policy and legal strategy.

Pedagogy And Practice: A Brief Context

Like many feminists who write in the area of biomedical ethics, Wolf rightly points out that the "generic patient" featured in philosophical analyses and biomedical cases is a patient emptied out of all subjectivity. Wolf, however, may understate the extent to which bioethics, as a fairly recent field, has been responsive to feminist critiques of female invisibility. Thus, typical cases do give us women as patients, as members of family networks,³ and as providers; indeed, the female doctor is now a standard character in bioethics vignettes. Further, narrative details help one to construct situated agents: Such details often include insurance status, age, and marital status; class is usually implied, race almost always assumed to be white, and ethnicity is hinted at through the use of ethnic names.⁴ The deeper problem, as I see it, is that the philosophical and cultural significance of these dynamics is never fleshed out, as if to do so either traps one in some version of essentialism or precludes broader generalization.

Thus, though medical ethics texts increasingly acknowledge the possibility that an attending physician is a woman or replace the generic "he" with "he or she," problems in bioethics continue to be treated as individual dilemmas framed in terms of "What ought I to do?" This approach generalizes from one's response to that question to a prescription for all physicians, all nurses, all patients, all proxy decision-makers, and so forth. Not only are questions of institutional power and coercion, individual situatedness, vulnerability, bureaucracy, and access to resources lost; the insistence on universalizability means that context drops out, no matter how rich the original case. Questions of power may obliquely appear in concluding chapters on "Social Justice," but this tendency only reinforces the problematic dichotomy I am criticizing between individual decision-making and social justice. Further, as Hilde and James Lindemann Nelson point out, philosophical discussions of justice ignore existing power inequities and tend instead "to start from standard theories of justice and to accept equably enough the relationships of power and reward in which health care is delivered" (1996, 354).

Not surprisingly, philosophical treatments of euthanasia suffer similar failings, almost regardless of their authors' normative positions. While such analyses inevitably cite the well-rehearsed cases (Cruzan and Quinlan in particular and, in more recent writings, Cowart, Wanglie, Bouvia, McAfee, and others), almost never does the analysis inquire into what difference gender might make or how other aspects of identity might weigh into the actual treatment decisions and the corresponding normative analysis. I have yet to see, for example, comment on the possible meaning attached to the fact that Karen Quinlan's father and not her mother was made her guardian, and that a male guardian ad litem was appointed when Joseph Quinlan was deemed "biased." The mixed message here only heightens the irony: While fictional and actual cases provide us with a gendered patient, the implication seems to be that, once known, gender drops out like one of modern philosophy's accidental qualities. If "all forms of strategy"--including feminist--"involve recognizing what is in order to move on to what should be" (Gross 1986, 197), then it is crucial to examine how gender shadows current treatments of euthanasia and PAS.

Gregory Pence's Classic Cases in Medical Ethics (1995), a well-written and researched textbook now in its second edition, is worth examining as a fairly typical representative of the pedagogical approach I am describing here. Three of the eighteen chapters total--"Comas," "Requests to Die," and "Physician-Assisted Dying"--explicitly address euthanasia. Yet nowhere does the analysis attend to what relevance the comatose patient's gender has to treatment. Indeed, Pence refers at one point to Nancy Cruzan as a "typical young adult" (1995, 31), leading one to infer that gender makes no difference. Though in Chapter 2 Pence mentions Elizabeth Bouvia's "devastating" divorce and miscarriage, he does not suggest that disability issues might affect men and women differently despite the fact that he does restate the commonplace statistical differences between men and women vis-à-vis suicide.⁵ Major categories of "ethical issues" include "Communication and Control" (not typical in ethics textbooks), "Standards of Brain Death," "PVS Patients: Costs of Care," "Kinds of Medical Support," "Kinds of Cases," and "The Slippery Slope"; neither gender nor feminist approaches appear here. No feminist writings are even cited among the hundreds of citations for these chapters.

One might infer from these omissions a more general ignorance of or even antipathy toward feminist theory; yet Pence does incorporate (albeit briefly) feminist approaches into three other chapters: one on in vitro fertilization and alternative reproduction; one on abortion; and one on surrogacy. This tendency to ghettoize gender/feminism is common in medical ethics textbooks; to link feminism to women's maternal/reproductive role is to reinforce the notion that feminism is limited in its usefulness to analyses of women's bodies and therefore that feminism is about women and all other theory is, in contrast, universalizable.⁶ Indeed, one testament to the success of feminism is the growing number of recent medical ethics anthologies including feminist ethics (usually as care ethics) in their introductory chapters outlining general ethical theory, but the articles selected for inclusion rarely apply feminist methodology, and the applications seldom incorporate feminist perspectives.⁷

Not surprisingly, then, euthanasia is generally treated in moral isolation; yet the issue, upon closer examination, can be seen as linked to a number of complex questions in medical ethics, including questions about power inequality (not only between providers and patients but also between the sick and the well); allocation of resources; obligations to the aged, the sick, and the dying; social priorities (both within health care and between health care and other social needs); choices, competence, and constraints; and quality of life. And given that the sex/gender system is partly constitutive of these arenas, it seems improbable that euthanasia and PAS are safe from its reach. As Wolf notes, "It would be implausible to maintain that medicine is somehow exempt from broader social dynamics" (1996, 294).

Given the power and pervasive invisibility of patriarchal discourse, Wolf cautions wisely against embracing PAS as part of an expanded package of "choices" for women. Who could disagree with the principle that, given that the consequences are fatal, "we had better understand the dynamic at work in that encounter [between physician and patient], why the practice

seems so alluring . . . , and what dangers are likely to manifest" (1996, 284)? And surely even the most ardent defender of euthanasia can accept the demand that "we had better determine whether tacit assumptions about gender are influencing the enthusiasm for legalization" (1996, 285). But Wolf uncovers these assumptions as more than a basis for thoughtful caveats about PAS and euthanasia. Her analysis of the gendered dynamics of medical care delivery leads her to the conclusion that "we should be reluctant to endorse these practices" (1996, 286) as a matter of social policy, despite her corresponding insistence on respecting women's refusals of life-sustaining treatment. While Wolf acknowledges a variety of factors in a momentous decision like the decision to die, sexism is for her so powerful and pervasive that it trumps those other factors. And it is noteworthy that she deploys that gendered lens to draw a generalizable conclusion about all patients (not simply women) seeking euthanasia or physician-assisted suicide; for Wolf, "what we glean from looking at gender should lead us to look at other characteristics historically associated with disadvantage, and thus should prompt a general caution applicable to all patients" (1996, 286). I want now to look more carefully at the argument itself.

Feminism And Death: Wolf's Analysis

Wolf's argument is organized around two general sorts of questions: First, she asks about the ways cultural ideology relating to gender might influence requests for PAS, reasons for requesting PAS, decisions by providers whether to grant those requests, and the ways we think about this issue; second, she uses feminist literature on "caring, rights, and context" (1996, 286) to move beyond specific questions about gender to analyze the standard arguments supporting PAS. The problematic influence of sexist ideology (as her cases expose), data from the Netherlands, and interpretation of literature and cultural codes lead Wolf to conclude that there is no way to implement any policy relating to PAS that guarantees protection for vulnerable groups, including women. I should note once again that her argument applies only to what the bioethics literature has termed active euthanasia; even as she rejects PAS, Wolf reaffirms her earlier stance linking feminist respect for women's decisions to reject unwanted bodily intrusions and to refuse treatment. I want to examine more specifically the claims leading to that conclusion.

Cases And Data

In surveying cultural practice and ideology, Wolf acknowledges that the empirical data currently available are inconclusive: The illegality of the practice in most places makes reliable data difficult to find. In addition, the data from the Netherlands are somewhat ambiguous; further, even if we could agree on interpretation, the enormous material and cultural differences between the Netherlands and the U.S. might render cross-cultural translation problematic. But Wolf does conclude from the data and the cases (she mentions a number: Kevorkian; the infamous 1988 Journal of the American Medical Association article, "It's Over Debbie"; and Dr. Timothy Quill's account of his assisting in the death of his patient Diane) that more women than men receive PAS; that the ideology of self-sacrifice coupled with women's greater difficulty in getting adequate pain medication means that women's reasons for requesting euthanasia may differ from men's (she notes that women are at greater risk for depression, suggesting that women's increased failed attempts at suicide may signal not a desire for death but rather for a change in circumstances); that physicians may more readily grant women's requests to die; and that gender ideology infuses the public debate.

Wolf and I do not disagree on whether gender influences decision-making on this "fatal practice." Commitment to feminism includes the transformative insight that gender ideology shapes culture in untold, unseen ways. But do the cases and the data Wolf cites support the conclusion that feminists ought to reject PAS? While Wolf is right that "the cases prominent in the American debate mostly feature women patients" (1996, 282), unlike her, I am not convinced that we are justified in inferring from these cases that women are worse off with PAS. Before I look more closely at this question, however, I want to consider briefly what role empirical data ought to play in this context.

Given feminism's commitment to contextualized reasoning, it would be absurd to ignore or minimize the importance of the empirical, a part (at least) of context. But a number of qualifiers are in order here. First, as noted, the data in this particular context are extremely hard to get and ambiguous when available. Second, any search for "unambiguous" data will necessarily be futile, as all data require interpretation; interpretation obviously flows out of (though need not be determined by) one's presuppositions and commitments. Third, the normative realm--Wolf's and my shared dominant concern--cannot be collapsed into the empirical; ultimately, choices political and moral involve departures from the descriptive. Finally, I suspect that Wolf's and my disagreement is not in the last analysis dependent on "facts," however ambiguous or unambiguous those "facts" might be. While the data clearly matter to us both, deeper value disagreements more likely divide us. For example, I cannot help but note the incredibly charged language Wolf occasionally uses to describe the practices pertinent to PAS; in her essay people are "annihilated" (1996, 293, 301) or "obliterated" (1996, 293), and PAS is analogized to domestic violence; "the mandates of caring," Wolf insists, "fail to bless killing the person for whom one cares" (1996, 307) and she tends to equate PAS with physician abandonment, a practice that all agree is never justified. I will return to Wolf's analogies in the final section of this essay. For now, I raise these points to suggest that Wolf's moderate language belies a nearly visceral revulsion to PAS; disagreements, then, occur not only around the question of agency but also over how great an evil death is.⁸ With that, I want to return to Wolf's argument.

The argument's first part has two interconnected claims: first, that the common characteristics of the well-known cases in the U.S. coupled with the empirical data gleaned from the Netherlands provide good reason to suspect that gender not only plays a role but also that that role differentially disadvantages women; second, Wolf examines cultural ideology as a strategy to expose possible images and associations that may unconsciously animate public debate over PAS and euthanasia. I consider each of these points in turn.

Wolf admits that the evidence from the Netherlands is open to conflicting interpretation and disanalogous enough from the United States (for example, the Netherlands health care system includes universal coverage) to make us cautious about drawing inferences even if we had consensus on the Netherlands experience. Despite these caveats, however, Wolf insists that "we nonetheless see something of a gender difference" (1996, 296) and suggests that such discriminatory treatment is likely to be worse in the United States. Yet the 1991 Remmelink Commission Report, "the first rigorous empiric study of euthanasia in the Netherlands" (Emanuel 1994, 1895) reveals that 52 percent of the patients receiving euthanasia were men, "exactly the proportion of all deaths in the Netherlands" (1994, 1895). Interestingly, only one-third of all requests for euthanasia were granted, and, as Wolf notes, many patients asked about euthanasia but did not request it. Though Wolf seems to use this higher request rate to suggest that patients don't really want euthanasia, one might alternatively read the phenomenon as suggestive of patients' desires to be informed of all options and/or of providers' unwillingness to rush to euthanize. Not even the most avid PAS supporter suggests that all patients want euthanasia or that every patient request should be granted (even Jack Kevorkian allegedly declines hundreds of requests for euthanasia); the fact that one-third of such patients do finally ask for euthanasia remains significant, however. While further study of the Dutch experience needs to be done (and a large-scale study of Oregon's policy is planned for 1999-2000), I suggest provisionally that the evidence thus far is less ambiguous and ominous than Wolf claims.

Wolf is the first to admit that the U.S. cases she foregrounds are but an early sample and that they "are no substitute for systematic data" (1996, 288). But she finds them useful not only because they feature female patients and male providers but also because they emblematize the dangers attending to legalized PAS. I want here to focus on the Quill case and bypass others she mentions: "It's Over, Debbie" (It's over 1988), most commentators agree, is an apocryphal case; for all we know, that essay was written to demonstrate the wrongness of physician-assisted suicide. As for Kevorkian, even granting that his first nine patients were women, his numbers (at latest count) are now fairly even in terms of gender. In fact, if more women than men seek him out, that gendered disparity may suggest a point opposite to that of Wolf, namely that women's genuine requests for euthanasia are ignored by the "legitimate" medical establishment. Indeed, early in the essay Wolf notes the possibility that physicians may ignore women's requests for death because of misogynis-tic beliefs that women are irrational and overly emotional; she never returns to that possibility in any of her later arguments, however.

Wolf attaches a series of questions to Dr. Quill's example: "why he responded to [Diane] as he did, what self-scrutiny he brought to bear on his own urge to comply, and how he reconciled this with the arguments that physicians who are moved to so respond should nonetheless resist" (Wolf 1996, 288). Wolf's rhetorical list functions to unite her and the reader in awaiting future discussions of the sorts of questions Quill was allegedly negligent in bringing to bear on his decision. Yet this rhetorical strategy is misleading, for Quill has shared his thinking on many of those very questions in his highly publicized essay documenting the case.⁹ Though his answers may not satisfy Wolf, his essay does explicitly address Wolf's rhetorical list and seems to provide the rich subjective context Wolf maintains euthanasia debates lack. While an in-depth analysis of Quill's actions is not appropriate here, some of the narrative details and his reflections on them bear on my later discussion and thereby warrant brief consideration here.

First, Quill had been Diane's provider for at least eight years. While one might argue that we cannot know how often he saw her or how well he knew her, the fact remains that they had a long-term relationship and that he knew a good deal about her, including her history of alcoholism, her three-year abstinence at the time of her diagnosis, and her "strong sense of independence and confidence" (Quill 1991, 692). In addition, Diane's acute myelomonocytic leukemia, if untreated, would have resulted in her death within, at most, months. The extremely painful course of treatment Diane refused had only a 25 percent chance of success; Quill notes that "the last four patients with acute leukemia at our hospital had died very painful deaths . . . during various stages of treatment" (1991, 692), and Diane made clear that she wanted to spend her remaining time with her husband and son. Quill tells us that he did everything he could to ensure fully informed consent (he clarifies the odds, makes sure she knew "what to expect if there were no treatment" [1991, 692], and so forth), that he had been a "longtime advocate of active, informed patient choice of treatment or nontreatment" (1991, 692), and that he was experienced in hospice care. Though he continued to hope that she would change her mind ("there was something about her giving up a 25 percent chance of long-term survival in favor of almost certain death that disturbed me" [1991, 692]), he did everything he could in the meantime to keep her comfortable. When she asked for help in dying, he did not casually prescribe the requested barbiturates but rather met with her to discuss her intentions and to assess her mental state; convinced that she understood the consequences of her decision and that that decision reflected her core values, he agreed to provide her with the prescription. Quill was not present when she died, though she did call him shortly before her death.

While Wolf implies that Quill experiences little self-doubt, his essay in fact is riddled with questions and self-doubts; further, importantly, Quill does not agree with Diane's decision and yet helps her to effect it. In the last paragraph of the essay Quill wonders "how many severely ill or dying patients secretly take their own lives, dying alone in despair" and "why Diane, who gave so much to so many of us, had to be alone for the last hour of her life" (1991, 694). "Diane," he says, "taught me about the range of help I can provide if I know people well and if I allow them to say what they really want" (1991, 694). Unlike Wolf, I cannot imagine what more one might want in a provider.

How does one assess the role that gender plays in such cases? As feminist theory sharpens our awareness of women's multiplicity, isolating gender becomes increasingly more difficult to accomplish on a practical level and increasingly more difficult to justify theoretically. Such difficulties do not imply that gender analysis is misguided but only that one must not oversimplify women's situatedness in multiple positions of both privilege and oppression. Can we say, in Diane's case for example, whether and how her alcoholism, her heterosexuality, her age, her race, her disease, her marital status, her motherhood inflect her decision to die and Quill's to help her? Wolf asks for details about "what failures of relationship, context, and resources have brought the woman to this point; precisely why death seems to her the best remaining option; what elements of self-sacrifice motivate her choice . . . "(Wolf 1996, 296-97). But Wolf's dismissal of those details when offered suggests that cases and their narrative details--a spectrum, as she would no doubt grant--are more peripheral to her argument than it might seem initially. Indeed, in framing her question in terms of "failures," Wolf exposes her presupposition that death can only seem to be the "best remaining option."

Given feminist analysis of the hierarchical dynamic between physician and patient, Wolf is rightly suspicious of physicians' involvement in these cases. But what if the women themselves--the Dianes, the Marjorie Wanzes, the Debbies, and so forth--were to speak and insist on their own agency? For Wolf, such testimonies, given that they take place in a broader context of the cultural ideology of women's self-sacrifice and guilt, cannot morally compel action. Wolf's analysis of that ideology, then, warrants further consideration.

Gender And Ideology

In the section "Gender in Cases, Images, and Practices," Wolf extends her argument against PAS by grounding the examples just discussed in a gendered context where female self-sacrifice and passivity have been the normative ideal. That insight leads her to explore the historical and cultural background of suicide and its ideology, suggestively using Greek tragedy, the nineteenth-century cult of True Womanhood, and Carol Gilligan's research to confirm that self-sacrifice has traditionally been associated with women and regarded thereby as a feminine virtue. Yet, while there is no doubt as to the misogynistic history of women's constrained choices, Wolf oversimplifies and overgeneralizes that history. Many cultures--the Stoic, for example--equated suicide with courage and thereby framed the practice as male. The Greek tradition of soldiers throwing themselves on their swords rather than be taken as slaves, the Japanese ritual of hara-kiri, the examples of Hemingway, Kohlberg, and numerous others--these easily recoverable cases suggest that suicide can be seen as part of a masculinist ideology or at least not unproblematically feminine.¹⁰ While a more in-depth analysis would probably reveal much divergence even in ancient Greek practice, Wolf's ascription of suicide as a "woman's solution" (Wolf 1996, 289) might be as inaccurate and overly monolithic a description of ancient Greek practice and ideology as it appears of the present, where statistics show that older white men kill themselves at a rate five times higher than the national average (National Center for Health Statistics Report 1987). Given patriarchal ideology's equation of masculinity with strength and power, men's heightened inability to cope with aging and illness makes sense intuitively. Further, women's lived experiences with multiple forms of dependence and interdependence--pregnancy, childrearing, and so forth--may mitigate some of the anxiety associated with aging, dependence on others, and decreasing physical autonomy.

Further, the slippage in Wolf's argument from self-sacrifice (a "feminine not masculine virtue" [1996, 289]) to suicide makes the argument suspect; rather than conflating the two, one might argue that, given that women's historical role has been to endure selflessly all forms of labor and abuse, particularly in the domestic sphere, suicide may for women be the ultimate transgressive act. One need not, however, go that far or make men's behavior normative to challenge Wolf's argument. For even if we agree that popular discussions of PAS and euthanasia "may be animated by unacknowledged images that give the practices a certain gendered logic and felt correctness" (Wolf 1996, 289), all that follows is the more modest conclusion that we must interrogate that logic before making a normative judgment about the practice.

The gender ideology fleshed out in Wolf's analysis may lead, as suggested earlier, to great reluctance, not eagerness, to allow PAS or euthanasia for women. Indeed, some evidence suggests that if there is any gendered difference in end-of-life treatments, it is that men are undertreated and women are overtreated. Steven Miles and Allison August, for example, have examined a number of judicial decisions relating to withdrawal of treatment at end-of-life and find a pattern of acceding to male patients' wishes over females'. They note that women are held to higher evidentiary standards when requests to die are examined, and they remark on the ways in which gendered language in judicial treatments of these cases tends to rob women of their agency. Women and not men, for example, are routinely infantilized by referring to them by their first names ("Debbie" and "Diane" fit this pattern); and men's statements about end-of-life treatment are held to reflect "mature, rational choice" while women's are seen as "unreflective, emotional, or immature" (Miles and August 1990, 87). Karen Quinlan's comments to her mother were thereby dismissed as a "wish" or personal "distaste" and not a genuine expression of her values. In another case, a woman's repeated comments regarding her desire not to be kept on life support were trivialized as no "more than immediate reaction to the unsettling experience of seeing or hearing of another unnecessarily prolonged death" (in Miles and August 1990, 88). Courts seem even to discount women's advance directives, preferring instead to appoint family members as decision-makers for the incompetent woman; in one case, the Court empowered a woman's husband/guardian to make the decision "for" her, despite the fact that she had been an active member of the state's "Euthanasia Council."¹¹

Women's "overtreatment" at end-of-life may seem odd considering men's greater access to earlier interventions, including more standard diagnostic procedures like angiograms and more "exotic" treatments like organ transplants. But the superficial inconsistency between men's end-of-life treatments and their greater access to earlier treatment options might instead reflect a pattern consistent with patriarchal ideology, namely that we hold to a higher standard of quality of life for men than for women. If such is the case, then gender ideology, in valorizing female passivity, may actively collude with the medical profession in keeping dying, suffering women alive. Likewise, ideological constructions of masculinity as inextricably aligned with agency, activity, and transcendence might lead to respect for men's medical directives--formal and informal--as well as to gendered distinctions on quality-of-life issues. Those unfamiliar with the ravages of persistent vegetative state (PVS) may picture the comatose or PVS patient as a comfortable "sleeping beauty" waiting for her miraculous awakening; such gendered imagery may help to account for the resistance to withdrawal of life support in the classic Quinlan and Cruzan cases, and the willingness of the Georgia Supreme Court to grant the physicians of Larry McAfee, a C-2 quadriplegic (a non-terminal condition), permission to provide him with the drugs necessary for him to be free of pain when his respirator was disconnected.¹²

Wolf's analysis of cultural ideology, while extremely suggestive, needs elaboration and nuance. Further, in the course of that extended analysis we should not be surprised by gaps and inconsistencies, for culture is never monolithic or fixed, and cultural practices do not follow consistently or irresistibly even the most hegemonic ideology. Thus, one can agree wholeheartedly with Wolf's claim that "the very meaning of the patient's request for death is socially constructed" (1996, 299) while rejecting her understanding of that meaning or being willing to entertain multiple interpretations.

"Beyond Gender": Feminism And The Arguments For PAS

Thus far, I have tried to suggest that Wolf's cases and the cultural ideology she identifies are far more complex than Wolf implies and that the possibility of feasible alternative readings means that her desired conclusion is not entailed. Wolf might agree that these empirical observations cannot determine our moral posture; indeed, her next section examines two arguments traditionally used to defend PAS: the view that the right to self-determination justifies PAS; and the view that beneficence grounds PAS. Wolf rejects both arguments. The first, she maintains, misreads rights arguments in a number of ways, but primarily by confusing the right to refuse treatment with the right to suicide (not a right, she says) and by presuming the right to involve a third party in one's death (also not a right). Further, rights approaches tend to denigrate dependence (Wolf 1996, 299) in portraying isolated human agents and ignoring context, especially the ways in which choices might be constrained. Wolf also rejects the second defense, including feminist arguments that an ethic of care might justify PAS. For Wolf, such a position suggests a "shallow" understanding of care; according to Wolf, we can care in ways other than killing, for example, by providing more pain medication.

Wolf's own view incorporates the research of Carol Gilligan (1982) and the theoretical insights of Susan Sherwin (1992) and others to demand a "proper integration of rights and caring" that would include a "deep and contextualized understanding" of requests to die (Wolf 1996, 286). Favoring feminist analyses of autonomy that reject mechanical applications of rights and foreground instead embeddedness and relationality, Wolf calls for what she terms "principled caring" as the standard for judging this issue. One aspect of that caring involves examining the reasons women may seek euthanasia or PAS. In considering these reasons, Wolf points appropriately to a number of gendered variables, including women's greater risk for inadequate pain relief and depression, poverty, vulnerability in the health care system, and fears of burdening their families. This context taints women's decision-making not by rendering it irrational but by constraining rational choice itself.

Wolf's analysis is consistent with much recent feminist theory that seeks to understand a contextualized agency. Further, feminists have recently begun to articulate a view of agency as dynamic and process-oriented in contrast to traditional views of agency as a static, all-or-nothing state. Caught between the Scylla of liberal "choice" and the Charybdis of radical "false consciousness," feminists have, like Wolf, sought to articulate a notion of female agency respectful of women's decision-making while at the same time seeing its embeddedness in a context of hierarchy and constraint. That context ought to make one suspicious of absolutist rights discourse in bioethics, which frames decision-makers as isolated monads and "wrongly assume[s] that all face serious illness and disability with the resources of the idealized rights bearer--a person of means untroubled by oppression" (Wolf 1996, 299). Likewise, though, we cannot assume unproblematically that "beneficence" or "care" alone can redress the failings of rights-based approaches. Indeed, "the background realities and history of male dominance and female subjugation" (1996, 293) in medicine are likely only to exacerbate the problem of physician "paternalism," often masquerading as "beneficence." Further, an uncritical acceptance of "care" can reinscribe female subordination and neglect serious questions of fairness.

Sherwin's analysis of paternalism in No Longer Patient rejects the paternalism/autonomy binary presupposed in mainstream discussions. She notes that "feminists share the perspective of their biomedical counterparts that much medical paternalism is unjustified" (1992, 140) even as they reject classical libertarian defenses of autonomy rooted in a conceptual framework of unequal power relations. While Wolf's rejection of PAS may seem to fly in the face of such feminist opposition to paternalism, her argument, as I suggest below, depends on the legitimacy of women's expressed desires for PAS. That is, if women asking for PAS do not really want to die, then refusing their requests is noncoercive by honoring women's deeper, more authentic desires.

Like Sherwin, Wolf insists on specifically feminist reasons for rejecting or accepting paternalism. Noting the vulnerability of the patient, Wolf briefly mentions a concept borrowed from Sherwin: amicalism, a model of egalitarian relationship grounded in friendship. For Sherwin, a friendship model can help patients (including patients with diminished capacities) "to communicate with others whom they trust--that is, those who have already demonstrated their commitment to them as individuals" (Sherwin 1992, 157). Reaching beyond the level of individual decision-making, Sherwin makes use of Sarah Hoagland's relational notion of autokoenony, or self in community. As concepts, amicalism and autokoenony complement one another and suggest new, nonhierarchical ways of understanding the dynamic of relationality and agency. The revisioned self is "both elemental and related, . . . has a sense of herself making choices within a context created by community" (Hoagland 1988, 145). Autokoenony, according to Sherwin, "offers a more realistic perspective of patients choosing in the company of others who help shape their lives" (Sherwin 1992, 156). Changes in ideology resulting from these new models would lead to "improved patterns of communication and mutual respect" (1992, 156) between patient and provider, a more genuinely beneficent approach Wolf supports.

Wolf gestures to a "superior vision of autonomy" (1996, 300) grounded in relationality rather than rigid exclusionary boundaries. This move allows her to take up Sherwin's suggestion that we mine examples of temporary inequality for their usefulness to feminist analyses of paternalism. Whereas permanent inequality, she notes, is a sign of oppression, temporary inequality is inevitable, dynamic, and shared. Wolf commends the work of feminists (for example, Jennifer Nedelsky and Martha Minow) who retain a notion of autonomy but link it to a feminist metaphor of childrearing rather than the traditional liberal metaphor of property; such a view, Wolf claims, "support[s] the relational context in which the rights bearer is embedded" (1996, 300).

Wolf's appropriation of rights and care discourses, though undertheorized, is consistent with the hybrid feminism I am advocating. But, as Jean P. Rumsey has noted (1997), while feminists may agree that the rights/care dichotomy is "questionable," they lack consensus on the appropriate relationship between the two orientations. Rumsey outlines three possible conceptualizations of the relationship, each of which has different policy implications. Minimally, it seems clear that a mere additive model (that is, rights plus caring) neither avoids dichotomous thinking nor offers particularly useful moral guidance. Further, if one takes seriously models like amicalism and/or autokoenony, rights approaches would have to be transformed beyond anything recognizable in a traditional liberal framework. For now, however, Wolf's insistence that considerations of justice always be examined through both care and rights "lenses" provides the frame by which she analyzes policy on PAS and euthanasia. In the last section I want to complexify and challenge the relationship Wolf draws between her feminist theory and normative practice and policy. In doing so, I suggest alternative directions consistent with my own reading of hybrid feminism.

Hybrid Feminism, Public Policy, And Physician-Assisted Suicide

As noted earlier, Wolf likens PAS to abandonment, a practice both legally prohibited and morally condemned. For Wolf, PAS represents a breakdown in the relationship between provider and patient; this claim once again exposes not only her conviction that death is the worst evil but also a further assumption about the appropriate ends of medicine. But, as Richard Momeyer has argued, medicine serves human purposes and has no essential, "naturally given" imperatives. "Medicine," he notes, "is just what we make it to be, not what nature decrees it must be" (Momeyer 1995, 17). Further, Momeyer rejects the single-minded insistence on the physician-as-healer, for it "holds up an impossible and finally self-defeating model of medicine" (1995, 19). Good physicians must also know when to end efforts to heal, and other values like dignity and patient comfort ought to play a role in that deliberative process. To assume, as does Wolf, that actively aiding (versus passively withdrawing) inevitably robs one of such dignity is to beg the question.

Likewise, Wolf seems to assume that a prescriptive model like amicalism obviates the need for PSA. She asserts without defense that "if a friend were to tell me that she wished to kill herself, I would not be lauded for giving her the tools" (Wolf 1996, 300). What does it mean for a principle like "amicalism" that she takes that statement as given whereas I am able to imagine circumstances in which such "lauding" is appropriate? Can friends reasonably disagree about a course of treatment? And isn't there a difference between knowing what a person would want in a certain set of circumstances and justifying acting on the knowledge? If there is a difference, then what criteria distinguish "amicalism" from what the law has termed "substituted judgment," where one determines as closely as possible the patient's wishes and acts on them? How is it different from a "best interests" standard, which clearly might conflict with substituted judgment?

The normative stance I have ascribed to Wolf is nowhere more evident than in her discussion of the use of pain medication for the suffering and the ill. In that context, she invokes Double Effect Doctrine (DED)--grounded in a now-seldom-invoked distinction between knowledge and intention and between active killing and passive letting die--to justify "giving pain relief and palliative care in doses that risk inducing respiratory depression and thereby hastening death" (1996, 302). Wolf urges better physician training in pain management, an uncontroversial recommendation ¹³ easily supported by PAS advocates; I would argue, however, that such recommendations do not get to the core of the issue. Setting aside the question whether all pain can be palliated (one of Kevorkian's patients was a physician, himself an expert on pain therapies), Wolf's strategy wrongly presumes that pain is the only (legitimate?) reason for patients wanting to die.

From the claim that most if not all pain is treatable, Wolf concludes that few patients would request euthanasia. But must untreatable pain be the only permissible reason for suicide? In the Netherlands, for example, pain is cited only as the second most common reason for people's requests for euthanasia, the most common being "dignity." This response may of course be tied to the intensity of one's pain, the severity of one's illness, the likelihood of one's im-provement, and so forth; but "dignity" is both more than and less than those variables. Further, patients in pain may prefer to die rather than to be "sedate[d] [in]to unconscious" (Wolf 1996, 302). Thus, even with more training for physicians on appropriate end-of-life care, insurance payments tied to certain procedures, modifications in anti-addiction laws, incentives for hospice care, and so forth, some reasonable patients may prefer death.

Nelson and Nelson (1996) insist that a theory of justice and resource allocation that does not incorporate gender is inevitably flawed, and they highlight as a case in point arguments about age-based rationing that ignore gender. Given that women live longer than men, an age-based facially neutral rationing policy will disadvantage women. We can see the centrality of this concern with respect to euthanasia as well. But this transformed vision does not necessarily lead to the conclusions Wolf draws. For example, while it is true that women live longer than men, it is also true that women are the primary caretakers in families, both at beginning and end of life. Wolf's emphasis here on the woman as patient mirrors feminist treatments of this and related subjects; the single-minded attention to woman-as-patient obscures the multiple positions and contexts in which women exist. What about women as the primary caretakers for the sick and the dying, including men? For example, when Wolf insists on context, she asks about the "family, social, economic, and medical supports she is or is not getting" (1996, 299; italics added). She does so to point to a failing in rights approaches that ignore such questions. But note how here she assumes a female patient and a failed system of personal and social networks. Setting aside the improbability that such failures are true in each and every case of a request for euthanasia, isn't it women in formal and informal networks who will most likely bear the burden of care for such patients? If that is the case at least some of the time, we cannot assume unproblematically that PAS differentially burdens women. Indeed, the availability of PAS might ease the burden of some female caregivers. Minimally, women's greater involvement in care for the ill and dying suggests that women may be well suited to serve as health care proxies and to participate in processes that involve "substituted judgment." Currently available evidence suggests that, just as dying women's requests are often ignored, so too are wom-en caretakers' perspectives trivialized or dismissed as overly emotional (Miles and August 1990). Thus, a more complex understanding of PAS requires that we consider women's roles not only as patients but also as caregivers and providers. While Wolf's position neither entails nor requires the simplistic scenario I am criticizing, its focus on women in only one of many roles tends to push her view towards a narrow vision of what might constitute "care."

"Dignity," as Wolf and other feminists would likely point out, is context-dependent, emerging not only out of individual circumstances but also out of cultural ideology and practice. Rights approaches tend to conflate "dignity" with the ability to express and act on whatever "choice" one makes. Care ap-proaches, on the other hand, might reject the very notion as overdetermined by patriarchal and liberal discourse; the danger here is that that normative stance soon becomes indistinguishable from nonfeminist defenses of paternalism, including moral paternalism. In contrast, a context-based feminism must assess a variety of factors, including constraints and options, material circumstances, and (inter)personal values. A fully developed elaboration of the notion of "dignity" would require much more analysis than this essay permits. But if one can imagine circumstances in which a decision to die is "dignified," where death is preferable to one's current condition, then--at least at the level of individual morality--suicide would appear to be justified. If so, then assisting one in that project cannot be wrong even if not obligatory. Ironically, if death is, under some circumstances, a benefit, then one of the injustices women, people of color, and the socially and economically deprived suffer is that where PAS and euthanasia are a benefit, they are deprived of it. Given that Wolf eschews absolutist arguments, it is reasonable to infer that she does not absolutely condemn suicide. For her, the real danger lies in any attempt to codify in law and policy the practice, particularly a third party's assistance; thus, in this context (even if some individual's wish to die is genuine), paternalism is justified.

Wolf's endorsement of childrearing metaphors to explicate her vision of autonomy/paternalism resembles in some ways the argument of Gerald Dworkin (1972, 1992) who analogizes paternalism to an insurance policy whereby one sacrifices some autonomy in the present for extended future autonomy. Likewise, the good parent, most agree, adopts paternalism as a temporary measure to ensure that one's child is safe during the stage of temporary inequality/vulnerability identified as childhood; the goal is to enable the child to develop a stable sense of self, to leave the home, and to create personally chosen relationships of her own.¹⁴ But how can this model apply to suicide and/or euthanasia? Unless one posits an afterlife, a move I am unwilling to make, there seems no meaningful way to imagine the physician as enabling the dying patient to achieve greater future autonomy, either through assisted suicide or through sedating one to unconsciousness. Wolf suggests in her application of paternalism that a difference inheres in the two practices, and that the latter maintains autonomy. I do not see that difference.

Wolf's use of John Stuart Mill, who rejects selling oneself into slavery in his libertarian rejection of paternalism, is problematic for similar reasons. First, while scholars disagree on how to interpret that exception, Mill seems to imply that selling oneself into slavery is a kind of contradiction, that one enters into a contract one can never under any circumstances break. But Mill does defend suicide, though Wolf is correct to point to the often-confused distinction between what one may do and what one may require others to do. As she puts it, "the negative right to be free of unwanted bodily invasion does not imply an affirmative right to obtain bodily invasion (or assistance with bodily invasion) for the purpose of ending your own life" (Wolf 1996, 300). But Wolf seems to confuse what one may require a third party to do (an "affirmative right") and what third parties are justified in doing. Defenders of euthanasia, including Mill, need not insist on a more extreme position requiring third parties to accede to one's desires; rather, all that is claimed is that third parties may accede to those desires if they wish. Further, one could argue that the concept of rights, even as negative entitlements, is absurd without protections for those who facilitate the exercise of those rights; imagine, for example, the right to abortion without laws protecting the providers who agree to perform them.

These "fatal practices" are part of a broader social pattern and that pattern, for Wolf, should make us "extremely wary" (1996, 308). But her conclusion opts for far more than "wariness" even of the extreme variety. While her rejection is provisional ("at least 'not yet' in this grossly imperfect society and perhaps a flat 'no'" [1996, 307]), she makes clear that in her view no formal policy could protect women and other vulnerable groups from the harm likely to result from legalization. Is she right about that? That is, can laws be constructed that attend to context, that do not exacerbate existing inequality? Taking seriously Wolf's warnings about the power of medical hegemony, we should be reluctant to permit any policy that might enhance that power and lead to greater abuse. The citizens of California, Washington, and most recently Michigan who rejected referenda legalizing PAS may have been expressing precisely that point of view. On the other hand, we cannot know if they would have been willing to permit the practice with stricter and clearer constraints.

Wolf clearly seems committed to the view that in our current climate protective guidelines cannot be formulated and/or enforced; I believe, however, that feminists ought not to be overly hasty in rejecting such a possibility. Even separate from new statutes, creative legal modifications or reappropriations of our current system might be considered. For example, Wolf rejects (prematurely, I believe) Howard Brody's suggestion that "compassionate and competent medical practice" might operate as a defense in a criminal proceeding (in Wolf 1996, 302). Such a policy suggests the seriousness of the action (killing) but its (exceptional) permissibility as analogous to, for example, a self-defense plea. A "euthanasia defense" would not require new, possibly over--or under--inclusive legislation, but would allow prosecutors discretionary power over whether to try such cases; if tried, juries would decide the merits. Less permissive than Dutch policy, that legal strategy provides disincentives for careless decision-making or outright misconduct. Another strategy might permit physicians to prescribe lethal doses of drugs to terminally ill and suffering pa-tients without allowing them directly to kill patients. Here what are traditionally known as "Good Samaritan" laws> might be triggered to protect a provider who can demonstrate that she has carried out a patient's wish to die.¹⁵

Other sorts of legal modifications deserve fuller moral and practical analysis than is possible here;¹⁶ such modifications might cohere with the public's putative intuitions on PAS and serve to formalize and regularize practices now occurring. If, as poststructuralist feminists suggest, normative problems do not lend themselves to a priori solutions, then any policy involves risk and uncertainty. While Wolf's seems the more cautious approach, her position risks colluding with the very patriarchal power relations she seeks to undermine (including the Catholic Church, the American Medical Association, and the Supreme Court), reminding us of the Foucauldian notion that everything is dangerous. Such a perspective suggests that any feminist vision that embraces or rejects a priori a specific practice must be reconsidered.

In producing discourse attentive to women's subjective experience, feminists are committed not only to a normative principle that subjugated knowledges ought to be treated seriously but also to a multiple (rather than binary) epistemology whose implications reach into ethical analysis. Theorists like Joan Tronto (1993) have examined cultural constructions of "autonomy" and "dependence" to demonstrate how the western tradition's valorization of autonomy has led to a devaluing of women's relational styles¹⁷ as well as women's caring work. Feminist critiques of autonomy are grounded in the simple but transformative realization that "actual people are not independent, and their decision-making does not always meet the norms that define rationality" (Sherwin 1992, 137).¹⁸ Tronto's work has enormous potential: Given that all of us begin as children, and--if fortunate--will live to old age, we cannot es-cape cycles of greater and lesser dependence. Such an awareness forces a rethinking of assumptions about dependence and traditional notions of subjectivity that have posited a "healthy" self as autonomous and have pathologized (implicitly or explicitly) female subjectivity. Acknowledging both human interdependence and the reality of dependence as inevitable in the human life narrative has transformative implications both for political ideology and for practice (for example, welfare policy); those implications reach far beyond a narrow focus on gender qua gender. Indeed, as feminists of color have insisted, for feminists to center gender as the feminist lens operates to occlude differences among women and to efface multiple aspects of identity. While decentering has not come without struggle, it does seem increasingly true that "as feminism grapples with the significance of gender differences, it also cultivates a heightened sensitivity to other kinds of differences" (Nelson and Nelson 1996, 354).

While the risk of solipsism must not be trivialized, underlining differences among women does not leave us in nihilism but rather enables us to articulate the situatedness of identity and the multiple memberships that mark us all. While feminists cannot afford easily to abandon the category "woman," concepts like, for example, Gloria Anzalda's "Borderlands" (1987), offer extremely useful metaphors for understanding both shared aspects of identity and relevant differences. Further, once we abandon an illusory, exclusionary notion of "sisterhood," those differences are no longer perceived as a threat to political organizing and social transformation; indeed, moving the margins to the center (hooks 1984) makes possible inclusive, progressive feminist praxis. "Borderlands" describes a kind of consciousness, a feminist consciousness of the mestiza who must "continually walk out of one culture and into another" (Anzalda 1987, 79), who learns to embrace ambiguity and to reject rigid boundaries. By virtue of being "in all cultures at the same time," the mestiza must operate in an unstable, pluralistic mode where privilege and oppression coexist. As Allison Weir notes: "Central to self-identity, then, is the capacity to sustain and in some sense reconcile multiple and often conflicting identities, and to understand, criticize, and reconcile multiple and often conflicting interpretations of those identities. Not to mention the capacity to live with and somehow reconcile all of the ambiguity and complexity of our lives that does not (and never will) readily lend itself to this identity work" (Weir 1996, 186). And the "special vantage point" (hooks 1984, 15) of operating from the margins shapes consciousness and grounds epistemological advantage; indeed, in contrast to standard deficit models of oppression, an "oppositional world view" will "sustain us, aid us in our struggle . . . [and] strengthen our sense of self and our solidarity" (hooks 1984, 1).

This approach has obvious implications for the "subjects of knowledge" who have been the fictionalized and realistic fodder of ethical analysis and for knowledge itself. In embracing heterogeneity and multiplicity, this stance encourages a "proliferation of voices" and a subversion of monopolistic conceptions of knowledge replaced by a transformed vision of rationality that is nonhierarchical, contextual, and grounded in lived experience. "No one form would be privileged as the truth, the correct interpretation, the right method; rather, knowledges, methods, interpretations can be judged and used according to their appropriateness to a given context, a specific strategy and particular effects" (Gross 1986, 204).

While still undertheorized, such insights offer important critical perspectives and make substantive contributions to analysis of PAS and euthanasia. Most obviously, the dominant tendency to characterize these issues as genderless collapses upon feminist scrutiny. Beyond this, however, a contextualized feminism challenges us to examine more critically our attitudes toward the dependence of the sick and dying in order to expand our understanding of euthanasia beyond the customary either/or thinking of most treatments. In this context, feminist work exploring patriarchal ideology of sickness and dependence--an ideology that tends to feminize all patients--has implications for men and women, especially regarding end-of-life treatments. Contextualized feminism's insistence on women's multiplicity and difference leads to a number of suggestive implications, most obvious that we must see patients not simply as gendered but also as having a class, a race, a sexual orientation, an age, and so forth. This recentering also suggests that some women in some contexts may have more in common with some men than with some other women, making it dangerous to generalize incautiously about Women. Finally, hybrid feminism, while rejecting any binary of self/other or self/community, must formulate a vision of community that embraces heterogeneity and pluralism.

There is, as feminist ethicists have pointed out, a sound moral principle embedded in the notion that we should give the interests of the disadvantaged special consideration. But this principle only points us in a direction; it does not, like some standard approaches to ethics, offer easy answers to thorny moral dilemmas. Further, how do we retain a meaningful notion of agency in the face of an attention to the material and cultural constraints that frame people's lives? Similarly, notions like "principled caring" or "autokoenony" can transform the ways we approach ethical problems and reframe ethical inquiry; but they do not provide answers to the cliched question "What ought I to do?" And many feminists have insisted that the demand for facile solutions in ethics ignores the richness and complexity of human experience. Perhaps we should remind ourselves of Aristotle's instruction that we not expect more of our subject than it can deliver. Both hybrid feminist theory and more recent bioethical theory have criticized dichotomous approaches to ethics, either a top down/deductive approach ("principalism") or a bottom up/inductive approach exclusively.¹⁹ But much more work needs to be done to meld abstraction and context and to provide the sort of "normative keel" (Wolf 1996, 303) we seek as moral agents and teachers.

A blanket prohibition against euthanasia, while clear and easy to maintain, seems to me inconsistent with feminism's rejection of rigid absolutism and its embracing of context and ambiguity. My point here has not been unequivocally to defend one alternative over another but rather to suggest that Wolf's dismissal of euthanasia and PAS is premature. Regardless of what position one adopts, I would insist that a feminist perspective on this issue must put euthanasia and PAS in the context of a health care system that denies millions adequate care based on morally irrelevant criteria; to defend a modified policy allowing physician-assisted suicide is not to confuse that policy with a desperately needed solution to broader societal injustice. Wolf notes in her essay's introduction that the most important aspect of her overall project is "to urge the necessity of feminist analysis" (1996, 286) of PAS and euthanasia, and that reasonable people may disagree on the moral rightness or wrongness of these practices. I offer this response in that same spirit.

Notes

I am grateful to Rick Momeyer and the three anonymous Hypatia reviewers for their helpful comments at various stages during the writing of this paper. My special thanks go to Angelique Davi for her emotional and editorial support, graciously given at a point in her life when she could ill afford the time.

1. See, for example, Helen Bequaert Holmes and Laura M. Purdy, Feminist Perspectives in Medical Ethics (1992); Susan Sherwin, No Longer Patient (1992); and Susan M. Wolf, Feminist Bioethics: Beyond Reproduction (1996). Page citations refer to the Wolf essay and are noted otherwise only when the context makes its referent unclear.

2. For example, a 1990 U.S.A. Today poll revealed that 67 percent of Americans favored physician-assisted suicide for the terminally ill; 77 percent of Canadians polled agreed. Yet voters have been reluctant to vote on this sentiment, as most state referenda to legalize physician-assisted suicide have been defeated. Strikingly, juries have been equally reluctant to convict agents like Quill and Kevorkian of any misdoing; Kevorkian's latest case involves active euthanasia (rather than suicide) and is clearly intended to push these limits.

3. Mothers, often described in stereotypical terms relating to maternal care and nurturance, figure significantly in these scenarios. The stereotypes discursively function to defend the trustworthiness of the mother's substituted judgment.

4. I know of no cases in the euthanasia debate where race is alleged to be a factor. The fact that the earlier cases deal with withdrawal of treatment means that these cases are already class--and probably race--biased. Poor people and people of color are less likely to have private medical insurance, personal physicians, and access to private hospitals. When critics of euthanasia (including Wolf) point to the vulnerability of such audiences in the face of the prospect of legalized euthanasia, they subtly ignore the reality that members of such marginalized groups are already the targets of --for lack of a better term--"passive" (!) euthanasia in not receiving extensive and expensive life support measures. For these reasons, issues like national health insurance and infant mortality loom larger as normative priorities. Finally, polls indicate (for example, see Rosenbaum 1998) that the better educated and more well-off tend to favor PAS, and blacks (70 percent to 20 percent) oppose it more often than whites (55 percent to 35 percent). Thanks to one of my anonymous reviewers for pointing out the use of ethnic names to hint at identity.

5. Strangely, that chapter is subtitled "A Woman with Cerebral Palsy" [Bouvia] and "A Quadriplegic Man" [McAfee] even though the discussion of the cases in no way includes anything about the relevance of sex/gender. Pence does emphasize Bouvia's depression and McAfee is described as "spoiled" and "demanding" (1995, 57); but, though these labels are gender-stereotypical, he does not clarify whether, from his point of view, Bouvia's and McAfee's strategies for coping with disability (and with the medical profession) have anything to do with their genders. Indeed, the standard view of these cases is that Bouvia's depression (resulting from the end of her marriage) and pain led to her wish to die; in contrast, McAfee's (and Cowart's) loss of physical activity/autonomy is blamed for their decisions. This discursive distinction lends support to a later point I make about gendered perceptions of "quality of life" issues. I have yet to see any analysis of these gendered patterns.

6. Remarkably, feminist treatments of bioethics tend to do the same. Susan Sherwin's No Longer Patient (1992) devotes at least a third of the book to ethical issues related to reproduction; though she has a chapter on paternalism, there is no mention of euthanasia or suicide and no listings in the index for those topics.

7. Examples are easy to find, so I'll mention only one: the fourth edition of Thomas Mappes and David DeGrazia's edited collection, Biomedical Ethics (1996). The publisher's marketing brochure notes that the new edition has an "extensively revised" General Introduction that includes "the ethics of care, and feminist ethics." In a collection of nearly 100 articles, with the exception of a feminist essay on rationing in the last chapter on "Social Justice," the feminist pieces, as far as I can tell, total five (including two early standards, Judith Jarvis Thomson's "A Defense of Abortion" and Mary Anne Warren's "On the Moral and Legal Status of Abortion") and fall into two chapters: "Abortion and Maternal-Fetal Conflicts" and "Genetics and Human Reproduction." By the way, this point should not be confused with the question how many women authors are anthologized in these collections.

8. In no way is this point meant to suggest that it is Wolf alone whose language reflects her normative inclinations. I reject any notion that implies an originary, innocent language and have no doubt that a closer examination of my text would expose my own presuppositions as well. For example, note how on page 9 I refer to Quill's "helping" Diane to die; Wolf would obviously reject that innocuous-seeming verb.

9. Wolf cites Quill's essay in her essay.

10. Ian Hacking makes the provocative claim that suicide may be a cultural construction and not a "timeless option" (1992, 85) as Jean Paul Sartre and others have suggested. Hacking points to the historicity of suicide--that it seems to be nonexistent in some cultures, and that where it exists it takes a variety of forms according to differing cultural ethos. This claim, if reasonable, suggests that labeling suicide either masculine or feminine--where now both sides of the equation are highly mutable terms--is misleading and dangerous.

11. Margaret Farley points out that at least 34 states have "pregnancy clauses" that invalidate women's living wills; while that issue is far too complex to take up in this essay, the existence of such restrictions offers yet another example of the ways women's agency is juridically contravened.

12. This case is far more complex than can be fleshed out here. McAfee ultimately died of complications from two strokes; my point here is not meant to imply gender determinism but rather to suggest some of the ways a complex ideological practice like gender might function.

13. Though I am describing these recommendations as "uncontroversial," taking them seriously would be a significant step for the medical profession. Indeed, one study (Saltus 1998) revealed that most cancer specialists did not receive any formal training in caring for dying patients, 40 percent of whom are diagnosed as clinically depressed and 20 percent of whom die in pain.

14. The class and cultural biases here are obvious. I rehearse this model not because I favor it but because I want to draw out some of its implications.

15. Oregon's "Death with Dignity Act" comes close to such a policy. "Safeguards" require informed consent, patient competence, and a terminal illness, among others. Further, "immunities" protect providers from criminal liability or professional disciplinary action if the provisions of the Act have been met. Finally, the Act makes clear that a provider's compliance is voluntary and not a legal or contractual obligation. Of course, none of these provisions meet Wolf's objections; nor do they reach opponents' predictions of an inevitable slippery slope.

16. One might, for example, consider viewing the person who commits an act of euthanasia as one who is civilly disobedient; that is, we can retain laws against euthanasia while recognizing that the family member or provider who assists in a suicide is not the typical lawbreaker and must not be treated as such. Many of the euthanasia trials on record seem to treat the "offender" in precisely this way without making the label explicit. Guilty verdicts are rare and sentences, when given, are generally quite light.

17. Such work is the philosophical offspring of Gilligan's work, though many theorists (including Tronto) reject the gender essentialism many theorists influenced by Gilligan (for example, Nel Noddings) have adopted. My discussion here cannot engage the wealth of materials devoted to the care debate. Rather, my concern is to underline shifts in thinking and practice that feminist interrogations stimulate.

18. Traditionally, philosophers have been eager to grant this claim with respect to women's decision-making. But in doing so they normalize men's modes of thinking and assume that men are independent. Psychoanalytically-oriented feminist thinkers like Dorothy Dinnerstein (1977) might assess such a maneuver as a pathological (or at least dysfunctional) response to fear of dependence connected psychically to fear of mothering (and thereby leading to misogyny) and fear of death.

19. Tom Beauchamp and James Childress, for example, propose a "coherentism" that is neither top-down nor bottom-up but rather links "the more general (principles, rules, theories, etc.) and the more particular (feelings, perceptions, case judgments, practices, parables, etc.) . . . in our moral thinking" (1994, 111).

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