Expertise and Scottish Abortion Practice: Understanding Healthcare Professionals’ Accounts
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Expertise and Scottish Abortion Practice: Understanding Healthcare Professionals’ Accounts Siân M. Beynon-Jones PhD, Science and Technology Studies The University of Edinburgh 2009 Abstract Current UK abortion law has been subjected to extensive feminist critique because of the relationships that it constructs between healthcare professionals (HCPs) and women with unwanted pregnancies. The law allows HCPs to opt out of abortion provision on the grounds of conscience, implying that it is not something which they have an automatic duty to provide to their patients. It also gives doctors the authority to decide whether an abortion can legally take place, thus suggesting that women’s reproductive decisions should be regulated by medical ‘experts’. However, little is known about how HCPs who are involved in twenty-first century UK abortion provision define their relationships with their patients in practice. My thesis makes an important empirical contribution by responding to this gap in the literature and exploring the subjectivities which these HCPs construct for themselves and their pregnant patients. I address this issue by analysing Scottish HCPs’ interview accounts of their involvement in (or conscientious objection to) abortion provision, using conceptual tools provided by Science and Technology Studies (STS) and feminist theory. I begin by utilising HCPs’ discussions of the practice of ‘conscientious objection’ as a means of exploring how they define the boundaries of their professional responsibilities for abortion provision. I then move on to address HCPs’ accounts of their interactions with women requesting abortion, and analyse how they define legitimate or ‘expert’ knowledge in this context. A key conclusion of the thesis is that HCPs do concede some authority to women with unwanted pregnancies; this is revealed by their reluctance to suggest that they have the right to prevent individual women from accessing abortion. At the same time, I argue that the legitimacy granted to pregnant women by HCPs is limited. My analysis reveals that, in constructing knowledge claims about the use of abortion, HCPs co-produce troubling definitions of femininity, socio-economic class, age and ethnicity. I develop a strong critique of this process, and highlight its potential implications for women’s experiences in the abortion clinic. However, I conclude that this situation cannot be addressed by simply attacking the practices of HCPs as individuals. Rather, it is necessary to understand and critique the limitations of the discursive context in which HCPs are working, because this context shapes the subjectivities available to pregnant women and HCPs. Declaration of Originality of Submitted Work In accordance with University regulations, I hereby declare that: 1. This thesis has been composed solely by myself; 2. It is entirely my own work; and 3. It has not been submitted in part or whole for any other degree or personal qualification Signed: Date: Acknowledgements This research would not have been possible without funding from the Economic and Social Research Council, as well as the support that I have received from staff and students at ISSTI. In particular, I would like to thank my supervisors, Sarah Parry and Nina Hallowell for their many insightful comments, as well as their endless (and much-needed) encouragement throughout my doctoral research and beyond. Special thanks also goes to my office-mates, past and present (including Isabel and James, who are honorary members of room 1.05). Over the past four years you have all put up with a great deal of singing, dancing and under-the-desk sleeping, as well as helping me out of many theoretical and emotional quagmires. I would also like to thank my family, in particular my mum, who bravely proof-read the final draft of the thesis for me and lived to tell the tale. Finally, I am enormously grateful to all the healthcare professionals who participated in this study. Although I may be critical of some of their ‘discourse’ in the analysis that follows, I have not forgotten that they were kind enough to take time out from their extremely busy days to talk to a stranger about a highly sensitive aspect of their work. Table of Contents Chapter One: Why healthcare professionals and abortion, now?........... 4 1.1 Introduction........................................................................................................ 4 1.2 A recent history of UK abortion law.................................................................. 5 1.2.1 The protection of medical discretion over abortion decision-making ........ 6 1.2.2 The definition of the fetus......................................................................... 11 1.3 Why focus on healthcare professionals?.......................................................... 18 1.4 Thesis outline ................................................................................................... 23 1.5 Negotiating a terminological minefield ........................................................... 25 Chapter Two: Theoretical positionings.................................................... 28 2.1 Introduction...................................................................................................... 28 2.2 STS and the deconstruction of scientific authority .......................................... 28 2.2.1 The politics of expertise............................................................................ 28 2.2.2 A new approach to expertise? ................................................................... 32 2.2.3 Expert-lay asymmetries?........................................................................... 33 2.3 Medical practice as the (re)production of gender? Insights from feminist STS ................................................................................................................................ 35 2.3.1 Shared understandings .............................................................................. 36 2.3.2 Productive tensions ................................................................................... 42 2.4 Making space for materiality ........................................................................... 50 2.5 Conclusion ....................................................................................................... 55 Chapter Three: Methodology .................................................................... 57 3.1 Introduction...................................................................................................... 57 3.2 Choosing interviews as a research method ...................................................... 57 3.3 Defining and recruiting a sample of HCPs ...................................................... 60 3.3.1 Why Scotland? .......................................................................................... 62 3.3.2 Which HCPs?............................................................................................ 64 Figure 1: Key abortion pathways in central Scotland ........................................ 66 3.4 Data analysis .................................................................................................... 72 3.4.1 Discourse analysis, in theory..................................................................... 72 3.4.2 DA in practice 1: Generating and analysing interview transcripts ........... 80 3.4.3 DA in practice 2: Beyond transcripts........................................................ 84 3.5 Obtaining ethical ‘clearance’ ........................................................................... 86 3.6 Engaging in reflexivity?................................................................................... 88 Intermission: Methods of abortion .............................................. 94 Medical abortion ......................................................................................... 94 Surgical abortion....................................................................................... 97 Chapter Four: “It’s like being a chest physician and saying you don’t do asthma”- Conscientious objection and the boundaries of professional responsibility for abortion......................................................................... 99 4.1 Introduction...................................................................................................... 99 4.2 Legitimating conscientious objection ............................................................ 102 1 4.2.1 The Othering of ‘genuine’ objections ..................................................... 103 4.2.2 Opting out: Enacting morality................................................................. 105 4.3 An ‘impossible’ option................................................................................... 112 4.4 The boundaries of ‘conscience’ ..................................................................... 115 4.5 Conclusion ..................................................................................................... 123 Chapter Five: Knowing women? Accounting for the decision to terminate a pregnancy............................................................................. 127 5.1 Introduction.................................................................................................... 127 5.2 Demarcating legitimacy: Denying responsibility........................................... 131 5.2.1 “Discourses of ignorance”....................................................................... 131