There is a long tradition of
feminist critique of reproductive technologies and the concept of
autonomy. Carolyn McLeod’s book, Self-Trust
and Reproductive Autonomy, builds on this tradition. Her unique and valuable contributions stem
from an enriched understanding of autonomy within a relational social
context. She skillfully uses narratives
of women with miscarriages, assisted reproductive technologies, and prenatal
screening to demonstrate the importance of self-trust for autonomous
decision-making. Ultimately, she makes
recommendations for how health care professionals can improve their patient’s
self-trust and autonomy.

Her book is clearly written and
well organized. With only a few
exceptions, the reader can easily follow her arguments. Each chapter flows logically into the next. She begins by arguing for the existence of
“self-trust.” Demonstrating a good
knowledge of the philosophic and psychological literature on trust, her
arguments were fair and sufficient to support the existence of such a
concept. She successfully distinguishes
it from self- confidence and self respect by defining self-trust as an emotion
of optimism that one will act consistent with one’s own moral integrity.

McLeod’s version of self-trust
opens it up to many of the benefits and risks of traditional trust. Self-trust makes us vulnerable to the risk
that our optimism is unfounded. Self-trust
is vulnerable to external input from individuals and society. This point is one of the most valuable
contributions of this book. McLeod’s
chapters on vulnerability and the epistemic nature of self-trust demonstrate
the various ways that oppression and discrimination can affect the degree of
self-trust that one has. For example,
the judgment of whether self-trust is reliable is made in part by comparing it
to external, as well as internal cues. 
If the responses from others consistently conflict with one’s own value
judgments, then one may assume that one’s own judgment is wrong. Oppressive messages from others and society
can cause one to adopt a mistaken view of one’s values, as well as the degree
of self-trust that is warranted.

McLeod builds on this in her
discussion of autonomy. When a person’s
degree of self-trust or distrust is warranted, it supports autonomy. Similarly, when either is inaccurate (too
much or too little) then autonomy suffers. 
But McLeod points out that the relationship is more complicated than it
seems. Consider an example of a woman
who distrusts herself to make complicated medical decisions because her social
feedback in this situation has consistently told her that uneducated women are
not capable of making such decisions. 
In such a situation, McLeod says that the woman’s distrust of her
decisional capacity may be well grounded if it accurately reflects her current
abilities. However the distrust is also
unjustified because the input from the oppressive environment is
inaccurate. This is an important
distinction because it demonstrates means for improving self-trust. It also demonstrates the relational nature
of autonomy. McLeod does not conclude
that those who are oppressed should not be treated as autonomous agents.
Rather, she recommends that health care professionals point out inaccurate
beliefs and help guide self-distrustful patients through the decisional process
in a manner that promotes self-trust.

The practical import of this
analysis of self-trust and its social elements for enhancing patient autonomy
is demonstrated by the use of cases throughout the book. The final chapter focuses on the
implications of her conclusions for medical practice. McLeod’s recommendations focus on practical changes that health
care professionals can take for improving the care of individual patients,
while granting that greater benefits would come from changing the culture of
medicine. While she focuses on
physicians, her recommendations are helpful for all health care professionals.

The book’s strengths are weakened
only by the occasional appearance of McLeod’s own biases. Most of the time she analyzes points fairly,
addressing major counterarguments to her approach. But, she occasionally lapses into overgeneralization. The biggest example of this is how assisted
reproductive technologies (ART) and pre-natal testing techniques are almost
universally portrayed in this book as oppressive and harmful to women. This
kind of bias leads to a few errors of reasoning. The logic supporting the final conclusions stands despite these
errors. However, this bias may
undermine communication of the book’s message to obstetricians and specialists
in reproductive endocrinology and infertility. This is a shame since the recommendations are directed towards
them.

With that last caveat, I highly
recommend this text. Its strengths
outweigh its weaknesses. It provides a
valuable addition to the discussion of autonomy and informed consent. Her elaboration of self-trust provides a way
to acknowledge the real damage of oppression and trauma on a person’s psyche
without undermining respect for his/her autonomy.

©
2003 Constance Perry

Constance Perry, Ph.D. teaches
courses in biomedical ethics and philosophy at Drexel University. She serves on two clinical ethics committees
and Drexel’s Institutional Animal Care and Use Committee. Her research interests include autonomy,
personhood, ethical issues in reproduction and pregnancy, and the ethics of
animal experimentation.

Categories: Ethics