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Health

How abortion ban exceptions muddy ethical care for pregnant patients

"How imminent must death be?"

woman in a doctor's office getting an ultrasound

Obstetricians are facing impossible dilemmas with abortion care in some states.

When the Dobbs decision overturned Roe v. Wade in the summer of 2022, experts warned that there would be medical consequences. Politicians have made abortion a black-and-white issue when it's a vast ocean of gray, and doctors are now stuck in dilemma after dilemma in states like Tennessee, which enacted some of the strictest abortion laws in the nation in the wake of Dobbs.

In Tennessee, it is now a Class C felony to perform an abortion. Exceptions are made for rape and incest, ectopic pregnancy, molar pregnancy, and if "the abortion was necessary to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman."

But as OB-GYN Sarah Osmundson explained on Radio Atlantic, that last exception is "very gray." Working as a maternal-fetal specialist at Vanderbilt University Medical Center, Osmundson serves on the abortion committee that decides whether a doctor has the green light to perform an abortion to save a mother's life or bodily function. In an interview with Hanna Rosin, Dr. Osmundson shared how making those calls can feel like an impossible task as providers walk the line between ethical care and the threat of legal action.

Osmundson explained that it's unclear what the exceptions to the law even mean because there's no predictable line for when a patient will cross over into imminent death or permanent injury. "It is a continuum of risk," she said. "Where is the cut point that we have to decide some aspect of risk is too high?"

Some cases are cut-and-dried, she said, but others present a conundrum for those who are tasked with assessing whether the risk to a mother's life or health is high enough to warrant an abortion. There are no clear thresholds, especially since risk assessment isn't an exact science.

She offered an example of a patient who has diabetes combined with an autoimmune condition, but they're both currently well managed, on top of kidney disease.

"You know, these are the kind of cases where we’re really trying to guess at: What is their risk of death or serious morbidity?" she said. "And even when I see these patients in the office, like, I can’t sit down with them and say, Your risk is X percent. I don’t have data to drive that individual case. Maybe their risk of serious problems in pregnancy is like 5 percent."

Osmundson pointed out that some patients choose not to screen for chromosomal abnormalities with an amniocentesis because there's a 0.1% risk of complication and they decide it's not worth the risk. "So we don’t do certain things because of very low risk. How am I to say that a risk of 5 percent is too low of a risk?" she asked.

Dr. Lisa Harris, an OB-GYN and professor at the University of Michigan, posed a similar questions to NPR shortly after the Dobbs decision was announced.

"How imminent must death be?" Harris asked. "There are many conditions that people have that when they become pregnant, they're OK in early pregnancy, but as pregnancy progresses, it puts enormous stress on all of the body's organ systems – the heart, the lungs, the kidneys. So they may be fine right now – there's no life-threatening emergency now – but three or four or five months from now, they may have life-threatening consequences."

Osmundson gave a specific example along those lines that posed a problem for some doctors on her committee. A woman was 14 weeks pregnant with a fetus that had no skull, which meant it had no chance of survival but an increased risk of excessive amniotic fluid, which could threaten the mother's life. Osmundson thought the case warranted an abortion, but others on the committee wouldn't commit, with one saying they weren't "brave enough."

The doctors were concerned about the way the decision would be scrutinized and the potential legal consequences if someone brought the case to court. Dr. Louise King, an OB-GYN at Boston's Brigham and Women's Hospital, had warned of this scenario when Roe v. Wade was overturned.

"Laws will exist that ask [physicians] to deprioritize the person in front of them and to act in a way that is medically harmful," King told NPR. "And the penalty for not doing so will be loss of license, money loss, potentially even criminal sanctions."

The reality Osmundson described in the Radio Atlantic interview demonstrates how prescient that warning truly was.

"I feel like I’m making a decision thinking about: How would our attorney general interpret this? How would the optics appear? And it makes me feel really uncomfortable, as a physician, that I’m considering care for the optics, rather than for what is right and best for the patient," she said.

Legal abortion ban exceptions like "to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman" may sound straightforward to the average person, in the reality of medicine, it's not. Doctors aren't magicians or oracles, they don't have a crystal ball that tells them if a patient is going to live or die or be irreparably harmed—they make their best guesses based on their deep well of knowledge and experience, which lawyers and politicians deciding on legal boundaries don't have. Abortion restrictions and exceptions like Tennessee's force doctors to think as lawyers and lawyers to think as doctors when they don't have the training for it, all while people's lives hang in the balance.

The ambiguity in risk thresholds also makes these legal questions impossible to navigate. As Osmundson pointed out, a 5% risk is actually quite high, especially when it's your own life on the line. That's a hard enough choice for a person to make for themselves, much less a choice we should expect a doctor to make for someone based on political decisions and legal judgments made by people with no experience in the intricacies of medicine.

The challenges are even causing some doctors to leave states where they feel they can't care for patients properly. Kylie Cooper, MD was a maternal-fetal specialist who moved from Idaho to Minnesota in the wake of the Dobbs decision.

“My husband and I would talk about this every day. It was consuming us,” she told the AAMC. “What if I lost my license? What would happen to our kids if I went to jail? What about my guilt if I didn’t help a sick patient to my fullest ability? It was a nightmare. I didn’t feel I could remain a health care provider in a place where I couldn’t help a patient sitting right in front of me. It was unbearable.”

And for many, it doesn't seem to be a matter of making the law clearer. There are simply too many factors on an individual patient basis for more clarity in the law to even be possible, much less helpful, while also preserving a doctor's ethical standards of care.

So what's the answer?

The simplest answer is medical privacy—the protection that was provided by Roe. v. Wade—which was argued for and passed by the majority of Republican-nominated Supreme Court Justices, by the way—for doctors and patients together to decide on healthcare decisions without government interference. We were warned by doctors of what would happen when abortion laws were left fully up to each state, and now we're seeing those consequences play out in state after state.

After going through various challenging scenarios, Osmundson summed up the crux of the issue with two questions that every person ought to consider: "Do you want your cancer doctor to be considering the opinion of an attorney general when they’re making recommendations about your cancer care? Why would you want those kind of external things involved in your care during pregnancy?"

Listen to Dr. Osmundson's enlightening Radio Atlantic interview here.

Identity

Celebrate International Women's Day with these stunning photos of female leaders changing the world

The portraits, taken by acclaimed photographer Nigel Barker, are part of CARE's "She Leads the World" campaign.

Images provided by CARE

Kadiatu (left), Zainab (right)

True

Women are breaking down barriers every day. They are transforming the world into a more equitable place with every scientific discovery, athletic feat, social justice reform, artistic endeavor, leadership role, and community outreach project.

And while these breakthroughs are happening all the time, International Women’s Day (Mar 8) is when we can all take time to acknowledge the collective progress, and celebrate how “She Leads the World.

This year, CARE, a leading global humanitarian organization dedicated to empowering women and girls, is celebrating International Women’s Day through the power of portraiture. CARE partnered with high-profile photographer Nigel Barker, best known for his work on “America’s Next Top Model,” to capture breathtaking images of seven remarkable women who have prevailed over countless obstacles to become leaders within their communities.

“Mabinty, Isatu, Adama, and Kadiatu represent so many women around the world overcoming incredible obstacles to lead their communities,” said Michelle Nunn, President and CEO of CARE USA.

Barker’s bold portraits, as part of CARE’s “She Leads The World” campaign, not only elevate each woman’s story, but also shine a spotlight on how CARE programs helped them get to where they are today.

About the women:

Mabinty

international womens day, care.org

Mabinty is a businesswoman and a member of a CARE savings circle along with a group of other women. She buys and sells groundnuts, rice, and fuel. She and her husband have created such a successful enterprise that Mabinty volunteers her time as a teacher in the local school. She was the first woman to teach there, prompting a second woman to do so. Her fellow teachers and students look up to Mabinty as the leader and educator she is.

Kadiatu

international womens day, care.org

Kadiatu supports herself through a small business selling food. She also volunteers at a health clinic in the neighboring village where she is a nursing student. She tests for malaria, works with infants, and joins her fellow staff in dancing and singing with the women who visit the clinic. She aspires to become a full-time nurse so she can treat and cure people. Today, she leads by example and with ambition.

Isatu

international womens day, care.org

When Isatu was three months pregnant, her husband left her, seeking his fortune in the gold mines. Now Isatu makes her own way, buying and selling food to support her four children. It is a struggle, but Isatu is determined to be a part of her community and a provider for her kids. A single mother of four is nothing if not a leader.

Zainab

international womens day, care.org

Zainab is the Nurse in Charge at the Maternal Child Health Outpost in her community. She is the only nurse in the surrounding area, and so she is responsible for the pre-natal health of the community’s mothers-to-be and for the safe delivery of their babies. In a country with one of the world’s worst maternal death rates, Zainab has not lost a single mother. The community rallies around Zainab and the work she does. She describes the women who visit the clinic as sisters. That feeling is clearly mutual.

Adama

international womens day, care.org

Adama is something few women are - a kehkeh driver. A kehkeh is a three-wheeled motorcycle taxi, known elsewhere as a tuktuk. Working in the Kissy neighborhood of Freetown, Adama is the primary breadwinner for her family, including her son. She keeps her riders safe in other ways, too, by selling condoms. With HIV threatening to increase its spread, this is a vital service to the community.

Ya Yaebo

international womens day, care.org

“Ya” is a term of respect for older, accomplished women. Ya Yaebo has earned that title as head of her local farmers group. But there is much more than that. She started as a Village Savings and Loan Association member and began putting money into her business. There is the groundnut farm, her team buys and sells rice, and own their own oil processing machine. They even supply seeds to the Ministry of Agriculture. She has used her success to the benefit of people in need in her community and is a vocal advocate for educating girls, not having gone beyond grade seven herself.

On Monday, March 4, CARE will host an exhibition of photography in New York City featuring these portraits, kicking off the multi-day “She Leads the World Campaign.

Learn more, view the portraits, and join CARE’s International Women's Day "She Leads the World" celebration at CARE.org/sheleads.


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Over or under? Surprisingly, there actually is a 'correct' way to hang a toilet paper roll.

Let's settle this silly-but-surprisingly-heated debate once and for all.

Elya/Wikimedia Commons

Should you hang the toilet paper roll over or under?



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