Contentious Practice - University of Regina

Hubbs – A Contentious Practice 1
A Contentious Practice:
Abortion and Ideological Agency in the American Medical Sphere
Christine Hubbs
ANTH 343 – Medical Anthropology
Term Paper
Dr. Marcia Calkowski
December 3rd, 2013
Hubbs – A Contentious Practice 2
The American biomedical sphere is not the rational system it purports to be. Medical
procedures are understood from a wide variety of viewpoints, and this allows some issues to
become so contentious that they blatantly challenge the idea that biomedicine exists apart from
the social world. Abortion is one of the United States’ most visible instances of medical
contention. By employing the research question of why the medical procedure is so contentious,
this paper will highlight some of the predominant themes that arise from discussion of abortion.
A description of the social factors which inform the procedure will first contextualize this
analysis. Two loose topics, gender and personhood, will be explored to outline the ways in which
Americans attempt to make sense of the procedure. Finally, an analysis of the “values”
Americans employ, as well as the ways in which the medical system itself is constructed, will
highlight the ideological ambiguities present in the abortion debate. This paper argues that
abortion is contentious partially because American people desire both a standardized medical
system and a medical sphere which reflects back to them a portion of themselves. Whether one
supports, vilifies, or altogether ignores the availability of the procedure, abortion is a moral
touchstone at the centre of a much larger attempt of Americans to navigate their medical sphere
while retaining their ideological agency.
An Overview of Abortion
There is a notion in the United States that abortion is a fringe procedure (Erdreich 2009:
69), but in reality, it is far more common than this discourse suggests. An estimated 25% of
American pregnancies end in elective abortion, and roughly 35% of women have had one at
Hubbs – A Contentious Practice 3
some point of their lives (Torr 2006: 12). While age and poverty-levels do come into play, there
is no stereotypical abortion recipient (Darney and Stewart 2006: 54).
Abortion in the United States is far from easily-accessible. Facilities are not evenly
spread across the country, and 87% of American counties lack abortion providers altogether
(Erdreich 2013: 48). The average abortion costs between $300 and $900, a price which rises by
an additional $100 per week after the twelfth week of pregnancy (Erdreich 2013: 169). Women
in areas devoid of abortion care may have to travel extensively for the procedure (Joffe 2009: 5),
and many states have legislation which requires mandatory ultrasounds and counselling. Very
little of this, if any, is covered by insurance (Erdreich 2013: 169). The financial circumstances of
a prospective abortion recipient figure greatly in her medical experience.
The history of abortion in America is fraught with contention. Abortion became legal in
1973 with the infamous Roe v. Wade case, when America’s highest court found that the Fourth
Amendment right to personal privacy protects the availability of the procedure (Torr 2006: 10).
While this means first-trimester abortion cannot be outright banned, individual states are
permitted to impose stringent regulations (Torr 2006: 11). Parental notification, spousal consent,
waiting periods, and even mandatory viewing of the ultrasound are requirements many states
have adopted with public support in an effort to curtail abortion numbers (Joffe 2009: 14). It may
seem strange that such public interest has been taken in the regulation of a medical procedure,
but some claim that abortion was always more of a political issue than a health one (Crandall
2006: 60). America is considered unique in the extent to which abortion ideology figures in
domestic politics (Joffe 2009: 6, 9).
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Coupled with structural restrictions is the intense controversy which defines how abortion
is understood. The abortion debate commonly centers on whether it should be normalized within
the medical system or outright banned, but the enactment of these opinions can become
problematic. Since Roe, eight people in the abortion-providing community have been murdered
because of their profession, and others have been threatened and stalked; abortion clinics have
been picketed, vandalized, and firebombed; and, opponents of the procedure have videotaped
patients entering clinics (Joffe 2009: xi). Those who support legal abortion employ the rhetoric
that doctors are expected to “provide medical care in a war zone” (Erdreich 2013: 153), and a
reluctance to provide statistics for abortion-related injuries suggests “bad medicine is glossed
over in the name of choice” (Crandall 2006: 65). Abortion is clearly much more than a procedure
to terminate pregnancy; it is a multivocal symbol, something which expresses meanings beyond
itself (Ohnuki-Tierney 1984: 157). It is through this lens that the question of why abortion has
become such a contentious medical procedure is explored.
Gender and Reproduction
It is not feasible to analyze the issue of abortion without discussing gender. Those who
undergo the procedure are biologically female, and such is how they are defined within the
medical system (Allen and Wiley 2013: 149). The biomedical emphasis on reproductive capacity
seems to leave little room for gender as a social construct, yet ideas of gender roles constructed
around reproduction are implicit. Some highlight that reproduction in America is highly
romanticized, and for women “having a child is considered one of the most natural and
biological impulses” (Erdreich 2013: 180). Because the nuclear family is seen as “the
cornerstone of American society”, choosing not to have a child challenges one’s ascribed gender
identity (Erdreich 2013: 180). Some feel that a woman’s social role is tied to childbearing, so a
Hubbs – A Contentious Practice 5
childless woman is inherently contentious (Allen and Wiley 2013: 165). While this may be true,
it should be noted that many American men choose to remain childless as well (Erdreich 2013:
224). The issue of abortion in the United States is not informed solely by the idea that women
should have children.
Notions of female identity discussed in American biomedicine are informed by much
more than biology. While people may understand medicine as scientifically based, “even the
most self-evident ‘givens’ of sexual embodiment belong not to some ubiquitous human nature
but to the shifting world of cultural meanings” (di Leonardo and Lancaster 1997: 1). Emily
Martin claims antiquated ideas of female reproduction are present in today’s medical practice
(Larkin and Robbins 2007: 255). The idea that the female eggs “wait patiently” for the male
sperm (Allen and Wiley 2013: 150) is coupled with the adage that “menstruation is the uterus
crying for lack of a baby” (Larkin and Robbins 2007: 255), and such ideas are part of what
inform medical practitioners’ knowledge of female health. The way people perceive the body
itself reflects society (Laqueur 1997: 221). Michel Foucault views the body as something
constructed by discourse, or the ways in which the surrounding society discusses, understands,
and presents it (Shilling 2003: 65). In this light, the idea of the female body becomes subject to
the dominant views of American culture (Shilling 2003: 65). While this is not to devalue the
individual, this idea highlights that the female body has become a site for political discourse
(Laqueur 1997: 219), of which abortion is one of the foremost debates.
Gender may figure greatly in how Americans understand social identity, but it is certainly
not the only contributing factor. Many also operate under the assumption that the body is less
important than the mind. There is the notion that “liberalism postulates a body that, if not
sexless, is nevertheless undifferentiated in its desires, interest, or capacity to reason” (Laqueur
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1997: 229). The body can therefore be considered a container for the rational person, and rational
people ostensibly have equal potential. This places the idea that identity depends on a person’s
reproductive capacity in jeopardy, because it stands at odds with Americans’ dualistic conception
of the body and person (Lock 2002: 95). These contradictions regarding gender become
particularly delicate in the discussion of abortion, for on the one hand fertility is still largely
constructed as the woman’s “purpose” (Allen and Wiley 2013: 164), but on the other, ideas of
individualism, equality, and privacy form the notion that the woman’s body should be inviolable
(Erdreich 2013: 179).
While gender, the body, and female reproduction cannot be wholly extracted from
discussion of abortion, the medical practice itself and its surrounding discourse must be viewed
as something larger than a feminist issue. It is true that only women who are biologically capable
of reproduction can undergo the procedure, but it is also true that people of all gender roles, ages,
and statuses form the wider social world in which abortion takes place. One American abortion
provider emphasized that safe access to abortion “is a reflection of our society’s values…
egalitarianism and freedom in general” (Erdreich 2013: 224).
Questions of Personhood
The concept of personhood is highly visible amidst the contention about abortion, and the
patient’s experience is no exception. Generally speaking, some consider the entrance to the
biomedical sphere an instance wherein a person’s identity is modified. Erving Goffman
postulates that patients are depersonalized when they enter a medical institute, because it is
necessary for them to put aside their normal identity and adopt the specific role of the patient –
complete with normative behaviours, attire, and responses – for the overall medical structure to
Hubbs – A Contentious Practice 7
function (Gambino 2013: 53). While this idea has been criticized for its reifying and fatalistic
tone (Gambino 2013: 53), it eloquently highlights the discomfort people may feel when they
enter a clinic and essentially grant strangers access to their body. This does not mean that the
patient’s constitution as a person is drastically changed, but rather that her personhood has the
potential to become exaggeratedly context-dependant.
It is crucial to note that not only are patients treated in a standardized way in
biomedicine, but that these standards do not always reflect what the average American considers
empirical knowledge. How a patient is treated by doctors is often determined by the legal
system, and increasingly by politicians (Joffe 2009: 71). The medical standards for abortion vary
from state to state, yet some areas – such as Texas – have introduced so many abortion
regulations that many patients are unable to receive the medical procedure they feel they are
entitled to (Erdreich 2013: 88). In addition to this, how medical experts are permitted to discuss
abortion with a patient may be limited because of the ideological rhetoric required, such as South
Dakota’s mandate that an abortion cannot occur until a woman’s doctor stresses she is
“terminating the life of a whole, separate, unique, living human being” (Joffe 2009: 3). Such
statements confer to the patient that her abortion casts her in a negative light, something which
undoubtedly affects her view of the procedure. While the medical sphere and the legal system
which regulates it are by no means completely hegemonic, they do play a strong role in the
patient’s subjective medical experience.
Much of how the average abortion recipient’s personhood is constituted, in terms of how
the social world views her and how she views herself, is also informed by social opinion. Talcott
Parsons claims the individualistic Americans are more concerned with a patient’s inability to fill
her social role rather than with her suffering, and the patient is expected to deal with her medical
Hubbs – A Contentious Practice 8
issues independently (1963: 23). The experience of suffering itself is a social product (Baer,
Singer, and Susser 2003: 7), which suggests that some of the emotions an abortion recipient feels
may be encouraged by the social world she occupies. Since diagnosis “bears heavily on the kind
of person one is taken to be, both in and out of the clinic” (Buchbinder 2011: 458), the way a
person’s medical procedure is viewed can result in the discourse that “certain types of people are
seen as more deserving of treatment” (Buchbinder 2011: 459). Stigma, a situation in which a
person cannot achieve “full social acceptance” (Joffe 2009:3), is frequently associated with the
abortion recipient. Goffman’s view of social stigma is that those who bear the brunt of it develop
“a spoiled identity”, in that the stigma continues to define the stigmatized socially even after
whatever situation encouraged it is over (Joffe 2009: 3). An abortion recipient may face direct
stigmatization from others; antiabortionists sometimes cluster around clinics to see who enters,
seeking to “out” recipients to their communities (Joffe 2009: 116), and many who picket
abortion clinics protest that the procedure can be equated with genocide (Erdreich 2013: 178).
When an American woman considers an abortion, she is aware that her actions are
politically and socially charged no matter what she ultimately decides. Even those who undergo
the procedure with no regrets sometimes state they should feel guilty, because that is what they
consider the normative response (Joffe 2009: 136). The rhetoric that abortion is selfish and
immoral, while commonly found within groups who oppose it, is noted by providers to also be a
dominant mentality among abortion recipients (Joffe 2009: 137). This becomes problematic
because patients may feel stigmatized even in situations where nobody but clinic staff is aware of
their procedure (Erdreich 2013: 88). While Americans say everyone has the right to personal
integrity (Borgmann and Weiss 2006: 24), in practice it seems that many are unsure how this
concept applies to medical issues. Meanwhile, even when demoralizing tactics on the part of
Hubbs – A Contentious Practice 9
government and society do not work, the patient may still internalize cultural messages about
themselves and take on stigma regardless of how they perceive their supposed medical rights
(Joffe 2009: 114).
More prevalent than the ways in which the patient’s identity is constructed is one of the
most apparent themes in abortion discourse: the question of whether the being in the womb is a
person. This often boils down to when people consider life to begin, but there may not be any
real consensus in this regard. Many Americans “understand death as an unambiguous, easily
definable point of no return” (Lock 2002: 4), and therefore search for a similarly definable
moment for the beginning of human life. A common perception in the medical industry is that
human life is located in the brain, and thus, so is personhood (Lock 2002: 207). Proponents of
this idea point to the start of a fetus’s “complex brain activity” as the moment it is transformed to
a person, which means a first-trimester and perhaps second-trimester being in the womb does not
yet have full personhood and can be morally aborted (Easterbrook 2006: 36). What a woman
aborts in early pregnancy can be medically considered “pre-human” despite any social
construction to the contrary, and some stress “we must not confuse potentiality with actuality”
(Peikoff 2006: 32). Others insist that the being in the womb is a person in its own right from the
beginning, since personhood is argued to be a process rather than an event (Dougherty 2006:
290). Such thinkers say nobody becomes a fully-formed person overnight, and the only reason
one would consider the fetus an exception is due to “personal convenience” (Dougherty 2006:
30). What is important is not whether the being in the womb really is a person, but rather how
social groups construct its personhood. A Pan-American consensus on the matter is likely not
possible because even supposedly empirical perceptions of life are subjective, and “can never be
Hubbs – A Contentious Practice 10
entirely divorced from culture” (Lock 2002: 12). Americans’ “long-term ideological struggle”
over the fetus will likely persist (Petchesky 1997: 136).
Technological innovations have a significant impact on the way Americans construct
fetal personhood. While biomedical experts claim the being in the womb is neither “the perfect
parasite” nor perfectly part of the mother (Allen and Wiley 2013: 121), medical advances have
encouraged many to consider the fetus “a patient in its own right” (Joffe 2009: 8). This idea is
perpetuated by the American emphasis on the volume of tests and technology as a measure for
quality care (Payer 1996: 133). Despite the idea that personhood begins with brain activity,
dominant practices like ultrasounds have strengthened “the idea that the fetus’s identity is
separate and autonomous from the mother” (Petchesky 1997: 139). These ultrasound “panoptics
of the womb” sometimes result in a woman feeling reduced to a spectator of her own pregnancy
(Petchesky 1997: 141), and that the being inside of her is considered a more important person
than she is. The way ultrasounds are used in connection to abortion heightens this process.
Visual images of the fetus are often used in antiabortion campaigns, images wherein the woman,
her doctor, and the clinic itself are generally excluded (Taylor 1998: 37, 38). The way a woman
perceives an ultrasound is often dependent on whether or not she wants to be pregnant
(Petchesky 1997: 144), yet the concept of “bonding” has arisen among the public to rationalize
practices like mandatory ultrasound viewings (Taylor 1998: 23). The “bonding theory” suggests
that the mere act of viewing an ultrasound will cause a woman to become attached to the being
inside her, which will “naturally” coerce her to continue an unwanted pregnancy (Taylor 1998:
19). The American rise in popularity of the bonding theory has contributed to ultrasound images
becoming far more present in popular culture, raising the question of whether it is more
important for the mother or for the general public to “bond” with the fetus (Taylor 1998: 38).
Hubbs – A Contentious Practice 11
The increasingly diverse usage of ultrasounds for non-medical purposes, such as the 2011
Ohio court case which considered the audible heartbeats of two fetuses “testimony” against
abortion (Erdreich 2013: 117), demonstrates that “key concepts that we recognize as life, such as
personhood, cannot be measured by medical devices” (Lock 2002: 75). When a woman ardently
does not want or cannot handle a pregnancy, when a doctor views the being in the womb as prehuman, and when a protester truly believes that an aborted fetus is a murdered person, does the
fetus in question possess personhood or not? A shallow response would state that personhood is
subjective and dependent on those who construct it, but this still leaves room for the American
public’s genuine confusion regarding how personhood should manifest in the highly-regulated
medical sphere.
Analysis: What about American Values?
Abortion does not occur in a vacuum. To truly grasp how Americans understand gender,
personhood, and the procedure itself, one must understand the social world this contentious
medical issue takes place in. Particularly with medicine, Americans consider themselves lacking
the all-consuming culture which drives non-pragmatic phenomena (Lock 2002: 7). While
“culture” is a rather elastic term, this perceived lack of social influence is obviously not the case.
It is, however, important that Americans view their social world as so normalized, for this may
explain why both those who support and those who oppose abortion consider their stance the
most rational. It is significant that the cultural idea of morality has shifted in the last few
decades, away from Church doctrine and towards the secular state (Verrips 2001: 190).
American people no longer trust informal institutions or the venerated individual to enact social
control, but rather want the government to police their moral issues (Verrips 2001: 187). This
Hubbs – A Contentious Practice 12
mentality is perhaps why discussion of abortion so frequently involves discussion of legality, and
why nearly all involved in the dilemma call upon legislation to enforce their ideals.
Stereotypical American values discussed in terms of abortion include freedom,
individualism, family, and the community (Thompson 2004: 6). However, in recent times
“cultural consensus has been replaced by the Culture Wars” (Thompson 2004: 24). The “Culture
War” of abortion is not confined to the medical sphere, but affects and is affected by many other
aspects of American life. It has been argued that abortion demonstrates the incompatibility of
privacy and morality (Latimer and Schwarz 2012: 145), concepts which figure greatly in how
people understand the procedure. The primary issue for American people may be that these
values are not the solid structures they think they are, but are mobilized in different ways
depending on context and those involved. Privacy likely will not mean the same thing in the
doctor’s office as it does on the sidewalk outside, and morals are fluid at best. Perhaps most
strikingly, it has been said that abortion taps “the vast store of sexual guilt and anxiety that lies
just below the society’s veneer of sexual liberalism” (Joffe 2009: 7). While abortion is a highly
contentious issue, it is juxtaposed with the fact that young Americans do not receive what the
medical system considers comprehensive sexual education (Darney and Steward 2006: 55). For
those who receive the procedure as well as those who oppose it, abortion has become associated
with “sexual irresponsibility and moral degradation” (Crandall 2006: 66), yet this does not
appear to be coupled with what all Americans consider a practical alternative.
The medical sphere abortion takes place in is a site for cultural reproduction. The medical
system reflects certain American ideals back to those who enter it, such as individualism,
emotional minimalism, and self-reliance (Baer, Singer, and Susser 2003: 12); yet, the issue of
abortion may seem to contradict these standards. While Parsons claims the idealization of small-
Hubbs – A Contentious Practice 13
town community was what formed the privatized medical model known today (Parsons 1963:
21), many have become concerned that the “personal touch” is gradually being edged out by
more science-based practices (Allen and Wiley 2013: 51). While people do enter the medical
sphere by their own volition, the concept of medical hegemony – “the process by which capitalist
assumptions, concepts, and values come to permeate medical diagnosis and treatment” (Baer,
Singer, and Susser 2003: 14) – can be applied to the American model. People are undoubtedly
aware that their complex medical system has created a host of factors which affect their overall
experience (Parsons 1963: 28). Due to this, some may feel that their system no longer includes
the care they had traditionally expected, and “there is increasing suspicion and distrust among
the public of what physicians and policy experts really value” (Kleinman 2011: 805). It is in this
social climate that pregnancy has been medicalized, the fetus commodified, and abortion
marginalized from the rest of medicine (Allen and Wiley 2013: 49).
Abortion does not encourage this level of controversy elsewhere in the so-called Western
world. The procedure has been normalized in Japan with little contention, but part of this may be
due to the “traditional” belief that an aborted fetus’s soul is easily reborn (Ohnuki-Tierney 1984:
80), a concept which America’s Judeo-Christian roots would likely not include. On the flip-side,
the Japanese experience an ongoing ethical debate over brain-death, something which many
Americans take for granted as medically sound (Lock 2002: 45). While this is certainly not
conclusive, it may be significant that the Japanese place value on personhood once someone has
“entered the network of human relationships” (Ohnuki-Tierney 1984: 81), a striking foil to
American individualism. This suggests that the biomedical ideal of separating fact and emotion
is illusionary (Lock 2002: 34). Medical procedures are intimately informed by the social world.
Hubbs – A Contentious Practice 14
This leaves the question of why abortion prevails as such a contentious practice in the
United States. There is no easy answer to this, precisely because those involved have such a wide
range of individual morals, values, and systems of belief. It is possible that this variation is
where a large portion of the contention arises from. Micaela di Leonardo explains, “on the one
hand, we’re all Americans, we all watch television, we all know who Madonna is… on the other
hand, we live in different regions of a large, sprawling country” (di Leonardo 1997: 63). The
idea that abortion can be reified to fit universal medical standards seems to be a prominent
American myth, but one which is made salient through the ongoing debate.
Abortion contention demonstrates that American people struggle to reconcile individual
and perceived community ideals, with an equally pervasive emphasis on an overarching medical
industry and nation-wide values. The majority of those involved in abortion contention frame
their opinions within the medical – and by extension, legal – sphere, which demonstrates that
many want their existing system to remain in place. The point of conflict is that they also want
this system to reflect their particular morals (Latimer and Schwarz 2012: 137). This may be
because “great potential exists for dehumanization” when personhood becomes replaced with
medical charts (Lock 2002: 63), or that “agency panic” can be a by-product of a standardized
system in an individualized society (Thompson 2004: 5). I argue that, when people mobilize their
particular opinions about abortion, they are asserting their agency in a system they understand as
hegemonic. Mark Nichter’s discussion of Joan, a frequent medical patient who protested being
treated as a medical “case” through the somatization of her problems, eloquently highlights this
idea (Nichter 1998: 344). Many Americans, like Nichter concludes Joan did, ultimately embrace
their society’s version of biomedicine and choose to enact their protests in such a way that does
not greatly change the overall system (1998: 345). Abortion may simply be the most currently
Hubbs – A Contentious Practice 15
visible example of this process, a topical debate informed by a variety of concepts with fluid
definitions. Abortion contention shows that, despite issues they may have with topics within it,
Americans accept their medical system, yet still desire medicine to be practiced in a way they
feel is tailored to them (Nichter 1998: 345).
I have long struggled to reconcile my desire for unbiased relativism with my personal
beliefs. My conviction that abortion is morally acceptable likely informs this discussion of
abortion contention as something which others understand from a similarly conflicted
perspective. For anyone involved, abortion is experienced in highly subjective terms, and “no
amount of rational debate… can provide conclusive answers to these intensely emotional
questions” (Lock 2002: 26). Regardless, this paper has attempted to illuminate certain aspects of
abortion which may contribute to its contentious status. The social circumstances, the multivocal
themes of gender and personhood, and the medical system itself become entangled with so-called
American values. This paper has argued that it is these interwoven factors from which abortion
contention arises. This contention manifests the way it does because American people are
attempting to retain ideological agency in a medical sphere they value, but perhaps fear being
devalued within. I postulate that so long as the American medical system remains a large, highlystandardized entity that attempts to regulate people from different communities and regions,
some form of public medical contention will continue to exist even if the abortion debate
subsides. It is perhaps not the procedure itself that is important, but rather the discourse
American people have built around it.
Hubbs – A Contentious Practice 16
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