Why gender matters to the euthanasia debate. On decisional capacity and the rejection of women's death requests.

On Decisional Capacity and the Rejection of Women's Death Requests The euthanasia debate has typically addressed the tension between patient autonomy and physician obligations. Where physician-assisted suicide and active euthanasia are concerned, ethicists balance a patient's request to die against both the physician's role as healer and her duty of nonmaleficence. The physician is seen to be in a moral dilemma in which her commitments to healing and saving lives conflict with her commitment to serving her patients' needs, respecting their autonomy, and maintaining their trust. The focal question for ethical debate has thus been: how much should patient autonomy govern the practices of physician-assisted suicide and active euthanasia? Such questions are too narrowly formulated because they fail to address the background conditions that may affect a patient's death request. Besides individual agency, we must take into account the ways gender roles and social circumstances affect patients' requests to die; and the way those requests are received by our culture. Feminist approaches raise such contextual and cultural questions, yet there is little available feminist literature on physician-assisted suicide and euthanasia. Although feminists are concerned about the cultural context within which women make medical decisions, they have primarily focused on women's reproductive decisions; only recently have feminist bioethicists turned to issues beyond reproduction. Susan Wolf offers one of the few feminist treatments to date of euthanasia. She argues that women are more likely to request euthanasia and physician-assisted suicide in an attempt to avoid burdening their families--a perversion of the feminine ethic of care that takes women's caring for and about others to the extreme--and that physicians are simultaneously more likely to fulfill women's death requests, based on "the same historical valorization of women's self-sacrifice and the same background sexism."[1] In a culture that valorizes their altruism and caring for others, women who suffer from severe pain or terminal illness may perceive themselves as failing in their appointed duties; unable to care for others, they may see themselves as actually burdening them. For Wolf, the authenticity and rationality of a woman's request to die seems suspect at the very least, given the extent to which cultural expectations about not burdening others have likely affected her. Indeed, Wolf chastens physicians "not to accede to the request for assisted suicide and euthanasia" for this very reason (p. 308). Wolf also discusses the unequal social conditions that may encourage women to seek death, such as poverty, higher incidences of depression, poor pain relief, lack of good medical care, and poor social support networks--essential topics in any ethical analysis of physician-assisted suicide and active euthanasia. While other feminists have shared these concerns for women's social conditions, Wolf is the first to relate them to the issue of euthanasia. Her analysis thus ushers in important theoretical and practical concerns regarding women's death requests and their implementation. I have isolated Wolf as an influential feminist voice because she brings depth to a debate that has, until recently, focused almost exclusively on the issue of patient autonomy. I suggest, however, that Wolf's reasoning may actually lead to very different conclusions. While some women in particular can exhibit a preoccupation with and overemphasis on relationships, terminally ill women's death requests can also, like men's, stem from basic personal concerns for pain, psychic suffering, and the determination that their lives have become meaningless or burdensome to them. In taking Wolf's feminist account seriously, I suggest that women's requests to die may be discounted, trivialized, and ignored for the same reasons that Wolf claims they are too likely to be heeded. …