The demise of Roe v Wade: a hematologist’s perspective

The impact of the Dobbs v Jackson Women's Health Organization decision by the US Supreme Court, removing federal protection of abortion rights, has important implications for a woman’s right to choose, which have been widely publicized. The most dramatic stories have focused on the burden placed on young girls who are victims of rape, pregnant patients who have had a miscarriage and cannot get the fetal remains evacuated, and others who are forced to carry a fetus with an abnormality that is incompatible with life. Other pieces written by physicians highlight the potential legal ramifications for performing standard medical procedures or prescribing commonplace medications. In less polarized times, these were issues that gave even the staunchest opponents of abortion rights pause and led to protections for victims of rape and incest and acknowledgment of other extenuating exceptions in proposed laws, restricting their access to choice. With the Dobbs decision, access even under these extenuating circumstances is no longer protected in some states. Such extenuating circumstances arise daily in the practice of hematology.

As hematologists, we are used to dealing with emergencies. We treat patients with acute leukemia, aggressive lymphoma, acute thrombotic thrombocytopenic purpura, sickle cell–related acute respiratory failure, overwhelming hemolytic anemia, aplastic anemia, and life-threatening thrombocytopenia. Several of these diseases occur in young women of child-bearing age. Even for physicians accustomed to these acute medical emergencies, pregnancy causes intervention and therapy fraught with greater challenges. In the face of potentially life-threatening diseases, decisions must be made quickly, as therapy is often pressingly urgent. Many such interventions are not deemed safe in pregnancy, and the patient, her family, and her physician must consider the implications of therapy for the mother and fetus, which often diverge. Therapy complicates pregnancy and may harm or kill the fetus. Withholding therapy risks the death of the mother, in which case, the fetus also dies. A necessary part of the discussion has always been to address the pros and cons of pregnancy termination in the interest of improving the chances of survival of the mother. These are often much-desired pregnancies, so added to the burden of an often-devastating diagnosis is the pain of dealing with another heartbreaking decision. But the considerations are necessary to prevent the loss of 2 lives.

Patients are faced with the following options: (1) terminating the pregnancy and maximizing the chance of successful therapy and survival of the mother, (2) maintaining the pregnancy and receiving appropriate therapy while understanding the increased risk to the fetus and patient, and (3) postponing or modifying therapy to enhance the survival of the fetus while incurring potentially fatal risks to the patient. The Supreme Court decision reversing Roe v Wade will have far-reaching horrific consequences for patients facing these heart-wrenching decisions by taking the decision out of the hands of the patient, her family, and her physicians. In addition to removing the first option, it injects potentially terrible consequences for the second option because if therapy results in intrauterine death, it is not clear whether physicians will be allowed to evacuate the fetus without risking legal consequences, or they may be forced to wait too long to demonstrate that the mother is at risk of death before acting. Modifying therapy to protect the fetus is often the least effective option for treating the patient and may risk her life, thereby ending the life of both mother and fetus. If this is not the first pregnancy, it also has the consequence of leaving other children without their mother.

For example, few diagnoses are more devastating than that of acute leukemia, and the implications of a concomitant pregnancy are huge. The impact of induction chemotherapy on the fetus may be lethal, and the physiological changes that occur during pregnancy may predispose the mother to more complications. Those opposing pregnancy termination would like to paint a scenario that would allow physicians to treat the patient successfully, while the patient continues the pregnancy to a happy conclusion. Unfortunately, that is unlikely to be the norm and it is inappropriate to assume or even suggest that it is. Deciding whether to terminate a much-wanted pregnancy to maximize the possibility of saving the mother’s life is a long and difficult conversation that takes place with the patient, her family, her hematologist, and her obstetrician. It is grounded in the belief that the patient can exercise autonomy over her body and have a final say in her care. Nowhere in the calculus should there be a place for the state to intervene.

Such concerns are not limited to patients with acute leukemia or even to patients with hematologic malignancies. Similar considerations are in play in a patient with potentially life-threatening intracranial thrombosis that is progressing during, and likely because of, pregnancy; in a patient with sickle cell disease who is admitted with acute pain crisis and respiratory failure where adequate therapy may endanger the fetus; in a patient with unexplained fever and rapidly progressive undiagnosed disease, whose diagnostic evaluation is limited by procedures that may threaten fetal development; in a patient with aplastic anemia requiring urgent therapy, with agents that are not approved in pregnancy because they pose a risk to the fetus, to name only a few.

These scenarios are not hypothetical; every hematologist who has been in practice has had these painful discussions with patients and has participated in the heartbreaking decisions that must be faced. To foreclose the option of terminating a pregnancy is not an inconvenience, but an attack on fundamental rights. Women have the right to control their own bodies, and the reasons why women feel it is necessary to terminate a pregnancy are personal and private and should remain that way. Thus, in some ways, the arguments presented here are beside the point, as no one should have to justify decisions regarding their bodily autonomy. However, the implication of the current spate of increasingly restrictive laws is that the decision to terminate a pregnancy is a whim to be prohibited. We as hematologists are here to say that is not the case. The “right to life” is something women have a right to demand for themselves. These laws threaten their lives.