Abstract
Feminist STS analyses of contemporary reproductive medicine have illustrated the proliferation of practices that position fetuses as individual subjects, and have highlighted the major implications of such practices for pregnant women. In an attempt to challenge medicine’s claims to ‘know’ the fetus, this body of literature has also demonstrated the renegotiable basis of pregnant/fetal subjectivity, using detailed empirical analyses of the practices through which particular pregnant and fetal subjects emerge in particular contexts. In this paper I contribute to this endeavour utilizing an empirical case study of an important, but neglected aspect of reproductive healthcare: the demarcation of temporal thresholds on abortion provision in the absence of diagnosed fetal abnormality. Drawing on semi-structured interviews with Scottish health professionals, I explore the discursive practices through which they demarcate ‘later’ abortion as a problematic decision. I argue that such practices are intimately dependent on particular co-constructions of temporality and pregnant/fetal subjectivity, and support this argument with reference to the counter-representations of the gestational timing of abortion that emerge from a minority of health professionals’ accounts. I suggest that, collectively, this body of data illustrates the opportunities that (re)presenting temporality would afford those engaged in attempts to foster the construction of less oppressive pregnant/fetal subjectivities. My broader aim is to illustrate the insights that feminist theorizations of pregnant/fetal subjectivity gain from explicit engagement with another important theme of contemporary STS scholarship, namely, the constitutive role played by representations of temporality in technoscientific innovation and practice.
Feminist STS analyses of contemporary reproductive medicine have highlighted the proliferation of practices that position fetuses as individual subjects whose status can be considered independently from – and prioritized over – that of pregnant subjects. 1 Such ‘fetal-centred’ (Steinberg, 1991: 179) medical practices (for example, fetal ultrasound, prenatal screening/diagnosis and fetal surgery) are a crucial site for feminist STS engagement, both because of their immediate implications for women’s reproductive experiences and because of the resources they offer to those who seek to impose legal restrictions on pregnant women in the interests of the fetuses those women carry.
This second strand of feminist concern has primarily been articulated with reference to the polarized abortion debate in the USA. However, medical representations of the fetus also occupy an increasingly prominent place in British debates about abortion. In recent years, such debates have centred almost exclusively on the issue of the upper gestational time limit – currently, 24 weeks – at which the ‘routine’ provision of the procedure (that is, performed in the absence of a diagnosis of fetal abnormality or life-threatening emergency) becomes illegal. Feminist analyses illustrate how regulatory decisions about this time limit have assumed that medical knowledge concerning the fetus can and should be used to decide when abortion becomes unacceptable. In a context where so much emphasis is placed on the significance of medical judgements about the status of the fetus, the pregnant subject involved in sustaining fetal life, as well as the broader socio-material context in which pregnancy takes place, have effectively vanished from regulatory debate (Science and Technology Subgroup, 1991; Sheldon, 1997).
As well as highlighting the consequences of reproductive medicine’s growing tendency to produce and prioritize fetal subjects, feminist STS scholarship has also challenged medicine’s claims to ‘know’ the fetus, by illustrating the situated practices through which particular pregnant/fetal subjects materialize in particular contexts. 2 For example, in her ground-breaking essay on this topic, Rosalind Petchesky illustrates that dominant visual representations of the fetus depend upon framing practices that exemplify ‘the distortion inherent in all photographic images: their tendency to slice up reality into tiny bits wrenched out of real space and time’ (Petchesky, 1987: 62). Through these practices of representation, the fetus emerges as ‘solitary, dangling in the air (or in its sac) with nothing to connect it to any life-support system but “a clearly defined umbilical cord”’ (Petchesky, 1987: 61), allowing the viewer to forget women’s involvement in pregnancy.
Petchesky’s analysis focuses primarily on the practices of spatial representation through which fetuses become constructed as individual subjects. However, in passing, she also draws attention to the fact that fetal images capture, and thus amplify the significance of, a particular moment in time. In other words, her analysis indicates that the constitution of fetal subjectivity through images is contingent upon particular practices of temporal, as well as spatial, representation. In recent years, such processes of temporal ordering have come to occupy a central place within STS theory. Several overlapping literatures have explored the constitutive role played by anticipatory visions of the future in technoscientific development and practice. Work within the sociology of expectations (for example, Borup et al., 2006; Brown et al., 2000; Selin, 2006; van Lente, 1993) has demonstrated how specific constructions of the future shape the possibilities of action during processes of technoscientific innovation, for example, the performative role that scientific entrepreneurs’ promissory claims play in attracting financial investment for research. Likewise, feminist theorizations of the practice of in vitro fertilization (for example, Franklin, 1997; Parry, 2006; Thompson, 2005) have emphasized that the actions of women undergoing invasive fertility treatments, as well as the destinies of the ex-vivo eggs/embryos produced through such interventions, are oriented with respect to (often conflicting) promissory constructions of the future.
In line with the growing significance that the politics of temporal ordering have been accorded within STS theory, feminists concerned with the constitution of pregnant/fetal subjectivity have also begun to explore temporal dimensions of this process. Particularly significant is Irma van der Ploeg’s (2001) illustration of the temporal practices involved in the production of ‘fetal patients’ upon whom it is possible for doctors to consider operating surgically in utero. Through her analysis of medical texts concerning fetal surgery, she demonstrates that this literature constructs the postnatal period as continuous with the prenatal period, rather than presenting childbirth as a site of disruption that renders these periods of time discontinuous. This facilitates a process of ‘time displacement’ (van der Ploeg, 2001: 61; emphasis in original), in which the present becomes conflated with anticipated future events. For example, medical texts regularly depict the potential future health problems of infants as affecting the fetus currently in utero. Likewise, they typically describe pregnant women as the mothers of fetal patients, implying that relationships between pregnant women and fetuses are equivalent to those between women and their infants after birth. Through such processes of ‘time displacement’, present relationships between fetal and pregnant bodies are obscured, ensuring that the interventions that fetal surgery implies for the latter are under-emphasized (van der Ploeg, 2001).
Another temporal practice central to the construction of fetuses as patients that van der Ploeg identifies is the way medical texts constitute the temporality of fetal development as uniquely significant in comparison to the rest of the human life course. In illustrating this practice, she mobilizes Franklin’s (1991) insights concerning the way in which medical discourses of fetal development position the embryo/fetus as an entity that contains the biological potential to become a human being from the moment of conception onwards. As Franklin notes, this ‘teleological construction of the fetus opens up the possibility of identifying with its developmental personhood, its entire imagined life course and its future as a human adult’ (Franklin, 1991: 200). Applying these insights, van der Ploeg argues that the ‘teleological construction of the fetus’ shapes medical assessments of the potential costs and benefits of fetal surgery, because ‘an intervention during pregnancy is never just the mending of a dysfunction or pathology in the present, but is carrying the weight of mending an entire future lifetime’ (van der Ploeg, 2001: 65).
While van der Ploeg’s and Franklin’s analyses offer the most explicit engagement with the co-construction of temporality and pregnant/fetal subjectivity to date, the significance of this analytical point is also implicit within feminist analyses of the medical management of childbirth. Several authors have drawn attention to the way contemporary obstetrics imposes measures that normalize the duration of pregnancy and labour (Martin, 1989; Simonds, 2002), as well as the tempo of fetal heartbeats (Cartwright, 1998). These temporal measurements shape the possibilities of pregnant/fetal subjectivity by pathologizing pregnant/fetal bodies that deviate from obstetrical time schedules and by legitimating medical interventions into such bodies.
Building upon such insights, the present paper illustrates the fruitfulness of moving considerations of temporality to the centre of feminist engagement with the production of pregnant/fetal subjects. It does so through a case study of an under-explored aspect of reproductive healthcare: the negotiation of temporal thresholds on abortion provision in the UK (in the absence of diagnosed fetal abnormality). As outlined above, UK regulatory discourse concerning the gestational timing of abortion has been subjected to considerable feminist scrutiny. However, surprisingly little is known about how the meaning of gestational time is constructed within contemporary UK abortion practice. In the analysis that follows, I explore the discursive practices through which Scottish health professionals sustain particular accounts of the meaning of the gestational timing of abortion. I illustrate that the configurations of pregnant/fetal subjectivity that emerge as a result of these practices are dependent on particular and contestable representations of temporality. In doing so, my broader aim is to highlight opportunities that the (re)presentation of temporality might afford feminist theorists seeking to foster practices that generate less oppressive pregnant/fetal subjectivities.
While pursuing this aim, however, I endeavour to circumnavigate the problem that Meredith Michaels (1999) suggests is often central to feminist analyses of the production of fetal subjects: namely, the utilization of the tools of constructivist social theory in attempts to render fetal subjects ‘less real’ than pregnant subjects. As Michaels rightly notes, this position is epistemologically untenable because, if it is accepted that subjectivity is an emergent, context-specific phenomenon (Casper, 1994, 1998), then both fetuses and pregnant women must be understood symmetrically in terms of this context-specificity; the latter cannot be treated as any less ‘constructed’ than the former. Moreover, as Lynn Marie Morgan highlights, blanket dismissals of the (always context-specific) subjectivity of fetuses are increasingly at odds with the experiences of many women who participate actively in the production of fetal subjects ‘through their avid consumption of infertility treatments, amniocentesis, ultrasound, and in-utero video services’ (Morgan, 1996: 59–60). Recognizing the importance of both of these arguments, I treat all forms of subjectivity symmetrically – as contingent, yet vitally important, accomplishments:
These ontologically confusing bodies, and the practices that produce specific embodiment, are what we have to address, not the false problem of disembodiment. Whose and which bodies – human and non-human, silicon based and carbon based – are at stake, and how, in our technoscientific dramas of origin? (Haraway, 1997: 186, emphasis in original)
Necessarily, within the framework of such an analysis, my own practices as a feminist STS researcher are equally implicated in the production of pregnant/fetal subjects. I focus on this issue in the conclusion to this paper, where I reflect upon the ‘kind of world’ (Morgan, 1996: 63) that I have supported through my decision to study health professionals’ accounts of gestational time and abortion.
A brief history of a medicalized legal framework
As the following analysis will illustrate, Scottish health professionals participate in the reproduction of dominant UK discourses concerning the gestational timing of abortion. At the same time, however, their accounts are also structured by these discourses, making it vital to preface my analysis with a summary of the key features of the contemporary regulation and public discussion of abortion in the UK.
An important aspect of the UK’s current abortion law is that it depicts the decision to terminate a pregnancy as one that depends on the judgement of two doctors, rather than that of the pregnant woman in question. This construction of abortion decision-making was introduced in the 1967 Abortion Act, which decriminalized the practice by specifying grounds on which two doctors could decide when an abortion would be necessary. Aside from minor modifications to these grounds (discussed below), the Abortion Act remains essentially unchanged and continues to regulate the provision of the procedure in the UK. 3
In decriminalizing abortion, the 1967 Abortion Act stated explicitly that it did not ‘affect the provisions of the Infant Life (Preservation) Act 1929 (protecting the life of the viable foetus)’ (The Abortion Act, 1967: Section 5, Subsection 1). The Infant Life (Preservation) Act 4 was introduced when abortion was still illegal in the UK, and was intended to close a loophole in existing abortion legislation that had allowed a fetus to be legally destroyed during birth (Brookes, 1988; Sheldon, 1997). It achieved this by creating a new (and more serious) offence of ‘child destruction’, to be applied to the abortion of fetuses capable of being born alive. On the basis of medical consensus, this capability was presumed to be present from 28 weeks’ gestation onwards (Brookes, 1988; Fyfe, 1991; Sheldon, 1997).
Throughout the 1970s and 1980s, this effective upper time limit on the provision of abortion came under attack in Parliament through a series of Private Members’ Bills (Keown, 1988; Newburn, 1992) that sought to reduce the gestational period during which the procedure could be provided. While none of these Bills resulted in legislative change, the Science and Technology Subgroup (1991) cite David Alton’s 1987 Abortion (Amendment) Bill as having a major impact upon the framework within which abortion is discussed in the UK. The Alton campaign’s principal argument was that medical advances in the care of premature neonates had reduced the point of fetal viability far below the 28 week limit contained within the 1929 Infant Life (Preservation) Act, and that this threshold was more accurately placed at 18 weeks. The significance that the Science and Technology Subgroup attribute to this campaign stems from its striking development in anti-abortion rhetoric that was becoming increasingly visible throughout the 1980s: the eschewal of religious discourse in favour of medical discourse concerning the ‘individuality’ of the fetus. As Franklin (1991) argues, this phenomenon must in turn be understood in relation to the development in medical practice described in the introduction to this paper, namely, a shift in attention away from the pregnant subject and towards the embryo/fetus.
Another critical point revealed by the Science and Technology Subgroup’s analysis of the Alton Bill is that MPs who opposed it actually accepted, and perpetuated, Alton’s ‘fetal-centred’ (Steinberg, 1991: 179) framing of the debate. Rather than introducing alternative discourses concerning the rights of women, those defending women’s access to abortion simply suggested that 18 weeks was an unrealistic estimate of the time of fetal viability, which the medical profession in the late 1980s placed at 24 weeks. In doing so, they accepted that there was a category of ‘late’ abortion which was more problematic than ‘early’ abortion, and that the medical profession was best placed to determine the point in time at which abortion became an illegitimate course of action (Steinberg, 1991).
Although the Alton Bill was ultimately unsuccessful, its legacy was an abortion debate in which both sides treated the meaning of abortion as an object of medical knowledge (Sheldon, 1997). This assumption came to underpin the amendments to the 1967 Abortion Act subsequently passed as part of the 1990 Human Fertilisation and Embryology (HFE) Act. To reflect medical consensus concerning the threshold at which it was possible to keep a neonate alive, this legislation imposed a 24-week upper time limit upon the clause under which most abortions are conducted in the UK (Sheldon, 1997). The amended clause states that an abortion becomes legal when ‘[t]wo registered medical practitioners are of the opinion, formed in good faith’:
that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family. (The Abortion Act, 1967: Section 1, Subsection 1, Clause a; as amended by the Human Fertilisation and Embryology Act, 1990)
However, the 1990 HFE Act also removed any time limit on abortion in cases where doctors deem a woman’s health to be at risk of ‘grave permanent injury’ (Clause b), where her life is at risk from the continuation of the pregnancy (Clause c), or in situations where it is judged ‘that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped’ (Clause d). In recent years, this final clause has generated considerable legal and media controversy, with disability rights activists arguing that it represents discrimination against fetuses diagnosed with impairments and devalues disabled lives (for a review of this controversy, see Statham et al., 2006).
Entering the clinic
As noted in the introduction, while feminist studies have addressed the discursive framing of gestational time within contemporary UK abortion law and debate, little is known about how its meaning becomes constituted within the abortion clinic. Accordingly, the following analysis moves the discussion into this new setting, drawing on semi-structured interviews I conducted with Scottish health professionals between 2007 and 2008. Prior to the recruitment of interview participants, the study was reviewed in accordance with the University of Edinburgh’s School of Social and Political Studies research ethics audit process. Advice was sought from my local NHS Research Ethics Committee who stated in writing that the study did not need to be subjected to NHS Research Ethics Committee review.
In contrast to England and Wales, where a large number of abortions are conducted by the independent sector, over 99% of the abortions performed annually in Scotland are conducted on NHS premises (Information and Statistics Division Scotland, 2009). The absence of an independent sector in Scotland means that, in order to access abortion, women must be referred either by a general practitioner (GP) or by a community sexual health clinic to the appropriate NHS hospital service (typically, a gynaecology department). To reflect this system of provision, I conducted interviews with GPs (nine men and eleven women), obstetrician/gynaecologists (six men and six women) and gynaecology nurses (ten women). Three of the obstetrician/gynaecologists and one of the gynaecology nurses worked in community sexual health clinics. The remainder worked in hospital clinics where, unless they held a conscientious objection to abortion, 5 they were involved in interviewing/counselling patients and/or in carrying out the procedure. In recruiting interviewees I adopted a purposive sampling strategy to ensure the inclusion of a range of different geographic locations and clinical sites.
An abortion can be performed using either medical (that is, drug-induced) or surgical procedures, the choice of which (according to interviewees) is linked to their varying efficacy at different periods of gestation. Between 9 and 13 weeks’ gestation, 6 Scottish practice is to employ the surgical method, which involves the use of a suction curette to empty the uterus under general anaesthesia; this is conducted by obstetrician/gynaecologists with the assistance of nurses. For a pregnancy of between 6 and 9 weeks’ gestation, or beyond 13 weeks’ gestation, the medical (drug-induced) method is used. This method involves two stages, throughout which the patient is conscious. The first stage is the administration of oral mifepristone, which blocks the action of the hormone progesterone and causes the lining of the uterus to start disintegrating and the cervix to become softer. Approximately 48 hours after taking mifepristone, patients then return to the hospital, where they are given misoprostol. This drug is a prostaglandin, which induces cervical dilation and uterine contraction, helping the pregnancy tissue and fetus to be expelled through the vagina. In most hospitals, women undergoing first trimester (less than 12 weeks’ gestation) medical abortion remain at the clinic for observation and assistance for approximately 6 hours after the administration of misoprostol, within which time they will usually expel the fetus. Second trimester medical abortions require multiple doses of misoprostol and typically involve lengthier hospitalization than first trimester abortions – often involving an overnight stay. Unless an emergency situation arises, all medical (non-surgical) abortion work is conducted by nurses (under the supervision of hospital doctors).
Demarcating ‘later’ abortion
Although UK law positions doctors, rather than pregnant women, as the experts who must judge whether an abortion is necessary, the popular portrayal of abortion provision in the UK is that, within the legal time limits, the procedure is available to any woman who has decided that she does not want to continue with her pregnancy (Lee, 2003). Echoing this portrayal, most of the health professionals I interviewed emphasized their distance from the decision-making process, arguing that it is their patients who are best placed to decide whether an abortion should take place. Nevertheless, in almost all cases they described important exceptions to this rule, occasions when it automatically becomes acceptable for them to assess, question and potentially decline an abortion request. The exception that emerged the most frequently was the case of a request for a ‘later’ abortion.
In some cases, health professionals talked about the significance of the gestational timing of abortion in relatively ambiguous terms, arguing that the later in pregnancy that a request for abortion is made, the more ‘reluctant’ they are to allow a woman to undergo it, and the more ‘carefully’ they would discuss this course of action. In other cases, they stated explicitly that length of gestation directly affects a woman’s access to abortion services. For example, at each different hospital where I conducted interviews I was informed of a different gestational time limit beyond which a woman would be told that she could not access services locally, and that she would either have to carry her pregnancy to term or travel to an independent abortion provider in England. 7 These limits ranged from 15 to 20 weeks’ gestation, all of which are lower than the 24-week threshold specified by UK abortion law. 8
Clearly, Scottish health professionals’ demarcations of ‘later’ abortion as problematic (and in some cases, unacceptable) have potentially major implications for women who request the procedure. However, in the analysis that follows, I argue that health professionals’ problematizations of later abortion are dependent precisely on representations of temporality that cause these future implications to disappear from the ‘frame’ of abortion decision-making. I support this argument with reference to the accounts given by interviewees who questioned their colleagues’ construction of boundaries between ‘earlier’ and ‘later’ abortion, and who challenged the understandings of temporality upon which these demarcation practices depend. Furthermore, I suggest that these counter-examples illustrate how abortion provision might be practiced in ways that have less oppressive implications for pregnant women.
Prioritizing (short-term future) fetal subjects
Considering the focus placed upon the fetus within contemporary medical discourse about pregnancy, as well as within British regulatory discourse on abortion, it is perhaps unsurprising that fetuses were often central to health professionals’ accounts. Echoing regulatory debates, a concept that was invoked regularly by health professionals in their attempts to classify temporal limits on abortion provision was that of medically constituted fetal ‘viability’. The following extract – in which Consultant 2 explains the basis of his hospital’s 20-week time limit – exemplifies the typical way in which this concept was mobilized by interviewees:
a twenty-four week fetus … I think has to be presumed capable of being born alive and certainly um widespread practice in this part of the country um is that you will struggle to find a Consultant who’s willing to terminate a pregnancy other than on the grounds of fetal abnormality, if the pregnancy is beyond twenty weeks. Now that’s partly based around … our presumption of viability is about the twenty-three week mark, yeah that’s, as far as I’m aware that is the earliest gestation at which a baby has been born and has lived. The ultrasound scan that we use to date a pregnancy has about a two-week error at that stage of pregnancy. So a pregnancy which is by ultrasound evaluation twenty-three weeks could be anywhere from twenty-one weeks to twenty-five weeks. So I think you have to assume that a twenty-three week pregnancy on the scan is a twenty-one week pregnancy potentially, and therefore we have a kind of, by mutual agreement amongst a group of consultants, an undertaking that we tend not to want to go beyond twenty weeks unless as I say … there is a fetal abnormality. (Consultant 2, male)
In his account, Consultant 2 constructs the measurement of gestational time as being essential to avoid aborting a fetus that is old enough to be kept alive (with medical assistance) ex utero. However, simultaneously, he reveals the complexities involved in treating this event as a particular, identifiable ‘point’ in time. Because the date of conception is never known precisely (except, perhaps, to the pregnant woman in question), the ‘age’ of a fetus is only knowable through the conventional practices used to measure and thus attribute gestational time to fetuses. Through these practices, the age of these entities can only ever be known as an approximation because ultrasound scans (particularly later in gestation) contain a 2-week margin of error. Thus, somewhat ironically, it is the inaccuracies of medical dating practices that determine the upper time limit on women’s access to abortion in Scotland; health professionals do not want to risk aborting a 23 week fetus (which they deem viable), so will not terminate any pregnancy that is identified as being 20 weeks or more through ultrasound scanning. 9
In addition to drawing attention to the complexities involved in constructing an upper time limit on abortion provision on the basis of a ‘point’ of viability, Consultant 2 explains his meaning in employing this concept, defined as, ‘[t]he earliest gestation at which a baby has been born and has lived’. As McNeil notes in the context of UK debates about abortion, this is an understanding of viability grounded in technical measurements of the biological functionality of a fetus rather than a pregnant woman’s assessment of the ‘social sustainability of new life’ (McNeil, 1991: 156). A similarly ‘technicist’ construction of viability also underpins Consultant 2’s account of the situations in which it becomes acceptable for health professionals to make exceptions to the hospital’s self-imposed time limit; that is, in cases where diagnoses of fetal abnormality have been made. In describing this exception, he echoes the controversial distinction regarding fetal abnormality made by the UK’s 1990 HFE Act. As feminist scholars have long argued (Science and Technology Subgroup, 1991; Sheldon, 1997), such special case arguments about fetal abnormality are not only problematic because of the way that they construct disability. In addition, these arguments contribute to the belief that decisions about later abortions should concern health professionals’ technical understandings of the fetus, rather than women’s understandings of what their pregnancies mean.
As noted in the introduction to this paper, this eclipsing of the pregnant subject, and of the broader socio-material context in which a pregnancy takes place, forms the target of feminist critiques of the production of fetal subjectivity through medical discourse. Such eclipsing is overwhelmingly obvious in Consultant 2’s account of the significance of fetal viability, when he describes a process of making decisions about ‘pregnancies’ and ‘fetuses’, without once referring to pregnant women as subjects whose bodies and lives are inevitably implicated in the fate of these entities. In drawing attention to this point, I do not wish to criticize Consultant 2’s account on a personal level. Rather, I want to raise questions about the routinized practices that make it possible for him (and many of the other health professionals I interviewed) to discuss pregnancies and fetuses in the absence of pregnant subjects.
With these questions in mind, a notable dimension of Consultant 2’s account is its reliance upon a particular set of representations of temporality. Any implementation of time limits on abortion provision on the basis of the measurement of the threshold of ex utero neonatal ‘viability’ involves the projection of anticipated future events onto the present: a measurement that can only ever be applied to a neonate post-childbirth is used to define the status of the present fetus in utero. This process of projection can be likened the phenomenon of ‘time displacement’, which van der Ploeg (2001) identifies as central to the practice of fetal surgery. As noted in the introduction, rather than being described as discontinuous time periods interrupted by a significant event (childbirth), medical texts concerning fetal surgery conflate prenatal time with future postnatal time, allowing present in utero fetuses and future ex utero neonates to be discussed as equivalent entities (van der Ploeg, 2001). In the case of Scottish abortion practice, the conflation is between a particular period of prenatal time (that is, beyond a particular threshold in gestation) and the postnatal future. In both cases the outcome is the same: the present relationships that exist between fetuses and pregnant women, as well as a pregnant woman’s future labour in childbirth – upon both of which a neonate’s future ‘viability’ is predicated – are rendered invisible.
Another crucial feature of Consultant 2’s account is the specific time-frame in relation to which he depicts the viable neonate as a subject of concern: the short-term future. This temporal frame of reference excludes consideration of the long-term futures of pregnant/fetal subjects – a point implicit in McNeil’s critique of the narrow framing of UK abortion debates when she notes that, ‘[s]aying that it is theoretically possible to plug a 24-week-old fetus into life support apparatuses is very different from saying that you personally will take primary responsibility for supporting – in every sense – a child through to adulthood’ (McNeil, 1991: 156).
As Consultant 2’s account illustrates, health professionals’ concerns with the short-term future of fetuses in utero leads to the imposition of a lower time limit (20 weeks) on abortion provision than the 24 weeks specified in UK law. However, while significant, this ‘gap’ between law and practice is actually quite small compared with the much lower thresholds invoked by some health professionals whom I interviewed. This second group of interviewees suggested that abortion becomes much more problematic throughout much of the second trimester (from approximately 12 to 16 weeks’ gestation onwards) because of the fetus’s relatively near-term future as a ‘viable’ individual.
I think there’s no doubt that uh the longer time goes on uh the more uh uh a fetus uh becomes, uh the closer it comes to, to viability uh the less uh the less you wish to interfere. (GP16, male)
Although some health professionals described an expanded threshold of time during which they could legitimately become more involved in, and concerned about, women’s abortion decisions, they were often reluctant to spell out what this concern meant for women’s access to abortion. In contrast, other interviewees were prepared to state directly that their knowledge of the fetus’s (short-term) future as a viable neonate could justify the imposition of firm restrictions on women’s access to abortion throughout much of the second trimester:
for a so-called social termination oh, I’d be reluctant to do it [referral] any later than sixteen weeks, possibly earlier. But I mean, clearly if there were dreadful birth defects found on an ultrasound scan or something then it’s a completely different kettle of fish. (GP12, male)
When I went on to ask him what he meant by the expression ‘social termination’, GP12 explained that this involved, ‘[a] pregnancy that would have produced a healthy baby if it had been left to its own devices probably, in all probability’. In relation to this point, it is worth noting that, in addition to relying upon processes of ‘time-displacement’ and the invocation of the short-term future as a temporal frame of reference, an important feature of this and the other accounts considered above is their use of what Franklin (1991) describes as a discourse of ‘fetal teleology’. In other words, their constitution of pregnancy as a process with a ‘naturally’ pre-determined end-point automatically de-naturalizes and problematizes abortion as a course of action.
Accounts such as this are particularly troubling when provided by GPs, because of the gate-keeping position these health professionals occupy in relation to hospital services. Women who reach a Scottish hospital after its local gestational cut-off point (for example, the 20-week limit described by Consultant 2) will at least be given the opportunity to access an independent provider in England. In contrast, those who are prevented from accessing secondary care facilities by a Scottish GP may not be aware of any option other than carrying their pregnancies to term. If women classified as ‘too late’ for referral by their GP do eventually manage to gain access to a hospital/independent provider, the barriers they have encountered will ensure that their pregnancy is terminated ‘later’ in gestation than would otherwise have been the case.
An unexpected finding of this study is that nurses are another group of health professionals whose classifications of the significance of gestational time have potentially major ramifications for pregnant women’s access to abortion. While nurses are not granted legal rights as decision-makers under current UK law, they have primary responsibility for later abortion procedures, which are conducted using the ‘medical’ drug-induced method. At some hospital sites doctors argued that their ability to offer later abortion to their patients was constrained by nurses’ reluctance to participate in its provision. Such reluctance was confirmed by interviews with some (but by no means all) nurses, who argued that, beyond particular thresholds in gestation, they became concerned about the short-term futures of fetuses as ‘nearly viable’ entities and/or as relatively ‘developed’ and thus emotionally distressing to handle and to dispose of post-abortion. Clearly, it is important to consider the embodied positioning of nurses in relation to abortion procedures (Bolton, 2005; Chiappetta-Swanson, 2005), and how, as a consequence, their experiences of this practice may differ from those of doctors (Beynon-Jones, 2009). However, in terms of the aims of this paper, the critical point is that, like doctors, those nurses who problematized later abortion provision on the grounds of the significance of short-term fetal futures did so by minimizing the significance of present and long-term future relationships between fetuses and pregnant women.
Alternative temporalities, alternative viabilities
Earlier, I suggested that my interview data offer a means to disrupt health professionals’ separation of ‘later’ from ‘earlier’ abortion, because several health professionals problematized the assumptions underpinning these demarcation practices. In particular, they problematized the representations of temporality upon which these practices depend. One of the most contested issues was the way in which fetal viability was characterized. In some cases, health professionals questioned dominant framings of viability on the basis that these foreground the immediate rather than long-term ‘life’ potential of neonates:
a colleague … used to say, ‘Don’t ask how many babies survive at twenty-two weeks and twenty-three weeks. Ask how many of them pick up a schoolbag and go to a normal school, healthy and well, four or five years down the line.’ And maybe those are the questions you ought to be asking. Because the success rate of, of keeping very prem[ature] babies alive and normally or reasonably normally functioning, nobody has perfect babies um but that is, is perhaps the question rather than can they survive for six months or a year or in some damaged fashion for a three, three or four years. (Specialist Registrar 3, female)
Such reflections illustrate that the criteria used to measure fetal ‘viability’ are contested within the healthcare profession. However, they do nothing to destabilize the more fundamental assumption that medical judgements about the functionality of fetal/neonatal bodies should determine the availability of abortion.
In contrast, a small number of health professionals did question whether technical attempts to measure the ‘viability’ of the fetus (over whatever time period) had any place within decision-making about abortion. In the following extract, Consultant 3 contests (and renders visible) the central assumption underpinning the arguments outlined in the previous section, namely, that in-utero fetuses and ex-utero neonates can be discussed as equivalent entities:
I suppose the, the discussion about it I think has got sort of quite muddied and it seems to have got mixed up with viability and, and with pregnancies now surviving, some surviving at twenty-four weeks’ gestation. I think it’s entirely different, I don’t really see that the two things are, are part of, of the same argument. … And just thinking of people that I’ve seen that have been at that gestation, they often have um quite dire circumstances that are leading them to request such a late termination. Whether it be, you know, a relationship that’s maybe split up in, in very difficult circumstances, often maybe domestic violence in the background, or young people that have concealed a pregnancy, or someone that’s just been too frightened to, to acknowledge that they were pregnant. And again, some people that, you know, genuinely did not realise that they were pregnant. … I suppose it’s making a bit of a generalisation but people that present later in pregnancy for a termination often because of their circumstances will be the people that would cope least well with looking after a baby. (Consultant 3, female)
The crucial features of Consultant 3’s account enabling her to contest the relevance of arguments about fetal viability are the central position she accords to pregnant subjects, as well as the temporal frames of reference she uses in relation to them. She describes pregnant women in terms of their current socio-material circumstances, as well as their anticipated long-term futures (that is, motherhood in difficult circumstances), which would be realized if their requests for abortion are denied. Interestingly, the situations that Consultant 3 highlights overlap closely with the reasons that UK women give for requesting abortion later in pregnancy, which include: lack of awareness of pregnancy (often due to irregular/continued menstruation or the use of hormonal contraceptives); difficulties in acknowledging a pregnancy/difficulties in abortion decision-making; experiencing changed circumstances during a pregnancy (such as the break-up of a relationship); and delays caused by service provision (Ingham et al., 2008; Robotham et al., 2005).
While foregrounding the present and future circumstances of women who request abortions may have positive implications for those who request the procedure later in pregnancy, it remains important to reflect critically on the co-constructions of ‘women’ and ‘later abortion’ that underpin Consultant 3’s account. Specifically, she presents later abortion as a compassionate act justified by the suffering of a blameless and atypical group of individuals. As Boyle (1997) points out, this framing of abortion has a long history within the UK and is problematic because it equates abortion with female suffering/frailty, as well as invoking motherhood as a ‘norm’ from which women have to be exempted on the basis of particular ‘inadequacies’ (Sheldon, 1997). Furthermore, Boyle argues, such framings depoliticize abortion by presenting it as a question of individual women’s needs, making it difficult to articulate the feminist argument that access to abortion is ‘a positive and necessary enabling condition for full human participation in social and communal life’ (Petchesky, 1984: 378).
Constructing pregnant subjects
In contrast to public debates about abortion in the UK, health professionals’ attempts to demarcate later abortion as a problematic decision were not dominated completely by concern for fetuses. In this section, I will discuss how the subject positions that health professionals constructed for women who request the procedure were equally important in this process of demarcation.
Focussing on patients’ past (in)actions
In contrast to Consultant 3, who emphasized the circumstances leading women to request abortion later in pregnancy, health professionals who demarcated later abortion as a problematic course of action tended to position pregnant women as agents who have generated a difficult situation by ‘allowing’ gestational time to elapse. In some formulations, patients were positioned as lazy individuals, who had created an unnecessary situation by failing to request the procedure earlier in their pregnancy. Through this representation of pregnant subjectivity, later abortion automatically became demarcated as a problematic act, simply because it was assumed that it could have been avoided. Here a gynaecologist explains why he has reservations about the provision of abortion beyond the first trimester of pregnancy:
I think as I say, because abortion is so readily available and publicized and, you know, such easy access and certainly in this hospital, particularly, the service here is incredibly well run and organized. And I don’t think there’s any reason why people shouldn’t come up earlier on in their pregnancy, and make their decision earlier on in their pregnancy. Except in the rare occasions. (Specialist Registrar 1, male)
When emphasizing women’s agency in ‘allowing’ gestational time to elapse, those who demarcated ‘later’ from ‘earlier’ abortion did not always blame their patients. Instead, they sometimes argued that this delay was evidence of ambivalence, and that a woman’s request for later abortion could not necessarily be trusted:
Most women will know that they’re pregnant long before that so you’re going to start wondering well why, what’s going on here that it’s got to this stage that um maybe there’s [some] ambivalence about having, having it. … Certainly I would explore, I would explore the issues and thinking at much greater length I think. (GP19, male)
A particular temporal representation of pregnant subjectivity as a continuous state is central to both of these problematizations of later abortion requests. This is another key point of contrast that emerges between these accounts and that of Consultant 3, who is sympathetic to women’s requests for later abortion because she is familiar with pregnant subjects whose situations change with time, for example, through their encounters with different social circumstances, or through their changing embodied awareness of, or feelings about, a pregnancy.
Focussing on the short-term suffering of the (later) aborting woman
In addition to positioning pregnant women as agents of their present circumstances, another key means by which health professionals demarcated ‘earlier’ from ‘later’ abortion was by problematizing women’s experiences of later abortion procedures. Many participants raised concerns that the method used to terminate a pregnancy at a later stage of gestation would subject a patient to immense suffering. I highlight below the contestable assumptions embedded in the demarcation of later abortion as an unbearably traumatic procedure, and its reliance on a particular temporal framing of pregnant subjectivity.
As noted previously, standard practice in Scotland is to utilize the medical (drug-induced) method of abortion for pregnancies at 6 to 9 weeks’ gestation, the surgical method at 9 to 13 weeks, and the medical method again beyond 13 weeks. However, although it is possible to construct ‘medical’ and ‘surgical’ abortions as two distinct methods for ending a pregnancy (for example, by highlighting the different tools employed in each case – drugs versus surgical equipment), the main criterion health professionals used to classify abortion procedures was length of gestation. In interviews, they tended to discuss first trimester medical and surgical procedures interchangeably as forms of ‘early abortion’, while distinguishing ‘later’ (second trimester) medical abortion as an entirely different, more complex, kind of procedure.
Many health professionals noted that, as with any medical intervention, they have a legal and professional obligation to obtain informed consent from their patients before performing the procedure or providing an abortion referral. Interestingly, in the case of a first trimester (medical or surgical) abortion, this consent process was positioned as secondary to a woman’s decision about whether or not she wanted to undergo an abortion. In other words, health professionals did not suggest that knowledge of first trimester abortion methods was relevant to a woman’s decision about whether she wanted to continue with her pregnancy. Moreover, when they did describe first trimester abortion methods, they generally discussed them as straightforward procedures, about which it was important to reassure patients:
Um I would outline how that was, you could consider a medical or a surgical and the pros and cons of that, how effective they are. I’d, I don’t overemphasise the risks, the risks are very small and at the end of the day it’s actually safer to have an early abortion than it is to continue a pregnancy. So I wouldn’t overemphasise that. (Consultant 1, female)
In contrast, when they discussed second trimester abortion, health professionals often suggested that knowledge of this procedure should form the basis for a woman’s decision about whether or not to continue with her pregnancy:
… I think because … second trimester’s a bit more traumatic to go through the procedure, people actually do have to have almost like a mini-labour. When you explain that to people it sometimes does affect their decision. But I don’t think it would affect my decision, I mean I think I would counsel the person, but I would explain very carefully about the procedure so that they absolutely understood what they were going to have to go through and more people do change their mind, the later it is more people change their mind.
But for example if a woman was in the second, at some point in the second trimester and she was adamant that that’s what she wanted, you would still refer?
Yeah I would still, yep. I would explain very carefully what was involved and make sure she did understand that there were higher risks, that it was a more prolonged procedure, you know, more traumatic for her, more pain involved, so I would explain that very carefully. But if she still felt that was the right thing for her to do I would refer her. (Consultant 1, female)
Crucially, when the immediate trauma caused by second trimester medical abortion is treated as the most pertinent ‘fact’ in decision-making, the long-term futures of women who are dissuaded or prevented from undergoing this procedure disappear from view. In describing later abortion as an experience so traumatic that it might be better avoided, health professionals did not reflect upon the long-term alternatives to this procedure: full-term labour, followed either by motherhood or the process of surrendering a baby for adoption.
When describing the second trimester medical abortion experience, many health professionals likened it to childbirth (‘a mini-labour’), an event that connotes not only physical pain but, simultaneously, enormous social significance. Indeed, some interviewees’ unease about the ‘trauma’ caused by second trimester abortion slipped between a concern with the bodily pain of vaginal delivery, and anxiety about the significance that their patients might attach to the fetus delivered at the end of this process:
Obviously you do have to say it is, it is going to look like a baby and the chances are you will see it um and that is going to make it more difficult for you because it does seem more real than it just being a little ball of cells. (Consultant 4, female)
What might it mean for a woman requesting this procedure to hear a doctor’s description of second trimester abortion as like a ‘mini-labour’ or a description of the fetus as ‘like a baby’? Health professionals themselves stated that the information they provide sometimes convinces patients not to undergo an abortion. It also seems important to consider what these descriptions might imply for a woman who does decide to have a second trimester abortion. How might exposure to particular conceptualizations of this experience become interwoven with the experience itself?
Re-situating suffering
When asking such questions, it is important to avoid perpetuating health professionals’ depictions of their patients as passive recipients of their ‘objective’ accounts of abortion. Such depictions are central to the accounts considered in the previous section and are challenged by studies that have highlighted women’s agency and resourcefulness in generating their own narratives of their experiences of (first and second trimester) medical abortion (Gammeltoft, 2006; Gerber, 2002; Simonds et al., 1998). The situated basis of health professionals’ descriptions of later abortion procedures is also underscored by the fact that multiple characterizations of these procedures emerge from the interview data. For example, some health professionals contested the process of temporal classification through which their colleagues likened later abortion to childbirth rather than to early abortion:
Um and the medical procedure I have heard also described as a sort of mini induction of labour by some people. Is that an accurate way of describing it?
I don’t know that I would … we could take you down onto the labour ward … . And in fact on a good day we could open the windows here and you could hear the women scream. Right. There is no comparison between that [gestures], and that. However, it is sore. But there is no comparison between labour and sub-twenty week abortion. And we cover it with morphine anyway. (Specialist Registrar 2, male)
Within this account, later medical abortion emerges as a less distinctive type of procedure; it becomes categorized as part of a continuum of medical abortion experiences, all of which are different from the birth of a baby. Notably, however, although Specialist Registrar 2 offers a challenge to his colleagues’ classifications of later abortion as a particularly problematic procedure, he does so by relying upon the same premise, namely, that there is a single, authoritative ‘truth’ (rather than multiple, inevitably situated ones) concerning the experience of medical abortion. 10
Another way that health professionals contested their colleagues’ problematizations of later abortion procedures was to contrast projections of the short-term future with those of the longer-term alternative:
So if we were to see say someone here who was fifteen, who had kind of blocked on the pregnancy and … was in denial, and then pitches up you, it might be that actually the right thing for her would be to have a second trimester termination of pregnancy because that’s her only option. And if you counsel them carefully and say, just be very clear about what they’re going to go through. It’s not a nice procedure … . And I would be very wary of a, of a young fourteen, fifteen year-old going through that procedure. You know you would want to say ‘Look you know … this is what’s involved. But if actually what you want is not at this point in time to continue with the pregnancy and to be a mother at the age of fifteen then this is your option and we’ll try and make it, and the hospital will try and make it as, as easy as they can for you. (Nurse 7, female – emphasis added)
Crucially, while she raises concerns about offering this procedure to her patients, Nurse 7 is able to invoke the longer-term future as an alternative frame of reference against which to re-situate, and reformulate, these concerns.
Conclusion: New temporalities?
The key analytical move made by the sociology of expectations (for example Borup et al., 2006; Brown et al., 2000; Selin, 2006; van Lente, 1993) is to emphasize that the realization of particular futures depends on the mobilization of particular representations of temporality in the present. This paper has illustrated how this sensitivity to the constitutive work performed by representations of temporality can be used as an analytical lens through which to understand – and challenge – Scottish health professionals’ attempts to demarcate later abortion as a problematic course of action. In doing so, it has extended the existing body of feminist empirical research that has addressed the framing of gestational time and abortion within the UK (Science and Technology Subgroup, 1991; Sheldon, 1997), and has also contributed more broadly to feminist theorizations of the construction of pregnant/fetal subjectivity.
By problematizing ‘later’ abortion, health professionals implicitly engage in the construction of expectations about the future of pregnant subjects as undergoing full-term labour and motherhood/adoption. Central to the success of this process, however, are a set of co-constructions of temporality and pregnant/fetal subjectivity which enable health professionals to obscure their own role (as questioners or refusers of later abortion) in shaping pregnant women’s futures.
One such practice identified by my analysis is a process of ‘time displacement’ similar to that observed by van der Ploeg (2001) in the context of fetal surgery. Through this practice, fetuses in utero beyond particular thresholds of gestation become equated with future ‘viable’ neonates, while women’s future labours in sustaining the pregnancy, undergoing childbirth and (potentially) motherhood are rendered invisible. Significantly, this process of ‘time displacement’ occurs with reference to a very specific time-frame – the short-term future – which means that the long-term futures of neonates, and the women who bear them, also become excluded from health professionals’ accounts of abortion decision-making. Moreover, alongside both of these processes, health professionals construct ‘teleological’ (Franklin, 1991) accounts in which ‘babies’ are positioned as the pre-determined end-point of a pregnancy, which in turn is naturalized as a state during which women are deemed to be passively ‘expecting’ motherhood.
Another set of practices that enable health professionals to problematize later abortion are their routine constructions of temporally delineated pregnant subjectivities. For example, when they depict pregnant subjectivity as a continuous state, health professionals are able to position their patients as past agents (whether wittingly or inadvertently) of their current circumstances. Through this focus on pregnant women’s past inaction, the futures of these women become excluded from the frame of abortion decision-making. Likewise, when health professionals claim as their responsibility the obligation to inform patients of the ‘trauma’ caused by later abortion procedures, the longer-term futures of pregnant women who are dissuaded/prevented from undergoing such procedures once again disappear from view.
Although the interview data provide numerous illustrations of health professionals’ attempts to demarcate later abortion as a problematic decision, a minority of health professionals challenged this practice. These alternative accounts reveal that the meaning of the gestational timing of abortion is contested within the health profession and also underscore the politically significant role that representations of temporality play in the production of pregnant/fetal subjectivities. In particular, when pregnancy is constructed as a dynamic, potentially discontinuous process that takes place through time rather than as a static, continuous, state, an important opportunity arises for health professionals to reflect upon the socio-material changes which may occur during a pregnancy, and which may lead to a woman’s request for later abortion. Perhaps more significantly, however, when accounts of abortion decision-making are expanded to incorporate consideration of the longer-term future, then it becomes possible (and indeed, mandatory) for health professionals to acknowledge and reflect upon the repercussions of refusing a woman’s request for abortion. Together, these two practices of temporal reframing represent a set of relatively simple techniques that, if they were to become routinized within clinical practice (for example, through training regarding abortion consultations), could potentially help to propel the construction of less oppressive subjectivities.
These findings concerning opportunities to reframe temporality and pregnant/fetal subjectivity within Scottish abortion practice have clear relevance beyond this case study to the wider body of feminist STS scholarship that is engaged in attempts to challenge ‘fetal centred’ (Steinberg, 1991: 179) depictions of pregnancy. In particular, my findings point to the value of examining the temporal frames of reference mobilized during public and legislative debates about abortion as a potential basis from which to open up the parameters of such debates. In a similar vein, it would be useful to explore and reflect critically upon how the possibilities of pregnant/fetal subjectivity become delineated by the enactment of routinized assumptions about temporality in other clinical settings (for example, prenatal diagnosis) and/or other cultural contexts. The importance of this point is underscored by the overlaps that I have identified between the practices that Scottish health professionals use to demarcate later abortion and the practices van der Ploeg (2001) identifies as central to the provision of fetal surgery.
While I have emphasized the opportunities afforded by health professionals’ ‘re-framings’ of abortion and gestational time, it remains important to reflect upon a limitation I have emphasized throughout my analysis, namely the (not unproblematic) constructions of female subjectivity upon which these, like all health professionals’ knowledge claims about abortion, depend. In foregrounding this issue, I have tried to acknowledge that the particular empirical dataset I have used to explore opportunities to reconstruct pregnant/fetal subjectivity in itself constrains such reconstruction. Any re-negotiations of subjectivity my analysis provides are limited by the narrow range of representations available to health professionals within the context of a research interview in which they were attempting to provide an ‘acceptable’ account of their practice to me, a professional outsider. Far more significant than the methodological limitations of research interviews, however, are the representations of abortion I have excluded from my dataset through my decision to interview only health professionals. As an analysis of the voices of people who are already granted enormous epistemological authority to delineate the possibilities of pregnant/fetal subjectivity in UK law and debate, it could be argued that my account has inevitably perpetuated the ‘objectification’ of pregnant subjects it set out to critique. My concerns about this possibility are intensified by the fact that, while an extensive social science literature has addressed women’s abortion experiences (for a recent review see Lie et al., 2008), UK women’s conceptualizations of the meaning of the gestational timing of their abortion(s) remain under-researched. 11
Nevertheless, it is important to emphasize that researching women’s accounts of this issue would not provide a straightforward solution to the problems perpetuated by the terms of my analysis. Indeed, the possibilities of utilizing ‘women’s experience’ as a basis from which to generate improvements in ‘women’s condition’ have been thoroughly problematized by post-second wave feminist theorists. First and foremost, projects that begin by assuming women have shared experiences of oppression will inevitably conceal important differences produced through the intersection of multiple structuring systems of inequality (Butler, 1990; Haraway, 1991; Harding, 1986). In addition, there is the obvious danger that the attempt to capture ‘women’s experiences’ of a phenomenon will result in the production of further un-situated and objectifying statements concerning the ‘nature’ of such experiences. Finally, the analysis of individual women’s accounts of their experiences presents specific difficulties within the particular context of abortion provision. This is because of an issue I noted during my analysis; the ease with which discussions of the circumstances in which individual women seek abortion lead to its de-politicization, instead making it a compassionate act justified by particular circumstances.
In acknowledgement of the dangers posed by the attempt to include ‘women’s experiences of gestational time’ in discussions of abortion provision, it seems vital to ensure that this process is not framed as one of ‘representing’ a silenced perspective, but rather as a method through which to generate alternative, and inevitably situated, accounts of pregnant/fetal subjectivity. Conceptualized in this more nuanced manner, women’s accounts of gestational time and abortion simultaneously become an important opportunity to multiply the forms of subjectivity available to pregnant women, and a vital topic for future feminist STS research.