Women are dying because a group of unelected right-wing judges in 2022 voted to overturn Roe v. Wade, which established the constitutional right to an abortion in 1973. The arguments against abortion do not make sense, a majority of people in this country believe it should be legal, and research shows that abortion improves women’s lives—particularly, it has a positive effect on socioeconomic well-being. Despite all this, women (and infants, too, it now appears) are dying, leaving behind children and spouses and partners and families. It is difficult to know exactly how many women have died or suffered needlessly because they were prevented from accessing timely reproductive care due to restrictive state abortion laws. ProPublica has already reported on three deaths in Texas, the latest being Porsha Ngumezi, who died after being denied a standard procedure to stop heavy bleeding during a miscarriage. As Lizzie Presser and Kavitha Surana write:

The 35-year-old’s death was preventable, according to more than a dozen doctors who reviewed a detailed summary of her case for ProPublica. Some said it raises serious questions about how abortion bans are pressuring doctors to diverge from the standard of care and reach for less-effective options that could expose their patients to more risks. Doctors and patients described similar decisions they’ve witnessed across the state. It was clear Porsha needed an emergency D&C [dilation and curettage], the medical experts said. [...] D&Cs—a staple of maternal health care—can be lifesaving. Doctors insert a straw-like tube into the uterus and gently suction out any remaining pregnancy tissue. Once the uterus is emptied, it can close, usually stopping the bleeding. But because D&Cs are also used to end pregnancies, the procedure has become tangled up in state legislation that restricts abortions. In Texas, any doctor who violates the strict law risks up to 99 years in prison. Porsha’s is the fifth case ProPublica has reported in which women died after they did not receive a D&C or its second-trimester equivalent, a dilation and evacuation; three of those deaths were in Texas.

What’s disturbing is that, as Presser and Surana write, the hospital that treated Ngumezi “declined to share its miscarriage protocols with ProPublica or explain how it is guiding doctors under the abortion ban.” The reporters also noted that “medical experts” have said that the “wait-and-see approach”—in other words, withholding care or altering the standard of care— “has become more common under abortion bans.”

What this means is that restrictive abortion laws ought to be thought of as an encroachment on the practice of medicine. Unsurprisingly, many obstetrician-gynecologists in one survey agreed: they said that these laws prevent them or their colleagues from providing the appropriate standard of care to their patients. And as the Guardian reported earlier this year, a post-Dobbs study by Advancing New Standards in Reproductive Health found, in a six-month period, dozens of examples of care that “deviated from the usual standard” due to restrictive abortion laws.

Given how commonly miscarriages occur (especially early in a pregnancy) and the fact that about half of all states either ban or restrict abortion, one can only imagine how often scenarios like what happened to Ngumezi and others are occurring every day. (Never mind the fact that someone could simply want an abortion for a reason completely unrelated to a miscarriage.) As long as doctors are willing to provide substandard care, women will continue to suffer and even die. And this is simply unacceptable. Doctors are going to have to start breaking these laws.

What’s happening now with patient deaths is simply a worsening of an already bad situation. Women have been living with burdensome and restrictive abortion laws, which make affordable and timely abortion difficult to obtain, since well before 2022. Reproductive rights expert Carole Joffe has detailed the “absurd and cruel array of obstacles” women have long faced in order to obtain abortions. Unlike with other legal medical procedures, Joffe points out, there is a kind of “abortion exceptionalism” in which this particular procedure is made very difficult to obtain. In addition to the social stigma of abortion and the psychological distress of encountering angry protestors outside of clinics, women have had to deal with the cost of the procedure itself, the cost of travel to a place (often out of state) where the abortion can be performed, the loss of wages from missed work, the cost of childcare, and so forth. 

The Roe era itself, unacceptable as it was, was an improvement from the era of criminalized abortion prior to that, when there was an “intensive regime of the surveillance and policing of pregnancy,” as detailed by Lesley J. Reagan in her book When Abortion Was a Crime. In the 1960s, for instance, women could get “therapeutic abortions,” usually for mental health reasons. But this required going before a roomful of (likely male) doctors to ask for approval, and it was mostly white and privileged women who exercised this option. 

As Reagan explained, and as I pointed out in 2022, it was medical doctors who became proponents of the decriminalization of abortion in the years prior to Roe. Essentially, doctors wanted their professional autonomy preserved in the realm of abortion care. And the Court listened. As Reagan put it in an interview with Current Affairs,

What feminists have long criticized about Roe v. Wade is that abortion became a decision that belonged to doctors because they had the medical expertise. And the law has to allow doctors to be able to use that expertise and make the decision when appropriate to provide abortions. Now, in practice, it has become that women can seek abortions from people who will provide them. But it really mostly was about giving that power to the doctor. It’s between the doctor and the patient. The Supreme Court was listening very carefully to the medical profession, and investigating what the situation was for doctors. If the most radical of feminists and even liberal feminists had had their way, the reasoning would have made abortion a human right, a medical right. Women are full citizens, and they may make decisions about their bodies because they have bodily autonomy. They can make decisions to carry a pregnancy to term or to have an abortion if they feel that’s right. But that’s not what was written.

As Reagan explained further, the Court’s ruling also left unresolved major concerns about access to abortion:

Nor did the Supreme Court address the major problem that everyone was concerned about and put into their briefs, which was the disparity by race and class in terms of access to this medical care, and the problem that some people truly were being forced to carry pregnancies to term against their will. Or they were going to providers who were dangerous or taking medications that were dangerous. There were thousands of women every single year in the public hospitals suffering and dying. But the Court did not address any of that. Yes, there is a right to perform an abortion, but no affirmative right which would make it available to everyone who needs it. So, no. By no means was it some radical decision or the Court listening to radical women.

What we really need, then, is (free) abortion on demand, which is what liberal physician Alan Guttmacher said decades ago was “the only civilized way to handle the problem.” Or, as Yasmin Nair put it in 2014, what we need is “safe abortions on demand, for any reason whatsoever, no questions asked, no waiting period. It’s time we expected nothing less.”

To achieve this, first we need to enact Medicare for All, a universal program that would include abortion, with services free at the point of care. We also need to get rid of restrictions on abortions and mandatory waiting period laws, which deny women autonomy and, in our current healthcare system, increase the cost of abortions. The World Health Organization recommends against mandatory waiting periods because they, like other barriers to care, increase the “risk of unsafe abortion, stigmatization, and health complications, while increasing disruptions to education and [the] ability to work.” So does the American College of Obstetricians and Gynecologists.

Until we get Medicare for All and free abortion on demand, we have to think about the role of doctors in this post-Roe landscape. Doctors are a powerful professional group. As we have seen, the Supreme Court ruled in Roe that abortion was a matter of privacy between patient and doctor. And doctors (along with others on their healthcare teams, including nurses, medical assistants, surgical assistants, and so forth) hold the knowledge and skills required to carry out safe abortions for all who seek them. As powerful professionals who have committed themselves to safeguarding the health and well-being of their patients, doctors must rethink how they are responding to these laws.

When doctors have to consult lawyers or committees or wait until a patient is critically ill or a fetal heartbeat is no longer detected to provide care, or when they have to refer a patient to a different facility even when they’re actively bleeding, or when they don’t mention care options at all, they are in fact violating basic medical ethics. Some doctors have decided to flee to different states to avoid these problems altogether. But doctors need to consider whether abiding by these laws at all is truly morally justifiable. Laws that force doctors to violate medical ethics are unjust and should not be obeyed.

In The Atlantic, Sarah Zhang described what happened as ob-gyn doctors tried to balance their duties to their patients with their understanding of the laws of their state. She said the doctors felt something called “moral distress” or the “psychological toll” experienced by people who “felt powerless to do the right thing.” “Moral distress” or “moral injury” has been described as “the feelings of guilt, sadness and defeat felt by health care professionals when we know what our patients need but can't provide it.” 

Most doctors can recognize this feeling. Anyone who has taken care of patients knows that providing ethical care already requires constant effort to work around restrictive rules—whether from insurance companies or administrators—that all but compel doctors to behave unethically. (A doctor who recently penned an op-ed in the New York Times, for instance, says that she told a patient who was worried about the costs of a hospital admission that she was “sure” his insurance would cover it when she wasn’t. In other words, she lied to the patient—which is wrong, especially when the patient could face financial ruin from a large hospital bill.) Doctors are used to patient care being denied or delayed by third-party payers. In short, doctors are used to being told, No. These anti-abortion laws are simply the latest insult in an already substandard and inhumane healthcare system, one in which bigoted lawmakers and judges who aren’t even physicians get to micromanage medical practice to the detriment of patients!

Are doctors so used to “moral distress” and having to follow unfair rules that they will adhere to any new law, however unjust?

 Zhang wrote that she heard “over and over” that doctors just “want to follow the rules,” are “very good rule followers,” and are risk averse. Based on my experience as a doctor, I would say that all of that rings true. But what if doctors listened to that moral distress and acted upon it? What if they stopped following these medieval laws? What if doctors started to be the ones to say, No?

In fact, doctors are not “powerless” to do the right thing. Now, they may be powerless to do the right thing without incurring potential legal consequences. But they do have the power to disobey the law. As professionals who have been entrusted with the public’s health, they have a moral obligation not to comply with unjust laws that their own consciences are telling them are wrong and that they see are killing and injuring their patients—not to mention degrading their professional integrity and harming the medical workforce.

Asking for clearer laws is not the answer here. The legitimacy of these unjust abortion bans and restrictions needs to be completely undermined, and doctors have to be the ones to lead the way on this because they are on the front lines. The simple fact is that under normal circumstances, practicing medicine according to established standards of care will not lead you to run afoul of the law. If routine care is being outlawed, then the law must be unjust. And the restrictions around abortion care are clearly unjust. 

Doctors—along with all other healthcare workers on a care team—need to give their patients the care that they need when they need it. In short, follow accepted standards of care without compromise. There may be backlash from administrators or supervisors. Jobs may be threatened, or doctors may even lose their jobs. But patients—and the wider community of doctors, healthcare workers, and others, including the medical boards—must stand with the doctors and the healthcare team in these cases. And if the authorities do come, there needs to be public outrage in order to highlight the gross injustice of healthcare workers being arrested for simply providing an appropriate standard of medical care in the 21st century. 

The horror of the law must be revealed through resistance to it—and to the legal consequences that come with that—similar to the way the horror of segregation was made apparent through lunch counter resistance to it. If doctors simply continue to quietly follow these laws, the injustice will not be as apparent. Newspaper stories of patient deaths, which can sometimes be galvanizing, clearly aren’t enough, and legislative advocacy, while necessary, won’t work fast enough to save people who could die today or tomorrow. 

Continuing to abide by these restrictive laws ensures that more people will suffer and die. And it will further erode the public’s trust in healthcare—which, due in part to general mistrust of our health-related institutions, is already hanging by a thread.