On January 17th 2014, Catherine Eagles, a federal judge for the Middle District of North Carolina, struck down as unconstitutional a portion of North Carolina’s 2011 Women’s Right to Know Act. The portion in question would have required abortion providers in the state to perform an ultrasound and display and describe the images presented to every woman seeking an abortion. Eagles concluded that this so-called “speech-and-display provision” was “performative rather than informative” and therefore served no medical purpose. She determined this in part because the original text of the law suggested that women might choose not to look at these ultrasound images: “Nothing in this section shall be construed to prevent a pregnant woman from averting her eyes from the ultrasound images required to be provided to and reviewed with her.” In a 42-page memorandum outlining her decision, Eagles wrote, “Requiring a physician or other health care provider to deliver the state’s content-based, non-medical message in his or her own voice as if the message was his or her own constitutes compelled ideological speech and warrants the highest degree of First Amendment protection.”
Abortion rights advocates in North Carolina hailed the ruling as an important victory. Yet the remainder of the Women’s Right to Know Act still stands: women must receive counseling with specific, state-mandated information at least 24 hours prior to an abortion procedure. To comply with the law, then, an abortion provider must “deliver a content-based, non-medical message in his or her own voice.” In our ongoing project, we are examining how abortion providers in North Carolina have grappled with this legal mandate. We have been especially interested in the social, ethical, and communicative dimensions of scripted abortion counseling.
Scripts play a key role in anthropology and science and technology studies. Foundational concepts like cultural scripts and technological scripts reflect a disciplinary preoccupation with the ways in which certain domains of human social life are partially predetermined. Yet the potential for social actors to stray from the script to improvise new possibilities and create new modes of action is also embedded in these concepts. In other words, the very presence of any script implies its logical opposite: that we also speak and act in fundamentally unscripted ways. In this way, the script reflects longstanding tensions in contemporary theoretical debates—between structure and agency, determinism and emergence, constraint and possibility, compulsion and choice.
Scripts are ubiquitous in science and medicine. Hospital procedures, informed consent documents, experiment protocols, standardized therapies, and ultrasound technologies all rely on scripts to order work processes, guide thoughts, speech, and action, and specify roles and relationships. As institutionally authored documents, scripts enact and shape worlds by conveying the author’s intended meaning. Yet scripts do more than relay referential meaning. They also produce effects, sometimes unintended, through the ways that they are implemented and performed. Such productivity can help us to bypass the dualisms mentioned above and generate potential new sites of theoretical inquiry.
The script at play in state-mandated abortion counseling is a highly formalized version of a much broader techno-social category. Clinicians rely on various scripts in conversations with patients—for example, asking “What brings you in today?” A few things distinguish abortion counseling scripts from colloquial uses of scripts in medicine: their legally compulsory nature, their selection of particular speech elements, and their capacity to transform healthcare providers into agents of the state. The state, an amorphous political subject, has relatively little power to speak to citizens in everyday life. By compelling providers to speak its message, the state flips the script undergirding most clinical interaction.
Most abortion providers in our study found both the state’s intentions and the potential effects of the counseling script on patients to be objectionable. As one physician told us, “I find it very condescending. As if women aren’t being given proper informed consent or decision-making about their abortion care. While others, you know, like legislatures, are trying to take away their decision-making and autonomy.” Because of this disdain for the script, the many possibilities for undermining its content have been empowering and even liberating. Some providers prefaced the script with disclaimers and apologies. Others read the script “word by word” to show that the words were not their own. Still others set the script in front of the patient to distinguish it as a legal artifact that they viewed as falling outside of normal clinical practice. Each of these actions served to denounce authorship, disaffiliate speakers from the animated content, and invite patients not to listen. Several providers noted that such strategies had the unanticipated consequence of fostering patient-provider rapport, revealing a misalignment between perceived legislative intent and the script’s performance. This highlights how the rift between meaning and intent can cut both ways, working both for and against the author’s agenda.
In our study, providers routinely distinguished scripted abortion counseling from the informed consent procedures that they were already doing prior to the law. As an enumeration of the risks and benefits associated with clinical treatment, drug research, or specimen donation, informed consent also relies on scripts. Providers distinguished the scripts used in state-mandated counseling and clinical informed consent on the basis of whether the content was medically relevant and necessary to women’s informed decision-making. This difference is also implicit in Judge Eagles’ distinction between the performative (i.e. non-medically relevant) and informative functions of the search-and-display provision. In making this distinction, both Judge Eagles and our interlocutors attempted to frame the law as an illegitimate instance of script-flipping—that is, appropriating the language, format, and authoritative voice of informed consent for another purpose. Yet insofar as informed consent is both one of the most routinized scripts in medicine and a paradigmatic example of information delivery in healthcare, this distinction begins to break down. Informed consent assumes the genre of disclosure that many patients in the United States have learned to view as a legal performance, an institutional requirement necessary to move along one’s clinical care. In other words, informed consent procedures have both informative and performative dimensions. By distinguishing between state-mandated abortion counseling and standard informed consent procedures, the providers in our study reified informed consent as purely informative, neglecting the performative dimensions of this everyday scripted practice.
State-mandated abortion counseling is a specialized case of the use of scripts in medicine. Medicine relies on many other taken-for-granted and routinized scripts. One strength of the script for scholars of science and medicine is that it “reads” across the ethical and legal, as in the case of informed consent. In doing so, it shows how the medical and the legal are not separate professional domains but necessarily co-constituted.
Mara Buchbinder is Assistant Professor of Social Medicine and Adjunct Assistant Professor of Anthropology at the University of North Carolina at Chapel Hill. She is author of Saving Babies? The Consequences of Newborn Genetic Screening (with Stefan Timmermans, University of Chicago Press, 2013) and All in Your Head: Making Sense of Pediatric Pain (University of California Press, forthcoming, 2015). Dragana Lassiter is a PhD candidate in the Department of Anthropology at the University of North Carolina-Chapel Hill. She researches bioethics, regenerative medicine, and organ transplant in Serbia. They are grateful for insightful comments from Keith Murphy and Stefan Timmermans, and for the editorial suggestions of Commonplaces Editors Tomas Matza and Harris Solomon.
 For the full legislative text of the North Carolina Woman’s Right to Know Act, see http://www.ncleg.net/gascripts/BillLookUp/BillLookUp.pl?BillID=H854&Session=2011.
 For the full text of this memorandum, see http://dig.abclocal.go.com/wtvd/docs/utrasound_rluling_011714.pdf.
 This work has been supported by grants from the Society for Family Planning and the Greenwall Foundation, in collaboration with Rebecca Mercier, Amy Bryant, and Anne Drapkin Lyerly.
 Madeline Akrich, “The de-scription of technical objects, in Shaping Technology / Building Society. Studies in Sociotechnical Change. W. Bijker and J. Law, eds. (Cambridge, MA: MIT Press, 1992); and Stefan Timmermans, “Saving lives or saving multiple identities?: The double dynamic of resuscitation scripts,” Social Studies of Science, 26(4) (1996): 767–797.
Carr (2011, 191) suggests that script flipping is an example of what Bakhtin (1984) calls vari-directional double-voiced discourse, “in which one’s speech has a semantic intent contrary to that which one mimics.” See E. Summerson Carr, Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety (Princeton: Princeton University Press, 2011). See also Mihkail Bakhtin, Problems of Dostoevksy’s Poetics. C. Emerson, trans. and ed. (Minneapolis: University of Minnesota Press, 1984).
 Erving Goffman, Forms of Talk (Philadelphia, PA: University of Pennsylvania Press, 1981).
 Marie-Andrée Jacob, “Form-made persons: consent forms as consent’s blind spot,” Political and Legal Anthropology Review, 30(2) (2007): 249–268. doi:10.1525/pol.2007.30.2.249
Image: “Lacy Script, by Evelyn Flynt.” Flickr.