In a Volatile Post-Roe World, Morals and Medicine Clash

• Morals, Ethics, And Medicine

Having kept in touch with one of my former clients (EN), an OB-GYN, I (LR) was curious about the personal and professional impact on him of the recent Supreme Court decision in the Dobbs v. Jackson Women’s Health Center case that overturned Roe, and with it, federal protection of womens’ reproductive choices.

While EN neither sought me out for counseling, nor was the following conversation part of a therapeutic interchange per se, I hope that excerpts from that conversation might be useful to fellow psychotherapists, counselors, supervisors, and trainees who are or will be working clinically with medical health care professionals who serve women.


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Morals, Ethics, And Medicine

LR: I was thinking of you and wondering, as a practicing OB/GYN, how the Supreme Court’s decision to overturn Roe has affected you both personally and professionally.

EN: It's challenging because there's EN, who has very strong political views, and then there's Dr. N, who is supposed to separate his political views from his medical practice — and EN doesn't necessarily care about offending people. But Dr. N doesn't want to offend anybody because people are entitled to their opinions. With that said, as a women's health care provider, obviously my first concern is women's care, women's health, women's access to care, what women can do with their own bodies. And having anybody try and place limitations on that is disconcerting.

In Florida, the new rule is 15 weeks. But there are loopholes, and you can read into it, and read around it; but it's up to the doctor's discretion. I personally don't perform terminations anywhere near that gestational age, but we’ve certainly had plenty of patients who have required it for one reason or another. It's one thing to refer somebody down the street; it's another to have to refer somebody out of state. And we've had that issue.

Typically, when you're referring somebody for those reasons, they're not happy about it because they've already likely been dealt a somewhat devastating diagnosis for their desired baby. Then they have to make a very challenging decision, and are forced to do so in an uncomfortable, unfamiliar environment, likely without the support of their family and friends that they would have at home. So, it's easy to say, “Sure, just travel to this state or that state,” but not everybody has the means or support to do that. There are so many different angles that you can come at which create their own additional set of problems.

LR: In thinking of the last one or several women that you had to refer out of state for pregnancy termination, what were some of those interactions like for you — since many of them, I would imagine, you've had ongoing relationships with?

EN: Fortunately, there haven’t been many, but those I’ve referred were due to major fetal anomalies that were diagnosed after the legal limit for termination. That in and of itself was a tremendous challenge. Most of our conversations were focused on their devastation and processing of the diagnosis — not about having to travel to get it done. I think that part of it was a bit on the backburner. But that was just for them. I think that the more cases one has the more complications that are going to arise.

LR: How did these conversations impact the relationship you had with these particular women as well as you personally?

EN: I don't think they impacted our relationship because they know that I don't perform the procedure anyway. It is a challenging procedure with more risks and more complications, regardless of where you have it. And many of us have chosen not to do it for that reason. I'd rather have someone who has quite a bit of experience do it. So, whether I'm referring them down the street or three states over, they know that I'm not the one who's going to do it. And so, I don't think that has any negative impact on our relationship. It's more just a matter of the logistics of finding somebody — helping them to locate somebody and them having to arrange their plans.

LR: Have you stopped performing procedures completely or just after 15 weeks?

EN: My limit was always about eight weeks. And it's never been something that I advertised doing. It's more if I have an existing patient who finds herself in that situation, it's something that I can offer to my existing patients. There are plenty of other resources. There are plenty of physicians who welcome referrals for it. That's a controversy that I've tried to avoid. But for my own existing patients, my preference has been, “I'd rather be the one to help you through this than have to refer you elsewhere.” But I have my limits also. And that's just out of comfort medically for the procedure and nothing else.

LR: Have you grown more wary or vigilant that somehow, you'll raise attention of a regulating body, or someone will launch a complaint, or someone will hear or mis-hear this or that and report you? I guess what I am asking is, have you become more fearful or threatened in this post-Roe environment?

EN: Not yet, because again my practice routines are well within the limits of current legality in the state. Should that change? Yeah, of course I'm concerned about the ramifications. But like I said before, I try to limit my exposure. I don't want it necessarily out there well known in the community that this is something that I do or offer, because no matter how you look at it, there's a stigma and there's controversy associated with it. And it's just something I'd rather avoid. I want to be there as a physician for my patients, and offer them what they need, and avoid all the other drama that might come with that.

LR: Have there been clients or patients you've consulted with or treated where your political and personal views clashed and were difficult to suppress?

EN: Yes, but not necessarily for that patient's particular healthcare needs, but more so because we'll strike up a conversation and they'll make an offhanded remark, not necessarily understanding all the medical implications. You know, it's very easy for somebody to pass judgment and say, well, 15 weeks seems very reasonable. But the reality is, it's incredibly challenging to diagnose a genetic abnormality, a chromosome abnormality, a major fetal abnormality prior to that time. And so, there are medical limitations to what we can do and when we can do it. So those tests aren't really available and they're not confirmable. You can't confirm it until right around that time at the absolute earliest. So, it's easy to say, ‘well, 15 weeks sounds reasonable’, and patients have had plenty of time to make a decision. That may be the case for an elective termination. But for medical purposes—which once you're extending into the second trimester, the great majority of them are for medical purposes anyway. It's not enough time to make that decision.

LR: Is it the case that genetic anomalies might not be manifest in an observable way at 15 weeks?

EN: We typically begin screening for chromosomal abnormalities — the most common example being Down syndrome — at around 12 weeks.

LR: Tight margin, but that’s a screening test which is by definition non-definitive.

EN: Correct! So, if that test comes out abnormal, the typical recommendation is for amniocentesis, which historically was performed after about 16 weeks. You can't make a screening test any more than it is, and they are inherently designed to have false positives. And so, you can't make a definitive diagnosis and a definitive management plan with just a screening test. And if you don't have the ability to confirm, then, you know, you're stuck. That's for chromosomal abnormalities.

In the case of fetal anomalies — let's just call them birth defects — the first full anatomy ultrasound is done somewhere between 18 and 20 weeks (about 4 and a half months). So, yes, you can see some vital anatomy earlier than that for sure. But not all the structures, not everything.

LR: And neurological sequala of these chromosomal or genetic anomalies won't show up until after birth?

EN: Right! That, there’s no way to screen.

LR: Do you get a sense that this 15-week window was determined after comprehensive consultation with medical specialists or the result of political footballing?

EN: I'm sure it was some kind of a behind-the-scenes compromise, and I don't know who came up with that 15-week gestational age. But, you know, I'm sure there was something behind the scenes.

LR: What about the overflow of the Roe decision into your personal life—conversations with your wife, with your friends, with family members, where the EN who is free to express his political views is not tethered by his professional obligations? How has it affected you outside of the consulting room?

EN: For the most part, the people I converse with are like-minded people. And even if some of these people vote Republican — which some of them do — they’re voting Republican for other reasons like Israel and taxes. And so, when we talk about this, it's easy to have a room of like-minded people, and just get angry, and talk about how ridiculous it is.

LR: In your deepest, most personal place, what has been your visceral reaction as a person, as an OBGYN, or some combination of the two? What has it been like for you since the overturning?

EN: It's frightening because there was always the threat that Roe would be overturned. But most people felt it would never happen, that it was established law. Look, even the most recent Supreme Court nominees would say it’s established law, and yet here we are. So, we all were fearful that it could happen but didn't really think it would happen. Now that it has happened, it's frightening. And then for a while afterwards, it was the thought of what's next? Is gay marriage next on the docket? Or contraception? You know, where are we going here?

LR: So, frightening in terms of what rights would be taken away from women and other groups next—frightening ideologically, frightening from a humanistic standpoint. What about this is personally frightening to you, perhaps as a father? I know you have sons.

EN: This country is regressing. I have sons who are perfectly capable of impregnating someone else. But, you know, we try to teach them responsibility. I don't have any intention or feel like I'm ever going to have the need personally to have a termination. And so, my fears and my anger are more because of how it affects others and because of the type of practice that I'm in and it affects me at work. So no, this is one of those issues that doesn't have a direct impact on me as a person, but I feel incredibly strong about it. And that's the part that has the deepest effect.

LR: So, the most frightening personally is, as a citizen of a country that seems to be going backwards?

EN: How about as a conscientious human recognizing that not all political issues are personal? I have no intention to marry someone of the same sex as me. But I feel unbelievably strongly that everybody should have the right to marry whoever they want. That's not affecting me directly. But that's deep down in my core.

LR: Do you see yourself as an active or increasingly active outward advocate in some way in your professional future?

EN: I’ve always emphasized prevention because I think it’s the right way to go anyway. So, I think termination is a choice. And you've got the morals and you've got the ethics and then you've got the medicine, right? So, from a strictly medical perspective, prevention is better. And so I've always pushed that, I've always emphasized it. But now, I'm doing so even more because while there might be certain limits now, those limits might become stricter down the road. And so, patients should want to be proactive in prevention anyway. Number two, they may not have the same options later. And who knows what kind of access they're going to have to birth control later on? You know, is that in jeopardy as well?

It's a ridiculous hypocrisy, because they want to limit access to birth control; they want to limit access to pregnancy termination. But they also want to limit the social programs that might help with these unwanted children once they're forced to be born to parents who can't afford to have them and don't want to. I don't think I am going out on a limb to say that a solid, substantial number of those who advocate pro-life have somewhere at some point in their life been in a situation either directly or indirectly where they probably needed a termination.

LR: In closing, are there particular patients that you've had over these last few months that have really struck a chord in you and sort of torn you up inside? And if so, how did you deal with it?

EN: How I dealt with it personally is different. Professionally, it's hard not to have empathy. It's hard not to feel for someone who was given the diagnosis that their baby, who they wanted, is not going to survive the pregnancy. And so now they had to make a very difficult decision, and it was just made that much harder for them.

I'm grateful that I don't have that many patients yet who I’ve had to refer out for terminations due to chromosomal anomalies. A fair number of those end in early miscarriage before you get to that point. But it's still there, and it's always going to be there. It's the nature of the field.

LR: Thanks so much for sharing with me today.   

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