Wellness Roe v Wade, Dobbs, and Reproductive Justice: A Case for Moral Injury to Physicians

Roe v Wade, Dobbs, and Reproductive Justice: A Case for Moral Injury to Physicians

By Stephanie Balint and Cindy Bitter, MD, MA, MPH, on behalf of the SAEM Wellness Committee

The day the Supreme Court decision on Dobbs v. Jackson Women’s Health Organization was leaked, I was studying with my first-year medical student friends. We discussed the ramifications of the decision on our intended specialties; nursing students and faculty joined in the discussion as they passed by. We were united in our disbelief and sense of powerlessness to affect the final decision that might disrupt access to reproductive health care. A common theme in modeling perinatal mortality in a post-Roe era is that complications and mortality will disproportionately impact those living at the poverty level. As medical students, it felt like the values we espouse — health equity, evidence-based medicine, improving geographic disparities — would be destroyed by this decision.

Defining Moral Injury

Dissonance between one’s values and an act one witnesses or perpetrates can lead to “moral injury.” Moral injury can also occur when one simply fails to intervene when witnessing a situation that contradicts one’s values. In health care, moral injury describes the challenge of “simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” Emergency medicine (EM) is a field with a great deal of experience dealing with moral injury. We treat victims of interpersonal violence and preventable complications of untreated disease and honor patient autonomy when the patient’s desired treatment goes against evidence-based recommendations. continued on Page 56

WELLNESS

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Emergency department personnel recently faced amplified moral threats as we encountered an overwhelming pandemic with inadequate personal protective equipment, then treated patients with COVID-19 who had declined vaccination. We continue to try to find ways to limit poor outcomes caused by delays in care and full waiting rooms due to inadequate staffing and boarding of inpatients. Just as we began to adjust to a new scope of COVID-19-related moral injury, the Supreme Court decision added another potential threat. Regardless of one’s political affiliation or views on abortion, I believe most physicians do not want to stand idly by as a woman becomes septic and dies while the lawyers and legislators argue about how imminent the threat to her life must be before she can be offered a termination.3-5

Implications of the Supreme Court Decision

Our obstetrics and gynecology (OBGYN) colleagues were the first to feel the impact of the Dobbs decision. Dr. Caitlin Bernard, and Indianapolis, IN OB-GYN, has been at the center of a firestorm after treating a victim of pediatric sexual assault who was referred to her for pregnancy termination. In a CNN interview, Dr. Bernard stressed that when treating medical emergencies there are not seconds to spare to consult with an attorney. In a specialty where timecritical decision making is common, these delays have the potential to impact patient outcomes and bring further assault to physician values. In a New England Journal of Medicine opinion piece, OB-GYN, Dr. Lisa Harris highlighted the need for hospitals to prepare, system-wide, for the repercussions of the Dobbs decision. As medically supervised terminations become less available, patients may seek alternative methods of termination which are projected to be associated with higher pregnancy-related mortality.1,8-9 The EM community is already researching and disseminating information on managing the life-

threatening emergencies created by these alternative attempts at pregnancy termination.10-11

What Can We Do?

With this new, potential source of moral injury upon us, we look to the literature for possible mechanisms for coping. The first step in reducing moral injury is awareness. Identifying the source of one’s discomfort as a moral injury can lead clinicians to seek support from peers and take their concerns to leadership to ensure that hospital protocols facilitate patient-centered behavior and values are upheld. In a 2019 commentary, Dr. Wendy Dean, et al., suggest that long-term solutions will come from collaboration between administrators and physicians. This is consistent with the Quadruple Aim, which adds the wellbeing of health care workers to reducing costs, improving population health, and improving the patient experience as ways to optimize the health care system. Additionally, physicians are often able to advocate for policy changes on a broader level. Physician advocacy has been crucial to the development of seat belt regulations, expansion of the Children’s Health Insurance Program, and ensuring coverage of indicated treatments for conditions such as opioid use disorder and hepatitis C. Dean, et al., suggest that “every physician leader has and uses the cell phone number of his or her legislators.”

Other proposed strategies for reducing moral injury include educational workshops, moral empowerment programs, social work interventions, nursing ethics huddles, reflective debriefing, and a multifaceted resiliency bundle.12-13 The paucity of evidencebased tools for dealing with moral injury presents an opportunity for research and innovation. Given the many moral threats EM faces, the specialty is uniquely equipped to be at the forefront of tackling this issue. Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the views or positions of the Society for Academic Emergency Medicine. Dr. Bitter is an associate professor, department of surgery, division of emergency medicine at Saint Louis University in Missouri. She attended medical school at the University of Kansas and completed her emergency medicine training at the Medical College of Wisconsin, and completed an International EM & Global Health Fellowship at the University of Illinois at Chicago. Stephanie Balint, a second-year medical student at Quinnipiac University, applied to medical school with the goal of becoming an emergency department physician. Prior to medical school she worked as an emergency medical technician, National Guard Healthcare Specialist, and for five years, as an emergency department registered nurse. Since 2020 she has worked as an Advanced practice registered nurse in the ED at a small 122-bed community hospital in Connecticut. @stephfosterski1

Read more:

• The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant • Reframing Clinician Distress: Moral Injury Not Burnout • Abortion ban leads to more maternal deaths in Nicaragua • When There’s a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals • Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women: an analysis of the death of Savita Halappanavar in Ireland and similar cases • CNN speaks to the doctor who performed an abortion on 10-year-old • Navigating Loss of Abortion Services — A Large Academic Medical Center Prepares for the Overturn of Roe v. Wade • Fatal necrotizing fasciitis in illegal abortion and the negligence tort • State Abortion Policies and Maternal Death in the United States, 2015-2018 • The Emergency Department After the Fall of Roe: Are You Prepared? • Post Abortion Complications • Reflective Debriefing: A Social Work Intervention Addressing Moral Distress among ICU Nurses • Effective interventions for reducing moral distress in critical care nurses