Maternal-fetal medicine doctors help patients with high-risk pregnancies bring them to term. Sometimes, the risks are too great, and an abortion is needed. The U-S Supreme Court's elimination of a federal right to an abortion in 2022 added layers of uncertainty to the obstetrics specialty. Dr. David Hackney practices maternal-fetal medicine and teaches at Case Western Reserve University. His new book is "Impossible Choices: A Physician's Guidance on High-Risk Pregnancy in a World Without Roe." He spoke with Ideastream Public Media's Amy Eddings.
The title, is this meant to be a practical guide for doctors and patients?
Yes, yes and no. The book is not straightforward guidance in the way like you'll sometimes have a book that's guidance on weight loss or guidance on trying to lower blood pressure. But I do intend for the book to have a lot of practical guidance in it. The book has been written for a general audience, and it does include specific chapters on common high-risk conditions and how those have been impacted after Dobbs (v. Jackson Women’s Health Organization).
What makes a pregnancy high risk, and how has the loss of a federal right to an abortion affected those risks, especially in states that have now adopted bans?
There's not a straightforward answer to that question because it's always important to emphasize that even the healthiest patient with the most straightforward pregnancy, pregnancy itself always carries risk, which is why it's important to focus on reproductive rights for all patients, including the patients that I see that are specifically high risk. A lot of the focus after Dobbs has been on patients such as mine. Patients, you know, the patients who have birth defects, the patients who are being forced to continue the pregnancy despite a serious medical problem. But that is complicated because that doesn't pick up the lion's share of the picture of abortion, as well as it risks having what we'll sometimes call the hierarchy of deservedness. If you have a patient with a serious fetal birth defect and then you have a 20-year-old who just simply doesn't want to be pregnant, you know, there shouldn't necessarily be a hierarchy between those two. The patient with the birth defect tends to endeavor more public sympathy and draw a little bit more focus, but what is the lifetime trajectory of the impact of not allowing abortion care for the completely healthy patient who's 20 and just simply doesn't wanna be pregnant at that stage of their life?
Many state bans have exceptions for the health of the mother. Many in the anti-abortion camp argue that these exceptions are clear-cut and that instances in which pregnant patients have died because they did not get the indicated abortion in time to avoid, say, sepsis or grave blood loss are due to medical negligence and not the law. You and many doctors and abortion advocates say it's not clear cut. Would the problem be solved by explicit language or a comprehensive list of complications? Would that solve the issue?
No, for several reasons. First off, if you have an abortion ban, and let's say you could somehow magically come up with a list of all of the maternal or fetal exceptions, that's still fundamentally a violation of basic rights and freedoms. And again, it's important when talking about high-risk patients to always keep in mind the freedoms of patients who are low risk. Also, you're not ever going to be able to cover every single human disease and. Also, we often use the word exception in a not legally exact manner because there are exceptions, and then there is an affirmative defense.
Tell me more about that. What does that mean, affirmative defense?
An affirmative defense is a defense that you are allowed to invoke, though in doing so, the burden of proof shifts from the government to yourself. So, if you look at Ohio's law that we were under for many months, SB23 [Ohio Senate Bill 23] had five conditions which were listed as specifically exceptions [pre-eclampsia, inevitable abortion, diabetes, pre-mature rupture of the membranes and multiple sclerosis]. But then everything else fell under an affirmative defense. So, cancer, for example, heart disease, kidney disease. Some of the particularly critical conditions that we take care of in high-risk obstetrics fell under an affirmative defense. I, or whoever the physician was, would then assume the burden of proof to demonstrate that the abortion was needed for that health problem.
So, this gets to this issue of indecision. You advise pregnant patients to ask a lot of questions of their doctor, writing of the potential paralysis that can affect their healthcare providers as a result of the Dobbs decision.
One of my goals in the book is to help the public understand how doctors think and how they emotionally are going to respond to these bans. So, we're used to fraught circumstances. We're used to clinical emergencies, having to make changes. We're not used emotionally to situations in which we know what the right thing is to do. But we're unable to do so under the law. Psychologically, we're not used to the specter of criminal charges, you know, that has taken a significant psychological toll on us. There is the potential for us to be frozen. There have certainly been well-reported tragic cases, including cases of patients who have died after the Dobbs decision, where we look back on the case and say they should have proceeded with the D&C (dilation and curettage) procedure. The D&C procedure was obviously, in retrospect, indicated and would have saved the patient's life, and you wonder why did it not move forward. Of course, we don't know without the actual medical records and everything, you know, but obviously in those cases there was something that got hung up, be it decision paralysis or administrative. It's incumbent on patients in our modern healthcare system to be able to recognize this and ask the questions you need to ask, as I outline in the book. Know how the healthcare system currently works. Know the emotional topography of doctors right now. Know the situations in which you're gonna have to act as your own best defense.
And for some women that may mean seeking their care elsewhere in other states where there are not abortion bans.
Yeah, and one of the things I talk about in the book is if you are even a completely healthy patient in a state with a ban, it's always worth giving some thought to what the escape plan would be. Where would you go? How would you get out if you need to get out? And when do you know that it's time to leave?
