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Abortion Rights Get to the Heart of the Doctor-Patient Relationship
— These decisions reflect the moments when our patients need us most
by Jill Kalman, MD, and Stacey E. Rosen, MD June 28, 2022"
A woman pregnant with twins showed up to an appointment with her cardiologist. She had a history of preeclampsia, the rapid onset of extremely high blood pressure, a medical emergency that can cause organ damage or failure. Or death.
The condition already had claimed the life of her unborn child during a previous pregnancy. The current pregnancy, the cardiologist explained, could prove fatal to the patient, her twins, or all of them.
About one in 25 pregnancies in the U.S. lead to preeclampsia -- it's one of many reasons physicians have to discuss the health risks of "simply" being pregnant. That's a fragile conversation because we physicians approach the doctor-patient relationship with reverence.
That reverence is missing from the U.S. Supreme Court's ruling that overturned Roe v. Wade, the 1973 Supreme Court ruling on abortion rights. The ruling kills shared decision-making between patients and doctors and has already led 11 states to ban or severely limit abortion, with a total of 26 states "certain or likely to ban abortion."
The decision also misses that abortion is more than a reproductive right: It is healthcare. More than 250,000 doctors, via the American Medical Association(AMA), agree. The AMA restated its support for shared decision-making. Members voted to adopt a resolution that "opposes any effort to undermine the basic medical principle that clinical assessments, such as viability of the pregnancy and safety of the pregnant person, are determinations to be made only by healthcare professionals with their patients."
The Supreme Court ruling disregards the sanctity of those determinations and eliminates basic healthcare while setting the stage for reducing other safe medical options. Some political leaders already are discussing restrictions and bans on medical abortions, morning-after pills, birth control pills, and intrauterine devices. That's dangerous because it doesn't acknowledge that, as legal restrictions on abortions rise, so does the proportion abortions considered to be "least safe."
A recent cover of The Lancet, written in response to the leaked draft of Supreme Court Justice Samuel Alito's opinion, framed the problem accurately: "If the U.S. Supreme Court confirms its draft decision, women will die. The Justices who vote to strike down Roe will not succeed in ending abortion, they will succeed in ending safe abortion. Alito and his supporters will have women's blood on their hands."
We physicians, on the other hand, promised to protect life when we began our medical training. It's clear the Supreme Court does not have a lock on protecting life: But we physicians do. And we always have, zealously.
From the moment we meet our patients, we're asking for their trust, even though that relationship begins as one between strangers. We ask these strangers to undress for a physical exam and answer questions about their health and medical histories, which often lead them to share the most intimate details about their lives.
When patients share with us the strain of their family dynamics, work obstacles, sex lives, drug use, and loss, it can be revelatory. We're not just collecting data; it's profound when patients demonstrate that level of vulnerability and trust.
We certainly learn about establishing patient trust in medical school. But until we're out of the medical school setting and practice medicine more independently, we may not yet know that faith, too, is bound up in the doctor-patient relationship.
Our patients have faith in our understanding and our judgment. They have faith that we have their best interests at heart. Sometimes we need faith that our guidance will lead our patients to make healthy decisions. We doctors may need extra faith when we don't fully comprehend a patient's choice. Yet, it is not our obligation to agree with that choice. We treat our patients with expertise and compassion regardless.
Those decisions can be life-altering, which makes it a privilege to walk alongside our patients as they decide how to care for themselves and their loved ones. Those moments are when our patients need us most.
It might've more easily averted a medical catastrophe to tell the patient with preeclampsia to end her pregnancy. But our professional responsibility is more nuanced.
The conversation with her and her family had to make ample space for neutral expertise, compassion, patience, and a deep respect for the patient's autonomy. There is no room for judgement and stonewalling between doctors and patients. There is no room for the cruel pressure of religious judgment, political control, and sexual shame, all of which undermine a relationship we consider holy.
We medical professionals are guided by a passion for helping others. For many of us, it's a calling to learn and to innovate, to offer more medical and surgical paths -- not to reduce safe medical options to the point that our patients are in danger. We work to balance what our patients need and want while helping them understand their medical histories and build healthy futures.
As they build those futures, we may not care for every choice our patients make. But we do have to care for our patients and show them grace in the face of life-or-death decisions.
The patient with preeclampsia was determined to have her babies after learning of the potentially catastrophic possibilities her pregnancy posed. Her decision placed her and her physician on the very edge of her personal medical risk -- and with expert, compassionate guidance, she and her babies survived.
That delicate balance is both the nature of choice and the heart of the doctor-patient relationship. We look to preserve and sustain life in the face of circumstances that threaten it. It's a fragile dynamic, but one that we treat as sacred and, hopefully someday again, legally unshakeable.
Jill Kalman, MD, is the senior vice president and chief medical officer and deputy physician-in-chief of Northwell Health. Stacey E. Rosen, MD, is the senior vice president of the Katz Institute for Women's Health and professor of cardiology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
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