The Management of Unequal Patient Status in Fertility Medicine: Donors' and Intended Parents' Experiences of Participatory and Imposed Enrollment.

This paper explores the micro-dynamics of medicalization and unequal patient statuses across donors and intended parents in assisted fertility practices. Based on twelve months of fieldwork in a fertility clinic, including direct observations of 108 patient-medical expert consultations and interviews with donors, I develop an "epistemic-orientation (EO) continuum" to examine the emergence and differing consequences of unequal patient status. Patients who experience practices closer to the "participatory" epistemic orientation end of the continuum enjoy joint decision-making, personal and emotional recognition, and incorporation of their personal values in interactions with medical experts in the clinic. Patients whose experiences align more closely to the "imposed" epistemic orientation end of the continuum experience top-down instruction, neglected personhood, and medical objectification. I find that medical experts rely upon their professional authority to enroll intended parents in participatory epistemic orientations, while donors more likely experience imposed epistemic orientations. Blended orientations also occur within each patient group, often based on individuals' prior fertility experiences. The EO continuum approach carries implications for future research to note how patients of various social identities (i.e. race, class, gender) and patient groups are positioned along the continuum, as well as practical interventions into micro-dynamics of social inequalities in healthcare.