By Banu E. Symington, MD, MACP

What does it mean to be a rural oncologist? It means being comfortable taking care of all types of cancer, it means being willing to spend the time creating a network of subspecialists you can reach out to when you need help, it means being on call frequently (sometimes 24/7/365), and now it means potentially being willing to go to jail to help your pregnant patients if you live and work in Wyoming, Idaho, Texas, or other states that have imposed abortion bans without reasonable exemptions.

On June 24, 2022, the Supreme Court of the United States overturned a nearly 50-year-old precedent guaranteeing an individual’s right to an abortion when it passed down the decision on Dobbs v. Jackson Women’s Health Organization.¹ This one act has led to far-reaching domino effects. Shortly thereafter several states, Wyoming included, enacted dormant anti-abortion trigger laws. While this trigger law is under fire in Wyoming, it has passed unimpeded in other states.² Hospital counsel and professional societies quickly offered reminders of the liabilities that physicians could face in contravention of new laws and many physicians started practicing as if abortion was completely illegal.

One of the two abortion clinics in Wyoming was burned down in a suspected arson and nearly chose not to rebuild because of the anti-abortion climate in the state.³ In March, abortion clinics in neighboring Utah closed, eliminating a relatively convenient option for pregnant patients in western Wyoming.⁴ Pregnant patients in Wyoming who choose to travel for a safe abortion will have to go further to obtain one. The travel time from western Wyoming to Denver, Colorado, for example, is at least 6 hours. If laws are enacted that require a waiting period or two visits before abortion, that travel will be impossible for many.

Meanwhile, Wyoming passed the first-in-the-nation total ban on medical abortions that will become effective in July if courts do not intervene.⁵ This ban passed despite compelling testimony from pediatricians, OBGYNs, and family physicians, some of whom said they would leave the already underserved state if the ban passed. In addition to the dizzying pace of laws and countersuits, there have been varied interpretations by public officials as to what constitutes danger to the mother and if even that is enough to justify an abortion. Those of us remaining in Wyoming wonder, will discussing the option of abortion or guiding our patients to a safe abortion result in our being reported to authorities by anti-abortion office staff or patients’ friends or relatives? Will we be sanctioned or jailed?^5,6 While the impact of the Dobbs decision is felt nationwide, the impact on rural and frontier patients and physicians will be greater due to already existing resource scarcity.

Physicians have previously practiced in an environment where their patient’s well-being and privacy were the priority. We are at a critical juncture where these principles may be superseded by the desire to protect a fetus. Rural states and those with abortion bans are losing pediatricians and OBGYNs, fewer obstetrics residents are choosing to train in these states, and recruitment/replacement of doctors is becoming more difficult since the Dobbs decision was handed down. This affects many thousands of patients and their doctors in rural America. What can rural oncologists do for their pregnant patients without risking jail and thus leaving their other patients with cancer without a doctor?

ASCO has provided an ethical guideline for oncologists where reproductive health care is limited by law.⁷ It represents ASCO’s guiding principles for oncologists and institutions where providing appropriate cancer care may be at odds with a healthy pregnancy. The options and limitations available to physicians practicing in environments where abortion care is safely available will be drastically different from those available to physicians practicing in locations where it is not, a trend that has worsened significantly since the Dobbs decision last summer and by all indications is likely to worsen in the years ahead. Many citizens in these rural states have a highly conservative view on the issue of abortion access, and potentially may be more likely to report physicians who may try to help their pregnant patients. As I read the ASCO framework through this lens, I wonder how to protect my patients, my practice, and myself:

Patient autonomy and informed consent: My pregnant patients now face the simultaneous devastating news of a cancer diagnosis, the burdens of a decision about termination of pregnancy, and the logistical nightmare of arranging a timely termination of pregnancy far away before they can start their cancer treatment. I worry that discussing the adverse effects of delaying treatment initiation and advocating for the patient choice to terminate a pregnancy may be viewed as implicitly or explicitly encouraging abortion. If so, it could be viewed as criminal activity. Will rural physicians be willing to speak truthfully about the range of therapeutic options and complications without fear of liability and legal repercussions?

Physician autonomy, conscience, and duty of care: The team of specialists necessary for timely fertility preservation treatment or therapeutic abortion implicit in this guideline may not be available in rural practices even if a provider is willing to discuss them.

Transparency and communication: Networks of colleagues and legal support are narrower in rural communities. Many rural facilities are struggling to survive and don’t want to invoke the wrath of authorities. Recall that the only official advice I was given after the Dobbs decision was a reminder not to do anything that could be viewed as illegal. The fear of legal consequences from an open discussion could lead to less honest communication with patients and to suboptimal care.

Privacy and confidentiality: We are all aware of HIPAA and patient rights to privacy. Oncologists reasonably fear that this privacy will be invaded in states banning abortions, with the rationale that the rights of a potential fetus outweigh privacy laws. Will attempts be made to obtain prechemotherapy pregnancy test results or travel records to obtain proof of an abortion? Or to determine whether the mother’s life would be endangered by treatment delays? How do I reconcile my duty to keep an accurate medical record with my concerns about protecting my patient’s medical privacy from overreach by enforcers of state abortion bans?

Impact on oncology and clinician well-being: I already experience moral distress from not being able to support my patient’s autonomy in reproductive care. If my every action related to fertile or pregnant patients will be scrutinized, if my pregnant patient’s privacy will be invaded, if my actions on behalf of pregnant patients can cause me to be physically attacked, jailed, and/or lose my license (and livelihood), my well-being will certainly be endangered. Furthermore, my inability to practice due to injury/death, incarceration, or loss of license will mean every other patient with cancer in my community will lose their provider.

Our goal should be to provide the best care possible to our patients without risking the license, freedom, or reputation of their oncologists. What can be done to help these isolated physicians who may be working without state or institutional support? Here are a few suggestions:

1. Make an anonymous toll-free number available for patients to call and get help making arrangements to access a safe abortion that does not involve or endanger the local oncologist.
2. Arrange for pregnancy consultants who are available by phone to discuss the risks to the patient’s cancer prognosis and her fetus’ health of carrying a pregnancy to term.
3. Identify and establish resources for counseling and support not only for pregnant patients but the oncologists who work with them.
4.  Support national efforts to protect abortion access for pregnant patients with cancer.
5. Inform oncologists about legal resources such as the Abortion Defense Network, where clinicians and patients can be connected with free legal advice related to abortion care.
6. Help connect oncologists with organizations that might be able to be more proactive in protecting oncologists from prosecution and persecution.
7. Acknowledge that abortion care may be needed infrequently but just as urgently in other subspecialties. Consider initiation of a cross-specialty collaboration.

A theme in many of these suggestions involves outsourcing the dispensation of advice and referrals to third parties to remove the onus (and legal risk) from the primary oncologist. Unless we take prompt action to protect rural oncologists from threats related to Dobbs, there will be few left to treat rural patients with cancer. The downstream effects of this will be enormous.

Dr. Symington is the medical director of Sweetwater Regional Cancer Center in Rocks Springs, WY. Disclosure.

References

1. Supreme Court of the United States. 19-1391 Dobbs v. Jackson Women’s Health Organization. Jun 24, 2022. Accessed Jun 16, 2023.
2. Knight S, Davis W, Gourlay K, et al. Here’s where abortions are now banned or severely restricted. NPR. May 1, 2023. Accessed Jun 16, 2023.
3. Saric S. Authorities charge woman with Caspar abortion clinic arson. Casper Star-Tribune. Mar 22, 2023. Updated Jun 1, 2023. Accessed Jun 16, 2023.
4. Metz S. Utah bans abortion clinics in wave of post-Roe restrictions. AP News. Mar 16, 2023. Accessed Jun 16, 2023.
5. State of Wyoming. Senate File No. SF0109: Prohibiting chemical abortions. Passed Mar 17, 2023. Accessed Jun 16, 2023.
6. Wyoming becomes first state to ban abortion pills. Here & Now Wyoming. WBUR. Mar 21, 2023. Accessed Jun 16, 2023.
7. Spence RA, Hinyard LJ, Jagsi R, et al. ASCO Ethical Guidance for the US Oncology Community Where Reproductive Health Care Is Limited by Law. J Clin Oncol. 2023;41:2852-8. Epub 2023 Mar 29.