From Reproductive Rights to Responsibilization: Fashioning Liberal Subjects in Mexico City's New Public Sector Abortion Program

Dirty Work in Medicine: Understanding U.S. Physicians' Agency in Contested Medical Practices

Physicians who participate in abortion and medically assisted death in the United States work at the margins of institutionalized medicine. What motivates them to engage in such "dirty work"? This article uses ethnographic materials from two recent projects to analyze physicians' roles as gatekeepers to contested medical services. Abortion and medically assisted death share many similarities: They are both deeply stigmatized practices that are heavily restricted in many U.S. jurisdictions, and which many physicians are reluctant to participate in for moral, religious, or professional reasons. They both also confer medicine with the power to govern life and death decisions through the apparatus of state law. However, state laws operate quite differently on physicians in these two cases, with different outcomes. This comparative analysis demonstrates how dirty work in medicine enrolls the agency and subjectivity of physicians in distinctive ways that may be eclipsed by totalizing biopolitical frameworks. [abortion, medical aid in dying, physicians, agency, biopolitics, United States].

Intimacy, Anonymity, and "Care with Nothing in the Way" on an Abortion Hotline

This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call "care with nothing in the way." By operating outside the State's scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments and that distances them from the direct harm they see caused by the political, financial, and bureaucratic constraints of their clinical work. By delineating the structure of this new regime of care, these providers call into question the notion of the "good doctor." They radically re-frame widely shared assumptions about the tenets of the ideal patient-doctor relationship and engender a new form of intimacy-one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of "care with nothing in the way" are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.

Collective Care Amid US Individualism Through COVID-19 Vaccine Trial Participation

We analyze interviews with participants in a COVID-19 vaccine trial to show how Americans navigate conflicting discourses of individual rights and collective responsibility by using individual health behavior to care for others. We argue that interviewees drew on ideologies of "collective biology" - understanding themselves as parts of bio-socially interrelated groups affected by any member's behavior - to hope their participation would aid collectives cohering around kinship, sex, age, race and ethnicity. Benefits (protecting family, representing one's group in vaccine development and modeling vaccine acceptance) existed alongside drawbacks (strife, reifying groups), to illustrate the ambivalence of caregiving amid inequality.

Necessary but not sufficient: a scoping review of legal accountability for sexual and reproductive health in low-income and middle-income countries

Background

This paper is a scoping review of the impact of legal accountability efforts for sexual and reproductive health and rights (SRHR), exploring the links between legal accountability strategies and changes in the desired SRHR outcomes.

Methods

We defined legal accountability as use of the judicial system following state failure to respect, protect or fulfil SRHR as enshrined in national law, as well as individuals’ or the state’s use of criminal law mechanisms to prevent unwanted behaviour and to provide remedy. We undertook a keyword search in PubMed, Scopus and LexisNexis and then consulted a group of experts to provide guidance regarding further peer-reviewed and grey literature, yielding a total of 191 articles.

Results

The majority of the empirical, peer-reviewed articles identified were regarding abortion law and abortion care availability, followed by violence against women. Most of these articles explore the gaps between law and practice. We identified seven key factors that shape the efficacy of legal accountability efforts, including the ways a law or court decision is formulated, access to courts, the (dis)advantages of criminal law in the given context, cultural norms, politics, state capacity and resources and the potential for further litigation. Many articles explained that use of the judiciary may be necessary to effect change and that the act of claiming rights can empower, but that legal avenues for change can be imperfect tools for justice.

Conclusions

Legal accountability can be effective as part of a broader, long-term strategy, with due attention to context.

'If I don't take care of myself, who will?' Self-caring subjects in Oaxaca's mutual-aid groups

Based on seven months of ethnographic fieldwork in two urban health centres in Oaxaca City, Mexico, this paper analyses the ways in which underprivileged middle-aged and older female patients experience and transform grupos de ayuda mutua (GAMs), or mutual-aid groups, a public health programme aimed at improving chronic patients' adherence to their biomedical treatments. GAMs work as 'technologies of the self' within the context of the Mexican neoliberal regime and patients are urged to be self-responsible. GAM members regard such urging favourably and act according to their broader understandings of life, which they see as a lucha (struggle) that requires cuidarse (a polysemic verb alluding to self-care for self-preservation) and hard work in a structurally unequal place characterised by precarity and social unrest. This seemingly rugged individualism is converted into microlevel collaboration through culturally distinctive Oaxacan practices of mutual help. By exploring the playful ways these women participate in GAMs, this paper shows how biomedical settings can be repurposed as spaces of socialisation and wellbeing for older women living in vulnerable conditions.

Doctors as moral pioneers: Negotiated boundaries of assisted conception in Colombia

New biotechnologies such as assisted conception are socially embedded artefacts that raise context-specific ethical, moral and social anxieties. In contexts where the regulations of these profitable developments are limited or ambiguous, and competition between private facilities is high, individual doctors become morally and socially responsible for determining the parameters of administering such therapies. Ethnographic research at two private fertility centres in Colombia reveals that doctors do not determine boundaries based on monetary gain but rather personal morals, social norms and professional obligations. Medical professionals hold diverse perceptions of assisted conception, and often struggle to make decisions regarding who should access such therapies, who are ideal gamete donors and the fate of extra embryos. The complexity of these perceptions applied in a context of limited regulation and the competition of private medicine impacts the praxis of assisted conception. As doctors determine the boundaries of their practice they not only create variation between clinical practices, but also make moral decisions regarding who should be parents, how families should be formed and the significance of embryos. Thus, in navigating their everyday practices, doctors also shape the social world.

"Morir En Camino": Community Narratives about Childbirth Care in Rural Chiapas

This anthropological study explores why more women in the rural Sierra Madre region of Chiapas, Mexico birth at home rather than at the hospital. Between January and May of 2014, the primary investigator conducted in-depth, semi-structured interviews with twenty-six interlocutors: six parteras (home birth attendants), nine pregnant women, four mothers, four healthcare providers, and three local government leaders. Participant observation occurred in the health clinic, participants' homes, and other spaces in a community with a population of 1,188 people. Drawing from narrative analysis, the findings suggest that women face structural obstacles to accessing high-quality childbirth care, which lead them to give birth at home instead of the hospital. These obstacles include financial barriers in obtaining facility-based care and poor quality of care, such as mistreatment in the facility. The study highlights the importance of centreing community narratives in healthcare programming in order to bridge the implementation gap between women in rural communities, healthcare workers, and policymakers.

Realizing Abortion Rights at the Margins of Legality in Mexico

I analyze the alternative tactics and logics of Las Fuertes, a feminist organization that has taken an "alegal" approach to realizing the human right to abortion in the conservative Mexican state of Guanajuato. Since a series of United Nations agreements throughout the 1990s enshrined reproductive rights as universal human rights, Mexican feminists have adopted the human rights platform as a lobbying tool to pressure the government to reform restrictive abortion laws. This strategy bore fruit in Mexico City, with passage of the historic 2007 abortion legalization. Las Fuertes has leveraged the human rights strategy differently - to justify the direct provision of local abortion accompaniment in a context of near-total abortion criminalization. By directly seizing abortion rights, rather than seeking to implement them through legalistic channels, Las Fuertes has effectively challenged Mexican reproductive governance in an adversarial political environment.

Lawful Sinners: Reproductive Governance and Moral Agency Around Abortion in Mexico

The Catholic Hierarchy unequivocally bans abortion, defining it as a mortal sin. In Mexico City, where the Catholic Church wields considerable political and popular power, abortion was recently decriminalized in a historic vote. Of the roughly 170,000 abortions that have been carried out in Mexico City's new public sector abortion program to date, more than 60% were among self-reported Catholic women. Drawing on eighteen months of fieldwork, including interviews with 34 Catholic patients, this article examines how Catholic women in Mexico City grapple with abortion decisions that contravene Church teachings in the context of recent abortion reform. Catholic women consistently leveraged the local cultural, economic, and legal context to morally justify their abortion decisions against church condemnation. I argue that Catholic women seeking abortion resist religious injunctions on their reproductive behavior by articulating and asserting their own moral agency grounded in the contextual dimensions of their lives. My analysis informs conversations in medical anthropology on moral decision-making around reproduction and on local dynamics of resistance to reproductive governance. Moreover, my findings speak to the deficiencies of a feminist vision focused narrowly on fertility limitation, versus an expanded framework of reproductive justice that considers as well the need for conditions of income equality and structural supports to facilitate reproduction and parenting among women who desire to keep their pregnancies.

Normal/Modern: Reconstructive Surgery in a Mexican Public Hospital

A growing corpus of anthropological scholarship demonstrates how science and medicine in Mexico are imbued by national concerns with modernization. Drawing on ethnographic research in a public hospital located in the south of Mexico City, I unpack one manifestation of this dynamic, which is the conjugation of the normal and the modern in Mexican reconstructive surgery. The aspiration toward normality underlies everyday clinic practices and relationships in this field, including why parents want surgery for their children and how doctors see their patients and their responsibilities toward them. It is also central to the professional ethic of reconstructive surgeons. I argue that the realities of health care provision in Mexico coalesced with this ethic to produce reconstructive surgeons as political subjects. They aimed to modernize craniofacial surgery in Mexico and so make the bodies of craniofacial patients normal.