A series of new laws and lower-court decisions about reproductive health driven by ideology instead of science are sowing confusion and uncertainty for physicians, threatening patient care, undermining our ethical obligations as doctors, and outrageously interfering in some of the most difficult and personal decisions patients and physicians make together.
In a case with significant bearing on reproductive health care, the Supreme Court will hear oral arguments April 24 and consider the merits of potential criminal prosecution of physicians and other health care professionals who provide medically necessary reproductive care—including an abortion—during medical emergencies in the state of Idaho.
This case, State of Idaho v. United States of America (PDF), is based on a law enacted by the Idaho State Legislature in 2022, one in a series of state-sanctioned assaults on reproductive health following the Dobbs decision. The Idaho Defense of Life Act makes it a crime, punishable by up to five years in prison, for anyone who performs or assists in performing an abortion.
The U.S. Department of Justice filed a legal challenge to that measure in August 2022, a few weeks before the law was set to take effect, citing a conflict with the federal Emergency Medical Treatment and Labor Act (EMTALA). A provision of EMTALA requires hospitals that receive federal funding to provide stabilizing emergency treatment—which can sometimes include abortion—to patients experiencing a medical emergency.
The federal government contends, and the AMA agrees (PDF), that this obligation exists even if a state has passed a law banning abortion. Doctors cannot be required by a state to sit on their hands and withhold the form of emergency care that would best avoid major harms to a patient’s health.
Following legal action in lower courts, the Supreme Court agreed to hear arguments in the case. Physicians and other health professionals who provide emergency care to pregnant patients understand that abortion may be medically necessary as stabilizing care when continuing a pregnancy puts a patient at risk of severe outcomes or even death.
Narrow exception
The one exception to Idaho’s abortion law permits the procedure “only when it is necessary to prevent the death of the pregnant woman.” This stands in sharp contrast to the federal EMTALA law, which protects patients not only from imminent death, but also from other emergencies that pose serious health risks, including seizures, stroke, major organ damage and failure, and future fertility loss.
In reality, pregnancy can and does present a number of emergent complications that sometimes place physicians in the untenable position of being unable to comply with both EMTALA and the Idaho law, given that law’s narrow exceptions. It is reckless for Idaho to tell emergency physicians that they must ignore their moral and ethical standards and stand by while a septic patient begins to lose kidney function, or when a hemorrhaging patient faces only a 30% of death. Medically unstable Idaho women in these circumstances may have to be packed up in ambulances and driven across mountains to another state for care.
Rapid treatment, better outcomes
The public knows that speed is everything in a health emergency. Pregnant patients regularly visit emergency departments with serious complications including excessive bleeding, preeclampsia, ectopic pregnancies, and infection or sepsis. Physicians must make an immediate assessment of these patients and reach a decision, in partnership with the patient, about what action must be taken. A delay of even a few minutes can lead to a devastating outcome.
Idaho’s law, however, forces physicians in these situations to delay care until a patient’s medical condition deteriorates to the point of becoming life-threatening. That dangerous standard cannot be applied to the real-life situations faced in emergency departments every day—there is no bright line when each patient’s condition suddenly reaches “life-threatening,” and deteriorating patients don’t want their physicians delaying care awaiting a crisis while their risk of catastrophic consequences steadily increases. This is having a chilling effect in states with such a ridiculous standard, and in Idaho, many obstetricians have made the difficult decision to stop delivering babies or leave the state to practice elsewhere.
Provisions of EMTALA
Requiring hospitals that receive federal funding to provide stabilizing care for every patient experiencing an emergency medical condition has been a vitally important provision of EMTALA since its enactment more than three decades ago. This has included abortion care when it is the medically indicated treatment to stabilize a pregnant patient experiencing a medical emergency.
EMTALA does not specify what treatment protocol should be followed in a particular situation, but properly defers to a physician’s professional medical judgment to provide the best options for stabilizing a patient. Those decisions, based on scientific knowledge, clinical guidelines, and physician experience, are made in collaboration with patients and their wishes and values.
The reverse is also true: EMTALA does not allow a physician to withhold a specific treatment for nonmedical reasons. If abortion care is required to stabilize a patient’s emergency condition, it must be made available to that patient. If the Idaho law is allowed to stand, any Idaho physician who considers terminating a pregnancy—even when the pregnant patient’s health hangs in the balance—must weigh the possibility of criminal prosecution.
This is dangerous and wrong. Physicians must be allowed to follow what their training, experience and judgment tells them is the optimal course of medically necessary treatment. And physicians must not be prohibited from protecting the health of a pregnant patient when that optimal course of treatment requires terminating the pregnancy.
An adverse decision in this case will undermine widely accepted principles of medical ethics by forcing physicians to consider their own legal jeopardy in treating a pregnant patient experiencing a medical emergency. The AMA Code of Medical Ethics obligates physicians “to place patients’ welfare above the physician’s own self-interest or obligations to others.” We must not accept a new normal in which calls must be made to hospital attorneys while minutes tick by and lives hang in the balance.
In every instance, the AMA will challenge punitive action taken against patients for their health decisions, as well as any type of civil or criminal penalty brought against physicians and other health professionals who provide reproductive health care or referrals. The consequences of inaction in these circumstances are just too dire to consider.
