The Supreme Court’s decision in Idaho and Moyle et al v. United States has preserved my ability to care for pregnant people.
Idaho officials had argued that because abortion is illegal under state law, emergency medicine physicians like me would not be able to perform the procedure in such states, even under a federal law known as EMTALA. The Emergency Medical Treatment and Labor Act demands I care for people who arrive in the emergency department as needed to stabilize their condition or save their lives. This treatment can include abortion.
The Court has decided that, in this situation, federal law can supersede state law. Had this decision gone the other way, it would have put lives at risk and physicians’ careers in jeopardy. But in deciding that abortion can be provided under EMTALA, the Supreme Court has helped, albeit narrowly, to uphold the relationship between doctor and patient in the most dire of circumstances.
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I take care of pregnant people during most of my shifts in the emergency department. They come to us with health issues that are both pregnancy-related and non-pregnancy-related, regardless of whether they have an obstetrician. When they arrive, we identify possible threats to life, provide stabilizing care and either consult with a specialist or, if patients need treatment we can’t readily provide, transfer them to hospitals that can.
What the highest court has preserved is my ability to fully care for people in cases like this: a pregnant person with a life-threatening infection that may cause what’s known as a septic abortion, a uterine lining so riddled with infection that the only way to save that person is through a hysterectomy.
Or this: If a pregnant person comes in and is dying from a massive blood clot in their lungs, their heart might stop, and we would have to treat them with acute thrombolytics to break up the clot. This would save their life, but could cause placental abruption, uterine bleeding, premature labor or fetal death.
In these cases and so many others, EMTALA has long made it possible for physicians to terminate a woman’s pregnancy to avoid life-threatening complications and, in rare occasions, death. This decision is a win for women’s health care, but the battle to preserve reproductive rights for people who can get pregnant is far from over.
Take medication abortion, part of the treatment I might prescribe to someone with an ectopic pregnancy (one in which the embryo has implanted somewhere other than the uterus) that hasn’t ruptured. Under EMTALA I would work with an obstetrician to get that person the care they need. While another recent Supreme Court ruling saves access to this drug, Justice Brett Kavanaugh effectively gave antiabortion groups a playbook on how to block access to this drug in the decision, when he wrote that groups could instead seek “greater regulatory or legislative restrictions” on the drug.
What the new ruling preserves is my ability to help a pregnant person if their ectopic pregnancy ruptures. The severe bleeding and possible infection that results from a rupture are some of the leading causes of maternal mortality in the first trimester and account for up to 14 percent of all maternal deaths. The only way to prevent this is surgery, immediately.
As I and my emergency medicine colleagues awaited the Supreme Court decision, here are some of the questions we had to ask ourselves, should the court have ruled in favor of Idaho.
If abortion is no longer protected under EMTALA, am I supposed to wait until my patient’s pregnancy ruptures before I can intervene? Do I have to consult with a legal team before being allowed to treat a patient with an ectopic pregnancy? How long will that take? Will this delay a person’s care?
What if that person is stable and in the process of waiting for me to clarify with legal that I can proceed with treatment, their ectopic pregnancy ruptures, and this person starts bleeding into their abdomen?
What if I’m in a rural hospital and the nearest operative room is an hour away, and now my patient is too unstable to transfer because they need a mass blood transfusion to stay alive long enough to make it to the operating room? What if my patient dies because I couldn’t navigate the uncharted territory fast enough?
Will I lose my license for giving pregnant people the standard of care? Will I be accused of malpractice if legalities impede such care?
The Supreme Court decision has spared us these torturous questions, and allows emergency medicine providers to focus on providing standard, lifesaving health care.
For now. Idaho is just one of many states fighting against reproductive rights.
In its case, state officials frequently cited that EMTALA does not specifically include the term or definition of abortion. EMTALA doesn’t specifically address abortion services, but it was purposely written to be broad because what constitutes stabilizing care varies widely from person to person.
And while part of our jobs in emergency medicine is to save people on the brink of death, we just as readily are stabilizing people who are sick, but not lethally so. What this decision helps save are the contingency plans to take care of people with infections from a missed abortion, preeclampsia or premature preterm rupture of membranes. Terminating a pregnancy is the stabilizing care required to avoid severe complications including stroke, kidney failure, sepsis, hemorrhage or death. I can continue to do this for those people and the ones who come into the emergency department for a dire reason not related to their pregnancy: heart failure, other types of infection, cancer, trauma and more.
The people who will benefit most from this decision include those who live in rural parts of the U.S. Their mortality rates are some 20 percent higher than their urban counterparts because of factors including lack of primary care, lack of access to specialized care, greater rates of poverty and being more likely to be uninsured. Add in pregnancy, subtract the care that is currently protected by EMTALA and what does that equal? Worsening outcomes that could have been preventable. I would have expected to see maternal mortality rise significantly had the Court swayed toward Idaho, especially for people who live in areas with fewer resources.
And finally this decision helps maintain some stability for health care in general. Had the Court decided differently, Idaho could have prompted future legislators, motivated by religious or political beliefs, to decide more broadly who should receive stabilizing care.
As EMTALA has been upheld, the work doesn’t stop now. Like other young physicians, I am considering where I will want to practice after this last year of residency. I have been paying close attention to where I can provide safe, evidence-based medicine for pregnant people. A gratifying outcome of this ruling, for doctors of my cohort, is the prospect of serving the millions of people in the U.S. who can and will get pregnant during our medical careers.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.