Since the June 2022 U.S. Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, 18 states have put functional abortion bans in place.
New research fills a gap in understanding impacts on physicians after these bans. Mara Buchbinder, Kavita S. Arora and colleagues identify sources of moral distress impacting physicians. Moral distress occurs when health care professionals know the right course of clinical action but are prevented from taking that action due to some kind of external constraint, such as a law or institutional policy.
Through interviews with OB-GYNs, the authors characterized sources of moral distress among OB-GYNs in states with abortion bans, including: delaying medically necessary abortion care for obstetric patients, conflict with other clinicians, denying care they would have provided locally prior to Dobbs, and restrictions on clinical counseling due to “aiding and abetting” clauses in some state laws.
When facing moral distress, OB-GYNs reported report anger, frustration, helplessness and emotional exhaustion.
For example, one OB-GYN shared that they had an “extremely emotionally stressful” case. The physician knew “’the best recommendation medically speaking…[but] nobody knew how [it] would be seen legally speaking.”
Another OB-GYN said they were “terrified” about the necessary medical care they provided. They reported: “I knew that the care that I was going to give them was the right care, but I was afraid that something would go wrong and then I would get arrested. I have small kids, it was just my first job out of fellowship. That’s a career-ending situation.”
The toll on wellbeing is clear from participants’ comments.
One OB-GYN said, “I was extremely upset. I cried at work and had difficulty sleeping for the next several weeks because I was so upset for her that she had done everything right and when her contraception had failed her, we also then failed her and she had a horrible outcome.”
Another physician expressed strong emotions and deep professional concerns: “Horrible, frustrating, and very infuriating. I trained a long time to do what I do and continue to train … I’ve always felt educating patients on their choices and their options and then allowing them to make decisions in a shared decision-making is the ultimate goal. To have people on the outside who basically say I can or cannot do things, it’s just like, let me just do this with one hand tied behind my back.”
OB-GYNs shared multiple examples of decisions and questions that caused intense feelings of distress. The authors characterize this ongoing stress as “chipping away” at professional and personal wellbeing, a previously unreported source of moral distress.
Buchbinder said, “We were sadly not surprised to find that OB-GYNs in our study experienced significant moral distress post Dobbs. More surprising, however, was that moral distress arising from constraints on counseling was for some even more upsetting than being unable to provide a desired abortion. This highlights the important value placed on fully informed consent.”
The new findings on moral distress are an important part of understanding post-Dobbs OB-GYN care.
Arora noted, “As an OB-GYN, providing empiric evidence regarding the impact of this intrusion on the patient-physician relationship was important so that we can describe what me and my colleagues are facing. More importantly, this data represents a foundation for action.”
The authors conclude that moral distress represents a serious threat to OB-GYN occupational health in the post-Dobbs era, with possible downstream consequences for patients’ access to reproductive healthcare, should OB-GYNs leave states with abortion bans.
“Sources of moral distress among obstetrician-gynecologists after Dobbs: A qualitative, multi-state study” is out now in SSM – Qualitative Research in Health.
Study abstract
Since the US Supreme Court’s 2022 decision in Dobbs v Jackson Women’s Health Organization, 18 states have enacted functional bans on abortion, yet little is known about how these laws contribute to workplace stress and its sequelae among clinicians. The purpose of this study was to characterize sources of moral distress—which occurs when a clinician knows the right course of clinical action but is barred from taking that action by external constraints—among obstetrician-gynecologists (OB-GYNs) in states with abortion bans. We conducted qualitative, semi-structured interviews with 54 OB-GYNs practicing in 13 of 14 states where abortion was illegal as of March 2023. Using a qualitative descriptive coding approach, we identified four types of clinical situations leading to moral distress: delaying treatment for patients with obstetric complications, conflict with other clinicians, denying care they would have provided locally prior to Dobbs, and restrictions on clinical counseling. These situations provoked feelings of anger, frustration, helplessness, and emotional exhaustion. Participants attributed moral distress to the cumulative toll of routinely being unable to provide evidence-based healthcare, in addition to the acute burden of managing obstetric emergencies in legal gray areas, which was relatively rarer. The findings demonstrate a previously unreported source of moral distress: the everyday chipping away of professional integrity that occurs when OB-GYNs cannot care for patients in the way that patients need. Next steps include developing institutional-level policies and programs to support clinicians and enable them to practice ethical medicine in abortion-restrictive policy environments.