Book Review

Women, Pregnancy, and Health Care

Women and Children in Health Care: An Unequal Majority

N Engl J Med 1994; 330:648March 3, 1994

Article

Women and Children in Health Care: An Unequal Majority
By Mary Briody Mahowald. 281 pp. New York, Oxford University Press, 1993. $39.95. ISBN: 0-19-0506346-5

“If we take a survey of ages and of countries, we shall find the women, almost -- without exception at all times and in all places, adored and oppressed. . . . Society, instead of alleviating their condition, is to them the source of new miseries.” Thomas Paine said this in 1775, but the same could be said today. The bioethics movement has been slow to pay attention to women's oppression by the health care system, but an emerging literature written from a feminist perspective attempts to redress the situation. This book is among the best of that literature.

Mahowald, a philosopher at the University of Chicago's Center for Clinical Medical Ethics, makes use of almost three dozen case studies drawn from either the literature or her own clinical experience in considering the ethical questions raised by the unequal treatment of women and children, as compared with men, in health care. She begins with an overview of her theoretical moral framework, egalitarianism, in which she proposes a set of guidelines for addressing a continuum of bioethical issues. These rules range from the simple (“Individuals that can suffer should not be caused to suffer”) to the complex (“Equality demands that all individuals have an equal share of the resources available, insofar as these are pertinent to their needs, desires, capabilities, and interests”). Although this introductory chapter is relatively free of jargon, readers not familiar with the bioethics literature may find it somewhat difficult, and it contains less clinical material than the rest of the book.

Still, patient readers will be generously rewarded. Mahowald reviews models of the physician-patient relationship and calls for a perspective that is dependent on context and richer than both paternalistic and maternalistic models. Subsequent chapters examine the familiar ethical questions raised by abortion, the curtailment and enhancement of fertility, in vitro fertilization, fetal-tissue transplantation, and decisions regarding disabled newborns. Significantly, Mahowald links feminist and nonfeminist philosophical arguments as well as current clinical thinking. Her analysis demonstrates her expertise in both philosophical ethics and clinical medicine.

In a particularly fascinating chapter she considers the possibility that children are capable of being moral agents. Clinicians, ethicists, and legislators alike too often assume that children do not have the capacity for moral agency, but Mahowald disagrees; she notes that children can voluntarily seek to promote the well-being or freedom of others. One practical implication is that physicians and others who treat children would do well to engage in meaningful discussions with them, even if there is no legal obligation to do so. Here, as elsewhere, Mahowald takes the familiar dictum “ethics cannot be reduced to the law” and applies it to an area in which many clinicians have probably not considered it before.

In befitting a book whose theme is equal and fair treatment, Mahowald concludes by reflecting on the impact of poverty on women's and children's health, the nature of the family, and the role of power in American medicine. She proposes to reduce inequality in health care delivery by paying “attention to differences,” because, she believes, ignorance of the disparities between groups of people is the root of the problem:

If we pay no attention to the fact that some persons are disabled, we will do nothing to help them experience opportunities that those who are advantaged commonly enjoy. If we pay no attention to the fact that minorities, women have been discriminated against historically, we will not notice that many still live with the effects of past discrimination. If we disregard the fact that children have no voice in major decisions affecting them, we will go on listening only to adults who may place their own interests first.

Women and Children in Health Care is an important addition to the bioethics literature. It should be in the library of every health sciences center, and its arguments should be critically examined by all health care professionals (and not just those specializing in pediatrics or obstetrics and gynecology). We should be grateful to Mary Briody Mahowald for reminding us what health care is supposed to be about and how far we still have to go to get there.

Bruce D. Weinstein, Ph.D.
West Virginia University, Morgantown, WV 26506