Column: Dobbs decision spurs moral injury to abortion patients, providers alike

On June 24, 2022, the landscape of reproductive healthcare in this country took a frightening turn for the worst. The Supreme Court decision in Dobbs v Jackson Women’s Health Organization that overturned what had previously been a constitutional right to abortion set off a whirlwind of changes in healthcare – not only as related to abortion, but also many aspects of pregnancy and other areas of reproductive care.

The status of abortion rights in this country is bleak and ever-changing, leading to immense uncertainty and confusion, among patients and providers alike. The fact that medical care is being dictated by legislators, most of whom are not healthcare providers, also results in legal confusion and uncertainty about how to comply with new rules and regulations. It has become common for patients to ask, even at the time of their abortion appointments, if on that day, it is still legal to have an abortion. We have seen patients who have had appointments canceled days or even hours before their appointments due to rapidly changing laws and legislation.

Healthcare providers face similar confusion also. We are now having to constantly wonder if the evidence-based, standard of care we know we should provide to our patients is, in that moment, legal and/or if it fits within the narrow yet often vague confines of poorly written legislation. We are having to call our hospital and clinic attorneys, consult with ethics committees, and at worst times, turn patients away or defer care.  Some are even unable to refer or transfer patients elsewhere for care due to concerns for repercussions of “aiding and abetting”. As physicians, we completed numerous years of education and training in order to take care of patients. We did not go to medical school and complete residency training to find ourselves spending hours in meetings with lawyers about patient care, but that is what hundreds of doctors have had to do over the last year since the Dobbs decision has allowed states to further interfere with reproductive healthcare.

The past year has felt somehow simultaneously long and grueling as well as one that has moved at lightning speed with constant blindsides of legislative restrictions, court cases, and worst of all, tragic stories of patient suffering. Abortion is now completely banned in 13 states, numerous other states have enacted new laws with extremely strict restrictions, and on a federal level there are ongoing attempts to revoke the FDA’s approval of mifepristone, one of two drugs in the most common medication abortion regimen in the United States.

In a post-Roe United States, the effects of each state’s abortion policy extends beyond its borders, with broad reaching impacts on abortion access regionally and even nationally. Here in North Carolina, we have seen firsthand the effects of increasing abortion bans and restrictions in many of our neighboring states, and much of the southeast region.  As reported by the New York Times, the “Fall of Roe Turned North Carolina Into an Abortion Destination”.  The Society of Family Planning’s #WeCount project, a national abortion reporting effort that aims to capture the shifts in abortion access, reports that the average difference in abortions post-Dobbs in North Carolina has been an increase of 881 abortions per month, ranking us 3rd of the states with the greatest increase. We now commonly see desperate patients from states like Tennessee, Georgia, and Florida as a direct result of their respective abortion bans.

Come July 1, NC will no longer be a refuge for those in dire need for basic healthcare, and for doctors who wish to practice in a state that respects the medical profession. Our new abortion ban restricts abortions prior to 12 weeks with medically unnecessary barriers and bans most abortions after 12 weeks. It became law on May 16th, a short 14 days after the public and most members of the legislature were first able read the bill that was introduced late in the night on May 2.

Just two weeks. That’s a shockingly short window of time for any bill to become law, let alone a 46-page monster bill that so negatively affects the practice of medicine. The NC Medical Society, NC Society of OBGYNs, and the NC Academy of Family Physicians are all against the law. The bill did not go through the typical process of vetting and debate which is how confusion over vague wording, contradictions, and uncertain intersections with other laws ended up as statute. And now we are having to do our best to interpret what the law says so that we are not criminally charged or do not lose our licenses for providing the best evidence-based medicine to our patients. A lawsuit filed on June 16th by NC healthcare professionals highlights a few of the most egregious aspects of the law, but even a successful outcome there will not stop most of the law’s harmful effects.

So what are the consequences of these hastily passed, poorly drafted, medically dangerous laws? Patients are unable to receive the best possible care, or at times any care at all.  Doctors have to choose between medical malpractice and criminal prosecution. Some patients who can come up with transportation and hotel costs, childcare, and time off work are forced to become healthcare refugees when they have to  leave their own state for less restrictive states. There will also be many who are unable to jump through the hoops and travel to access care, therefore being forced to carry a pregnancy against their will or resort to self-managed abortion (a safe option in some situations but not one that is universally preferred.).

Medical professionals are burned out by the moral injury of turning patients away, and soon new abortion ban states like North Carolina are no longer desirable places to practice medicine. OBGYN applications are down 10% in abortion ban states, and that is only the beginning of this phenomenon. Doctors and medical students look for other places to practice when state politicians interfere with the practice of medicine. This healthcare provider shortage goes far beyond abortion care. Family physicians and OBGYNs providing abortion care often do so as a part of their practice. We also provide prenatal care, deliver babies, and serve as primary care providers. When we move away, those services become harder to find. Maternity care deserts grow, the struggle to find a PCP for diabetes and hypertension care becomes even more difficult, and overall accessibility to high quality, full scope medical care suffers. These harmful laws need to be repealed. Leave the practice of medicine to healthcare professionals, not politicians.