For doctors, abortion restrictions create an 'impossible choice' when providing care

Now that the Supreme Court has overturned Roe v. Wade, medical ethics experts say many physicians will be caught in a bind: unable to fulfill their professional obligations to provide care to their pregnant patients because of state laws that forbid it.

Physicians take an oath to "do no harm" as part of their medical training. They learn about how to stay up to date, throughout their careers, on the best standards of care for treatment. And they learn about patient privacy and safety, and how patients should have a say in their care based on their values and lived experience.

"The goal is for a patient to make a decision for themselves about what's right," says Dr. Stephanie Mischell, a family physician in Dallas who is a fellow with Physicians for Reproductive Health.

But too often, Mischell says, the conversations she has with pregnant patients have less to do with their values and health and more to do with navigating a labyrinth of legal requirements. "There's a running list of different types of restrictions and bans that exist on abortion care, whether it's pre-viability bans, mandatory waiting periods, mandatory counseling, bans on telehealth – Texas really has all of them," she says.

Under the 6-week abortion restriction in Texas, many patients don't know they're pregnant early enough to get a legal abortion. "Every single day I have a conversation with a patient in which I say, 'Abortion would be a really safe and valid option for you and I'm so sorry that I can't do it here,' " she says.

Two dozen medical groups, including the American Medical Association and the American College of Obstetricians and Gynecologists, laid out the ethical dilemma faced by physicians in an amicus brief to the Supreme Court in the case Dobbs v. Jackson: "The ban forces clinicians to make an impossible choice between upholding their ethical obligations and following the law," the brief reads.

That "impossible choice" has already been a feature of reproductive health care in the South for years, says Dr. Louise King, an obstetrician and gynecologist at Brigham and Women's Hospital in Boston, who's also an attorney and ethicist. "It's just going to get much, much worse," she says.

"Laws will exist that ask [physicians] to deprioritize the person in front of them and to act in a way that is medically harmful. And the penalty for not doing so will be loss of license, money loss, potentially even criminal sanctions," King explains. "How can you possibly resolve that conflict?"

Watching patients get 'sicker and sicker'

Clinicians in states with abortion restrictions that have just gone into effect – or will imminently – are racing to understand the exact outlines of the restrictions in cases where complications arise in pregnancy.

"It's very frightening and confusing for physicians and the whole team that cares for patients to know, what can we do, what is OK and what's not OK?" says Dr. Lisa Harris, an ob-gyn and professor at the University of Michigan who joined a university task force last December to prepare for Roe to be overturned. She wrote about their work for the New England Journal of Medicine in May, and her arguments were cited in the Dobbs dissent.

She has been puzzling over the language in Michigan's decades-old abortion law – currently on hold – which makes abortion a felony except when it "shall have been necessary to preserve the life of such woman." A variation of that language is included in most abortion restrictions in other states.

"How imminent must death be?" Harris asks. "There are many conditions that people have that when they become pregnant, they're OK in early pregnancy, but as pregnancy progresses, it puts enormous stress on all of the body's organ systems – the heart, the lungs, the kidneys. So they may be fine right now – there's no life-threatening emergency now – but three or four or five months from now, they may have life-threatening consequences."

So, she asks, does the language in these laws allow for abortion early in pregnancy if a life-threatening complication could arise later?

If not, the laws put both the physician and patient in the position of just standing there to "watch somebody get sicker and sicker and sicker until some point – and where is that point? – where it's OK to intervene and we won't be exposed to criminal liability," says King, who is vice chair of ACOG's Committee on Ethics.

Cancer diagnoses raise questions as well, Harris says. "There are some cancers that the hormones of pregnancy make grow and spread faster, and people will choose to end a pregnancy because of that or because the treatment that their oncologist is recommending would be toxic or potentially lethal to a developing baby," she says.

If abortion is not an option in their state, then must they carry their pregnancy to term and delay treatment? "That might mean their cancer is more serious and more widespread than early in the pregnancy, and so they may indeed have a higher risk of dying, but it's not a risk that's going to happen immediately – it might be a recurrence in months or years."

If Michigan's abortion ban does take effect, Harris also wonders if it would be legal for her to prepare patients to receive abortions out of state by doing bloodwork and ultrasounds in Michigan.

Even for providers in states where abortion is reliably legal, like King in Massachusetts, there are legal and ethical questions. "Let's say that I'm providing abortion care to persons that I know that are traveling to me from out of state – does that mean then that I can't travel, for example, to Texas?" she asks.

"Nobody has the answers right now, and my fear is that the fear that doctors and nurses and health care administrators and leaders will feel – their fear of intervening – will mean that some patients will die when they didn't need to," says Harris.

Caption

A 33-year-old mother of three from central Texas is escorted down the hall by a clinic administrator prior to getting an abortion in October of 2021 at Hope Medical Group for Women in Shreveport, La. / AP

Messiness and fear in the months to come

The path to clarity on these questions is itself unclear.

"They could be resolved by a legislature trying to engage in more specificity, which they will not do," predicts Kim Mutcherson, co-dean of Rutgers Law School whose scholarship focuses on bioethics and reproductive justice. In places where abortion is illegal, legislators will broadly "want to make it as difficult as possible, and one of the ways that you do that is [by] creating a standard where people don't know with specificity whether what they're doing is right or wrong."

Instead, she says, "You have to wait until somebody gets in trouble. You have to wait until there's a case. You have to wait until somebody gets arrested. And then you start to understand, 'OK, this is what the parameters are.'" Clarity through the court system is likely to take months, if not years.

In the meantime, Dr. Amy Addante, an ob-gyn based in Illinois who's also a fellow with Physicians for Reproductive Health, suspects the new legal restrictions on abortion will have a chilling effect on health care institutions and medical providers. "From a medical malpractice and legal standpoint, I think a lot of health care systems, and even individuals, are going to be very risk averse," she says.

"I'm scared for my colleagues who are providing [obstetrical care] in these states where they can't just make medical decisions based on good clinical judgment and evidence, but also have to consider 'What is the law?'" she says. In most medical schools and residencies "there is no class on 'How to make sure what you're doing is legal in obstetrics,' " she adds.

"I have no interest in going to jail – I did not go to medical school to go to jail," Dr. DeShawn Taylor, an ob-gyn who provides abortions in Arizona told NPR in May. Arizona is one of many states with an abortion ban that could be enforced if Roe is overturned.

"I'm just going to be honest – I don't have the complexion to assume the risk and say, slap my hand later. We see the [pregnant] people who have been criminalized already – they have not been white," she said. "So I have no illusions about where I stand on the issue and what type of risk I can take and not take."

King says, from an ethical standpoint, "I can only help patients if I keep my license, so if you're a utilitarian, you'll say, 'Well, the greater good demands that I just comply with these laws because if we all get our licenses taken, there'll be nobody to care for anyone,' " she explains.

With all of this uncertainty, how things actually play out may depend on what jurisdiction you're in, says Harris. "I think it's just going to be profoundly local," she predicts – state by state or even county by county. "You'll see some prosecutors in some counties will say, 'I'm not prosecuting this, it doesn't break the law,' or 'I don't want to enforce the law.' "

"It's going to be very messy," she adds.

Physicians and medical groups didn't always champion abortion

Doctors played a key role in the movement to outlaw abortion in the U.S. in the 1860s – specifically, doctors who were members of the American Medical Association. Today's AMA has become increasingly vocal in support of abortion rights. A few years ago, it sued North Dakota over an abortion ban.

In a statement released Friday, AMA President Dr. Jack Resneck Jr. condemned the Dobbs ruling and said it is "a direct attack on the practice of medicine and the patient-physician relationship, and a brazen violation of patients' rights to evidence-based reproductive health services." He also said the AMA would fight these restrictions, which may signal more legal action from the group on abortion.

Former AMA president Dr. Gerald Harmon told NPR in early June that the AMA hasn't surveyed its 270,000 dues-paying doctors about abortion specifically — and he says individual physicians may have religious or conscience-based objections to abortions — but as an organization, the AMA is united in fighting excessive government intrusions into medical care.

"We speak with one voice against government – politicians and lawyers and judges – in the exam room, whether it's maternal fetal medicine, women's reproductive health, gender [identity] medical treatments," he said. "We need to be more outspoken and protect our ability to perform medically appropriate safe abortions and be able to teach that."

Not all physicians subscribe to this view, nor do they see physicians as having an ethical conflict when treating patients in places that restrict abortion. In fact, the American Association of Pro-Life Obstetricians and Gynecologists filed its own amicus brief to the court enumerating the risks of abortion and saying opposition among doctors is part of the medical tradition. "In declining to perform abortions, doctors are keeping with the longstanding tradition of their profession. Abortion has been deemed contrary to sound medicine for thousands of years," the brief reads.

But most medical groups and journals defend access to abortion as a legitimate and safe health care option, especially in recent weeks. "The fact is that if the US Supreme Court confirms its draft decision, women will die. The Justices who vote to strike down Roe will not succeed in ending abortion, they will only succeed in ending safe abortion. Alito and his supporters will have women's blood on their hands," the Lancet editorial board wrote in May.

King says physicians, hospitals and medical groups haven't always spoken "loudly enough" in defense of abortion. "I've always been outspoken, but I'm in the minority," she says. "Typically, hospitals are not vocal about providing abortion care because they don't want to invite controversy and protests on the street. That makes sense – we don't want to disrupt patient care," she says.

But the country has reached a tipping point, she argues. Abortion providers like her "should all be very proud of the care that we provide and very vocal about how we all believe it to be essential health care."

Pien Huang contributed to this reporting.

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