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This column neither supports nor opposes abortion rights. It focuses solely on the adverse unintended consequences of restrictive state abortion laws and their exceptions affecting obstetrical practice.
Most abortion laws have exceptions, including preserving the mother’s life, preventing significant harm to the mother’s health, the presence of lethal fetal abnormalities, and pregnancies resulting from rape and incest.
Abortion-law exceptions often leave clinicians in impossible, confusing and uncertain situations attempting to practice appropriate evidence-based medicine while risking adverse consequences. Sanctions include loss of medical licenses, monetary fines, lawsuits and even imprisonment if doctors’ decisions are second-guessed and legally challenged as violating medical-exemption provisions. Physicians are trained to “First, do no harm.” They must follow accepted ethical standards, practice within “standard of care,” deliver care in “good faith,” and exercise “reasonable medical judgment.” These responsibilities are actually used in exemption language. How does one determine with certainty and objectivity that a medical decision was made consistent with these obligations?
Most exemptions are written broadly and are open to opinion and subjectivity. How ill must a mother be to qualify as being at risk of death or substantial and/or permanent morbidity? Must the risk be immediate or likely over time? What maternal conditions qualify if there is no list in the law? If there is a list, are other conditions excluded? These laws do not account for combinations of medical conditions that together become life-threatening. Some states have multiple bans with conflicting exception provisions, producing uncertainty and confusion. And there are unresolved conflicts between federal and state laws that place hospitals and doctors in “Catch-22” situations.
There is peril in exceptions being underdefined, and conversely, too specific. It’s impossible to create inclusive lists of qualifying conditions. In Texas, attempts to clarify vague exemptions with more detail resulted in only minimal improvements.
Recent articles give clinical examples. They include descriptions of patients who were refused emergency abortions because they were not sick enough or not bleeding enough, only to return in critical condition. A woman with a life-threatening ectopic pregnancy was refused treatment until it ruptured. Termination care was delayed in cases of inevitable miscarriage until serious predictable complications arose. In states with restrictive abortion laws, pregnancy-termination delays have even occurred in fetal demise cases, placing mothers at risk for severe complications.
A March of Dimes report found that one-third of U.S. counties do not have an obstetrical provider, and the situation is worsening. The fewest number of obstetrical providers are in states with restrictive-abortion laws.
During a General Assembly hearing, an obstetrician from Indiana University School of Medicine was testifying. She interacts with practicing obstetricians, medical students and residents. I publicly asked her, “Is it true that threats of legal sanctions arising from navigating abortion laws discourage medical school graduates from entering OB/GYN and prompt OB/GYNs to avoid practicing in abortion-restrictive states, leave practice early, or drop obstetrics and limit their practices to gynecology”? She answered without hesitation or qualification, “Yes.”
No one really has answers to these untenable situations. It’s impossible for a law to completely capture whether an exception applies. Second opinions and expert review panels would help, but these wouldn’t be realistic in situations demanding immediate action. Imagine doctors watching while patients grow sicker and sicker until the condition deteriorates to the point of the exception indisputably applying.
What are doctors to do?•
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Feldman is a family physician, author, lecturer and former Indiana State Department of Health commissioner for Gov. Frank O’Bannon. Send comments to ibjedit@ibj.com.
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