In the previous chapter I argued that biologism and pronatalism can explain why some women choose FP in the cancer context. I suggested that biologism can coerce some women to choose FP in an attempt to secure the option of future biological reproduction, while pronatalism can unduly compel women to choose the medical procedure or action that is most likely to result in pregnancy. In this section I employ the feminist relational
account of autonomy described above, in order to illustrate how pronatalism and
biologism can impede patient autonomy in the FP decision-making context. To do this, I evaluate the oncofertility cases of Idelle and Jenn (below).
Case 1- Idelle
Idelle is a 39-year old woman who is diagnosed with breast cancer. She is single, has no children and works in business development. Upon her cancer diagnosis, healthcare professionals discussed Idelle’s FP options with her. Although Idelle describes her relationship with her parents as good, her parents have always placed pressure on her to have children so that they could have grandchildren like the rest of their friends. Idelle’s father was very “proactive in encouraging Idelle to undergo oocyte harvesting”.
According to Idelle, her parents played a direct role in her decision to cryopreserve oocytes. Her father paid for the FP procedure because he wanted to make sure he had “insurance on a grandchild”. Idelle accepted her father’s offer to pay for the FP procedures and proceeded with ovarian stimulation, egg retrieval and cryopreservation prior to the onset of her cancer treatment. (Snyder et al., 2010, p. 424)
Case 2- Jenn
Jenn is a 23-year old woman who is diagnosed with breast cancer. She is married and has no children. Jenn was informed that her cancer treatment could cause infertility and told to consider FP. She was devastated by the news that her cancer treatment could cause infertility because ever since she was a little girl she knew that her “purpose in life [was] to raise a family”. Jenn says that as she got older, this desire to “be a mommy” developed into a desire not only to want to be a parent, but also to “want to experience pregnancy and childbirth”. According to Jenn, adoption, surrogacy and egg donation were not options for her because she “feared [they] would not complete [her] the same as bearing [her] own children”. Jenn contemplated forgoing cancer treatments in order to protect her fertility, but she elected instead to undergo oocyte harvesting prior to the onset of her cancer treatment. The extracted oocytes were fertilized and the resultant
embryos were cryopreserved. Jenn claims that she prefers to get pregnant on her own; the cryopreserved embryos are a “back up plan just in case” natural conception fails. She also says that she can now rest easy knowing that her “lifelong dreams will be fulfilled”. (http://fertilefuture.ca/patients/survivor-stories/jenn-23-breast-cancer- survivor/)
I maintain that the cases of Jenn and Idelle warrant examination from a feminist perspective. This is because both Idelle and Jenn’s decisions occur within a(n)
(American) patriarchal social context in which oppressive social norms around women’s reproduction can unduly influence women’s reproductive autonomy. As such, women’s choices about reproduction, especially those that can be risky for women (as in the cases above) raise concerns about whether the reproductive choices were autonomous. In what follows I do not intend to prove that Idelle and Jenn’s FP decisions were influenced by pronatalism and biologism. Indeed, too little is known about either case to discern (as a matter of fact) the extent of which Idelle’s or Jenn’s decision was autonomous. Instead, in this section I show how a feminist theory of relational autonomy is useful for uncovering how oppressive social norms, such as pronatalism and biologism, can impede patient autonomy. I begin by discussing the similarities between the cases of Idelle and Jenn. I then describe how each of these cases of oncofertility decision-making could have been influenced by pronatalism or biologism.
The cases of Idelle and Jenn share some important similarities. Both patients were diagnosed with breast cancer and offered the option of undergoing FP procedures before beginning treatment. Each woman chose to undergo oocyte retrieval and a subsequent cryopreservation of reproductive material (oocytes and embryos, respectively). Prior to oocyte retrieval, each woman was injected with oestrogen hormones, which stimulated her ovaries to release multiple mature oocytes. In each of these oncofertility cases (and nearly all oncofertility cases involving breast cancers) the patient’s breast cancer is especially sensitive to oestrogen hormones (Azim et al., 2008; Prest et al., 2002;
oocyte retrieval are risky to patients because they can accelerate the rate at which the cancer spreads. Furthermore, the process of ovarian stimulation and oocyte retrieval usually takes between two to six weeks to complete, so patients, like Idelle and Jenn, experience a delay in the onset of their cancer treatments.46 Both hormone stimulation and delays associated with oocyte cryopreservation are serious risks for breast cancer patients, such as Idelle and Jenn. For these reasons, some physicians are uncomfortable with offering oocyte or embryo cryopreservation to breast cancer patients (Kondapalli, 2012, p. 64). It is likely that choosing the option of oocyte cryopreservation was more risky for these women, as opposed to choosing another type of FP procedure or foregoing FP altogether. I now examine how biologism and pronatalism may have influenced each woman’s FP decision-making.
In Idelle’s case, she attributes her FP decision to her father’s wishes for genetically- related grandchildren and his offer to pay for the FP procedure. On one reading, it may seem as though Idelle’s choice in favour of FP is an example of shared decision-making with her father. On another reading Idelle’s choice to use FP might have been caused by the desire to please her father. This desire might itself have been caused by sexism because within patriarchy, many women are conditioned to view men (especially their fathers and husbands) as figures of power and authority. Both of these interpretations are possible, but below I shall focus on how pronatalism and biologism may have impeded Idelle’s autonomy.
Insofar as Idelle lives in a pronatalist society, she may be conditioned to believe that her womanhood is connected to her fertility. She may also believe, because of biologism, that providing her parents with genetically-related offspring is important and markedly better than giving them grandchildren who are not genetically-related (to her parents) or not giving them any grandchildren. It is possible that social pressures to (genetically) reproduce and the high social value that Idelle’s parents placed on having genetic
46
The urgency with which cancer treatments must begin depends upon the stage of the patient’s cancer and how fast the cancer is spreading.
grandchildren could have caused Idelle to distrust her own judgements about FP. Also, she may have over-identified with her parents’ biologistic desires for grandchildren. In part, the biologistic pressures from her parents may have compelled Idelle to choose FP and biologism may have directly compelled her to value genetic ties over social ties and thus not really see adoption or future egg donation as equally valuable options for reproduction or for making her parents into grandparents. The serious risks incurred by Idelle in order to preserve the option of giving her parents genetically-related
grandchildren lend support to the idea that oppressive social norms unduly influenced Idelle in making her FP decision. In addition, Idelle may have been conditioned to tie her sense of self-worth to fulfilling the pronatalist and biologistic mandate. In other words, Idelle may have believed that her value and identity as a woman (and as a daughter) rested on whether or not she would produce genetically-related children in the future. Idelle may lack the appropriate self-referring attitudes such as self-worth or self-trust that are necessary for autonomy. If this is the case, Idelle’s FP decision would have not been autonomous.
On Stoljar’s account of relational autonomy, oppressive socialization within patriarchy could have caused Idelle to distrust her own ability to decide about reproduction. This distrust could have compelled Idelle to defer to her parent’s wishes when deciding whether or not to maintain her future option for genetic reproduction by using FP technologies. If Idelle distrusts her ability to choose well with respect to FP specifically or reproduction generally, it explains why she agreed to undergo oocyte harvesting at the request of her parents. This inappropriate self-referring attitude would compromise Idelle’s autonomous choice about FP.
In the case of Jenn, she clearly expressed her desires to gestate genetically-related offspring. However, her case raises some question as to whether her desire to become a genetic (and gestational) mother is an authentic desire. Within patriarchy, women are conditioned to desire and place high personal and social value on motherhood. However, patriarchal practices surrounding reproduction and mothering can contribute to women’s
oppression. Jenn’s assertion that she has desired to be a mother “ever since she was a little girl” along with her admission that she believed that motherhood was “her purpose in life” could both be indications that Jenn has internalized oppressive patriarchal norms concerning reproduction and parenting. Her desires conform to the oppressive pronatalist norms that mandate gestation (and motherhood) for women. These desires are also in accordance with biologism and value genetic ties over social ties. Jenn could easily be suffering from false consciousness, in which case she fails to meet the authenticity condition for autonomous agency.
In Jenn’s testimony, there is no indication that she considered whether she ought to desire biological gestational motherhood. Thus, her desires could have been unduly shaped by pronatalist and biologistic social norms. A theory of relational autonomy calls attention to whether her strong desire to “be a mommy” and to fulfil her “lifelong dream” are
authentic. In Jenn’s case, a relational theory of autonomy draws attention to the
possibility of Jenn holding deformed desires that inhibit her ability to be self-governing. Moreover, Jenn might lack the normative competency required to critically evaluate her desire to be a mother. This is because under oppressive social conditions, the values or goals promoted by society can limit the “self-concepts or identities” of members in oppressed groups insofar as oppressed persons come to adopt values and goals that further their own oppression (McLeod, 2002, p. 112-3). This is not to say that there is no value in becoming a mother, nor that some women do not or should not desire
motherhood (as individuals). Rather, desires that match up with oppressive social norms warrant at least some degree of normative evaluation.
To count as autonomous, according to Stoljar’s description of relational autonomy, Jenn must perform a strong evaluation of her desires and discern whether wanting to be a mother or wanting to gestate a genetically-related fetus are indeed authentic desires for her. A strong evaluation of her desires would require that Jenn compares the value of gestational and genetic motherhood to other types of motherhood or other ways of becoming a mother. Insofar as Jenn’s use of FP puts her at risk for worsening her cancer
and her discussion of motherhood suggests little indication of seriously entertaining other ways of becoming a parent and that her desires match pronatalist and biologistic
ideologies, there are some reasons to question the authenticity of Jenn’s desires.
If the FP decision making of Idelle and Jenn were influenced by pronatalist and
biologistic norms, then a relational theory of autonomy is well-suited for identifying the ways in which patient autonomy might be impeded. Through the lens of relational autonomy, Idelle’s FP decision will only count as autonomous if she holds appropriate self-referring attitudes with respect to reproduction, such as self-trust and self-worth. In the case of Jenn, her FP decision will only count as autonomous if she critically and strongly evaluates her desires for genetic reproduction and chooses on the basis of those values which she authentically endorses.
Relational autonomy provides an ethical framework for assessing the impact of
oppressive socialization on Idelle and Jenn’s FP choices. The application of a relational theory of autonomy is important for two reasons. First, it can pick out instances where decision-making fails to be sufficiently autonomous. Second, what is more important is that it can help to establish the conditions that are necessary for autonomous choice, action and authentic desire. Enhancing patient autonomy in oncofertility contexts is important for women because FP technologies are risky and because reproductive autonomy is closely tied to women’s well-being. In the remainder of this chapter I respond to Stoljar’s criticism of informed consent. I also show how patients’ (relational) autonomy can be secured through an ethical process of informed consent.