On May 2nd, POLITICO published the leaked SCOTUS majority opinion draft indicating the imminent intention of the court to overturn Roe v. Wade, Planned Parenthood v. Casey and 50 years of legal precedent that ensured access to necessary health care for anyone capable of becoming pregnant. Social media was taken by storm, led by abortion providers, OB/GYNs, family medicine physicians and abortion rights advocates. The following day, OB/GYN clerkship directors and residents held space to talk about this threat to health care. However, while this was front-page news for current and future abortion providers, other medical professionals not on the abortion frontlines were not aware of the many ways that the health of their patients could be in jeopardy from this decision.
Should the Dobbs v. Jackson case be decided in a manner indicated by the leaked SCOTUS brief, the federally protected right to abortion care would become nullified. As a result, the right to access abortion care would be returned to the states, meaning the representatives elected via midterm elections are the ones dictating the rights of their respective state constituents. As it stands, 22 states have trigger bans already in place, such that once the final SCOTUS decision is delivered, abortion would be effectively banned.
Who would this affect most acutely? One in four people capable of becoming pregnant in the United States undergoes an abortion in their lifetime. Unsurprisingly, abortion rates are already disproportionately high amongst low-income and historically marginalized populations, so this decision would thus disproportionately affect already vulnerable groups. Additionally troubling, maternal mortality rates in the United States are already significantly higher than those of other industrialized countries.
To add insult to injury, one study estimated that a total ban on abortion in the United States would result in a 21% increase in maternal deaths — adding to an already unacceptably high disease burden. It has been shown internationally that banning abortion does not reduce abortion, rather it reduces safe abortions. Should this decision materialize, it is not an exaggeration to state that the medical community will have to prepare for the consequences of forced birth, including complications from unsafe, unsterile abortions and lack of social support systems for postpartum management.
This will not only affect the OB/GYN and family medicine departments, but the entire spectrum of medical care. As medical students, we need to see the imminent threat that this SCOTUS decision has on the health care system, and rally together to fight for safe, ample and equitable access to abortion care. The consequences of unsafe abortions, and/or of not receiving indicated care for miscarriages and/or ectopic pregnancies, are quite literally deadly. They can include sepsis, coagulopathies and hemorrhage.
The medical system will need anesthesiologists, surgeons and staff to be prepared for dilation and curettages (D&C), dilation and evacuations (D&E) and surgical procedures to treat the consequences of unsafe abortions. General surgeons and OB/GYNs will need to be ready to treat bowel perforations and gynecologic trauma cases. Critical care and infectious disease teams need to be prepared for an influx of septic abortions, many of whom have never previously seen one, thanks to protection from Roe V. Wade.
Neonatologists and pediatricians will need to be prepared to care for fetuses with genetic anomalies incompatible with life, who will die shortly after being born. Medicine physicians will need to be prepared to manage care for extremely sick pregnant patients, with cardiac and pulmonary conditions who otherwise would have chosen to end their pregnancies to maintain their own health status, had that option been available to them. Already overflowing emergency departments will need to be prepared for immediate action in cases of trauma, infection and extremely sick pregnant people with complex conditions.
The Turnaway Study evaluated the impact of receiving an abortion compared to carrying an unwanted pregnancy to term through a prospective five-year study with 1,000 participants across 30 centers across the country. The study found a profound impact of receiving an abortion on mental health; while receiving an abortion had no negative mental health impacts, being denied an abortion was associated with elevated levels of anxiety, stress and lower self-esteem, as well as increased risk for physical complications, such as preeclampsia and hemorrhage.
The consequences of not receiving an abortion represent a need for increased social and mental health support, riding the coattails of the COVID-19 pandemic, which already caused mental health infrastructure to be spread thinly. In a world where hospital beds are already overflowing and clinicians are leaving the health care force in record-shattering numbers, this influx across specialties will not be insignificant. Hospitals need to prepare staffing, space and resources to accommodate their already largely burnt-out and under-resourced workforce.
Moreover, for those carrying forced pregnancies, the consequences will extend far beyond the individual’s medical management. As it stands, forced birth will occur without expansions to proper social support systems, and in many cases, the structures implicated were overburdened at baseline. Access and equity in childcare, healthcare, public education and food security will be strained. Medical bills outstanding for labor and delivery can cost families thousands of dollars out of pocket.
Increased numbers of children will grow up in homes with parents who were not financially prepared for them, or, if placed for adoption, may grow up within an already extremely strained and oversaturated foster care system. This decision would further cycles of poverty for marginalized communities. There will be an increased need for mental health counseling and social work, for space within the foster care system, and for health care resources to mitigate the influx of sicker and more resource-scarce families. This will decrease the health status of the entire family unit and simultaneously stress the system as a whole, as it still struggles to manage a devastating global pandemic.
To say that advocates in this arena are tired would be the understatement of the century. Advocates have been sounding the alarm on threats to reproductive rights since Donald Trump was elected in 2016, and abortion-limiting legislation has skyrocketed since his inauguration. 2021 had a record number of anti-abortion legislation presented nationally since Roe v. Wade. Many OB/GYN departments had discussions this week about Dobbs’ impact, how they plan on moving forward medically and professionally, and the departmental obligation to rally for abortion access. However, those experiences are not universal; many medical students in other rotations proceeded with business as usual without a word about the Dobbs’ leaked brief. We are not naive — we’re aware management of other patients demands time and attention.
However, this attack on reproductive rights and privacy is an attack on the entire health care system and treating it as less, or as an isolated incident, is a grave mistake. Every corner of the health care system will be affected by this decision, and allowing that attack to occur without pause is alarming and dismissive to those who have spent their lives working for reproductive equity and justice.
Ethically speaking, prioritizing the core tenet of patient autonomy is the professional duty we are taught on our first days of medical school, regardless of what specialty we pursue. Patient autonomy is the first lesson in ethical lectures: respecting that patients have the right to determine their own care, regardless of their reasoning or logic. We are obligated to educate them about the benefits and risks, and they sign consent forms assuming them. Though these cases can be emotional and difficult, you will not find a physician forcibly treating a patient with the capacity to consent who wants to leave AMA, for that would be considered unethical.
However, in the case of abortion, pregnant people who are educated about the risks and benefits and desire abortion care are denied it, and patient autonomy is completely disregarded. The organs of a deceased body for direct donation, which require an extensive consent process and medical management, have more rights than those of a living, breathing, consenting pregnant person. If that doesn’t make sense to you, it should not.
Overturning Roe v. Wade will discard the right to privacy that has been upheld in cases around reproductive care, gender and sexuality equity and many other realms. This decision implicates other basic human rights and will result in a slippery slope where other aspects of reproductive care are no longer guaranteed. Bans on birth control and Plan B have already been brought up in several states, and murmurs of federal bans on abortion care have already begun to circulate.
We cannot overstate this enough: the medical and legal ramifications of a decision like this are not going to be limited to abortion. This is not only a physical threat to the health and safety of millions of our patients, but also a threat to the psychological safety of all, and heightened stress on an already overextended health care system. We do not all have to love abortion, but we need to understand why it must be safe, accessible and unstigmatized. We need to rally as medical students to fight for abortion to be protected permanently, and accessible to every person in every state, without limit or stipulation.