Professional Civil Disobedience - Medical-Society Responsibilities after Dobbs

Post-Roe v Wade psychiatry: legal, clinical, and ethical challenges in psychiatry under abortion bans

In recent history, the world has witnessed a trend towards liberalization of abortion laws driven by an increasing understanding of the negative personal and public health consequences of criminalizing abortion. By contrast, several countries have recently implemented restrictive reproductive laws, joining the 112 countries where access to abortion care is banned completely or with narrow exceptions. On June 24, 2022, the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization overturned its landmark decisions in Roe v Wade that established abortion until the point of viability of the fetus as a constitutional right. After Roe v Wade having been overturned, it is projected that many women in the USA will be prevented from accessing safe abortion care. Importantly, abortion bans not only impose constraints on patient autonomy, they also restrict physicians' ability to practice evidence-based medicine, which will negatively impact psychiatric care. It is therefore crucial for the practicing psychiatrist to be familiar with this new legal landscape. In this Personal View, we aim to provide a topical overview to help clinicians gain a clear understanding of legal, clinical, and ethical responsibilities, focusing on the USA. We also discuss the reality that psychiatrists might be called upon to determine medical necessity for an abortion on psychiatric grounds, which is new for most US psychiatrists. We predict that psychiatrists will be confronted with very difficult situations in which lawful and ethical conduct might be incongruent, and that abortion bans will result in greater numbers of patients needing psychiatric care from a system that is ill-prepared for additional demands.

How Can Newborn Toxicology Testing Be More Equitable? An Interactive Ethics Workshop

Introduction

Practice variation in newborn toxicology testing during the birth hospitalization exists across institutions and legal jurisdictions. While testing can provide benefits, indiscriminate testing has been shown to perpetuate health care inequities. In the backdrop of an opioid epidemic and a charged medicolegal landscape, this workshop guides participants to reexamine newborn toxicology testing through a shared ethical lens.

Methods

We conducted a live, 90-minute workshop in English at an international pediatric conference. Physicians, residents, and fellows participated in large- and small-group breakout sessions to learn relevant clinical and bioethical frameworks, share their own local context and expertise, and explore ethical applications through case-based discussions. We administered two anonymous online follow-up surveys to assess self-perceived impact on participant knowledge, behavior, and clinical practice.

Results

Seven facilitators and 45 individuals participated in the workshop. Eighteen participants completed survey 1 immediately following workshop conclusion, and six participants completed survey 2 after 3 months had elapsed. Immediately following the workshop, 94% of respondents reported that they had been introduced to a new idea, and 82% were considering practice change. A low response rate to survey 2 limited interpretation, but some respondents reported self-perceived change following workshop attendance.

Discussion

This workshop facilitated conversation between physician participants on a complex pediatric health care inequity issue using an ethical framework.

Principled Conscientious Provision: Referral Symmetry and Its Implications for Protecting Secular Conscience

"Conscientious provision" refers to situations in which clinicians wish to provide legal and professionally accepted treatments prohibited within their (usually Catholic) health care institutions. It mirrors "conscientious objection," which refers to situations in which clinicians refuse to provide legal and professionally accepted treatments offered within their (usually secular) health care institutions. Conscientious provision is not protected by law, but conscientious objection is. In practice, this asymmetry privileges conservative religious or moral values (usually associated with objection) over secular moral values (usually associated with provision). In this article, we first argue for a legal right to one kind of conscientious provision: referral for procedures prohibited at Catholic hospitals. We then argue that a premise in that argument-the principle of comparably trivial institutional burdens-justifies legal protections for some additional forms of conscientious provision that include, for example, writing prescriptions for contraception or medical abortions. However, this principle cannot justify legal protections for other forms of conscientious provision, for instance, the right to perform surgical abortions or gender-affirming hysterectomies at Catholic hospitals.

Conscientious commitment, professional obligations and abortion provision after the reversal of Roe v Wade

We argue that, in certain circumstances, doctors might be professionally justified to provide abortions even in those jurisdictions where abortion is illegal. That it is at least professionally permissible does not mean that they have an all-things-considered ethical justification or obligation to provide illegal abortions or that professional obligations or professional permissibility trump legal obligations. It rather means that professional organisations should respect and indeed protect doctors' positive claims of conscience to provide abortions if they plausibly track what is in the best medical interests of their patients. It is the responsibility of state authorities to enforce the law, but it is the responsibility of professional organisations to uphold the highest standards of medical ethics, even when they conflict with the law. Whatever the legal sanctions in place, healthcare professionals should not be sanctioned by the professional bodies for providing abortions according to professional standards, even if illegally. Indeed, professional organisation should lobby to offer protection to such professionals. Our arguments have practical implications for what healthcare professionals and healthcare professional organisations may or should do in those jurisdictions that legally prohibit abortion, such as some US States after the reversal of Roe v Wade.

Navigating the post-Dobbs landscape: ethical considerations from a perinatal perspective

Restrictive abortion laws have impacts reaching far beyond the immediate sphere of reproductive health, with cascading effects on clinical and ethical aspects of neonatal care, as well as perinatal palliative care. These laws have the potential to alter how families and clinicians navigate prenatal and postnatal medical decisions after a complex fetal diagnosis is made. We present a hypothetical case to explore the nexus of abortion care and perinatal care of fetuses and infants with life-limiting conditions. We will highlight the potential impacts of limited abortion access on families anticipating the birth of these infants. We will also examine the legally and morally fraught gray zone of gestational viability where both abortion and resuscitation of live-born infants can potentially occur, per parental discretion. These scenarios are inexorably impacted by the rapidly changing legal landscape in the U.S., and highlight difficult ethical dilemmas which clinicians may increasingly need to navigate.

Beneath the Sword of Damocles: Moral Obligations of Physicians in a Post-Dobbs Landscape

Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them.

Current Challenges for Conscientious Objection by Physicians in Spain

The College of Physicians of Madrid organized an open debate on conscientious objection (CO) in the medical profession on September 14, 2022. We summarize here the main arguments discussed. CO is defined as the right to raise exceptions to the performance of legal duties when they involve a contravention of personal convictions, whether religious, moral, or philosophical. It is not insubordination. Some authors contend that any decision by elected authorities should be uniformly followed by all citizens, physicians not being an exception. However, suppressing the ethical dimension of medical care may have an unacceptable cost with harm to physicians, their patients, and ultimately society. Health professionals are not blind instruments or mere "executors." The practice of medicine must follow the aim of the profession, namely the pursuit of the patient's good. Medical care must conform to medical ethics, which was first defined twenty-five centuries ago in the Hippocratic oath, and summarized with the triad of precepts "cure, relief, accompaniment." Since then and particularly in light of the Nuremberg trials, most medical declarations have highlighted the duty of defending human life and the importance of CO. In modern societies, there may be medical services that are not health care, even if they are legal. Then, which comes first law or ethics? Ultimately, CO is the tool that protects the freedom of the physician to refuse to perform actions that go against the values of medical ethics. With respect to the recent Spanish laws on abortion, euthanasia, and sex re-assignment of minors, if administrators want to know who is available for a health service that raises issues of conformity to medical ethics, requesting a list of volunteers is preferable to producing an objector list. Asking for registration of conscientious objectors goes against the right to privacy and is coercive, intrusive, and abusive.

Ethics, Abortion Access, and Emergency Care Post-Dobbs: The Gray Areas

Clinical management of emergency pregnancy care, such as ectopic pregnancy or heavy bleeding with pregnancy of unknown location, includes upholding legal and ethical standards. For health care providers unwilling to provide evidence-based life-saving abortion care due to personal beliefs, clear guidance dictates disclosure of these limitations to the patient and colleagues, followed by immediate referral for appropriate care. However, this decision-making pathway may not be engaged due to a variety of factors: providers' beliefs preclude adherence to referral responsibilities, political discourse confuses patients as to their options and rights, and a constantly changing state and national legal landscape leads providers to question their ability to practice to their full scope of clinical care. Although this disruption of evidence-based standard of care existed pre-Dobbs, the moral disorder is now heightened. This Clinical Rounds highlights a patient vignette describing the risks of abortion restrictions for patients and providers alike, particularly when an individual provider's concerns for violating institutional guidelines sets a precedent for nursing response and forecloses on collaborative input or ethics consultation. The history of physician-only abortion exceptionalism and exclusion of nurses and midwives despite a significant history of nurses and midwives in abortion care grounds an argument for focusing on the impact of unethical and substandard care on the interprofessional care team leading to moral distress and negative patient outcomes. Patient-centered models of care, such as frameworks common in nursing and midwifery, offer opportunities to consider how all providers practicing to their full scope in interprofessional and collaborative ways, such as in emergency rooms and labor departments, might mitigate obstructions to abortion care that risk pregnant people's lives.

Counseling for the option of termination of pregnancy for severe fetal anomalies in light of the recent Supreme Court ruling to remove the constitutional right to an abortion

A birth defect is a structural or chromosomal change present at birth that can affect almost any part or parts of the body. Birth defects can vary from mild to severe. On June 24, 2022, with its Dobbs v Jackson Women's Health Organization decision the Supreme Court of the United States overturned Roe v. Wade, removing the longstanding landmark 1973 ruling that secured a person's constitutional right to an abortion. With this decision individual states can now decide their own abortion laws. In about one-half of the states that continue the legality of pregnancy termination, the process of offering, discussing, and performing terminations of pregnancy remain the same as previously. In states where abortions are not legal, there will be conflicts between the law and the ethical responsibility of physicians to offer and discuss termination of pregnancy for severe anomalies.

ASCO Ethical Guidance for the US Oncology Community Where Reproductive Health Care Is Limited by Law

The decision in Dobbs v Jackson Women's Health Organization overturned federal protections for abortion rights, making way for states to enact abortion bans with or without exceptions for the health or life of the pregnant patient. Patient care across many areas of medicine including oncology continues to be affected. Although the change in the legal landscape is widely felt, the core ethical considerations for physicians do not change because of restrictions on the practice of medicine. ASCO offers this guidance to assist US oncologists and institutions who must balance limitations with established ethical duties. This paper articulates principles for cancer care and pregnancy, offers a framework for ethical reflection and action for oncologists who care for pregnant patients, and makes recommendations for individual and institutional action to support evidence-based, patient-centered care in the United States where abortion is illegal or access is limited.

Dobbs, the Intrusive State, and the Future of Solidarity

The intrusive state has long viewed women as fetal containers. The Dobbs decision goes further, essentially causing women to vanish when fetuses are abstracted from their relationships to pregnant persons. The ways in which women are first controlled and then made invisible are clearly connected with the move from obedience to omission that has historically affected black Americans. When personal decisionmaking and participation in democracy are regarded as threats, those threatened restrict decisional freedom and political power, deepening structural injustices relating to sex, race, and poverty. Fear of Dobbs has health effects on conditions unrelated to pregnancy and connects with erasures of human value that are not health-related. We reaffirm solidarity as a countering influence. Taking account of the richly relational context in which issues like abortion and political representation arise should lead to better, more meaningful policies, making so many people impossible to unsee.

Abortion: Perspectives from an APA Past-President

The United States Supreme Court's decision in Dobbs v. Jackson Women's Health Organization, eliminating the national right to abortion, poses challenges to psychiatrists and patients. Abortion laws now vary widely from state to state and are constantly changing and being challenged. The laws affect both patients and health care professionals; some prohibit not only the performance of abortion but efforts to inform and assist patients seeking abortion. Patients may become pregnant during and/or because of episodes of clinical depression, mania, or psychosis, and recognize that their current circumstances will not allow them to become adequate parents. Some laws allowing abortion to protect a woman's life or health explicitly exclude mental health risks; many prohibit transfer of a patient to a permissive venue. Psychiatrists working with patients contemplating abortion can convey the scientific evidence that abortion does not cause mental illness and help them identify and work through their own beliefs, values, and likely responses to the decision. Psychiatrists will also have to decide whether medical ethics or state laws will govern their own professional behavior.

Policy Changes as a Context for Moral Injury Development in the Wake of Dobbs v Jackson Women's Health Organization

The U.S. Supreme Court's 2022 ruling in Dobbs v Jackson Women's Health Organization held that the U.S. Constitution does not confer the right to an abortion, which set into motion an overhaul of reproductive health care services in certain states. Health care professionals are now operating within a rapidly changing landscape of clinical practice in which they may experience conflict between personal and professional morals (eg, bodily autonomy, patient advocacy), uncertainty regarding allowable practices, and fear of prosecution (eg, loss of medical license) related to reproductive health care services. The ethical dilemmas stemming from Dobbs create a context for exposure to potentially morally injurious events, moral distress, and moral injury (ie, functional impairment stemming from exposure to moral violations) among health care professionals. Considerations related to clinical intervention and approaches to policy are reviewed. Early identification of health care professionals' potentially morally injurious event exposure related to restricted reproductive services is critical for preventing and intervening on moral injury, with implications for improving functioning and retention within the medical field.

Protecting reproductive health information in the post-Roe era: interoperability strategies for healthcare institutions

On June 24, 2022, the US Supreme Court ended constitutional protections for abortion, resulting in wide variability in access from severe restrictions in many states and fewer restrictions in others. Healthcare institutions capture information about patients' pregnancy and abortion care and, due to interoperability, may share it in ways that expose their providers and patients to social stigma and potential legal jeopardy in states with severe restrictions. In this article, we describe sources of risk to patients and providers that arise from interoperability and specify actions that institutions can take to reduce that risk. Institutions have significant power to define their practices for how and where care is documented, how patients are identified, where data are sent or hosted, and how patients are counseled, and thus should protect patients' privacy and ability to receive medical care that is safe and legal where it is performed.

Legal Risks and Ethical Dilemmas for Clinicians in the Aftermath of Dobbs

This Viewpoint discusses the ways in which the Supreme Court’s ruling in Dobbs v Jackson Women’s Health Organization, which triggered abortion bans or restrictions in half of states, presents serious legal risks to clinicians and major ethical dilemmas.