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

Addressing challenges related to the professional practice of abortion post-Roe

The landmark Roe vs Wade Supreme Court decision in 1973 established a constitutional right to abortion. In June 2022, the Dobbs vs Jackson Women's Health Organization Supreme Court decision brought an end to the established professional practice of abortion throughout the United States. Rights-based reductionism and zealotry threaten the professional practice of abortion. Rights-based reductionism is generally the view that moral or ethical issues can be reduced exclusively to matters of rights. In relation to abortion, there are 2 opposing forms of rights-based reductionism, namely fetal rights reductionism, which emphasizes the rights for the fetus while disregarding the rights and autonomy of the pregnant patient, and pregnant patient rights reductionism, which supports unlimited abortion without regards for the fetus. The 2 positions are irreconcilable. This article provides historical examples of the destructive nature of zealotry, which is characterized by extreme devotion to one's beliefs and an intolerant stance to opposing viewpoints, and of the importance of enlightenment to limit zealotry. This article then explores the professional responsibility model as a clinically ethically sound approach to overcome the clashing forms of rights-based reductionism and zealotry and to address the professional practice of abortion. The professional responsibility model refers to the ethical and professional obligations that obstetricians and other healthcare providers have toward pregnant patients, fetuses, and the society at large. It provides a more balanced and nuanced approach to the abortion debate, avoiding the pitfalls of reductionism and zealotry, and allows both the rights of the woman and the obligations to pregnant and fetal patients to be considered alongside broader ethical, medical, and societal implications. Constructive and respectful dialogue is crucial in addressing diverse perspectives and finding common ground. Embracing the professional responsibility model enables professionals to manage abortion responsibly, thereby prioritizing patients' interests and navigating between absolutist viewpoints to find balanced ethical solutions.

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.

Bridging the Knowledge Gap: A Toolkit on Reproductive Rights for Pediatric Surgeons in the Post-Dobbs Era

BACKGROUND

The ripple effect of the Supreme Court ruling in Dobbs v. Jackson Women's Health Organization has impacted physicians and patients across numerous medical specialties. In pediatric surgery, the patient population ranges from fetus to the pregnant patient. There is a gap in the knowledge of pediatric surgeons regarding abortion laws and access. This project aims to bridge the gap by creating access to reliable resources which may be used to optimize patient care and support physicians.

METHODS

We collaborated with the Reproductive Health Coalition, co-founded by the American Medical Women's Association and Doctors for America, to curate a list of resources beneficial to pediatric surgeons.

RESULTS

We created a web-based toolkit with the purpose of providing easily accessible and reliable information on reproductive rights in the United States. We identified up-to-date resources on state-by-state abortion laws, legal resources, patient-centered information on obtaining abortion care, and resources for physicians interested in getting involved in advocacy.

CONCLUSION

Pediatric surgery rests at a critical juncture with respect to reproductive rights in the United States. Our toolkit enables users to understand the current climate and identify next steps to advocate for patients and physicians amidst a formidable legal environment.

LEVEL OF EVIDENCE

Level V.

Prevalence of childfree adults before and after Dobbs v Jackson in Michigan (USA)

Childfree adults are the most common type of non-parent in the United States and are distinguished by their lack of desire to have children. Although there are many reasons one may choose not to have children, recent restrictions on reproductive health care may also contribute to this decision. For example, the United States Supreme Court's decision in Dobbs v. Jackson eliminated a long-standing constitutional protection for abortion access, which reduced patients' medical autonomy and increased the risks of pregnancy and childbirth, and therefore may have led adults to decide not to have children. In this study, we use representative data on Michigan adults immediately before and after the Dobbs decision to examine changes in the prevalence of childfree adults in this population. We find that 21% of Michigan adults were childfree before the Dobbs decision, but this number rose to nearly 26% after the decision. Controlling for demographic characteristics, a Michigan adult was 32.8% more likely to be childfree after the Dobbs decision than before. We conclude that when access to safe reproductive health care is uncertain or unavailable, adults that do not already have children may decide that they do not want children.

US Obstetrician-Gynecologists' Perceived Impacts of Post-Dobbs v Jackson State Abortion Bans

Importance

Following the Dobbs v Jackson Women's Health Organization decision in June 2022, 17 US states have functionally banned abortion except in narrow circumstances, and physicians found in violation of these laws face felony charges, loss of their medical license, fines, and prison sentences. Patient impacts are being studied closely, but less research has focused on the consequences for obstetrician-gynecologists (OB-GYNs), for whom medically necessary care provision may now carry serious personal and professional consequences.

Objective

To characterize perceptions of the impact of abortion restrictions on clinical practice, moral distress, mental health, and turnover intention among US OB-GYNs practicing in states with functional bans on abortion.

Design, Setting, and Participants

This qualitative study included semistructured, remote interviews with OB-GYNs from 13 US states with abortion bans. Volunteer sample of 54 OB-GYNs practicing in states that had banned abortion as of March 2023.

Exposure

State abortion bans enacted between June 2022 and March 2023.

Main Outcomes and Measures

OB-GYNs' perceptions of clinical and personal impacts of abortion bans.

Results

This study included 54 OB-GYNs (mean [SD] age, 42 [7] years; 44 [81%] female participants; 3 [6%] non-Hispanic Black or African American participants; 45 [83%] White participants) who practiced in general obstetrics and gynecology (39 [72%]), maternal-fetal medicine (7 [13%]), and complex family planning (8 [15%]). Two major domains were identified in which the laws affected OB-GYNs: (1) clinical impacts (eg, delays in care until patients became more sick or legal sign-off on a medical exception to the ban was obtained; restrictions on counseling patients on pregnancy options; inability to provide appropriate care oneself or make referrals for such care); and (2) personal impacts (eg, moral distress; fears and perceived consequences of law violation; intention to leave the state; symptoms of depression and anxiety).

Conclusions and relevance

In this qualitative study of OB-GYNs practicing under abortion bans, participants reported deep and pervasive impacts of state laws, with implications for workforce sustainability, physician health, and patient outcomes. In the context of public policies that restrict physicians' clinical autonomy, organization-level supports for physicians are essential to maintain workforce sustainability, clinician health and well-being, and availability of timely and accessible health care throughout the US.

Ethical research when abortion access is legally restricted

Risks and benefits of some clinical research may be altered.

The Impact of New and Renewed Restrictive State Abortion Laws on Pregnancy-Capable People with Diabetes

PURPOSE OF REVIEW

When the Supreme Court handed down its decision in Dobbs v Jackson Women's Health Organization in June 2022, the constitutional right to abortion was no longer protected by Roe v Wade. Fifteen states now have total or near-total bans on abortion care or no clinics providing abortion services. We review how these restrictions affect the medical care of people with pregestational diabetes.

RECENT FINDINGS

Of the ten states with the highest percent of adult women living with diabetes, eight currently have complete or 6-week abortion bans. People with diabetes are at high risk of diabetes-related pregnancy complications and pregnancy-related diabetes complications and are disproportionately burdened by abortion bans. Abortion is an essential part of comprehensive, evidence-based diabetes care, yet no medical society has published guidelines on pregestational diabetes that explicitly discuss the importance and role of safe abortion care. Medical societies enacting standards for diabetes care and clinicians providing diabetes care must advocate for access to abortion to reduce pregnancy-related morbidity and mortality for pregnant people with diabetes.

Southeastern US anesthesia providers' perspectives on abortion provision: inductive findings from a qualitative study

OBJECTIVES

Healthcare providers, including anesthesia providers, hold varied personal views on abortion, which influence their involvement in multidisciplinary abortion care. We aimed to explore Southeastern US anesthesia providers' perspectives on abortion provision and factors impacting their decision to provide anesthesia for hospital-based induced abortion.

STUDY DESIGN

We conducted in-depth, individual interviews with currently practicing anesthesia providers in the southeastern United States. We recruited participants from regional anesthesiology conferences and via snowball sampling. A semi-structured interview guide explored domains of obstetric experiences, standardized abortion cases, and personal abortion attitudes. We coded data iteratively and analyzed data thematically using inductive approaches with qualitative software.

RESULTS

Fifteen participants completed interviews, at which point thematic saturation occurred. Participants represented a range of provider type and prior abortion experience. Participants weighed 'personal and professional viewpoints' in considering their willingness to provide anesthesia care for hospital-based abortion. Many participants who personally disagreed with some abortion indications were still willing to provide anesthesia in those cases, some implicitly naming principles of medical ethics to justify differing professional and personal opinions. Participants also considered their 'role in abortion decision-making:' all participants reporting that the abortion decision belongs to the patient or their obstetrician and not the anesthesia provider.

CONCLUSIONS

Southeastern US anesthesia providers are influenced by multiple factors when considering their participation in hospital-based abortion care. Acknowledging differences in professional and personal viewpoints and identifying roles in abortion decision-making might be important to engaging anesthesia providers in abortion care, especially for high-risk medical or fetal indications.

IMPLICATIONS

This original, qualitative study identified several inductive themes that characterize how Southeastern US anesthesia providers formulate their level of participation in hospital-based abortion care. Acknowledging differences in professional and personal viewpoints and identifying roles in abortion decision-making might facilitate interdisciplinary abortion care, especially for high-risk medical or fetal indications.