Abortion bans in America are corroding some doctors’ souls

The patient was about 16 weeks pregnant. As Donna stood by her bed, steeling herself to deliver the bad news, she tried to stifle the now-familiar feeling of helplessness. It was November 2022 and they were in the triage area of the hospital in Texas where Donna (a pseudonym) worked as an ob-gyn (obstetrician-gynaecologist). The pregnant woman’s waters had broken. At this stage in the pregnancy, the fetus’s lungs are months away from fully forming and stop developing as the amniotic fluid drains away. Doctors therefore usually recommend aborting the fetus or waiting to miscarry. The latter course can take days or weeks, during which time the mother is at high risk of infection – and must endure the trauma of carrying a non-viable fetus.

But in Texas, termination was no longer an option. A year and a half earlier, its Republican-dominated legislature had passed Senate Bill 8 (SB8), which outlaws abortion from the moment a fetal heartbeat can be detected (around the sixth week of pregnancy). In June 2022 America’s Supreme Court struck down Roe v Wade, a nearly half-century-old ruling that said there was a constitutional right to abortion. States were suddenly free to ban the procedure. Texas did so immediately, with exceptions only if the mother is at risk of death or a “substantial impairment of a major bodily function”. Doctors who refuse to comply are classed as criminals.

“It’s hard looking at a patient and saying I am doing the wrong thing for you,” she said. “It makes you feel like you’re not a physician.”

Having told the patient that her baby was going to die, Donna then had to deliver more distressing news. “Normally we would offer you an induction but right now because of the law – because your baby still has a heartbeat – we have to send you home.” She had seen many women in this position since SB8 had come into effect, and knew to speak slowly and calmly, choosing her words carefully. Though the curtain around her patient’s bed gave the appearance of privacy, the other patients on the ward could hear almost everything. “If you develop an infection or start bleeding heavily, come back to the hospital, and then we can give you medicine to deliver the baby or do a procedure.”

The patient looked confused and Donna empathised. It was her job to make people better. Yet here she was, withholding treatment, her hand forced by the law. A patient who was already suffering was now at risk of deteriorating. Donna’s sense of herself as a doctor was rattled. “It’s hard looking at a patient and saying I am doing the wrong thing for you,” she said. “It makes you feel like you’re not a physician.”

Fourteen states have banned abortion since Roe v Wade was overturned; several others have restricted access to it. Those states are home to some 44m American women: the primary victims of abortion bans. But these laws have also had a dramatic impact on the doctors treating them. Torn between their obligation to obey the law and their “ethical duty” to care for patients, physicians have been put “in an impossible position”, said Dr Jack Resneck, then-president of the American Medical Association, in May.

Donna wondered why pregnant women should be treated differently from other patients. “If someone breaks their arm and bleeds, do we wait until they’re close to death to treat them?”

All states with abortion bans make exemptions if a woman’s life is in danger – some exemptions claim to protect her health more broadly. Yet many doctors are not sure how to interpret these provisions, which tend to be vague. What exactly is a major bodily function, per Texas’s ban, and what would substantially impair it? Donna wondered why pregnant women should be treated differently from other patients: “If someone breaks their arm and bleeds, do we wait until they’re close to death to treat them?”

Should a judge or jury disagree with a doctor’s decision, the consequences can be serious. They could lose their medical licence or be hit with a steep fine (up to $100,000 in Texas) or several years in prison (in Texas doctors could face a life sentence). “Clinicians are terrified. I don’t blame them,” said Dr Michele Heisler of Physicians for Human Rights, an advocacy group. Medical malpractice insurance in America does not cover criminal charges, so doctors accused of violating an abortion ban risk bankruptcy.

Doctors are treading cautiously. Some delay care, in order to seek legal advice or to ensure that patients are ill enough to merit treatment. Many physicians now feel they have to “call the hospital attorney to ask, ‘Hey, is a 20% chance of death high enough to intervene under my state laws?’” said Resneck. “In many instances, [they are] being told no, let that patient get a little sicker before they clearly meet our criteria.”

One study, conducted in the nine months after SB8 came into effect, tracked the outcomes of women at two hospitals in Dallas who presented with pregnancy complications before their fetus was viable. Patients in this position used to be treated immediately by inducing labour or aborting the fetus. The women in the study had to wait an average of nine days before they miscarried or their condition was considered sufficiently life-threatening to warrant induction or a termination. In some cases, this delay caused patients to haemorrhage; one woman had to have a hysterectomy. Two-thirds of ob-gyns surveyed by KFF, a charity focused on health, believe that overturning Roe has exacerbated maternal mortality.

Psychologists reckon that many ob-gyns could be suffering from “moral injury” – when you feel distress at having been compelled to violate your ethical code

Their hands tied, doctors may suffer from shame, anger and disgust. Psychologists at the University of Colorado reckon that many ob-gyns could be suffering from “moral injury” – feelings of distress that arise when people are compelled to violate their ethical code. The term was originally used to refer to the existential crisis that some soldiers experience as a result of having to maim or kill; during the pandemic it was applied to doctors in overwhelmed hospitals who had to choose which patients to save. Ob-gyns know how to help women but are prevented by law from doing so.

A month after SB8 came into effect, Donna logged into a departmental meeting on Zoom about the implications of the new law. Her boss told the group that if a mother’s waters break before the fetus is viable, that was no longer considered a medical emergency. Doctors could intervene surgically only after the fetus’s heart stopped beating or the woman contracted a severe infection. Donna was astonished that her boss, knowing that this would put patients at risk of sepsis or haemorrhage, could relay this news so matter-of-factly. “I remember just being like, you know, you’re asking us to send people home to die, and I just broke out in tears.”

“I’m not a crier,” Donna told me when I met her at a Tex-Mex restaurant near her home. She is 45 but looked younger: her immaculately curled eyelashes and silver hoop earrings accentuated the roundness of her face. Her cornrows were gathered in a bun at the nape of her neck. Donna, who has three children, is highly successful: she did her residency at an Ivy League school, and works for Planned Parenthood alongside her day job. I got the impression that she was in command of herself.

But since Texas banned abortions, Donna’s composure has cracked. She recalled patients “begging, wailing, pleading” with her to let them have a termination, and having to tell them “over and over and over again” that because the fetus had cardiac activity, “I can’t help you.” During difficult conversations with patients, she often has to leave the room because she starts welling up. At home, Donna found it hard to switch off: she had to stop watching “The Handmaid’s Tale”, a TV adaptation of Margaret Atwood’s dystopian tale of female subjugation, “because it was too much like life”. She stopped watching the news. The only thing she could bring herself to listen to on the drive to work was “spa music”.

Donna noticed that on certain days of the week – when she wasn’t rushing to and fro on the labour ward, when she had a bit more time to herself – she was getting palpitations. Once, when she was interviewing residents, she spilled her coffee – it felt like she had lost control of her hands. She thought she might be having a heart attack, but a doctor at the urgent care centre told her she’d had a panic attack. She started seeing a therapist once a week, who is helping her manage her emotions. “I can only control what I can control,” said Donna.

Some ob-gyns in her position are moving to states where abortion is legal or abandoning the field altogether. There is a risk that retirees will not be replaced. In states with abortion bans, the number of applicants for ob-gyn residencies declined by 10.5% this year compared with last, according to the Association of American Medical Colleges (twice the rate of decline in states without restrictions).

Donna sympathises with doctors fleeing places like Texas. She has considered it herself. After all, her raison d’être as a doctor is to prevent harm. “It’s almost like we’re just rolling the dice on someone’s life,” she said, the frustration in her voice palpable. “I don’t know what I would do if I had a patient that died and it was like, this didn’t have to happen.” ■

Charlie McCann is a feature writer for 1843 magazine

Illustrations MICHAEL GLENWOOD