Public Health from a Feminist Point of View: A Commentary on "Public Health and Precarity" by Michael D. Doan and Ami Harbin

Sue Sherwin was among the first feminist bioethicists to insist that bioethics needed to become much more richly contextual and relational than traditional approaches to the discipline were ready to acknowledge. Targeting clinical bioethics and its central notion of patient autonomy, feminist bioethics focused on how broader social inequalities were likely to manifest themselves within clinical encounters among patients, family members, and healthcare professionals. The general idea was that by attending to how more general social inequalities might be affecting clinical encounters, an explicitly feminist bioethics could play a crucial role in developing institutional pathways for empowering patients to make more genuine decisions about what was medically best for them (Sherwin 1992).

More broadly, feminist bioethics shifted the focus of bioethical thinking from the clinical encounter to the broader aspects of social inequality that affect the health and social well-being of individuals. Abortion decisions, to take a central example, can only be fully understood in their broader social context of women's childrearing roles and how these roles affect women's economic position as they raise children and age. An emphasis on public health is thus a natural fit with feminist bioethics as it has continued to develop and vice versa, as we learn from the literature on the social determinants of health, a public health literature that began about the same time as feminist bioethics. The key point of this literature is that in economically well-developed societies, individual health and well-being is significantly affected by relative social position. If we want to pursue public health in ways that genuinely matter to population health, we need to address social inequalities (Wilkinson 1996; Marmot and Wilkinson 1999).

Feminist approaches to public health promise to move us beyond more narrowly epidemiological approaches to the social determinants of health by focusing our attention on the actual imbalances of social power that shape the effects on population health tracked by such approaches. Because feminist approaches to health are relational and contextual, they need to focus, as Doan and Harbin's (2020) paper does, on the health of particular social groups as defined by particular imbalances of social power. Public health case studies must therefore play a significant role in feminist approaches to public health. They enable us to understand what is negatively happening to whom and why. This is important because we need to understand who has what kind of power with what kind of negative effects to be able to explore ways in which these and other forms social power can be positively realigned to achieve better health outcomes. These sorts of relational questions are best answered not in the abstract but in the context of actual social situations.

This said, some particular cases may be more generally instructive than others. The two cases that Doan and Harbin examine take place in the United States. At the level of individual healthcare, a significant number of Americans have no health insurance or health insurance that is significantly limited. At the level of the social determinants of health, differences in wealth and income are highly skewed toward the top 1 percent of Americans, with resultant population health outcomes among the worst for economically well-developed nations (Wilkinson and Pickett 2010). Socially, politically, and economically, American society is deeply polarized. So while we can and should admire the organizational impetus and resilience within the particular communities that Doan and Harbin discuss, we should also recognize that such organizational efforts are bound to be episodic and of limited geographical reach within the more general social context in which they are taking place. Although these efforts are undoubtedly important for the immediate communities in which they take place, such case studies seem destined to stand as isolated and limited efforts against overwhelming social forces emanating from outside the communities themselves.

In this context, it is instructive to consider another example that begins about the same time as the Black Panther case in a wholly different society. Anthropologist Nancy Scheper-Hughes first encountered the mothers of Alto do...