Systems Thinking in Gender and Medicine

Abstract

If there is a single thread running through this issue of the journal, it may be the complex interplay between the individual and the system(s) of which they are apart, highlighting a need for systems thinking in medical ethics and public health. Such thinking raises at least three sorts of questions in this context: normative questions about the locus of moral responsibility for change when a system is unjust; practical questions about how to change systems in a way that is morally appropriate without triggering unintended, potentially harmful side-effects; and epistemic questions about how to predict the multidimensional consequences of a proposed change or set of changes to an intricate social system such as healthcare. My focus will be on gender bias in the surgical profession.

Full text

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Systems thinking in gender and medicine
Brian D. Earp
If there is a single thread running through this issue of the journal, it may be the complex
interplay between the individual and the system(s) of which they are apart, highlighting a
need for systems thinking in medical ethics and public health (1,2). Such thinking raises at
least three sorts of questions in this context: normative questions about the locus of moral
responsibility for change when a system is unjust; practical questions about how to change
systems in a way that is morally appropriate without triggering unintended, potentially
harmful side-effects; and epistemic questions about how to predict the multidimensional
consequences of a proposed change or set of changes to an intricate social system such as
healthcare (3). These questions crop up throughout the issue, as I will discuss, but my focus is
the target article and linked commentaries on gender bias in the surgical profession.
Hutchison (see pages …) conducted in-depth interviews with 46 Australian women surgeons
and surgical trainees, taking care to avoid leading questions regarding gender bias or
gendered mistreatment. Nevertheless, despite minimal prompting, at least four types of
gender-related concerns were described by the surgeons, whether directly or indirectly:
This is the author’s copy of a published paper:
Earp, Brian. D. (2020). Systems thinking gender and medicine.
Journal of Medical Ethics, 46(4), 225-226.

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(1) structural bias in workplace factors, including insufficient (or stigmatized)
parental leave for women, exclusion from men’s spaces (e.g., changing rooms) where
informal training may occur, and a dearth of senior female role models;
(2) epistemic injustices including unfair doubting of women’s surgical competence
or knowledge relative to men;
(3) stereotyped expectations that women surgeons would or should shoulder the
burden of medical carework, for example, by attending to patients’ emotional needs;
and
(4) objectification, both by colleagues and patients, including sexual innuendo,
remarks about clothing, and even outright sexual assault.
Each of these concerns is disturbing on its own, and yet they do not operate in isolation.
Rather, they interact with each other, often in mutually reinforcing ways, and they may cause
aggregate harms to women that are greater than the sum of their parts. As Hutchison notes,
addressing such harms thus requires (a) “understanding the functioning of the system” from
which they emerge, (b) “making the harms and the way they aggregate visible,” and (c)
“challenging expedient practices that support them.”
Hutchison’s study makes a valuable contribution primarily to (b), while leaving (a) and (c)
ripe for further discussion. How, then, should we make sense of the wider system from which
the harms identified by Hutchison flow; and who is responsible for challenging the structures
and practices that support those harms?
To answer these questions, we must first step back and acknowledge analogous biases and
harms befalling women in other fields traditionally dominated by men—for example,
academic philosophy (4). As McCleod notes in a linked commentary (see pages …),
“objectification of women or the assumption of credibility deficits among them” are not
unique to the world of surgery; rather, they are “common to disciplines in which women are
seriously underrepresented.” More broadly, they are a predictable consequence of any
gendered system in which access to resources, positions of authority, and the concomitant
power to shape norms and institutions are not distributed equally among stakeholders of
different genders (5).

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The usual way of theorizing such a situation is by appeal to patriarchy. On classic models,
this refers to a gendered system of male dominance and female subordination, wherein
gender is analyzed in terms of binary, hierarchical, sex-based positioning in social or
institutional space (6). Yet as Scully observes in another of the linked commentaries (see
pages …), “biases and epistemic injustices undoubtedly affect not just female surgeons, but
minority and LGBT surgeons as well.” Of course, some racial/ethnic minority or LGBT
surgeons are also female; some have non-binary gender identities, some are recently
immigrated, some are dealing with physical or mental disabilities, and so on. The remark by
Scully thus underscores the need for an intersectional analysis of gender (whether in the
context of medicine or in any other domain). Classic models typically fail to achieve this.
In a forthcoming book, Dembroff seeks to rectify this problem by proposing a new, more
sophisticated account of patriarchy that is intersectional to its core (6). Dembroff calls this
account the Real Men view. In a nutshell, it holds that the defining feature of patriarchy is not
male dominance and female subordination per se—although that is certainly part of the
picture—but rather, the dominance of “real men” over everyone else. Here, “real men” refers
to the group of persons taken to sufficiently exemplify the characteristics of “natural”
manhood, as that concept applies in a given context (6). These characteristics thus include the
cluster of physical traits typically considered to ground membership in the male biological
sex category (7), but also the whole suite of biopsychosocial attributes that are prototypically
“masculine” in the relevant culture.
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A strength of this account is that it preserves the notion of male dominance—reflected in the
“old boys club” quality of surgical culture noted by participants in Hutchison’s study—
without ignoring the ways in which patriarchal gender systems can confer structural
disadvantages along numerous social-identity axes. Thus, on Dembroff’s account, even males
can be harmed by patriarchy, to the extent that they fail to qualify as “real men” according to
the prevailing gender ideology.
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If that is right, the surgical culture described by Hutchison’s
participants might best be understood, not as an “old boys club,” but rather, as a “real men’s
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For my own take on a biopsychosocial understanding of gender, see the video “What is (your) gender? A
friendly guide to the public debate,” https://youtu.be/LZERzw9BGrs.
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Thus, in many cultures, adolescent boys—or older males who have not yet “proven” their manhood by, for
example, undergoing a prescribed rite of passage (8)—as well as gay men, trans men, men of color, disabled
men, and others, may be disadvantaged as men within the logic of patriarchy, alongside women, non-binary
people, and others who are “not real men.” For an important discussion of the need to study (at least) male and
female aspects of a gender system holistically and together (i.e., in relation to each other) in order to understand
either aspect of the system, much less the system as a whole, see (9).

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club,” with various harms and biases befalling everyone who does not fit the—presumably
white, male, heterosexual, etc.—stereotype of a “proper” surgeon (10). Future research
should consider this possibility.
Now to the question of responsibility. If we assume that Real Men patriarchy is at least one
of the systems behind the harms, biases, and injustices identified by Hutchison, who is
responsible for changing that system? Brennan (see pages …) argues that change must be
sought and pursued at the level of the institution, as opposed to the level of individuals,
advising against strategies that involve finger-pointing and blame—at least when it comes to
unconscious biases and unintentional mistreatment. Brennan writes that blaming individuals
in such cases “is unlikely to be effective even if one thinks it is warranted. It is certainly not
the case that only male surgeons, staff and patients are to blame [for instance, as] research on
implicit bias [indicates] that both men and women undervalue the work of women and
overvalue the work of men.”
Brennan’s analysis seems right as far as it goes. But, as Brennan would no doubt agree,
institutions do not reform themselves. Rather, individuals, both within and without unjust
institutions, must work together to make concrete changes to relevant polices, while staying
mindful of their individual-level moral responsibilities. And insofar as Real Men have
disproportionate power and authority within an institution like surgery, they may have
disproportionate responsibility to initiate changes at the institutional level—in collaboration
with, and centering the perspectives of, those with less power—while also ensuring
respectful, unbiased interactions with (inter alia) their female colleagues. As Gupta has
argued in another context, addressing injustice is not an either-or proposition: individual-
level and social-structural factors are often co-constitutive and synergistic (11). In other
words, one can both lobby for systemic change where appropriate and take responsibility for
one’s own behavior (12).
In their article on medical cannabis prescribing, Glickman and Sisti (see pages …) make a
similar point. Decrying the current political situation in which medical cannabis policy is
driven more by moralization and wishful thinking than by a sound appraisal of the evidence
concerning benefits and risks of cannabis use, they are clear that systemic change is needed.
For example, they suggest that the training pipeline needs to be reformed so that physicians
receive an adequate (or indeed any) education about why and when to prescribe medical

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marijuana. But given the messy reality of politics coupled with institutional inertia, they
argue that individual primary care providers now have a personal and professional obligation
to “develop a level of clinical and ethical competency to enable them to recommend cannabis
to their patients when it is indicated.”
Systems thinking is also evident in the papers by Winters et al. (see pages …), Semrau (see
pages …), and Decullier and Maisonneuve (see pages …). Winters et al. defend prioritarian
principles for digital healthcare in low-resource settings, arguing that certain structural
inequalities speak against utilitarian health policy and in favor of prioritizing the needs of the
worst off. Semrau responds to critics of an earlier paper on kidney markets, distinguishing
pressure to sell one’s kidney, specifically, from a more general pressure to make money, with
kidney vending as one viable option. And Decullier and Maisonneuve focus on abuse of
authorship criteria, citing researchers’ claim that the publish-or-perish system of academia
leaves them with no choice but to accept gift authorships and even ghost authorships.
Although detailed philosophical analysis of discrete, often stylized cases undoubtedly has an
important role to play in medical ethics, it is encouraging to see so many authors taking a
more holistic approach that positions actors, practices, and behaviors within the wider
systems of which they are a part.

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References
1. Midgley G. Systemic intervention for public health. Am J Public Health.
2006;96(3):466–72.
2. Stephens A, Jacobson C, King C. Describing a feminist-systems theory. Systems
Research and Behavioral Science. 2010;27(5):553–66.
3. Earp BD, Savulescu J. Love’s dimensions. In: Love Drugs: The Chemical Future of
Relationships. Redwood City: Stanford University Press; 2020. p. 16–35.
4. Hutchison K, Jenkins F, editors. Women in Philosophy: What Needs to Change? Oxford:
Oxford University Press; 2016.
5. Manne K. Down Girl: The Logic of Misogyny. Oxford: Oxford University Press; 2017.
6. Dembroff RA. Putting real men on top. In: Breaking Labels. Oxford: Oxford University
Press; forthcoming.
7. Hodson N, Earp BD, Townley L, Bewley S. Defining and regulating the boundaries of
sex and sexuality. Med Law Rev. 2019;27(4):541–52.
8. Earp BD. Between moral relativism and moral hypocrisy: reframing the debate on
“FGM.” Kennedy Institute of Ethics Journal. 2016;26(2):105–44.
9. Merli C. Sunat for girls in southern Thailand: its relation to traditional midwifery, male
circumcision and other obstetrical practices. Finnish Journal of Ethnicity and Migration.
2008;3(2):32–41.
10. Peters K, Ryan MK, Haslam SA. Marines, medics, and machismo: Lack of fit with
masculine occupational stereotypes discourages men’s participation. British Journal of
Psychology. 2015;106(4):635–55.
11. Gupta K. Anti-love biotechnologies: integrating considerations of the social. The
American Journal of Bioethics. 2013;13(11):18–9.
12. Earp BD. Hymen ‘restoration’ in cultures of oppression: how can physicians promote
individual patient welfare without becoming complicit in the perpetuation of unjust social
norms? J Med Ethics. 2014;40(6):431–431.