by Tiia Sudenkaarne
A bioethicist and a queer feminist philosopher for the past years working with social study of microbes, I was delighted to accept the offer to join CrimScapes for eight months 2023-2024. I was impressed by its exploration of the growing mobilisation of criminal law, crime control measures and imaginaries of (il)legality as both responses to, and producers of, the politics of threat and uncertainty that are currently expanding across the European region.
Bioethics can be defined as considerations of the moral, societal, and political issues brought about by sickness, health, care, and environment: what kind of ontological assumptions these concepts build on, what kind of knowledges they entail and how should ethical issues around them be resolved. Learning from the work of my CrimScapes colleagues, I have been particularly struck by their sobering analyses of how the concept of care is weaponized in various settings to deliver the very opposite of its intuitive meaning to those seemingly cared for. This excellent work has led me to think more about carceral care: in women’s prisons, in controlling and criminalizing discourses targeting HIV/AIDS, with seemingly benevolent yet authoritarian management of people who use illegal substances. Carceral care thus denotes the messy and entangled conglomerate of discretionary practices, performative measures, and material actions used to forestall the possibility of future interference and or interrogation of the underlying institutional violences of carceral spaces (Hwang 2019, 559). Carceral violence via carceral spaces can range from death-wielding enforcement to death-making negligence by institutions and their actors—parole boards, wardens, correctional officers, prison officials, medical staff, and administration (ibid). In this blog entry, I reflect on my own previous and ongoing work in relation to carcerality of care.
The ethical relevance of vulnerability
Most recently, I have been developing a queer feminist posthumanist framework for ethics thinking about antimicrobial resistance (AMR). The World Health Organisation (WHO) has declared AMR as “one of the top ten global public health threats facing humanity” (2021). AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness and death. However, as for example my CSSM colleagues Jose Cañada, Salla Sariola and Andrea Butcher (2021) have observed, this dominant understanding of AMR only covers one aspect of microbial resistance. The current definition of AMR lacks understanding of the more-than-human, that is multi-species perspectives and ecosystems, while also addressing but not prioritizing human health. To frame such an understanding, the environment must be seen also as key to the development, transmission and spread of AMR to humans, more-than human entities and plants (UN Environmental Report 2022, 1). Many human activities create pollution which promotes the emergence of AMR in the environment and can cause animal or plant diseases or soil biodiversity loss (ibid; Gillings & Paulsen 2014). This leads to further use of antimicrobials that only increases the selective pressure across eco-systems (Gillings & Paulsen 2014). This problem of scale directly relates to social inequalities in low- and middle-income countries. Calibrating a society toward thinking critically about and through AMR resilience and prevention also requires attention to species interdependencies (Haraway 2008; Chandler et al 2016; Brives et al 2021) while refraining from reproducing social injustice issues between people further into interspecies considerations.
A crucial analytical tool in my work has been the concept of cis- and heteronormativity and its effects on ethical analyses, including the definition and application of principles like justice and vulnerability as a principal concept. One of the key queer feminist critiques of principles is that common morality that they presumably build on reproduces moral objectivity as an unsituated rationality that is prone to be biased toward the moral realities and views of those with more social power (Donchin 2001). Further, acknowledging the critical work of feminist philosophy regarding how the premises of Western philosophy are built on gendered, racialized, binary, and hierarchical concepts (Lloyd 1984; Code 2007; Lugones 1994; Anzaldúa 1999), bioethical theories must, as Rosemary Tong persists, include critical lenses clear enough to recognize the unjust power relations that result in wrongful distributions of limited resources, and a motivational force strong enough to prompt people who currently benefit from unjust power relations to renounce them (Tong 2013, 29–30). I have suggested a queer feminist posthuman framework as one of such lenses (Sudenkaarne 2021).
Feminist thinking of vulnerability has established the ethical relevance of becoming vulnerable (vulnera) (Shildrick 2000). In feminist bioethics, many of us are attuned to layered vulnerability, as introduced by Florencia Luna (2009; 2018). The metaphor of layers renders somebody vulnerable, not categorically vulnerableizes them, based on contexts, situations and structures (Sudenkaarne 2021). Layered vulnerability does neither render such subjects without agency nor make them politically passive, despite for example, being dependant on care (Clifford Simplican 2015). What is crucial is ethical analyses not only to detect but also to eradicate layers of vulnerabilities (Luna 2018). (Sudenkaarne, Vaittinen & Sariola 2021.)
Often times groups whose needs are unintelligible from a gendered, heteronormative, white middle-class viewpoint, are excluded (Vaittinen 2022; Sudenkaarne, Vaittinen & Sariola 2021). Hence population approach to vulnerable groups reproduces existing power structures that include racialized, gendered and ability- and age-based assumptions of helplessness. Such notions of vulnerability continues to shape its use – and hence, to vulnerableize (Tremaine 2020) those considered marginal.
Queer vulnerabilities meet antibiotic vulnerabilities
As part of my article dissertation (Sudenkaarne 2021) I developed layers of queer vulnerabilities focusing on intimacy, kinship, agency and ethical sustainability (Sudenkaarne 2019). During my time at CrimScapes I was invited to consider them in relation to politics of (in)visibility, which led me to revisit the notion of bioethical voyeurism.
To Wahlert and Fiester (2014) who originated queer bioethics as a distinct approach, bioethical voyeurism is overtly scrutinizing the sexual lifestyle choices and gendered embodiment of queer persons beyond clinical or ethical relevance, based on heteronormative discourses having a long history of an assumed entitlement, or even a mandate, to scrutinize the intimate life of queer persons. According to Wahlert and Fiester (2014: S59), medical professionals continue to occupy the role of sexual authorities in deciding sexual morals: that clinicians are often guided to ask sexuality related questions in a way that is as seemingly nonjudgmental as possible and in a manner that distinguishes between the behavior and the person. However, it is crucial to analyze how through such seemingly innocent implications, anti queer moral judgements are foisted into medical ethics. To Wahlert and Fiester (ibid.), the distinction of being “as non-judgemental as possible” can be made only against the backdrop of a profoundly negative judgment about the behavior itself. Moreover, it reinforces a moral critique of the activity as warranted, even though a negative judgment about the person, while perhaps justifiable, is not clinically appropriate. Despite queer sexual acts and behavior having been and persisting as the object of medical interest in some cases for diagnostic reasons, too, simply understanding this layer as vulnerability through sexual scrutiny would not suffice in my view. Bioethical voyeurism is a form of violence in the worst case and indeed interrogatory in the best case. Titillatingly, by using the term voyeurism Wahlert and Fiester provide an opportunity to play on the vocabulary of pathologization and fetish or, going even further back in the history of sexology, with associations with the perverse or queer. Including pejorative vocabulary as a methodological tool seeking queer bioethical empowerment may indicate beating the master with his own stick: turning scrutiny from the queer subject to the seemingly objective medical view by exposing their ethically unwarranted interest as inappropriate and perverse, achieved by looking at the history of medical ethics and ethics of sexuality through the queer bioethical lens. Such a conceptual backlash can also help to challenge carceral care through deviant care (Hwang 2019).
If to choose only one layer of vulnerabilities for analysis, focus on ethical sustainability is the most robust and overlapping. As established with bioethical voyeurism, it is fundamentally linked to value judgements based on hetero- and cis-normativity. It is important to determine whether medical or other interest in a case is based solely on gender and sexuality diversity, and does the case reinforce negative perceptions. A crucial comparison is to see whether the analysis or outcome is different for a cis- and heteronormative agent as opposed to a queer one, and in this analysis, does cis and heteronormativity become a necessary condition for moral coherence. My current interest is thinking about this normativity in the context of AMR and gender and sexual variance, following Eleanor E. MacPherson (2022) and colleagues’ notion of antibiotic vulnerability.
MacPherson and her team (2022) suggest to me a multilayered connection between vulnerability and AMR. One the hand, ineffectiveness of antimicrobials will have significant ramifications for health systems, where treatment of vulnerable patients is likely to become more challenging, as well as the treatment of everyday illness where next-line antibiotics are unavailable (McPherson et al 2022; Jasovský et al 2016). As we know, stemming resistance to antimicrobials – particularly antibiotics – has become a global priority as the decreasing efficacy of these previously taken-for-granted substances renders visible the vulnerability of our health, economics and security systems globally (McPherson et al 2022, 2632). Yet the proposed framework to address AMR – the WHO’s Global Action Plan (2015) – has primarily framed AMR as a problem of excess, centering overall reduction in antibiotic use as the main goal (McPherson et al 2022, 2632; Sariola et al 2022). Ushered in by ‘pharmaceuticalisation’ since the 1990’s, the shift from prevention of disease to pharmaceutical intervention and treatment (e.g. Bell & Figert 2015), McPherson and colleagues (2022, 2632) observe that over time AMR discourse has come to consider not only people themselves as vulnerable to resistant infections but antibiotics too as vulnerable resources. As such, the expansion of stewardship programs that aim to protect medicines foregrounds certain forms of vulnerability. To them (ibid), an exploration of the intersection of the assumed and enacted vulnerabilities of both people and medicines has the potential to steer the course of stewardship, especially if these vulnerabilities can be traced as dynamic, emergent of systemic and programmatic features and amplified in contexts of scarcity. Further, they argue that these dynamics co-constitute a form of care that both responds to and creates antibiotic vulnerabilities. Dimensions of care in chronic scarcity present a scenario in which optimising antibiotic use will require not only stable availability of essential medicines but also a re-ordering of the system around provision of quality care rather than of medicines. So practices of case management can be understood to both respond to and create antibiotic vulnerabilities. (McPherson et al 2022, 2632.)
Based on their analysis, McPherson et al (2022, 2643) conclude that recognizing vulnerability often provokes a need to protect. Antibiotics are often portrayed as vulnerable, for example in awareness campaigns which call on publics and professionals to protect these medicines (e.g. Langdridge et al 2019). Patients are also vulnerable in the face of drug resistance, but moreover, they (ibid) show that by tracing out the ways in which antibiotics are deployed in case management in resource constrained settings, patients are also vulnerable to receiving sub-standard care that is provided through an unhelpful antibiotic. Similarly to previously discussed queer vulnerabilities critique against cis- and heteronormative bias in medical ethics, McPherson et al (2022, 2643) show that both patients and health workers police the boundaries of expected scripts of ‘care’, delivered without explanation, bolstering a scenario that perpetuates patient vulnerabilities. They conclude that ensuring a stable drug supply including antibiotics is vital but must be accompanied by wider changes that enable quality care to be performed and received beyond antibiotic-oriented case management. They propose context-specific programs be designed not only to protect vulnerable antibiotics, and patients vulnerable to antibiotic resistance, but also to protect patients from systems that have come to be organised around antibiotics, resulting in case management that leaves patients vulnerable to insufficient care. Building on their proposition that considering multiple dimensions of antibiotic vulnerabilities has conceptual promise as it can at once bring to the frame the vulnerability of antibiotics, people and systems, we plan to look at AMR, gender and sexuality for context-specific programs and specific antibiotic vulnerabilities.
Further, what we have called for in our work at the CSSM is an approach to issues like AMR that theoretically seeks to reject human exceptionalism in health and justice. While I plan not to go into detail of the posthumanist component of my queer feminist posthuman framework here, suffice is to say that such a perspective, attuned to both social and more-than huma-justice is crucial to show how seemingly unified stakeholders, such as power structures within human networks or similar more-than-human networks, have intersecting, layered vulnerabilities that align with existing social justice issues reproduced by the concept of race, ability/embodiment, and gender and sexuality (cf. McKnight 2022; Will 2018; Sariola et al 2022). In such structures, reproduced through social practice, those already marginalized are at higher risk to become vulnerableized (cf. Tremain 2020), such as sex workers. For example, Manuya and colleques (2022) have shown how with the threat of AMR and entrenched gender disparities, sex workers are vulnerable to greater surveillance, stigmatization, and criminalization “to control both infections and women”. This also reveals a lacuna of queer positioning in AMR frameworks, including mapping out specific needs and vulnerabilities (cf. Charles et al 2022; Yingwana 2022). Further, such a framework should be able to address multispecies vulnerabilities. (Sudenkaarne 2023.)
As I have discussed, there is a lacuna in moral theory to navigate gender and sexual variance as normative component when addressing phenomena like AMR that demand answers to core philosophical questions. What kinds of subjects can we imagine as morally significant? How are multispecies relations managed without prioritizing human ways of being? How are intersecting layers of vulnerabilities minimized between groups of people? Is species an oppressive category or in fact needed to ground subversive politics? How to move from human-oriented use of technology to solutions benefitting the entire global ecosystem? (Sudenkaarne 2023.)
Vulnerability as politics of visibility
In answering these questions, to me it is crucial to see how vulnerabilities and justice are integrally connected while still remaining distinct realms of conceptual inquiry. In establishing layers of vulnerability in superwicked contexts like AMR, visibility is key for both politics and ethics: to acknowledge and address specific needs and injustices that may be in part reproduced through biased scientific modes of viewing that require similar ethical scrutiny as any politics.
Under the quintessentially volatile conditions from pandemics to wars of aggression, it is crucial to map out current European trends of cis and heteronormativity –based criminalisation targeting LGBTQI+ people. For me poignantly, there remains a lacuna in research literature that addresses conscientious objection in a queer feminist framework, targeting both reproductive justice issues around pregnancy but also a wider scope of legislative apparatuses seeking to extend the legal rights of health care professionals to cite their personal religious or moral beliefs as a reason to opt out of performing specific procedures or caring for particular patients, even for their basic needs. This can be seen as a direct attack on specific lives as rooted in “animus against some of the most marginalized and vulnerable communities” (Sudenkaarne 2021, 57; Bollinger 2019).
CrimScapes of Care
Working with CrimScapes has left me with a further motivation to analytically grasp the motivations behind, and challenges and implications of, criminalisation for the variety of actors and practices that (re-)shape entangled landscapes of criminalization in relation to carceral care, a grim landscape between caring, curing and control. To Hwang (2019, 561), carceral care is not simply the deterrence, reduction, or interruption of carceral violence; rather, it is a mode of tracing how the penal administration of care multiplies the very scales, technologies, and cultural structures of violence itself. Disrupting those very impulses to be trapped by the rigged gamble that is carceral care requires to inhabit “a deviant set of relations” not only to the state but also to one another (ibid). Hwang asks, how might we resist and build our collective capacity to continuously trouble our notions of care? How might we resist both inferred and overt modes of racialized and gendered pathologies of individuated care that require the weaponization of personhood (ibid)? How might we account for the dualisms embedded within care—success or failure, curable or incurable, rehabilitated or recidivistic (ibid)? To Hwang, care, even in its etymological tie to cure, is not necessarily carceral. However, the attendant logics of care mimic a curative model of carcerality by requiring individuated pathologies as central to administrative measures of correction. (Hwang 2019, 561.) For future research would be to think about the carcerality of care in relation to criminalization and healthcare systems – how they create moral harms through care – in a queer feminist posthuman framework.
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