Abortion Restrictions Weakening Cancer Care, Other Treatments

Monica Vetter typically would treat the cervical cancer on “Patient M” with a low dose of chemotherapy and a high dose of radiation. But Patient M was 21 weeks pregnant and living in Kentucky, which took the recommended treatment off the table.

The Lexington, Ky.-based gynecologic oncologist saw Patient M just after the US Supreme Court overturned the constitutional right to an abortion in June 2022. Kentucky now has a near-total abortion ban.

Since a pregnant patient can’t receive radiation due to risks of birth defects, Patient M’s case to terminate the pregnancy went before a hospital panel, which ruled the mother of five didn’t meet the narrow exception for medical emergencies under Kentucky law.

“She always told me that she wanted to be alive for the ‘kids she already had.’ It was heartbreaking,” Vetter said in an interview. Patient M is doing well now, but “she could have not been okay. She may still not be okay,” Vetter said.

Patient M couldn’t receive what Vetter described as the “tried and true” curative treatment for locally advanced cervical cancer while she was pregnant. Instead, she first received what’s called neoadjuvant chemotherapy, a treatment Vetter said hasn’t been rigorously tested for this cancer. She ultimately delivered her baby seven weeks early so she could get the standard-of-care treatment after an 11-week delay.

“I have a patient that tells me that she wants to do everything to maximize survival, and I was potentially forced to give her a treatment that is likely inferior to the standard of care treatment,” Vetter said.

Vague Laws Lead to Medical Dilemmas

Vetter and her colleagues were warned they could go to prison if they did anything to jeopardize Patient M’s pregnancy.

Providers found in violation of Kentucky’s abortion ban face one to five years of prison time, fines, and potential loss of their medical licenses.

Since the Dobbs ruling, 27 states have banned or severely limited abortions. The laws reach far beyond terminating pregnancies, due to vaguely written statutes and confusion over the bans, legal experts and providers said.

These laws also change rapidly, with injunctions and appeals changing a law’s status as soon as the next day and making it even harder for providers to stay current.

“Oncologists are not abortion providers,” and it’s not an expected part of their care to keep up with changes in law, Rebecca Spence, chief ethics counsel for the American Society of Clinical Oncology, said in an interview.

Cancer isn’t special in that sense, Spence added.

“This issue affects also cardiology, neurology, rheumatology and other specialties where patients might need medications that are inconsistent with a healthy pregnancy,” she said.

Because abortion bans have shuttered publicly funded family planning health centers, sexually transmitted infections also could increase, one study found.

“The trickle down effect of this law has affected every single aspect of medicine,” said Leilah Zahedi-Spung, an OB-GYN at the University of Colorado who specializes in maternal-fetal medicine. “It is impacting basic health care that people should be able to get. And it’s awful.”

State’s Exceptions Lack Clarity

Many exceptions to abortion restrictions are ambiguous, Deborah Bachrach, a partner at policy consulting firm Manatt Health, said.

Arizona, Florida, Indiana, Ohio, and Wyoming’s statutes provide an exception if there’s serious risk of substantial and irreversible impairment of a major bodily function. But they don’t define what constitutes a serious risk or irreversible impairment nor do they list which bodily functions are considered major under the law, Bachrach said during a webinar.

“The exceptions have proven unworkable, so they really aren’t exceptions at all. They are not protecting pregnant women facing emergency medical conditions,” Bachrach said in an interview.

In Texas, a life-threatening condition has to be caused by a pregnancy to meet the exception, leaving in question what happens if a patient is in a car accident or has cancer or any other condition that’s exacerbated by the pregnancy.

A Texas district court judge found the law was unclear about how to apply the medical exceptions. In an injunction issued Aug. 4, Judge Jessica Mangrum ruled Texas can’t enforce its abortion ban if a pregnant person has a complication that risks infection or is otherwise unsafe, or if the person has a condition made worse by pregnancy that can’t be treated.

But an appeal filed the next day prevented the temporary block from taking effect.

“Protecting the health of mothers and babies is of paramount importance to the people of Texas, a moral principle enshrined in the law,” the office of Texas Attorney General Ken Paxton (R) said in a statement announcing the appeal. “The OAG will continue to enforce the laws duly enacted by the Texas Legislature and uphold the values of the people of Texas.”

State law and medical terminology often differ in how they define conception, abortion, or end of life, Delphine O’Rourke, who’s presented on Dobbs for the American Health Lawyers Association, said in an interview. Those inconsistencies add confusion to interpreting the state laws and how they intersect with other laws on the books.

More than 70% of states with restrictions or bans currently face pending litigation.

“When you have lack of clarity in legislation, that leads to more legal disputes,” O’Rourke, president and CEO of Safe & Green Medical, said. “The worst thing you want are vague laws.”

One example is that providers can’t prevent sepsis in a subset of patients “because the law seems to apply, and the mom doesn’t seem close enough to death for the law to kick in,” said Mary Ziegler, a law professor at the University of California Davis who’s written six books on abortion law and history.

Judette Louis has seen this first hand, both as the OB-GYN chair at the University of South Florida and as a specialist in high-risk obstetric care. More patients are being sent to intensive care or even losing their uteruses because, under Florida’s law, hospitals need to see more visible signs of the infection that’s endangering a patient or the pregnancy.

“Every single legislative session, I have to sit down with lawyers and figure out: How does this impact what we’re doing and how we’re treating patients?” Louis said. “It’s no longer based on what is medically appropriate, and what the patient wants.”

Florida Gov. Ron DeSantis (R) signed a six-week ban into law in April, but it’s currently held up by a legal challenge.

‘I Couldn’t Stay’

Restrictions that go beyond abortion could exacerbate an existing OB-GYN workforce shortage, making it tougher for patients who want to carry their pregnancies to term.

“We’ve had a high turnover in our department, and at least half of them have cited this new legislation as part of the reason why they moved,” Louis said.

Bonner General Health, a critical access hospital in Sandpoint, Idaho, closed its labor and delivery department in March and cited the state’s legal and political climate as one of the reasons. Idaho has one of the strictest bans in the nation.

Zahedi-Spung loved her job in Chattanooga, Tenn. She was the only practitioner in a 10,000-patient area who could treat abortions, miscarriages, and similar procedures over 14 weeks. But the all-out ban in Tennessee triggered by Dobbs made abortion a felony with up to 15 years in prison.

“It became abundantly clear that I couldn’t stay, unfortunately,” Zahedi-Spung said. “I hired my own criminal defense attorney, like some kind of mob boss.”

Shield Laws

Zahedi-Spung now works in Colorado, one of more than a dozen states with a shield law to protect patients and providers from legal attacks. These laws generally include reproductive health-care services more broadly, including access to contraception, in vitro fertilization, and miscarriage management, said Natalie R. Birnbaum, a health-care regulatory attorney at Nelson Hardiman LLP and co-owner of the consulting company Repro Solutions.

Ronald G. Blum, a litigator at Manatt, Phelps & Phillips, LLP, said these laws create potential conflicts with federal law, including: the full faith and credit clause in the US Constitution, which requires courts to honor other state laws; and the extradition clause, which means that if someone has been charged with a crime and flees to another state, that person has to be returned from the harboring state.

It’s important for providers and patients in shield law states to conduct a through risk analysis, Birnbaum said. “The more states that adopt shield laws, the less risky it becomes, and then it becomes a norm.”

Still, the shield laws aren’t a silver bullet, so doctors continue to wrestle with thorny ethics issues around all types of medical care, but especially reproductive health.

“Patients feel like they’re getting denied even proper clinical care,” Louis said. “OB-GYNs chose the field because they loved it. But now they’re being faced with the moral injury of being told how they can practice medicine.”