Women with Disabilities

Women with disabilities face challenges related to their disabilities of access and accommodation for infertility care. This chapter explores the societal and structural barriers to infertility care these women experience, including legal issues, training and attitudes of physicians, ability to pay, lack of adaptive equipment, inexperience of providers in treating these patient populations, and lack of access to health insurance coverage for infertility care. Ethical arguments respond to providers’ concerns about offering reproductive care to women with disabilities, including concerns about physician competence, physician choice, risks to the woman, inability to consent, risks to any offspring, conscientious objection, and ability to pay. It concludes that there is at best limited and partial justification for many of these concerns, especially in the context of background injustice. The chapter ends with an account of reasonable modifications and accommodations to allow women with disabilities to enjoy reproductive services on equal terms with other women.

Indigenous Women, Health, and Healthcare

For Indigenous women, gender intersects with cultural and racialized identities to create complex inequities in health and healthcare. The experience of Indigenous women within the Canadian healthcare context is explored using the Xpey’ Relational Environments Framework. Relational environments that shape Indigenous women’s wellness encompass human and non-human interactions, healthcare and community settings, and sociocultural contexts. By framing determinants of Indigenous women’s health in this way, the chapter demonstrates the layered complexity of risk as well as opportunities for healing. Indigenous women over the lifespan are shown to have a disproportionate burden of illnesses and comorbidities that are situated within the foundations of colonialism, racism, violence, and a range of socioeconomic inequities. Sources of strength and resilience that nurture the physical, mental, emotional, and spiritual wellness of Indigenous women are highlighted.

Women’s Healthcare Through a Feminist Ethics Lens

This chapter provides the book’s rationale, reviews themes that are central to the book, and presents an overview of its chapters. The collection aims to bring insights from healthcare providers, clinical ethicists, scholars, and community together as a way of broadening feminist bioethics and being responsive to ethical issues in women’s healthcare. A starting premise is that gender is central to the evaluation of healthcare and healthcare practices. Several feminist themes that are pertinent to the ethics analyses throughout the book are described. These include relational components of moral life, justice and oppression, women-centered care, implications of sex and gender distinctions, and examining issues through an ethics lens. The overview of chapters highlights the specific gaps in the literature each one fills, along with how they fit together as a collection.

Perinatal Mental Health

This chapter reviews ethical issues pertaining to the care of women with mental illness during pregnancy and the postpartum period. The incidence of perinatal depression and anxiety and psychotic disorders and their respective treatments are described. Ethics principles and perspectives that guide perinatal mental health care are discussed critically. Relational autonomy is shown to be a key principle to guide treatment decisions for these women. The value of relational autonomy in addressing ethical challenges is illustrated by three cases in reproductive mental health: psychotropic medication decisions during pregnancy; enforced treatment; and disclosure of medication use to fathers. A fourth case addresses social justice considerations of mother–baby units for women experiencing a perinatal mental health crisis. This analysis calls for a notion of self-determination that accounts for how autonomy occurs and is enacted within specific relational, social, cultural, and political contexts.

Ethical Issues in Healthcare for Women in the Context of Violence

Violence against women is a complex social and health issue. Addressing it meaningfully requires careful ethical reasoning. This chapter offers an overview of the issue of violence against women, beginning with its definition and the link between structural and interpersonal forms of violence. The implications of using traditional bioethical reasoning in this context are analyzed, followed by the use of relational ethics, which is shown to be superior. The chapter ends by focusing on healthcare policies and practices that respond ethically to violence against women. Considered are managing disclosures of violence, establishing trauma- and violence-informed policies, using case finding as an alternative to screening, and ensuring that responses are culturally safe and supportive, do not stigmatize the woman, and consider the context of women’s lives and relationships, especially their caregiving relationships.

Drivers and Dilemmas of Female Genital Cosmetic Surgery

Female genital cosmetic surgery includes many procedures undertaken at the request of the woman and is the fastest-growing area of cosmetic surgery, despite calls for avoidance or extreme caution from professional organizations responsible for women’s health. Low genital self-image is presumed to drive requests, but root causes have not been studied. The vast majority of these surgeries are not indicated medically, have unknown long-term effects, and are being performed in a private-pay environment in a context of significant ethical concerns regarding informed consent, autonomy and beneficence, and conflict of interest. This chapter explores normal physiologic development of female genitalia as it pertains to knowledge of what is “normal,” self-image and the drivers of genital self-image, concerns about specific procedures, and statements of professional organizations. Ethical tensions and dilemmas for clinicians highlight physicians’ ethical responsibility to provide accurate information about potential harms and benefits of these procedures.

Research with Pregnant Women

Despite progress in representing various populations in clinical research, one group has been left behind: pregnant women. Though millions of pregnant women annually need to use medication, whether to treat chronic illness or prevent infectious disease, pregnant women have been systematically excluded from the social investment in clinical research required to generate evidence to inform their care. This chapter articulates three models that have been advanced for morally framing research with pregnant women: an unfettered protectionist model, in which pregnant women are categorized as a “vulnerable population” for purposes of clinical research; a model of unrestricted deference to the pregnant woman’s autonomy; and a model that construes the fetus as a pediatric research subject. Each, it is argued, is critically flawed. With lessons learned from their respective limitations, the chapter points toward ways in which research during pregnancy must be given unique consideration, and toward development of an adequate framework.

Technology and the Ethical Practice of Reproductive Care

This chapter applies the lens of woman-centered care to examine the complexity of ethical decision making involving technology in contemporary reproductive health settings. It begins by situating the discussion within an international perspective, revealing that pregnancy is still a highly risky state globally for women, including risk of abuse from both within and outside healthcare. The model of woman-centered care is presented as an ethical strategy to approach a woman considering reproductive options and decisions. Using this model and a series of vignettes, ethical issues involving technology in routine reproductive care during key periods are examined, including contraception and adolescence, genetic screening, woman-centered care in childbirth, technology in labor (induction, informed consent, fetal monitoring), human rights during labor, and infant feeding. Solutions beyond technology are also offered.

The Moral Agency of Abortion Providers

Until very recently, only negative claims of conscience related to abortion provision were recognized; that is, conscience-based refusal to provide abortion care was recognized but conscience-based provision was not. In fact, to the contrary, abortion providers were and are routinely stigmatized as being devoid of conscience or moral principles. This chapter takes up the moral agency of abortion providers. It deepens understanding of the concept of conscientious provision and considers the intersection of stigma and conscience claims. In addition to stigma, deep social polarization on abortion prevents abortion providers from feeling that they can safely and freely speak about their work. This means that the lived experiences of abortion providers, including their openness to the moral ambiguities and complexities of abortion, remain hidden. Ultimately the chapter suggests that abortion providers’ capacities to live in contested arenas, to see the complexities of abortion, and to hold a “tension of opposites” are a manifestation of deep moral engagement, a potential path out of our current polarized state, and a model for civic engagement on any number of issues.

Primary Healthcare for Queer Women and Trans People

This chapter supports primary healthcare providers in understanding and challenging heteronormativity and cisnormativity in their practice. Healthcare provision for queer women and trans people must be approached with an understanding of the way these patients’ healthcare needs are shaped by systematic and historical oppression in the healthcare system. Heteronormativity and cisnormativity are institutionalized in clinic spaces and procedures, including forms, washrooms, brochures, and interactions with healthcare providers and administrative staff. Preemptive structural changes can be made to clinic forms, procedures, spaces, language, and knowledge to address queer women and trans patients’ needs. Changes within the healthcare interaction that focus less on maintaining healthcare providers’ neutrality and comfort, or on the exoticized aspects of queer and trans identities, will further disrupt cisnormativity and heteronormativity within the patient–provider interaction, build trusting provider–patient relationships, and increase access to quality healthcare for this community.