“I have always held [the view that] abortion is wrong, but have recently come to the decision … that it is my duty as a future [general practitioner] to ensure that I don’t make it any easier for a baby to have his or her life ended. This may mean telling a patient that in her case, an abortion is not justified legally, morally, or medically. This may mean not telling a patient which colleagues do and do not refer for [termination of pregnancies].”
–Philip Davies, Birmingham physician in a letter to the editor of Triple Helix, a Christian Medical Fellowship Publication
This summer, Illinois passed a law set to take effect in the beginning of this year that stipulated that any doctors who cite conscience-based objection to abortion must have a system in place to give information about or provide referrals to providers who will perform abortions. Of note, the law requires doctors to provide this information only when specifically asked for it by a patient. Doctors refusing to do so can be fined $10,000 or risk losing their medical license. The law’s aim was to ensure that “patient’s rights are not trampled on because of [doctors’] religious objections,” according to Assistant Attorney General Sarah Newman. The Alliance Defending Freedom, a conservative nonprofit legal organization, brought a case to court on behalf of a number of clinics that care for pregnant women and argued that the requirements outlined in the law impose on clinicians’ religious freedom and freedom of speech. In December, Illinois County Circuit Judge Eugene Doherty issued a temporary injunction in response to the case, meaning that, at least temporarily, the state cannot enforce the law against the doctors who filed the suit.
Illinois state lawyers argue that the requirements are essential to patients’ health, writing in a court filing that “patients generally believe that their doctors are telling them everything and therefore may not know that they should ask about additional treatment options.” Guidelines published by many international human rights organizations and health professional organizations largely align with the state’s arguments. The American College of Obstetricians and Gynecologists (ACOG) maintains that “while individuals may personally oppose abortion, they must not impose their personal beliefs upon patients nor impede women from accessing abortion services.” They cite physicians’ commitment to promoting patient safety and autonomy as the primary rationales for this stance.
The extent to which clinicians adhere to these guidelines in practice is variable, however, reinforcing the need for laws like the one in Illinois. A 2007 survey of U.S. physicians found that almost 30% of those who morally objected to a procedure did not feel professionally obligated to refer the patient. Clinicians at Catholic health care institutions (which account for almost 20% of all U.S. hospital beds), are bound by the Ethical and Religious Directive for Catholic Health Care, which caution physicians against “cooperation” in providing abortion services — terminology that some institutions interpret as including referrals and even basic information.
One 2011 study surveying 1800 U.S. OB/GYNs found that the willingness of the cohort who objected to abortion to refer women to other providers varied widely based on the context of the clinical encounter, including the reason why the woman sought abortion and what (if any) contraception she had used prior to pregnancy. A 2017 study in Contraception that posed hypothetical questions about abortion referrals to several hundred Nebraska family medicine and OB/GYN clinicians found that 41% of practitioners either would not provide any information at all to women seeking abortion or would provide information that the study authors classified as “misleading.” This “misleading” information included referring the patient to another doctor that did not provide abortions, a therapist, a social worker, or a crisis pregnancy center. These practitioners largely cited moral or religious objections as rationale for their refusal to provide information or referrals. One rural OB/GYN in the study remarked, “Morally, I have the obligation not to refer her.”
A common justification for this behavior was, as one rural family medicine physician cited in the study put it, “Patients wanting abortions don’t have any difficulty finding a clinic in the city.” Another practitioner said, “I don’t believe in abortion for religious reasons and feel uncomfortable assisting in this process. I think these services are easily accessible for patients on the Internet and in the phonebook.” In an op-ed in The Chicago Sun Times, physicians against the Illinois legislation argued, “In the age of Google and smartphones, it is lost on us how [the law] would provide any benefit to women. It’s even incredulous to think women aren’t intelligent enough to find an abortion clinic unless they receive assistance.” The clinics bringing the lawsuit against Illinois largely say the same, declaring that information about where to get abortions is freely and easily accessible elsewhere.
Frankly, the data does not support this claim. As abortion restrictions have increased dramatically in the past decade, resulting in closures of abortion clinics across the country, women are more and more likely to find themselves at a loss for where to go to access this legal service. Additionally, women contacting individual physicians are more likely than not to strike out — a 2011 study estimated that while 97% of OB/GYN physicians encounter patients seeking an abortion, only 14% actually provide the service.
The responses of the practitioners surveyed in Nebraska suggest that even they were often uncertain where patients could go to get abortions. At least one practitioner noted that he would refer women to a local crisis pregnancy center to receive an abortion, seemingly unaware that the facility did not offer the service. If trained practitioners can be mistaken about the nature of services crisis pregnancy centers provide, certainly patients can be as well. Indeed, analysis has shown that crisis pregnancy centers deliberately mislead women about the services they provide both online and over the phone. These centers often choose names similar to or locations nearby facilities that actually perform abortions. In short, finding facilities that provide abortion in this contentious environment is not that straightforward. This confusion has been shown to contribute to delays in access to care. In 2004, a study of 1,200 women who got an abortion found that 12% who would have preferred to have had the intervention earlier cited not knowing where to get an abortion as a key reason for the delay. This share rose to 16% when considering only women who got second term abortions.
Delays born of women’s inability to get information or referrals for abortions have real implications for women’s health and safety. Early abortions are preferable to later-term abortions by virtually all measures. Though abortion is a very safe procedure (a recent study found it much less risky than a tooth extraction), medical risks increase the later in pregnancy abortion is performed. In some circumstances, such as ectopic pregnancy, delaying abortion can be life threatening. Additionally, given the medical and legal regulations on abortions — medical abortions are only available until 10 weeks and all abortions must take place before 24 weeks barring a threat to the mother’s life — a delay in access to care could de facto erase her right to make health care decisions about her own body. Women who want an abortion but are denied one because they have passed the gestational age limit are at increased risk for adverse psychological outcomes, including anxiety, lower life satisfaction, and lower self-esteem. Early abortions have also been shown to be much cheaper: in 2001, abortions at 10 weeks were 300% less expensive than abortions at 20 weeks. Finally, a majority of women seeking abortions simply prefer to have the procedure earlier.
Ostensibly, young and socioeconomically disadvantaged women are less likely to have the resources to locate an abortion provider if their doctor doesn’t help them. Doctors’ refusal to provide information thus likely disproportionately impacts already disenfranchised women — who have been shown to get their abortions later than older, wealthier and more educated women.
All of this is not to say that women do not or cannot self-refer to abortion providers. Certainly, many women do. However, when a woman asks for information or a referral from the physician she has built a relationship with over time, it seems unconscionable for that doctor to mislead her or refuse to give her information. For almost every other medical intervention the standard of care includes ensuring your patients get the care they need if you cannot provide it for them directly. If a patient needs to see a cardiologist, particularly for a time-sensitive complaint, her primary care doctor doesn’t just assume she can find one on Google and leave her to her own devices. Rather, they call over to the cardiology office, send over relevant medical records, and may even help her make the appointment. For abortion, this paradigm dramatically shifts and unarguably puts women at risk.
In most states in the United States, doctors have the right to refuse to provide abortion, a medical intervention that is safe, legal and common, on the basis of strong moral or religious opposition. (Of note, there are several countries, including Sweden, Finland, and Iceland, that do not guarantee this right, based on a strong national belief in women’s right to reproductive choices.) This physician’s right must be balanced against the patient’s right to autonomy over her own body. Given the medical risks and legal boundaries associated with delayed abortions, safeguards must be put in place to ensure that doctors’ personal preferences do not interfere with women’s legally guaranteed right to choose. While guidelines espoused by professional societies generally outline these basic principles, the research shows that physician adherence to them is variable. Illinois’ legislature is a commendable first step in ensuring that no woman’s reproductive choices are limited by the personal beliefs of her doctor.