Illusion of Choice

Meera Nagarsheth, MA

As a medical student rotating through one of the largest public safety-net hospitals in the nation, I often witness the intersection of social injustice and health in communities, particularly communities of color. Racism, capitalism, housing instability, wealth inequality, lack of comprehensive health insurance, lack of child care, mistrust in the medical system secondary to systemic racism, incarceration, inequitable food access, and immigration status are only a few of the systemic, structural factors that affect health care access and health outcomes. Throughout my clinical experience and extracurriculars in reproductive health, I have seen how these intersecting factors shape access, available “choices” for my patients, and the delivery of comprehensive reproductive health care. Reproductive health “choices” are inextricably tied to systems of power such as racism and capitalism that dictate what is accessible to my patients, making choice an illusion.

I question whether “patient-centered care” can exist when impacts of larger structural forces prevent provision of the care our patients need and desire. What does comprehensive pregnancy or contraception counseling look like when our patient’s options are limited by their socioeconomic context? For my uninsured patients who desire LARC (long-acting reversible contraception), how can I offer them the full spectrum of contraceptive or pregnancy options? When working with my first patients seeking contraception while unemployed, uninsured, and/or low-income, I documented these issues in their social history. However, these aspects of my patients’ lived experience directly restricted patient autonomy and choice, and the care I was able to offer them in that moment. For example, patients would tell me LARC would best fit their needs, and I would call other clinics and providers across the county to learn about sliding care options or financial assistance. Costs ranged from hundreds to thousands of dollars, which is unaffordable for my patients; economically coercing them into settling for a different form of contraception.

After these experiences, I considered how medical training can improve by both acknowledging these systemic factors exist and teaching students how to address them in the patient care setting. While we are trained on contraindications to contraception and abortion, how can we be comprehensively trained on the structural context in which our patients’ access is embedded? How can our history-taking improve to capture how broader systems of power impact our patients’ choices and their health outcomes? How can we ensure our patients have access to the reproductive health services they want and need and not just what is afforded to them because of racism and capitalism?  As my patients shared their social histories, I remember my empathetic statements like “that must be hard” or “I’m sorry” only making me feel better and not changing my accountability to my patient’s story. I craved more tools in my medical education toolkit to serve my patients’ needs, and expand reproductive access and choice as basic human rights that are not allocated to you based on manufactured structures of power. Our education must expand past question banks and practice tests that oftentimes utilize social qualifiers as proxies for specific medical diagnosis, and as buzzwords to ignorantly guide students to a diagnosis. I must actively relearn how systems of oppression are inextricably tied to my patient’s health outcomes and options and how to responsibly mobilize against those systems.

Truly providing “patient-centered care” means ensuring equal and affordable access across the full-spectrum of contraceptive and pregnancy options. As a medical student and future provider, I have social power to foster partnerships with and uplift the work of community organizers, and integrate them in the delivery of my patient care. I aim to cultivate radical partnerships deeper than conveniently collaborating to increase attendance at a school-sponsored health fair, clinic, or event. Through community events I’ve attended, I’ve learned how various social injustices have health consequences for my patients. I’ve also seen how communities come together to provide healthcare and healing outside of the medical system. Perhaps it’s time to redefine what it means to be a healer or health-care provider, surrender our power, and offer opportunities for community healers to form partnerships with us and for us to prioritize and uplift their work.

Throughout medical school, I have seen time and time again how my patients’ access to reproductive health care is not a function of individual choice, but rather an illusion of “choice” produced by systems of oppression and inequity. These systems contribute to the stark disparities in reproductive health care access across the country, further demonstrating the pathogenic role of social and economic injustice. As I pledge to “first, do no harm” as a future physician, ignoring these systems would have serious health implications and cause harm to my patients. Reproductive health access and reproductive choice cannot be separated from the broader context of inequity in which they are embedded. The reproductive justice framework that centers reproductive rights within the context of structural oppression and promotes radical coalition building must be prioritized by reproductive health providers. Reimaging the illusion of choice means we must move beyond our silos of medicine to organize to dismantle structural racism, capitalism and systems of oppression that afford choice to our patients both at our institutions and in our patient’s communities.


Acknowledgements: I would like to thank Dr. Sarah Stumbar, Chris Garcia-Wilde, Julie Heger, Ryan Schooley, and the MSFC Staff for helping with the edits and for their perspectives as well as my patients who shared their powerful stories with me and have had a profound impact on my understanding of the intersection of medicine and social justice. I also would like to acknowledge the work of the group of Black women who called themselves Women of African Descent for Reproductive Justice in the creation of reproductive justice in 1994. I want to thank reproductive justice organizations and activists for tirelessly advocating to dismantle systems of oppression and prioritizing the intersection of reproductive health and social justice. Finally, I would like to thank MSFC for providing me with tools, hands on experiences, and educational resources related to abortion and contraceptive care to further my medical education.