‘There’s going to be a lack of honesty.’ Two Washington doctors on the fallout of overturning Roe v Wade

Dr. Monica R. McLemore is a nurse scientist with a research group advancing new standards in reproductive health. She recently joined the University of Washington School of Nursing. In a conversation with KUOW, she didn’t mince words about the ruling.

“We need some civil disobedience for clinicians like us who know that that it violates our national standards,” she said.

And she’s not alone in that sentiment: that the court erred in terms of medical ethics, among other things.

Dr. Megan Eagan-Torkko is an associate professor and director of nursing at the UW Bothell School of Nursing and Health Studies. She is also a practicing midwife. And she said this ruling could fundamentally change the provider-patient relationship.

“This creates a situation in which providers are potentially being required to act as law enforcement with our patients, which is both unethical and totally inappropriate,” she said. “This decision is, essentially, translating into a breach of trust. There’s going to be a lack of honesty because people will not feel safe disclosing information to their providers. And that’s going to translate into worse health care outcomes.”

Eagen-Torkko and McLemore spoke with KUOW’s Angela King about these and other concerns they have in the wake of the Supreme Court’s decision.

This interview with has been edited for clarity.

Angela King: There are important medical implications, even outside of abortion-related care, that providers will have to consider. How will other areas of care will be impacted by this ruling?

Dr. Megan Eagan-Torkko: One of the largest concerns that I have about health care going forward is what this is going to mean for people seeking care that is not specifically abortion related. In particular, what’s going to happen to people who present to an emergency room or who would present to their provider as having a complicated miscarriage, for example, that requires treatment, including aspirating their uterus? Are they going to be able to access that? Or is their access to that going to be limited by either the actual legal culpability of their provider or the provider’s fear that doing so will limit their ability to practice in a particular setting?

One of the reasons that this is a big concern for me is that we’ve already seen it happen in Catholic health care facilities nationwide. So, this is not something that has been theoretical for some time. This is something that actually does happen.

Do you get the sense that the justices really understood how this ruling would go beyond the core issue of abortion?

Dr. Megan Eagan-Torkko: No. They understood none of how it would go beyond the core issue of abortion or how it works and fits into health care.

Dr. Monica R. McLemore: I completely agree. And I actually want to put a pin in the piece around religiously affiliated organizations, where we’ve already seen restrictions of other types of care, because abortion is so exceptional — or has been deemed exceptional, but it really isn’t. It’s actually quite consistent with other health services that physicians, nurses, midwives and other healthcare providers provide.

But one other point I really want to make is when we have individuals who have multiple waiting periods or other restrictions around abortion access: One of my biggest concerns is what happens to the people who had appointments before this ruling. And now, where do they go for their care? Let’s say you had your first appointment two days ago, and now we have this ruling. Well, where are you supposed to go? Especially if you either initiated abortion by taking medications or you you began your process, where are you supposed to go?

The second piece I would add to that is this notion of our health care workforce and the people who actually are doing abortion-related work. These people still have to call patients. They still have to get people rescheduled. They still have to get people care. But they have no job. I don’t want us to lose sight of the fact that this has huge drastic implications for people seeking abortion care, but then also, what about the workforce? Are they expected to be able to work without pay? Are they working in a legally precarious situation? Because now, what they did yesterday was completely legal, and now, in those states that have automatic trigger laws, it’s not.

Monica, can you detail your research on inequities within our healthcare system for Black communities, Indigenous communities and people of color? Those communities will almost certainly feel a disproportionate impact from this ruling.

Dr. Monica R. McLemore: Absolutely. There is no single majority of people who have abortions — about a quarter identify as white, about a quarter identify as Black and a quarter as Latinx or other people of color. When you think about the proportions of individuals in the population, however, Black people are over-represented among people who are seeking abortions. And there’s a whole variety of structural racism reasons why that’s true.

And so, we already know that people who are already the most burdened with health inequities and disparities and, quite frankly, have to struggle with structural racism in the context of health care are going to be the most impacted by this decision. To place an additional burden on people who are already greatly burdened — and I would also like to remind the listeners, we’re still in the context of Covid — health inequities are actually going to be widened and exacerbated, because of these restrictions in care.

Layer on top of that an already existing maternal health crisis for pregnant people who want to remain pregnant and carry pregnancies to term. It is just, I think, a cruel and uninformed decision that is going to have long-term impacts for Black, Indigenous and other people of color.

Dr. Megan Eagan-Torkko: One of the realities of this decision is that it ignores how people interact with the health care system, how the health care system interacts with them and the structural racism that disproportionately impacts Black and other women of color in the United States. My concerns as a midwife are that people can access care that they need when they need it, and that it is appropriate care. And this decision does absolutely nothing to improve that.

Do you have other concerns that people may not immediately think of?

Dr. Megan Eagan-Torkko: One of the things that is concerning for me is whether some forms of contraception will be relabeled as abortifacients (substances that induce abortion) and considered to be banned under some of the new laws. If conception or pregnancy is defined as fertilization of an ovum, there are a number of contraceptive methods, including some of the IUDs and really most hormonal methods, where you cannot guarantee that there’s not going to be interruption of ovulation. That interruption of implantation of a fertilized egg may, in fact, be the way that the contraception is working. And I am very concerned that this decision really opens the door to banning some of our most effective methods of contraception.

This ruling will affect providers, and could lead to laws that hold them legally responsible for abortion services. We’ve seen this in Texas already. Monica, are you worried about how this will affect your practice?

Dr. Monica R. McLemore: It is really hard to think about this notion that I have to somehow interpret myself as an arm of or an agent of the state. Federal ethics guidelines from the American Nurses Association and from the American Medical Association are in direct conflict with this ruling. It is not the job of health care providers to call police on our patients or to notify authorities when we suspect that they either have had a miscarriage or have had an abortion. This was completely in conflict with our code of ethics.

The Washington Board of Nursing and Washington Medical Commission need to be very, very clear around the protections for providers that are aligned with our national ethics standards, because I am very concerned that people will leave the profession and will discontinue providing comprehensive reproductive health services out of fear. And I find that to be completely offensive and, quite frankly, unacceptable.

Will this change anything about how you teach courses or interact with students who are looking to pursue careers in the medical field moving forward?

Dr. Monica R. McLemore: Absolutely not. I am proud and was able to participate in the first ever hands-on abortion workshop that Dr. Eagan-Torkko and I participated in at the American College of Nurse-Midwives’ annual meeting in Chicago last month. It was led by a colleague and a collaborator of ours, Dr. Michelle Drew, teaching students and existing clinicians how to be able to provide comprehensive reproductive-justice-informed abortion care, all the way from values clarification to doing the actual procedure.

It has not changed and will not change how I plan to teach students and to bring skills to individuals, because the people that we serve, they really deserve excellent care and nurses, midwives, physician assistants, physicians and nurse practitioners to provide excellent abortion care.

We’ve been hearing reports of how people here in Washington and other states where abortion rights are still protected are offering to send people out of state contraception or house those who come here to get an abortion. What do you think of this informal effort to help others?

Dr. Monica R. McLemore: We don’t need to recreate the wheel, because these kinds of practical support and other kinds of state-based and regional abortion funds have been doing this work for decades. There is the National Network of Abortion Funds, which is a social and practical support organization that has been around for decades. They have been doing this kind of work, providing people with guest cards or train tickets if they need to travel, providing childcare and other kinds of supports.

This was all built out and led by Black, Indigenous and other people of color, almost as an organized effort towards mutual aid. This has been in existence for years. So, I personally believe that in order to help people get the care that they deserve, we need to be amplifying these national efforts and making sure that people have access to travel — because, again, the people who are most impacted by these abortion bans aren’t people who have money and wealth and access to insurance coverage.

We need to think about the Women’s Health Protection Act, which has been stalled in D.C. And we actually, quite frankly, need to be able to expand access to coverage. A reminder to the listeners: Abortion is an outcome of pregnancy, just like birth is an outcome of pregnancy, and we need to cover it as we do other types of health care.

Monica, what do you think people should consider before they either turn to an individual for help or being offered help to begin with?

Dr. Monica R. McLemore: Well, the National Abortion Federation runs a national hotline for people who need assistance with practical support around abortion, as does the National Network of Abortion Funds. There are several independent clinics that also host hotlines. I Need An A, for example, is a provider-agnostic online digital repository and platform. Plan C is an organization that provides access to evidence-based information and to medication-abortion, or abortion using pills. If people need fact-based information, there are resources that we’re happy to share that will allow for individuals to be able to have the practical support that they need for abortion care, including money to be able to pay for procedures, travel and child care.

You know, there are folks who have abortions who don’t have insurance coverage at work. So, how do you make up for the lost income and revenue if you needed a multiple-day procedure? All of those organizations are primed and ready to be able to provide information to people.

Dr. Megan Eagan-Torkko: I think it’s really important to remember that there are not people who have abortions and people who have babies — there are just people. Whether someone thinks that they may, at some point, need to have an abortion or want to have an abortion is irrelevant to what actually happens. We provide health care. And what these laws do is they make it difficult or impossible for me to do my job, which is to provide health care that people need when they need it. There isn’t any way to sugarcoat that reality. People are not going to get the care that they need in the United States.

Dr. Monica R. McLemore: And the last thing I would say is the estimated rates of abortion have been dropping. Since we’ve been keeping statistics, and specifically over the last decade, we’ve seen an estimated 800,000 abortions in the United States. And that’s widely thought to be an underestimate. That, however, still is a very large number of pregnancies, that if they all continued, would need to come into our existing pregnancy services and health care where we have an estimated 4 million births per year in the United States.

We already have an existing maternal morbidity and mortality crisis where we can’t even keep people alive when they give birth. We need the creativity of nursing, medicine, social work, public health, health care, policymakers, funders to really think about how we can reimagine and rebuild our health care infrastructure to be able to provide optimal services and outcomes for pregnant-capable people.

Just to follow up on that last point, Monica, about maternal morbidity more. How might this ruling affect both the pregnant person’s morbidity or ability to thrive and as well as infants?

Dr. Monica R. McLemore: The reality is, in states that have more restrictive abortion policies, they tend to have fewer supportive policies in place to support parents and their families. And so, it is extremely, in my opinion, disingenuous to enact extreme abortion restrictions when many of the states — and there are still 11 — have not expanded Medicaid under the Affordable Care Act that would provide services to be able to expand access to things like maternal health care, perinatal mental health and interventions that we know that reduce infant morbidity and mortality.

What happens when those pregnancies continue on to term when we don’t still have the health care and social service supports to set those parents and those pregnant people up for success? It really comes back to this idea: We need to reimagine this notion of how do we better cover women and pregnant-capable people? And how do we get them not only medical supports that they need but also the social services that they need that we know are associated with good health outcomes?

This is a watershed moment. We will have an opportunity to have new conversations about how we are going to reimagine and set up health services for this new landscape that we are in. How do we make sure that people on public insurance have support? To me, it’s a bigger discussion: How are we going to think about rearranging or reimagining our existing services? And what new dollars and what new workforces do we have? What new policies do we need in order to ensure good health outcomes? That’s the discussion I’m interested in having.

Do you get the sense others are interested in having that conversation as well?

Dr. Monica R. McLemore: Recently, in my world, yes. I’ve been able to talk to a whole lot of people who weren’t historically interested in having this discussion. I think one of the unintended consequences of recognizing the precariousness of having our legal rights protected by a single unelected entity is that people are now starting to understand that, as citizens, we actually have the capacity to have different conversations about how to be able to allocate resources, specifically for pregnancy outcomes and pregnancy-related care.

Dr. Megan Eagan-Torkko: The loss of Roe has clarified the reality that, for most people in the United States, it has not been an absolute or complete right since the Hyde Amendment was passed in 1976. So, I think that what this has done is really brought into focus the reality that Roe was never a complete coverage. It was never a promise. It’s a floor, not a ceiling for what we should expect from our government and from our access to health care.

Dr. Monica R. McLemore: And that is one of the reasons why we need reproductive justice approaches to reimagining how we want to allocate money, time and space resources when it comes to pregnant-capable people. Reproductive justice, very simply, is grounded in human rights. Every human has the right to become a parent, to not become a parent and to parent the children that we have in safe environments without fear of violence from any individual or from any government.

Listen to the interview by clicking the play button above.