The future of physician decision-making and patient welfare
The overturning of Roe v. Wade has shocked millions, with many grappling with the implications of the June 2022 Supreme Court decision to no longer ensure that abortions are a constitutional right to all individuals living in the United States. Amidst the shock caused by this decision with many questioning how we, as a nation, got here, health care providers, patients, activists, policymakers, and the like, began to immediately articulate the consequences of this decision. Including the obvious impact on reproductive health care access and reproductive rights, this decision will have a disproportionately negative toll on individuals of color, and will lead to the criminalization of patients and health providers who offer abortion care.
With each passing day, the consequences of this decision continue to permeate the news. Most recently, reports have revealed the heavy restrictions being placed on medications that are known to impact a fetus and/or can result in an abortion. For instance, Methotrexate, a common and affordable drug used to treat multiple conditions including rheumatoid arthritis, inflammatory bowel disease, and cancer, is currently being denied to individuals with a uterus. With providers choosing not to prescribe these medications and pharmacies refusing to carry such medications, individuals of childbearing age are disproportionately impacted and at high risk of their health care needs being unmet due to anti-abortion legislation.
The decision to refuse to provide medication to an individual of childbearing age is just one example of the difficult decisions providers are now expected to make in the post Roe v. Wade nation. Such decisions resonate with the complex decision-making process of physicians revealed in my book, Conflicted Care: Doctors Navigating Patient Welfare, Finances, and Legal Risk ». In this book, I demonstrate how physicians encounter a hidden curriculum of doctoring on the clinical wards of a prestigious academic medical center that forces them to make medical decisions amidst conflicting medical, financial, legal and training pressures. These conflicting pressures inevitably compel physicians to make trade-offs when formulating clinical decisions, which are rarely uniform. In some instances, financial considerations drive clinical protocols, in others, malpractice litigation fears play a primary role. Ultimately, while patient welfare is always an important feature of the clinical decisions providers make, it does not necessarily emerge as the driving factor in medical decisions due to the highly commodified and bureaucratized health care system in the United States.
The overturning of Roe v. Wade has created a political landscape where there are additional institutional and legal pressures and constraints that must be considered by physicians on the ground. In states where abortions are highly restrictive, physicians must face the risk of criminalization if they provide abortion care to individuals who want or need it. Furthermore, providers must now consider multiple penalties when making care decisions, such as losing a medical license, conviction of a felony, and variable prison time in multiple states across the country, including Arkansas, Louisiana, Michigan, Missouri, Tennessee, Utah, and Wisconsin, to name a few. In addition, in Idaho and Texas, pregnant individuals who go to an emergency room and present with the need for an emergency abortion are not necessarily able to be treated, as abortion laws are being privileged over the 1986 Emergency Medical Treatment and Labor Act.
As documented in Conflicted Care, as providers must learn to juggle and reconcile such conflicting pressures, patient welfare is not always at the forefront of the decisions that are made. Furthermore, as physicians navigate this complex health care landscape, there are inevitable spillover effects for the patient population and the larger health care system. First, states with strict anti-abortion laws can see an exodus of medical professionals providing abortion care and/or physicians turning down jobs in those regions, further limiting access to much needed reproductive health care. Such migration is devastating to patients who are in need of emergency, life-saving abortions. Second, there are immediate implications for medical training as well, as trainees are no longer able to perform abortions, which creates competency and skills gaps for future OB-GYNs. This further exacerbates care quality and access issues in under-resourced and marginalized communities. Third, progressive states with pro-abortion laws intact may see such an exponential influx of patients, that they are unable to treat all patients who need care. This can result in delayed care or patients falling through the cracks, which is a dilemma for our health care system far beyond abortion care, that has been exacerbated amidst the COVID-19 Pandemic.
Physicians of course are incredibly resourceful and find ways to navigate these unexpected dilemmas with some engaging in more telemedicine to ensure that patients from other states are able to receive the reproductive care that they need. Others are traveling across state lines to provide care in clinics expected to receive an unmanageable influx of patients traveling from states with highly restrictive abortion laws. As documented in Conflicted Care, physicians will continue to need to learn how to be creative and resourceful when faced with such conflicting pressures and political and legal constraints. This may be a hard pill to swallow for health care providers as these factors and considerations that weigh quite heavily in the medical decisions they make on a routine basis, have little resonance with what drew them to medicine in the first place; and in many instances, can seem quite foreign and antithetical to the clinical teachings that were touted in medical school. Yet as physicians continue their work on the ground, they soon realize that such considerations are inevitable in the current health care and political landscape, and the decisions they make have direct implications for patient health and welfare and their own professional well-being.
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