Addressing Moral Distress After Dobbs v. Jackson Women's Health Organization : A Professional Virtues-Based Approach

"I'm supposed to be a helper": Spiritual distress of abortion providers after the Dobbs decision

Background

The Dobbs v. Jackson Women's Health Organization decision has undoubtably affected the practice of abortion providers nationally. We hypothesized that Dobbs has also impacted the ways in which providers experience meaning and purpose through their work, which are elements of spirituality.

Objective

We sought to describe the spectrum of spirituality of abortion providers and understand whether and how the Dobbs decision caused spiritual distress.

Study Design

For this qualitative study, we conducted video interviews with 26 abortion providers from 17 states between November 2022 and February 2023. States were classified according to the Guttmacher Institute classifications from most restrictive to very protective as of December 2022. Interviews included questions such as, "Can you describe your own sense of spirituality or spiritual identity?" and "How does your spiritual belief inform your response to the Dobbs decision?"

Results

Participants' states of practice were well-distributed across the abortion restrictive-protective spectrum. The majority of participants were spiritual, while less than half identified as part of an organized religion. Many participants felt a spiritual call or obligation to provide abortion care and 46% described abortion as a spiritual act for provider and/or patient. Most participants experienced spiritual distress (74%), including those practicing in states across the restrictive-protective spectrum. Of note, 92% of participants described their spirituality as helpful in coping with the effects of the fall of Roe v. Wade. Sources of strength included advocacy, agency, legislative work, and community; over half specifically cited the abortion provider community.

Conclusions

The Dobbs decision-and subsequent state-level abortion restrictions-impacts abortion providers by causing spiritual distress. While many abortion-restrictive laws are influenced by religious or spiritual beliefs, it is important to recognize that abortion providers are also spiritual individuals.

Cicero's universal law: a timeless guide to reproductive justice

Marcus Tullius Cicero's concept of "ius gentium," or universal law, provides a timeless framework for understanding and defending fundamental human rights, particularly in the context of reproductive freedom. Cicero distinguished between "ius gentium" and "ius civile," emphasizing that while civil law governs specific communities, universal law, rooted in natural reason, applies to all humanity. This philosophical foundation resonates with modern discussions on reproductive rights, where universal principles of justice and bodily autonomy are at stake. Enlightened by Immanuel Kant's notion of innate freedom, Cicero's philosophy challenges present day's US states' restrictive reproductive laws, which often contradict the universal principles of justice. Applying these concepts to contemporary issues, such as abortion rights, underscores the need to align civil laws with universal ethics, ensuring that individual freedoms are upheld against arbitrary state interventions. By advocating for policies that promote equitable access to reproductive healthcare, Cicero's vision of universal law remains a powerful tool for advancing human dignity and autonomy in modern society.

Respect for history: an important dimension of contemporary obstetrics and gynecology

"Those who cannot remember the past are condemned to repeat it." This maxim underscores the importance of historical awareness in medicine, particularly for obstetricians and gynecologists (ObGyns). ObGyns significantly impact societal health through their care for pregnant women, fetuses, and newborns, uniquely positioning them to advocate for health initiatives with lasting societal benefits. Despite its importance, the history of medicine is underrepresented in medical curricula, missing opportunities to foster critical thinking and ethical decision-making. In today's climate of threatened reproductive rights, vaccine misinformation, and harmful ideologies, it is imperative for ObGyns to champion comprehensive historical education. The history of medicine, particularly in relation to societal issues - such as racism, discrimination, genocides, pandemics, and wars - provides valuable context for addressing challenges like maternal mortality, reproductive rights, vaccine hesitancy, and ethical issues. Understanding historical milestones and notable ethical breaches, such as the Tuskegee Study and the thalidomide tragedy, informs better practices and safeguards patient rights. Technological advancements in hygiene, antibiotics, vaccines, and prenatal care have revolutionized the field, yet contemporary ObGyns must remain vigilant about lessons learned from past challenges and successes. Integrating historical knowledge into medical training enhances clinical proficiency and ethical responsibility, fostering innovation and improving health outcomes. By reflecting on historical achievements and their impacts, current and future ObGyns can advance the field, ensuring comprehensive and ethically sound approaches to patient care. This paper highlights the crucial role of historical knowledge in shaping modern ObGyn practices, advocating for its integration into medical education to address contemporary health challenges and ethical considerations.

"I am putting my fear on them subconsciously": a qualitative study of contraceptive care in the context of abortion bans in the U.S

BACKGROUND

Since the Dobbs vs. Jackson Women's Health Organization decision in June 2022, providers throughout the U.S. have been navigating the shifting legal landscape of abortion bans, which diminish the delivery of evidence-based healthcare. The Dobbs decision has had a detrimental impact on medical training, the physician-patient relationship, and provision of medical care. However, few studies have captured the effects on providers in adjacent fields, including contraceptive care. Our objective was to examine the impact of Dobbs on contraceptive care.

METHODS

We conducted semi-structured in-depth interviews (August 2022-July 2024), with 41 contraceptive healthcare providers across the US, with the majority (63%) in abortion restrictive states. We utilized deductive thematic analysis to assess providers' practice changes and experiences related to contraceptive services.

RESULTS

In reaction to the Dobbs decision, providers noted increased requests for contraception, especially for highly effective methods. Providers worried that certain methods, such as IUDs or emergency contraception, would become restricted, and mentioned advance provision of pills and other ways that they would try to ensure supplies. Providers also discussed that their patients were worried about threats to contraception, including for adolescents. Some expressed concern, however, that the abortion bans may prompt providers to overemphasize high-efficacy methods with directive counseling. Providers shared that it was stressful to practice in contexts of uncertainty, with shifting abortion policies affecting contraceptive care, including emergent needs such as providing contraceptive services to out-of-state patients before they go home. Several providers shared that they felt an increased importance of their role in their communities, and a deepened commitment to advocate for their patients.

CONCLUSIONS

Abortion restrictions profoundly impact providers' contraceptive counseling and care. The effects of Dobbs on providers and their clinical practices underscore providers' legally precarious position in today's reproductive health landscape. Attention to contraceptive access and person-centered care has become a salient public health need across the U.S. The long-term impacts of limited reproductive rights may stretch an already under-resourced healthcare system and further emphasize moral pressures.

Teaching Moral Courage & Rights-Based Leadership in Medicine: A Cross-Disciplinary Exploration

Clinical medicine's complexities and demands often surpass the scope of formal ethics and leadership training that medical schools and residency programs provide. The discrepancy between medical education and the realities of clinical work may contribute to ethical erosion among learners, namely, medical students and residents. Unlike traditional approaches to teaching professional ethics and leadership in medicine, rights-based (aspirational) pedagogies approach trainees as autonomous moral agents, whose work has moral value to themselves and others, who live with the ethical consequences of their professional choices, and whose work shapes their individual moral character. By incorporating teaching strategies that intentionally build learners' rights-based leadership through the development of moral courage, medical educators may counter important aspects of ethical erosion while promoting learner preparedness, outcomes, and well-being. Military teaching approaches offer a valuable example to medical educators seeking to create structured curricula that foster moral courage to promote rights-based leadership, given the high level of moral and managerial complexity present in both medicine and the military. Through a comparative analysis of professional ethics in the medical and military disciplines, this Observation article explores the validity of applying precedents from military ethics and leadership education to medical training. Through arguments rooted in moral philosophy, military history, and military organizational research, we explore the expansion of rights-based teaching methods within the predominantly traditional and rules-based norms of medical education. In relating these findings to real-life clinical scenarios, we offer six specific, rights-based modifications to medical ethics curricula that have potential to promote morally courageous leadership and counteract the ethical erosion medical students and residents face.

The importance of professional responsibility and fetal viability in the management of abortion

In June 2022, the Dobbs v. Jackson Women's Health Organization Supreme Court decision ended the constitutional right to the professional practice of abortion throughout the United States. The removal of the constitutional right to abortion has significantly altered the practice of obstetricians and gynecologists across the US. It potentially increases risks to pregnant patients, leads to profound changes in how physicians can provide care, especially in states with strict bans or gestational limits to abortion, and has introduced personal challenges, including moral distress and injury as well as legal risks for patients and clinicians alike. The professional responsibility model is based on the ethical concept of medicine as a profession and has been influential in shaping medical ethics in the field of obstetrics and gynecology. It provides the framework for the importance of ethical and professional conduct in obstetrics and gynecology. Viability marks a stage where the fetus is a patient with a claim to access to medical care. By allowing unrestricted abortions past this stage without adequate justifications, such as those concerning the life and health of the pregnant individual, or in instances of serious fetal anomalies, the states may not be upholding the equitable ethical consideration owed to the fetus as a patient. Using the professional responsibility model, we emphasize the need for nuanced, evidence-based policies that allow abortion management prior to viability without restrictions and allow abortion after viability to protect the pregnant patient's life and health, as well as permitting abortion for serious fetal anomalies.