Reid Ewing and the Failure of Autonomy in Bioethics

Reid Ewing of Modern Family fame recently wrote publicly about his struggle with body dysmorphia in a personal essay on the Huffington Post. Ewing revealed that his dysmorphia led him to seek and receive several surgeries. He feels his surgeons should have recognized his mental illness and refused to perform surgery. He wrote, “Of the four doctors who worked on me, not one had mental health screenings in place for their patients, except for asking if I had a history of depression.”

The principle of autonomy is by far the most discussed principle of bioethics. Discussions typically focus on the rights of patients to refuse treatments, not to seek them. On either side, the issues can be thorny. If a depressed and suicidal patient refuses life-prolonging treatment, is it ethical to respect the patient’s autonomy or should mental health services be provided first? As in Ewing’s case, the ethical problem arises from the claim that the decision is driven by mental illness and not reason. If someone is mentally ill, they are not fully autonomous agents as they are not fully rational.

This is a problem with autonomy in general. Our ideas of autonomy come largely from Immanuel Kant, who claimed that all rational beings, operating under full autonomy, would choose the same universal moral laws. If someone thinks it is okay to kill or lie, the person is either not johnny-automatic-gloved-hand-with-scalpel-800pxrational or lacks a good will. How do we determine whether someone is rational? Usually, most of us assume people who agree with our decisions are rational and those who do not are not rational. If they are not rational, they are not autonomous, so it is ethical to intervene to care for and protect them.

Earlier this year, a woman named Jewel Shuping claimed a psychologist helped her blind herself. She says she has always suffered from Body Integrity Identity Disorder (although able-bodied, she identified as a person with a disability). Most doctors, understandably, refuse to help people damage their healthy bodies to become disabled, which can lead clients to desperate measures to destroy limbs or other body parts, sometimes possibly endangering others.

Jewel Shuping never named the psychologist who may have helped her, so it is impossible to check the story. It is possible to imagine, however, that some doctors would help someone with BIID in the hopes of preventing further damage to themselves or others. Shuping says she feels she should be living as a blind person, and she appreciates the help she received to become blind. In contrast, Ewing feels he should have undergone a mental health screening before he was able to obtain his surgery and that his wishes should not have been respected.

Plastic surgeons are often vilified as greedy and unscrupulous doctors who will destroy clients’ self-esteem only to profit from their self-loathing. On the other hand, these same plastic surgeons are hailed as heroes when they are able to restore beauty to someone who has been disfigured in an accident or by disease. Unfortunately, we do not have bright lines to separate needless surgery to enhance someone’s self image and restorative surgery to spare someone from a life of social isolation and shame. Some would argue the decision should not be up to the doctors in the first place but should be left in the autonomous hands of clients.

Many have similarly argued that doctors should refuse gender confirmation surgery to transgender men and women. As with BIID, many assume that transgender individuals are mentally ill and should see a mental health professional, not a surgeon. Transgender activists (and I) argue that transgender individuals need empowerment to live as the gender that best fits what they actually are. If surgery helps them along that path, they should have access.

All this leaves us with the question of when to respect autonomy and when to take the role of caregiver, which may involve a degree of paternalism (or maternalism for that matter). Is it more important for doctors who ensure the patient’s rights to seek whatever treatment they see fit, or is it more important to provide a caring and guiding hand to resolve underlying mental health issues before offering any treatment at all?

One of Ewing’s complaints is that he was offered plastic surgery on demand with no screening at all. The process for people seeking gender confirmation surgery, by contrast, is arduous. Before surgery, transgender people go through counseling and live as their true gender for an extended period of time. At the far end of the spectrum, people with BIID rarely find doctors willing to help them destroy parts of their bodies and resort to self-harm. These three cases are not the same, but make similar demands on the distinctions between respect for autonomy and a commitment to compassionate care.

It seems reasonable to accept Ewing’s claim that mental health screenings should be a part of body modification surgery, especially when someone has no obvious flaws that need to be repaired. In all these cases (dysmorphia, gender identity, and BIID), mental health support is necessary. In each case, patients describe depression, emotional turmoil, and, too often, thoughts or attempts of suicide. Mental health care does not require a violation of autonomy, but it may help a person’s autonomous decisions to form more clearly from deliberation and not desperation.

 

Tom Digby on Militarism, Sexuality, and Romance

In a post on how men can be better feminist allies, Emma Cueto advises men to avoid the temptation to put men’s issues first. She sums up the problem of “toxic masculinity” by noting, “is not fun for anyone and often limits men’s choices in terms of interests or self-expression, and it means that many men are never really given the tools to properly deal with their own emotions.”  She goes on to say that men are not sexually assaulted at the same rate as women, are not victims of domestic violence as often as women, are not victims of pay disparities or sexual discrimination as often as women, and aren’t confronted by laws designed to control their bodies. She is right on all counts, but Tom Digby’s book, Love and War: How Militarism Shapes Sexuality and Romance , helps show why it is impossible to separate culturally programmed masculinity from sexual assault, reproductive regulation, domestic violence, and job discrimination and why feminists must deal with how sexism affects both men and women simultaneously.

His thesis is that militaristic societies establish values and goals that require men to cut off their feelings of care for others and for themselves, see women’s freedom as a threat, and rely on violence to solve their problems. In order to achieve military objectives, subject both boys and girls with intense cultural programming from birth to encourage strength in boys and passivity in girls. With this thesis, he flips the script from what many assume: that men are violent and cut off from their feelings by biological programming. Early in the book, he offers two pieces of evidence that this assumption is faulty. First, men and women in some societies do not show the differences that are so prevalent in militaristic societies. Second, he shows that men often fight against their own biology to retain the appearance of stoicism. Indeed, almost all men have been cruelly taunted for their failure to maintain their composure (choking back tears) even before reaching adolescence. If biology prevented boys from crying, no one would have to keeping telling boys not to cry. The conditioning is relentless and severe.

War dependent societies must maintain ample supplies of expendable men as well as childbearing women who will provide future generations of warriors. This requires shutting down empathy in men, glorifying risk and violence, and valuing women according to sexual availability and passivity. To the extent that maintaining near constant war was the goal, this model worked for centuries, but things have changed. I wish I could say we are no longer reliant on war, but that is sadly not driving the change. Digby points out that while war is still with us, the need for individual warriors who do one-on-one combat, relying on brute strength, has greatly diminished. Combat is now highly mechanized, and what physical differences may exist between men and women often offer no benefit to either side or may even give an advantage to women (he notes the case of jet fighters).

As a result, most men do not experience direct combat, or any kind of combat, in their lives. Our warriors must find other outlets for their masculinity. They may do it through aggressive sports, war games such as paintball, or even through violent video games. Digby points out that while women may be attracted to warriors, the guy who dominates video games doesn’t get quite the accolades of war combatants.

Another change is the material relationship between men and women. In the past, women were materially dependent on men and would comply with men’s wishes in order to avoid poverty. As women have entered the workforce, many are now the primary wage earners for their families. As women earn college degrees and professional credentials at higher rates than men, it is inevitable that men will become increasingly dependent on women for material support. These social changes leave our masculine warrior with an identity crisis. One option is for him to change his identity, which requires becoming more dependent and empathetic. This would be to become more “feminine” (a horror to the warrior). Or, the second option is for him to become more strident and militant, which may account for increased attacks against feminism and women these days.

When we observe the vitriol in attacks against feminist women online, graphic violence against women in video games and movies, and actual physical brutality and murder of women, it is easy to see the desperation of the warriors who refuse to go down without a fight. The fact that their opponents wish them no real harm seems to be of no consolation. It took me awhile to read this book because I assumed I would agree with it, and I did. I already knew that men were programmed to cut off their empathy, to expect women to be passive, to have the greatest disdain for “feminine” men, and so on. This book does bring a new analysis to these facts, though. It gives a new understanding of how things have gotten where they are and how they may be different.

I have only one minor quibble with one claim in the book. In chapter two, Digby quotes Sandra Bartky to explain the transactional nature of heterosexual relationships. He quotes Bartky as saying, “He shows his love for her by bringing home the bacon, she by securing for him a certain quality of nurturance and concern.” The claim is that men are emotionally unavailable or unsuited for empathy and emotional nurturance. On the other hand, women are expected to provide comfort and emotional support for men. I do think it is true that men are more likely to seek emotional support from women than from men, but I do not think this transaction is so readily accepted in heterosexual relationships.

I’ve spent quite a bit of time talking to both men and women in grief. Many men are so conditioned to “be strong” that they will never ask for support from the women in their lives for fear of appearing weak. Also, many feel they must suppress their emotional needs for the good of the family. Because they succeed in appearing strong, the women around them believe they are strong and do not need emotional support. As a result, men too often face grief and depression in complete isolation. When they finally crumble under the pressure, many will say, “I had no idea things were so bad.” This may help explain why men commit suicide at higher rates than women. Sadly, I’ve heard too many women say that they, also, do not feel supported by other women. Increasingly, at least in the United States, I feel grief is becoming a solitary activity for both men and women.

I hope we can all begin to support one another by offering each other protection, emotional support, material support, and just human kindness.

Suffragette, Slavery, and the Appropriation of Suffering

Controversy erupted recently over a photo shoot in which the stars of the movie, Suffragette, wore t-shirts that said, “I’d rather be a rebel than a slave.” A group of white women wearing a shirt with a message comparing themselves to slaves was a problem to begin with, but people familiar with the fact that southern defenders of slavery in the US are known as Rebels only made things worse.

Defenders of the movie, the photo shoot, and the quote said the outrage was based on a misunderstanding of the quote, which comes from a speech by the British suffragette, Emmeline Pankhurst, rallying women to free themselves from the oppression of patriarchy. In the United States, abolitionists and suffragettes were sometimes, though not nearly always, the same people. The comparison of slavery to women’s oppression was noted by many, including former slave Frederick Douglas, who wrote, “In respect to political rights, we hold woman to be justly entitled to all we claim for man. We go farther, and express our conviction that all political rights which it is expedient for man to exercise, it is equally so for women.”

In the UK, people are less sensitive to comments about slavery and rebels. Some have suggested that the UK did not have slaves and that the quote is therefore not offensive. Time Out London, which published the photos, said in a statement: “Time Out published the original feature online and in print in the UK a week ago. The context of the photoshoot and the feature were absolutely clear to readers who read the piece. It has been read by at least half a million people in the UK and we have received no complaints.”

The UK does have a history with slavery, though. Unlike the US, Britain did not have a large workforce of slaves, but that doesn’t mean the UK had no involvement in slavery. Slavery was abolished in the UK in 1833 by the Slavery Abolition Act, which ended slavery throughout the British Empire with the exception of territories under control of the East India Company, Ceylon, and the island of Saint Helena. The exceptions were eliminated in 1843. In the US, President Lincoln issued the Emancipation Proclamation in 1863.

Having been neither a woman nor a slave, I hesitate to comment on the controversy of the use of the Emmeline Pankhurst quote, but it turns out that philosopher Elizabeth Spelman made an insightful and relevant commentary on the issue in her 1997 book, Fruits of Sorrow: Framing Our Attention to Suffering. In the first place, she points out that phrases such as “women and minorities” excludes and ignores the existence of minority women. Comparisons to slavery are a case in point. She says,  “Consider the talk about women being treated like slaves. Whenever we talk that way we are not only making clear that the ‘women’ we’re referring to aren’t themselves slaves; we’re making it impossible to talk about how the women who weren’t slaves treated those who were.” When a white woman suffragette declared her preference for rebellion over slavery, was she honoring the suffering of slave women or, indeed, setting herself apart from them?

Drawing on the work of Jean Fagan Yellins, Spelman continues, “The female slave is made to disappear from view. Although presumably it was the female slave’s experience that originally was the focus of concern, the other women’s experiences were made the focus.” Somehow, white women made use of the suffering of slaves without experiencing the actual realities of slavery, even if the oppression of white women was intolerable, it was not an experience shared with actual slave women.

When this relationship between white suffragettes and slaves is exposed an analyzed, of course white women will want to deny their privilege and insist that they were only honoring their sisters. They can say this with great honesty, because they are not aware of their privileged status. Further, Spelman says, “The deeper privilege goes, the less self-conscious people are of the extent to which their being who they are, in their own eyes as well as the eyes of others, is dependent upon the exploitation or degradation or disadvantage of others.”

When privilege is pointed out, it makes us uncomfortable. As a result, our reaction is motivated by shame. Self-awareness is necessary to effect change, but it is also painful. Spelman says, “Seeing oneself as deeply disfigured by privilege, and desiring to do something about it, may be impossible without feeling shame.” The shame provokes a defensive reaction, but it can also help to facilitate healing and solidarity–in some cases, anyway.

With the Emmeline Pankhurst quote used by the magazine, we can see the defensive reaction. Many people defended the quote as being taken out of context, as being somehow separate from slavery because it was British, or being a victim of PC culture gone mad. In the end, though, the outrage at the use of the quote helped spark a conversation about the suffragette movement, Britain’s role in slavery, and sensitivity to women whose experiences lie outside the realm of so-called “white feminism.”