Book Project

Under Contract with University of Chicago Press

Gambling on Fertility: How Doctors and Patients Weigh Stratified Risks in Consumer Medicine

Fertility treatments work by increasing patients’ chances at getting pregnant; Raising the odds of conception, however, also usually means increasing the chance that the patient will become pregnant with more than one fetus. Due to their increased health risks, twins and higher order multiples have become the central medical and public health concern related to fertility treatments, but twins at least have remained an acceptable or desired outcome for most patients, who by and large are paying customers with a high degree of consumer power to dictate the course of their care. In this context, how do patients and fertility providers negotiate upping the odds of pregnancy without “going over,” come to a shared decision about this ambiguous risk, and how might this vary depending on the clinical context?

Through ethnographic observations at three fertility clinics with different positions in the field as well as over a hundred interviews with fertility specialists and patients, I use the case of twins as a byproduct of fertility treatments to argue that patients and doctors conceptualize pursuing fertility treatment as gambling, that is, as wagering resources on technologies and techniques with the hope of achieving the most successful outcomes with the fewest drawbacks. Treating medical decisions like a gamble made up of different options with corresponding risks allows fertility doctors and patients to temper the uncertainty of potentially life-changing processes with high emotional stakes. A gambling framing also facilitates managing the asymmetry between doctors and patients, by defining them as partners in the same game of chance. While patients are ostensibly in charge of choosing the strategy they will play, doctors retain their authority by presenting themselves as expert guides to the game’s rules and probabilities, and they limit the set of strategies available to play.

Clinics define this game of chance—its rules and best strategies—differently depending on their position in the field, which includes their resources and economic incentives, the typical patient-consumers they serve, and their medical philosophies. Thus, even among people who have all accessed fertility treatment, divergent ways of gambling, namely economizing or optimizing temporal, financial, and emotional resources, end up reproducing class differences in key life strategies plotted under economic constraint. Put simply, this book will transform how we think about reproductive decision-making by underlining the inequalities that undergird how patients and doctors weigh and negotiate reproductive risks.