In Abortion Ban States, Women Get Second-Class Healthcare—Across *All* Specialties

Physicians across specialties, from oncology to dermatology, report that abortion bans are undermining patient care.

In the wake of the Dobbs decision, Physicians for Human Rights (PHR) issued a press release pinpointing with prescient accuracy that it would “trigger nothing short of a public health crisis, exacerbate existing health disparities, and further endanger already marginalized populations most.” The U.S. was now in “clear violation of international law and globally recognized health and human rights standards.” 

In the years following Roe‘s overturn, PHR has issued state-specific research briefs on the harms of abortion bans. It has also worked to “empower clinicians and advocates to speak out against the human rights violations occurring under these draconian laws.”

On Sept. 30, PHR issued a groundbreaking research brief, “Cascading Harms: How Abortion Bans Lead to Discriminatory Care Across Medical Specialties.” Based on in-depth interviews with 33 physicians from varying health specialties across the country, the study found that abortion bans “have hindered the ability of providers in diverse medical fields to follow evidence-based practices and standards of care, creating a pervasive chilling effect that results in substandard care and discriminatory treatment for reproductive-age women and pregnant patients.”

Ms. recently had the opportunity to sit down with PHR medical director Michele Heisler, MD, MPA, and director of research, legal and advocacy Payal Shah, JD, to discuss how abortion bans create hindrances in healthcare beyond the reproductive space.

Readers of Ms. are likely familiar with the terrible quandaries faced by abortion providers in ban states, as described by public-health scholars Liza Felix, Asha Sobel and Alina Salganicoff, “who now face the increased possibility of criminal charges in a legally ambiguous and dynamic environment.” The law, they write, “fails to consider the nuances of pregnancy and the ramifications of these restrictions both within and beyond the context of abortion.”  

As tragically exemplified by Zurawski v. Texas—and echoed in Kate Cox’s account of her own treatment under Texas law—these dynamics have resulted in the denial of abortion care even in the face of dangerous, life- and health-threatening pregnancy complications.

Less studied, are the ways that the Dobbs decision has impacted medical care across non-reproductive health specialties. Carving out a new space in public health research, the PHR study included interviews with physicians from the non-reproductive specialties of “hematology, dermatology, pulmonology/critical care medicine, oncology, neurology, and cardiology.” 

Cutting across these diverse practice areas, interviewees reported that in their practices they regularly:

• prescribe teratogenic medications—defined as “any agent that causes an abnormality following fetal exposure during pregnancy … including causing increased risks for pregnant women.”
• treat patients with chronic health conditions that may worsen during pregnancy and endanger the pregnant patient’s life if pregnancy continues; and/or 
• treat patients who develop medical conditions (e.g., cancer) for which immediate treatment would necessitate abortion care.

Discussing the option of abortion is part of the standard of care, such as in the case of a pregnant patient with breast cancer, since some forms of chemotherapy that may be necessary are teratogenic. However, offering the option of abortion becomes problematic for physicians treating cancer in abortion ban states with a limited life-saving exception.

“I … cannot prove that the woman will live only if they get treatment now, and die by postponing it six months,” said one oncologist.

Dr. Heisler explained what happens when treating patients with cancer in abortion ban states:

“When people are afraid to even provide the option of abortion or if they say, look, you have to go out of state, and the patient’s like, there’s just no way I can do that. So, then that would mean delaying the treatment. In some cases, you can delay the treatment just beyond the first trimester. You might be able to try radiation, depending on where the location is … or … in some cases, there is the option of less-effective medications that would not harm the fetus.”

As Heisler explained, the post-Dobbs reality of patients “not being prescribed the best treatment” extends well beyond cancer care.

She provided the example of a dermatologist in an abortion ban state who reported that dermatologists in his state aren’t prescribing Accutane, a highly teratogenic medication used for “horrible, cystic, disfiguring acne” to reproductive-age women. “They don’t want to have the discussion about abortion should someone become pregnant on Accutane because abortion’s not an option in the state,” said Heisler. “They don’t want to even raise the question.” 

Rather than a blanket refusal to prescribe teratogenic medications to women patients of reproductive age, some specialists reported that they and their colleagues instead base their prescription determinations on an assessment of a patient’s ability to “reliably take contraception.” While this means that some patients are given access to the more effective, teratogenic medication, it also means that reproductive age women are being sorted into deserving and non-deserving groupings based upon an often-subjective assessment of their contraceptive reliability, and prescribed medications accordingly.

Both Heisler and Shah elucidated that this practice exemplifies how abortion bans have resulted in discriminatory treatment well beyond reproductive health carespecialties. Heisler pointed to the “vast, rigorous body of literature that we, as physicians, no matter how well-meaning we are, have unconscious biases” which, she elucidated, is coming into direct play here.

“You have cases where you’re like, you know what? Even if you’re doing the best you can, you may get pregnant, so this medication is not a good idea. … Then there’s other cases where you’re like, oh, okay, you’re just like me. I trust you …”

She said abortion bans are resulting in “two types of discriminatory treatment.”

First: “discrimination against all reproductive-age people with pregnancy potential, most women, compared to men. The men are getting the treatment, but the reproductive-age women are not.”

Second, as typified by the contraceptive reliability assessment, is that “within reproductive-age women, even if it’s unconscious, marginalized groups [are] less likely to get necessary, effective treatment.”

… Reproductive age women are being sorted into deserving and non-deserving groupings based upon an often-subjective assessment of their contraceptive reliability, and prescribed medications accordingly.

The possibility that “abortion bans are leading to discriminatory care for marginalized groups beyond reproductive healthcare” had, as Shah noted, “come up in several earlier reports we had done, and was prompting us to start delving into it … to understand what is the scope of this? Who is impacted? Who can avoid this harm, but also, who can’t?”

For Shah, the conclusion of this study—“that abortion bans are leading to discriminatory care for marginalized groups”—was “one of the most chilling findings.”

“If you can’t get an abortion in your own state and can’t afford to cross the state line, then that’s it. … You have no other way to seek care. … It’s a really horrifying finding,” said Shah.

Criminalizing abortion care is constraining healthcare professionals, making it harder for them to do their jobs. As she explained, abortion bans put clinicians in “an impossible situation.” 

“They have their obligations to their patient and then obligations to either their employer or the state that are, essentially, in opposition. So, they are now no longer able to both meet their obligations to their patient and also, in this case, meet their obligation under the law. That’s the situation that they are in, and this leads to all sorts of issues, and often, leads to moral distress. … Leads to violations of patient rights. Leads to breaches of ethics, medical ethics, and so, this is a really concerning situation.

“They are being mandated by the states in which they’re practicing to act in violation of their obligations to their patients … to act against their patients’ best interest.

Some specialists get to the point where they feel, “I just can’t do that. I need to feel that I have the flexibility to use my clinical skills and to engage in shared decision making with my patients and not wait until I can document that there is serious harm or death,” said Heisler.  

They are “perceiving these as environments that are hostile to science. They’re hostile to medicine, and they’re hostile to clinicians’ ability to provide the highest standard of evidence-based ethical care.”

Both Heisler and Shah stressed, this stressful environment has produces yet another cascading harm of abortion bans—namely, “the exodus of other specialties, besides OB-GYNs from states … which already have healthcare [and] maternity care deserts.”

Ultimately, this leaves us with the chilling reality that medical care deserts are continuing to grow, contributing to communities’ suffering.