It has been more than one year since the United States Supreme Court, in a controversial decision not supported by a majority of Americans, overturned Roe v. Wade, returning authority over abortion’s legality to the states. Since the decision in Dobbs v. Jackson Women’s Health Organization, 14 states have prohibited abortion and another six have added restrictions on this basic component of reproductive health care. These states’ policies are already the least supportive of mothers and their children, and the U.S. as a whole has the highest maternal and infant mortality in the developed world.
Organized dissent has been surprisingly lacking, even from groups with a long history of promoting comprehensive reproductive health care. A recent New Yorker article called out Planned Parenthood for not supporting independent abortion providers and for focusing more on self-preservation and legal attempts to curb abortion restrictions, attempts unlikely to be broadly successful given the makeup of a relatively young Supreme Court stacked with conservatives — even as the court faces criticism over previously undisclosed levels of influence peddling by private citizens and companies, eroding public trust in a once-respected institution.
Academic medical centers need to commit to continuing to provide full reproductive health care, including abortion, regardless of state laws. Academic medical centers are the logical leaders to undertake such civil disobedience for the following reasons: 1) They are the setting for the training of future physicians; 2) they share a commitment to providing sound, science-based, ethical, human rights-oriented care which respects the sanctity of the doctor-patient relationship; 3) they have large numbers of supportive physicians, public and legal support, and a communications infrastructure to quickly mobilize and implement such a protest.
The Right Encroaches on Medicine
Changes in abortion law have been driven primarily by Republican men, yet adversely affect women, especially young women, women of color and those with low socioeconomic status. Some laws call for the prosecution of those who have had an abortion and even those who assist someone having an abortion. This is a very large number of individuals, since by the age of 45 about one-quarter of women have had an abortion and one-fifth of men have impregnated someone who has had an abortion (not to mention all those who have utilized assisted reproductive services).
Dobbs has also complicated the care of ectopic pregnancies, miscarriages, emergency contraception and in vitro fertilization. Doctors’ hands are often tied due to fears of incarceration, loss of license and malpractice, resulting in increased morbidity, mortality and infertility among patients. Physicians have been leaving states with abortion restrictions and graduating medical students have been applying to fewer OB/GYN training programs in these states, which are sadly those where women’s health care is already limited and poorly funded.
Dobbs has come at a time when demagogic conservative leaders like racist, sexist, anti-immigrant and ecocidal former President (and current Republican frontrunner) Donald Trump and his opponent, the similarly racist, xenophobic and anti-LGBTQ Florida Gov. Ron DeSantis — along with a host of right-wing and “religious” organizations and complicit individuals — have attempted to undermine the medical profession. Medicine, nursing and public health have been under attack, through bans on education regarding institutional racism (a major contributor to health disparities) and gender identity and sexuality (impacting groups already at higher risk of mental health problems and suicide); anti-science promulgations and anti-vaccine measures (which are largely responsible for well over 100,000 excess COVID deaths in the U.S.); underfunding of basic public health programs; and direct insertions of the state into the exam room (e.g. requiring that providers misinform patients, outlawing widely accepted gender-affirming interventions and proposing to collect patients’ immigration status).
Now Is the Time for Civil Disobedience
In an article published by the journal Social Medicine, I recently issued a call for civil disobedience to my fellow physicians, arguing:
While Nazi comparisons are sometimes overused, and not to minimize the horrors of the Holocaust, it remains noteworthy that unethical pronouncements regarding bodily integrity and patient care from a central authority is how Nazi medicine became an immoral agent of the state (similarly, Soviet psychiatry). History has shown us the value of widespread resistance to immoral laws (e.g., Dutch physicians during World War II, the U.S. Civil Rights Movement, the dismantling of Apartheid, the occupation of Lincoln Hospital by the Young Lords). Physicians have the right, indeed the obligation, to act when confronted with immoral laws that impact our patients’ lives.
I have also shared this idea on one of the major public health listservs and raised it with a number of colleagues at a major national public health meeting. The reluctance I have encountered from other medical workers indicates how much work has yet to be done to organize the medical sector and mobilize our community toward mass action. The initial responses I have received thus far have been minimal and muted; many said the idea was somewhat impractical, although upon further questioning admitted that they had not considered the idea and that they were concerned that a significant number of individuals may be afraid to join the civil disobedience. They favored slow change through elections, litigation and public education campaigns. Nonetheless, failure to act in itself constitutes a negative action and weakens our profession’s independence and moral standing.
I also directly contacted the leadership of major academic and professional medical organizations responsible for education, training and patient care, as well as many of the largest reproductive rights organizations. Not one responded.
While I strongly support those who are striving to continue against long odds to provide abortions, as well as those who are working through the legislative process and in the courts to support access to comprehensive reproductive health care, I still believe that direct civil disobedience is the only measure that could immediately put a de facto halt to Dobbs.
As I argued in my Social Medicine piece:
All academic medical centers in the US should commit to continuing to provide full reproductive health care, including abortion, regardless of state laws. Such a commitment, supported by Deans and Department Chairs, could be facilitated within a week, given extensive formal (e.g., Association of American Medical Colleges, Organization of Program Directors Associations, American Board of Medical Specialties) and informal links between institutional leaders. Furthermore, health professional societies should commit to moving all national meetings and board exams from any state which makes abortion illegal.
Ideally, this should coincide with widespread public civil disobedience (e.g. anyone who has had an abortion, whose partner has had an abortion or who has utilized in vitro fertilization demanding to be arrested; lawyers and judges refusing to prosecute Dobbs-related cases; corporations committing to abortion access for their employees and leaving and/or refusing to hold meetings in states with abortion restrictions). The criminal legal system could not possibly accommodate the large numbers of providers and patients involved, nor the health care system the loss of so many providers (many of whose practices are focused mostly on other aspects of women’s health care). Such widespread civil disobedience would likely convince Congress to pass the Women’s Health Protection Act, which would reverse Dobbs and make abortion a legally protected medical procedure.
The time is now for academic medicine to take the lead, stand up for its lofty pronouncements, and act, in order to save countless lives and help to maintain the integrity and independence of the medical profession.