The power of suggestion

This article examines an ethical controversy that has received relatively little attention in public debates about the legalization of medical aid-in-dying (AID): should physicians inform patients that they have the option of hastening death? Drawing on ethnographic research about the implementation of AID in Vermont, I argue that how we understand the moral stakes of this debate depends on divergent views regarding language use in social interactions. Some stakeholders in this debate view a physician’s words as powerful enough to damage the patient-physician relationship or to influence a patient to hasten her death, while others believe that merely informing patients about AID cannot move them to act against their own values and preferences. I illustrate how these divergent perspectives are tied to competing language ideologies regarding clinical disclosure, which I call ‘disclosure ideologies’. My analysis of these two disclosure ideologies surrounding AID highlights disclosure practices in medicine as a rich site for medical anthropological theorizing on linguistic performativity and the social power of clinical language

Neural imaginaries and clinical epistemology: Rhetorically mapping the adolescent brain in the clinical encounter

The social work of brain images has taken center stage in recent theorizing of the intersections between neuroscience and society. However, neuroimaging is only one of the discursive modes through which public representations of neurobiology travel. This article adopts an expanded view toward the social implications of neuroscientific thinking to examine how neural imaginaries are constructed in the absence of visual evidence. Drawing on ethnographic fieldwork conducted over 18 months (2008–2009) in a United States multidisciplinary pediatric pain clinic, I examine the pragmatic clinical work undertaken to represent ambiguous symptoms in neurobiological form. Focusing on one physician, I illustrate how, by rhetorically mapping the brain as a therapeutic tool, she engaged in a distinctive form of representation that I call neural imagining. In shifting my focus away from the purely material dimensions of brain images, I juxtapose the cultural work of brain scanning technologies with clinical neural imaginaries in which the teenage brain becomes a space of possibility, not to map things as they are, but rather, things as we hope they might be. These neural imaginaries rely upon a distinctive clinical epistemology that privileges the creative work of the imagination over visualization technologies in revealing the truths of the body. By creating a therapeutic space for adolescents to exercise their imaginative faculties and a discursive template for doing so, neural imagining relocates adolescents’ agency with respect to epistemologies of bodily knowledge and the role of visualization practices therein. In doing so, it provides a more hopeful alternative to the dominant popular and scientific representations of the teenage brain that view it primarily through the lens of pathology

TRAP laws and the invisible labor of US abortion providers

Targeted Regulations of Abortion Providers (TRAP laws) are proliferating in the United States and have increased barriers to abortion access. In order to comply with these laws, abortion providers make significant changes to facilities and clinical practices. In this article, we draw attention to an often unacknowledged area of public health threat: how providers adapt to increasing regulation, and the resultant strains on the abortion provider workforce. Current US legal standards for abortion regulations have led to an increase in laws that target abortion providers. We describe recent research with abortion providers in North Carolina to illustrate how providers adapt to new regulations, and how compliance with regulation leads to increased workload and increased financial and emotional burdens on providers. We use the concept of invisible labor to highlight the critical work undertaken by abortion providers not only to comply with regulations, but also to minimize the burden that new laws impose on patients. This labor provides a crucial bridge in the preservation of abortion access. The impact of TRAP laws on abortion providers should be included in the consideration of the public health impact of abortion laws

Potentializing Newborn Screening

Virtually all 4.25 million babies born annually in the United States are screened for more than 50 rare genetic conditions. In a country plagued with widespread health-service access problems, this remarkable public health achievement depends on policy visions of newborn screening as the linchpin of secondary prevention and saving children's lives. Based on ethnographic research and drawing from a semiotic framework, we illustrate that newborn screening has had a much wider range of effects in the clinic than those anticipated by policy makers. How does the disconnect between policy potential and clinical experience affect the technology? We demonstrate that only some discrepancies are considered in policy circles and that instead, parents, geneticists, and policy makers renew visions of potentiality that preserve the technology's benefits in spite of evidence to the contrary. While rearticulating the potential of technologies may help actors cope with situations that do not measure up to expectations, the inevitable cost of reformulating potentiality once a technology has been implemented is that some accumulated experiences will be rendered invisible. © 2013 by The Wenner-GrenFoundation for Anthropological Research. All rights reserved

Potentializing Newborn Screening

Virtually all 4.25 million babies born annually in the United States are screened for more than 50 rare genetic conditions. In a country plagued with widespread health-service access problems, this remarkable public health achievement depends on policy visions of newborn screening as the linchpin of secondary prevention and saving children's lives. Based on ethnographic research and drawing from a semiotic framework, we illustrate that newborn screening has had a much wider range of effects in the clinic than those anticipated by policy makers. How does the disconnect between policy potential and clinical experience affect the technology? We demonstrate that only some discrepancies are considered in policy circles and that instead, parents, geneticists, and policy makers renew visions of potentiality that preserve the technology's benefits in spite of evidence to the contrary. While rearticulating the potential of technologies may help actors cope with situations that do not measure up to expectations, the inevitable cost of reformulating potentiality once a technology has been implemented is that some accumulated experiences will be rendered invisible. © 2013 by The Wenner-GrenFoundation for Anthropological Research. All rights reserved

Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide

While the concept of conscience has broad philosophical underpinnings relating to moral judgment, agency, and discernments of right and wrong, debates in bioethics have tended to engage the concept primarily vis-à-vis rights of conscientious refusal. Here, we suggest a broader frame for thinking about claims of conscience in healthcare. Drawing on empirical findings from our research with abortion providers in North Carolina, we elucidate an empirically grounded approach to ethically justified care when healthcare providers face legal or institutional policy mandates that raise possible moral conflicts. We highlight, in particular, how providers may be motivated by matters of conscience, including relational concerns, in the active provision of certain forms of care. In so doing, we challenge the dichotomy between conscientious refusal and morally compromised action, demonstrating how providers may work within the constraints of laws or institutional policies that raise moral challenges and act in accordance with conscience

“Is there any way I can get something for my pain?” Patient strategies for requesting analgesics

We examined the direct and indirect means by which patients express a desire for analgesic medication

The experiences and adaptations of abortion providers practicing under a new TRAP law: a qualitative study

Abortion laws are proliferating in the United States, but little is known about their impact on abortion providers. In 2011, North Carolina instituted the Woman’s Right to Know (WRTK) Act, which mandates a 24-hour waiting period and counseling with state-prescribed information prior to abortion. We performed a qualitative study to explore the experiences of abortion providers practicing under this law

Teachable moments and missed opportunities for smoking cessation counseling in a hospital emergency department: a mixed-methods study of patient-provider communication

BackgroundWhile primary care medical clinics have been the most common setting for the delivery of advice about smoking cessation, the hospital emergency department (ED) is a valuable context for counseling medically underserved tobacco users. We conducted a secondary analysis based on a larger audio-recorded study of patient-provider communication about pain and analgesics in the ED. Within a sample of ED patients with back pain, the purpose of this mixed-methods study was to examine how physicians and nurse practitioners capitalize on “teachable moments” for health education to offer spontaneous smoking cessation counseling in the ED.MethodsPatients presenting to an academic ED with a primary complaint of back pain were invited to participate in a study of patient-provider communication. Audio-recorded encounters were transcribed verbatim. Two coders reviewed each transcript to determine whether smoking was discussed and to build a corpus of smoking-related discussions. We then developed inductively generated coding categories to characterize how providers responded when patients endorsed smoking behavior. Categories were refined iteratively to accommodate discrepancies.ResultsOf 52 patient-provider encounters during which smoking was discussed, two-thirds of the patients indicated that they were smokers. Providers missed opportunities for smoking cessation counseling 70% of the time. Eleven encounters contained teachable moments for smoking cessation. We identified four primary strategies for creating teachable moments: 1) positive reinforcement, 2) encouragement, 3) assessing readiness, and 4) offering concrete motivating reasons.ConclusionsMost providers missed opportunities to offer teachable moments for smoking cessation. In encounters that contained teachable moments, providers employed multiple strategies, combining general advice with motivation tailored to the patient’s particular circumstances. Creating motivational links to enhance smoking cessation efforts may be possible with a minimal investment of ED resources

Access to HIV care in jails: Perspectives from people living with HIV in North Carolina

Most incarcerations for people living with HIV (PLWH) occur in jails, yet studies of HIV care during jail incarceration are limited. As part of a larger study to explore the ethical considerations in extending public health HIV surveillance to jail settings, we conducted semi-structured interviews with twenty-three PLWH with more than 300 distinct jail incarcerations post HIV diagnosis in 21 unique North Carolina jails. Interviews included questions about HIV disclosure in jail, the type of HIV care received in jail, and overall experiences with HIV care in jail. We report on participants’ experiences and perspectives in four domains: access to HIV care in jail; impact of jail incarceration on continuity of HIV care; privacy and stigma; and satisfaction with HIV care in jail. Although most participants received HIV medications and saw providers while in jail, almost half reported that their greatest challenge in regard to HIV care was obtaining their HIV medications in the face of limited jail resources or policies that made access to medications difficult. Findings from this study suggest that jail leadership should review internal policies regarding HIV medications to ensure that PLWH can receive them quickly upon entry into jail. Findings also suggest that more external resources are needed, for example from state and local health departments, so that jails can provide timely HIV medications for PLWH incarcerated in their facilities