Chapter 10: Women and Medicine

1. Chapter 10: Women and Medicine

2. Introduction • Sexism is the unjustified (unfair) discrimination against a person (or group) because of the person’s (or group’s) gender. (Another, near equivalent of “sexism” is “unjustified gender bias”.) • More precisely, an action, practice or policy is sexist when one gender is treated differently from another gender where there is no gender-specific characteristic that would justify the different treatment. • (This formulation leaves open the possibility that there may be instances of discrimination based on gender-specific characteristic that are justified as suggested in the idea of the “Office of Men’s Heath discussed later.)

3. Introduction • The qualification “gender-specific characteristic” is important from the point of view of distinguishing sexism from other kinds of unjustified discrimination. • (For example, suppose that a job interviewer dislikes blonds and as a result rates the qualifications of people with blond hair lower than people with other hair colors. This is discrimination but not sexism.) • Discrimination against a person or group may be conscious or unconscious, so sexism too may be conscious or unconscious.

4. Introduction • Conscious or not, the presumed point of describing a practice as “unjustified or unjust discrimination” is to change it or to prevent it from continuing in the future. • In calling a practice “sexist”, we are also asking for change but there seems to be an important difference: • We are not just drawing descriptive attention to the fact that the discrimination involves gender-specific characteristics. We are also suggesting that in seeking to correct or eliminate the practice, we must quite self-consciously take gender-specific characteristics into account.

5. Introduction • Adding this demand – to deliberately take gender specific characteristics into account - can lead to ethical controversy, as the topic of this chapter – women and medicine – demonstrates. • The proposal for an “Office of Men’s Health” discussed in the chapter well illustrates the nature of the possible disagreements. The readings in Section 2 examine those disagreements in greater detail.

6. Office of Men’s Health? • In a 1982 study called the Physician’s Health Survey, researcher Charles H. Hennekens showed that small, regular doses of aspirin could reduce the likelihood of a first heart attack by as much as 30 percent. • But did the study’s finding also apply to women? • Critics immediately pointed out that the 22,071 subjects in Hennekens’ study were all men. • What grounds were there to be sure that the same measure which prevented a heart attack in men would also prevent one in women?

7. Office of Men’s Health? • Why weren’t women included in the study? At the time, cardiovascular disease was known to kill about as many women as men. • Hennekensreplied to his critics that the study participants had all been physicians, and at the time the study was initiated, only about 10 percent of physicians in the country were women. The population was simply not large enough to supply him with subjects.

8. Office of Men’s Health? • Whatever the merits of Hennekens’s explanation, the gender exclusive character of the study led many advocates for women to look at other scientific studies. • When they did, many decided that women weren’t being adequately represented as subjects in medical research. Their findings suggested a pattern of bias against including women subjects in medical research studies. • For the most part it has simply been taken for granted that the best drugs and most effective treatments for men are also the best and most effective for women. • Yet, without studies that include women or studies that focus on the way women respond to treatment, there is no way of knowing to what extent a particular drug (or a certain dose of a drug) or treatment may benefit women.

9. Office of Men’s Health? • Beginning in the late 1980s, advocates for women, armed with facts about the exclusionary practices of scientific research, began pressing researchers to include more women in their studies and to do research on women-specific issues such post-menopausal health. • In addition, advocates for women demanded that women receive medical care equal to that of men. • One study found that women with kidney disease sufficiently severe to require dialysis were 30 percent less likely to receive a kidney transplant than were men. Moreover, men in every age category were more likely to receive a transplant than were women in the same category.

10. Office of Men’s Health? • Significant changes over more than two decades have increased the amount of attention given to women’s health. • Among those changes was the establishment, within the Department of Health and Human Services, of the Office of Women’s Health with the mandate to conduct educational and outreach programs focusing on diseases and issues crucial to promoting the health and well-being of women. • The success of the Office of Women’s Health (and associated programs such as the Women’s Health Initiative) has prompted the question of whether an Office of Men’s Health and a Men’s Health Initiative should be established.

11. Office of Men’s Health? • Some advocates for women’s health scoff at the idea, on the grounds that for more than a century Western medicine has been concerned almost exclusively with men and the way disease affects them. • Men thus have no need of special outreach organizations or male-oriented research projects. • Advocates for men’s health argue that, to the contrary, even granting that women’s health has been unfairly neglected by medicine in the past, the health of men in our society needs a great deal more attention than it is receiving. • The health of men, by many standard measurements, is worse than that of women. Men suffer from more fatal diseases, yet women seek medical advice one hundred times more often than men do.

12. Office of Men’s Health? • Almost twice as many men as women die of heart attacks, and 50% more men than women die of cancer. Men have a life expectancy about six years less than that of women. • Women’s health concerns need not be neglected, men’s health advocates say. Nor should research on diseases relevant to women be curtailed. • What they want, say men’s advocates, is that the health needs of men be addressed appropriately by our society. • Decades of ignoring women’s health concerns don’t justify ignoring the present needs of men. Those needs are serious and pressing, and if they aren’t dealt with, thousands of men will die whose lives could have been prolonged.

13. Section 1: Women and Pregnancy • When there is conflict of interest between what a pregnant woman wishes to do (such as drink alcohol) and what others consider the best interest of the fetus, does the woman have a duty to adjust her life to favor the fetus? • By some estimates, as many as 375,000 newborns each year may be affected by drug abuse by pregnant women. Alcohol is estimated to cause harm in 2 or 3 of every 1000 fetuses. These kinds of statistics strongly suggest such an obligation. • But what is to be done when a pregnant woman refuses to abide? There are a number of possible actions, including legal punishment. How morally acceptable are they? The readings in this section address this question.

14. Reading: Pregnancy and Prenatal Harm to OffspringJohn A. Robertson and Joseph D. Schulman • John Robertson and Joseph Schulman argue that individuals can be held morally and legally responsible for the harm they cause their children before birth. • In the case of pregnant women, the responsibilities and the ways they are enforced must be determined by balancing a child’s welfare against the woman’s interest in preserving her liberty and bodily integrity. • The most desirable social policy is to inform pregnant women of risks to their unborn child and make needed services (such as drug rehabilitation) available to them. However, if these voluntary measures fail, coercive measures by the state to protect the child’s interest may be justified.

15. Reading: Pregnancy and Prenatal Harm to OffspringJohn A. Robertson and Joseph D. Schulman • These may include holding a woman liable to civil and criminal penalties after the birth of a child, prenatal seizure of a woman to prevent her from acting in ways harmful to her developing child, and the forcible treatment of a pregnant woman who has refused therapy that is medically necessary to protect the interest of the child. • None of this infringes on the right to an abortion, the authors assert, because the duties of a pregnant woman to her unborn child are conditional upon the live birth of the child. • We have no duty to see that fetuses are born alive. However, we do have a duty to see that if they are, they show no effects of needless harm as a result of the actions of the pregnant woman or anyone else.

16. Reading: The Rights of “Unborn Children” and the Value of Pregnant WomenHoward Minkoff and Lynn M. Paltrow • Minkoff and Paltrow argue that legislation expanding the definition of “child” to include fetuses has adverse effects for women carrying a child to term. • Laws criminalizing the death or injury of a fetus during the commission of a crime have been used against mothers and establish a parity between the life of a fetus and the life of a mother. • This suggests a need to balance the rights of the two if they ever conflict and, potentially, to subordinate the rights of the mother to the rights of the fetus.

17. Reading: The Rights of “Unborn Children” and the Value of Pregnant WomenHoward Minkoff and Lynn M. Paltrow • The move to establish parity, the authors argue, grants rights to the unborn denied to born individuals. • For example, no born person can be forced to have surgery to benefit someone else. Similarly, laws requiring women intending to terminate a pregnancy to listen to a monologue about fetal pain confer on midterm fetuses rights denied to born humans of any age. • This happens, the authors claim, at the expense of autonomy, informed consent, and justice.

18. Section 2 Gender and Fairness • The readings in this section take up the main theme of the Introduction: when is medical practice fair to both sexes?

19. Reading: A “Fair Innings” Between the Sexes: Are Men Being Treated Inequitably?Aki Tsuchiya and Alan Williams • The term “inning” is used in both cricket and baseball to refer a fixed interval of play, but it has come to be used metaphorically in discussing life spans. • Tsuchiya and Williams point out that the “fair innings” argument holds that when people have reached a certain age, they have had their fair innings, so nothing should be done to prolong their lives. • The authors use the argument to address the inequality of health between the sexes: Men in developed countries do not get their “fair innings” because women live longer.

20. Reading: A “Fair Innings” Between the Sexes: Are Men Being Treated Inequitably?Aki Tsuchiya and Alan Williams • Even though women may have a lower health-related quality of life, especially in old age, this does not offset the life-expectancy shortfall men experience. • Tsuchiya and Williams outline and respond to six arguments against making men’s health a priority because of this basic health inequality. • Although they concede the need for more data and a better way of capturing the relation between health and other domains of well-being, they conclude that health care distribution is unfair to men and that the inequality ought to be corrected.

21. Reading: Research Involving WomenAmerican College of Obstetricians and Gynecologists, Committee on Ethics • The ACOG Committee argues that women should be presumed eligible for participation in clinical studies. • Their inclusion is necessary to advance knowledge in such areas as medical conditions in women and sexual differences in response to drugs. • For similar reasons, the Committee claims, pregnant and postpartum women should also be presumed eligible, although appropriate safeguards, informed consent, and current and future medical care should be in place.

22. Reading: Research Involving WomenAmerican College of Obstetricians and Gynecologists, Committee on Ethics • The involvement of women in clinical studies, the Committee holds, is also justified by the ethical principles of beneficence, non-malfeasance, respect for autonomy, and justice. • The Committee describes procedures that need to be followed to secure legitimate consent from potential participants.