Maternal Fetal Medicine Chief: Impossible Choices

you all of a sudden after dos and under abortion bans with criminal jeopardies the oncologist has the question of do I give this pregnant patient you know chemo you know if we are performing a DNA there's an anesthesiologist involved in the case if it's potentially a criminal case is your anesthesiologist or co-conspirator on behalf of Harvard bookstore I'm so excited to welcome you to our event with Dr. David N. Hackne presenting his new book, Impossible Choices, a physician's guidance on high-risisk pregnancy in a world without in conversation with Dr. Khloe Zera. Dr. David Nhackne is a professor of reproductive biology at Case Western Reserve University, a division chief of maternal fetal medicine. He is currently district legislative chair of the American College of Obstitricians and Gynecologists, and was the section chair for Ohio at the time of the dog's decision. His new book, Impossible Choices, explores how the overturning of Row has imperiled high-risisk pregnancies and provides knowledgeable, thoughtful guidance to patients and practitioners contending with high-risisk pregnancies in our new reality. Nuanced and cleareyed, Impossible Choices offers the informed compassion and way forward that this fraugh moment in maternal medicine calls for. Joining him is Khloe Zera, chief of the division of maternal fetal medicine at Beth Israel Deaconist Medical Center and an associate professor of of uh obstet obstetrics, sorry, gynecology and reproductive biology at Harvard Medical School. And she currently serves as the chair of the Massachusetts section of the American College of Obstitricians and Gynecologists as well as the chair of the health policy and advocacy committee for the Society for Maternal Fetal Medicine. Now, please join me in welcoming Dr. David N. Hackne and Dr. Chloe Zer. I was standing in my kitchen in Cleveland on a Friday evening in June 2022 when the text started to pour in. How long until it goes into effect? I asked a colleague. It's the law right now. Like literally now. Yes, right now. The United States Supreme Court had released the DOS decision that morning. The landmark ruling revoked the constitutional right to abortion, ushering in a new era of risk for patients and doctors. Soon after, Ohio's attorney general requested that the injunction blocking the enforcement of Senate Bill 23 be lifted. The bill was a near total abortion ban with no exceptions for rape, incest, or fetal birth effects, including those that were limiting to life. SP23 then became the law that very same day with no buffer zone or time for medical doctors to prepare and I was on call that night for MFM referred to as high-risisk objectrics. Maternal fetal medicine is the subsp specialty within OBGYn that focuses on pregnancies with a wide array of complications. We see patients in preterm labor or with medical conditions like diabetes, lupus, cancer, and heart disease. We care for patients carrying triplets or even higher order multiples and those who learn from screening tests that they are carrying a fetus with birth defects. I'd like to say that MFM addresses pregnancy plus any disease or complication existing under the sun. Because most of our days are spent ensuring that pregnancies successfully advance. Issues like abortion account for only a small percentage of my work. Likewise, only a small percentage of abortions occur in the context of birth effects or maternal disease. However, there are a few million pregnant people at any time in the United States, thousands of whom are high risk. So, my MFM colleagues and I routinely confront questions about difficult decisions about abortion. Medicine at its most fundamental lies at the intersection of facts and choices. When you describe the details of someone's disease, you also describe almost at the same time their choices now lying ahead. And there are always decisions to make, no matter how dire. Decisions ultimately made by patients rather than doctors. For instance, in MFM, we often see people not yet pregnant, but considering conception, but with a medical condition that would make pregnancy dangerous. For these patients, we will review their risk and likely obstetric management. We describe the impact of pregnancy on their own health and chances of uncomplicated live birth. At the end of the visit, do we make a recommendation? Normally in medicine, physicians make recommendations after weighing the alternate clinical options. For example, my wife is also a doctor, a practicing pediatric oncologist. When cancer strikes a child, she helps the parents balance the risk of surgery against the risk of radiation or chemotherapy A versus chemotherapy B. optimally in concert with clinical research and randomized control trials. But for the MFM patient considering pregnancy despite risk factors, the two options are not the same as selecting between medications or surgery versus radiation. It is the risk of pregnancy balanced against having or not having a child. Whereas my wife often makes clear recommendations, I cannot in the same way counsel someone about their desire for a child as that is a personal choice transcending medicine itself. Some patients would reasonally never want children, making any risk from a pregnancy ill logical. Some, however, are willing to risk their entire health itself. In both cases, it is the patient's choice and not mine. >> Um, I think the obvious question is, you're an MFM, you're in practice, you have the same role I do, which is managing MFMs. Why write a book in the first place? That's a very good question. And um so as I read from the start of the book, I was um in a leadership role and on and on call on the night of DOB. So I sent out a tweet about how some point soon I was going to potentially have to tell someone with lifelimiting birth effect that they were going to have to continue against their will. That tweet went viral. Then I was contacted by the New York Times. Then I wrote an essay in the New York Times and then after that people started to reach out to me saying that I should write a book that um someone you know especially a doctor who is on the front lines you know and was bearing witness to tragically historic events should write a book. Um for those who know me I have a almost pathologic tendency to say yes to things that sometimes lands me in places like this. it sometimes lands me in um you know problems but um I said yes and then things moved forward and then um you know I had a book contract and a book you know a non-fiction book contract if you haven't written a book before it's it's a little bit of a strange thing because you're sort of saying I can write a book and um you know of course I hadn't really um written before so I started off you know at the beginning they Um, you know, they have uh Audible has those great courses books. They they actually have a great courses on how to write a non-fiction book. >> Who knew? >> I started that I um, you know, started off with. But the other thing that I quickly realized is the honor it is to write a book. You know, like there's um, in all seriousness, there's many people who obviously want to write books and never land a agent. you know, most non-fiction book contracts don't land, you know, and when you write a book, you have a tremendous team that's uh working with with you in your corner. So, um I felt a tremendous amount of nervousness at the beginning. I'm I'm a doctor. I'm not normally a um writer and between the subject ma matter and the honor of writing the book but um what I found is that I wrote it best when I was trying to not think of myself as a writer. I think sometimes people feel as though they're writing a book and they have to feel the certain pressure to come up with like flowing sentence sentence structures and use you know high vocabulary words. Writing is actually best when you are yourself and I think writing is best when you write in a manner which is clear. you know when you use words that people understand you know when you write in a more you know simple manner when you try not to get I'm being a writer in your head and I think to what to some extent what I found is it's not different than what we as doctors do on a daily basis you know in the office with our patients we have to take a very complicated subject matter and translate it to the person in your room who doesn't have a medical background background. So, how do we do that in the office? You know, we speak as clearly as we can. You know, we use simple words. We try to avoid medical jargon. So, what I found that sort of helped me um write this book was to sort of pretend the world was my p patients and that I was in my doctor role as opposed to a writer role. But now what I was trying to explain was, you know, state laws, you know, the problems with with abortion bans, but take the same mindset of, I guess, trying to be clear. >> I think that clarity is is um what you have such a gift for actually. uh because what you wrote about and what what you talk about and what you have talked about in your sort of physician advocate role which we'll talk about a little bit um is how much gray there is in what we do every day. I think um you very clearly give example after example after example of how hard it is to legislate that. Um, so I I think you achieved the clarity >> and and the sort of what we're trying to do with patients all the time because as we know so little of what we do is is definitive. We give people a lot of like sort of it could be this, it could be that. We don't know. We'll have to wait and see or not, you know. Um, whatever you want. Um, so I think you managed to somehow thread that needle where you actually give people a lot of information and very clearly lay out a very compelling argument um, for really unrestricted >> yes >> access to bodily autonomy. Um, which gets into sort of a question I guess that is tied into why write this at all, which is like how important do you think it is for physicians to to be advocates and like how does this tie into your advocacy and sort of can you tell talk a little bit about your advocacy journey? >> Yeah. Yeah. So um you know I I do believe that physicians need to view themselves as a broader me member of the world you know like what are and I have a chap chapter in the book about this but what is our role as a doctor on the one hand it's relatively straightforward we have our contracts for the patients that we see you know there's the pa patients that we have duties to you know things along those lines But if we look at our role as doctors as improving patients health then you know it's far more broader than what we do and um you know so let's say a patient's disease will advance or something terrible happens to a patient one of the mindsets that we often take is is this something I could have stopped is this something I could have done better was this in my control or was this not in my control. And sometimes, you know, it was direct directly in our control. It was related to the medical decisions, but sometimes it's the stray bullet, the cancer which will advance despite everything you do. But then how do we take that framework and then how do we apply it to the laws that hurt our p patients? you know, if you have a re restrictive abortion ban that's going to hurt our patients and have a genuine im impact on their health, you know, do we view that as within our control? Do we re view that as within our responsibil? And I would argue yes, you know, I mean, obviously we're not the legislator, but we should never view ourselves as passive in that process. And at the end of our day, if our goal is to improve our patients lives, then we have to take the broadest possible view. >> Yeah. I I think um there's you talk a little bit about how every time somebody is hurt by an abortion ban, that was actually a very definitive choice that was made. Um so tying that together with our role, like what is the choice we're making? I guess I have a question about sort of what is our duty as physicians in terms of um communicating what we do to the world and and kind of uh speaking up and particularly about abortion. like what made you feel comfortable or not starting to talk about it publicly and like what made you decide now is the time that I have to start talking about it publicly? >> Yes. Yes. Well, um on a very practical note, when my New York Times essay was coming out, I was like I have to talk to people about this beforehand because that's the uh because that's that's the uh times, you know. Um I would say as a field we've had a major shift you know like a lot of um colleagues you know support abortion rights before DOBS were potentially you know involved with abortion but you know didn't necessarily talk about it when it advertised it you know um to some extent within the state um ACOG back in the late teens was looking for someone to write a a op a oped about abortion and a lot of the people at the time involved in the leadership felt nervous doing so and again I pathologically say yes to everything. So you know I I wrote that and then that was how that sort of ball started to roll. I would say though I do feel as though a lot of things change in our field after after dos you know a a lot of the people who were hesitant you know and it's sort of unfortunate that that was what had to happened to change the stakes and I think about our ballot initiative in our state so in uh 2023 we had um the ballot initiative to secure re reproductive rights. I had never been involved in a statewide campaign before. Uh that was that was the whole thing, but it passed and now Ohio is actually one of the few states where we have fewer abortion restrictions now after DOBS than uh before. In fact, I I'm not sure, but we may be the only state, you know, because we we had some problematic abortion restrictions um prior to DOS. Then we had the reproductive freedom ballot initiative in 2023. And now, not not only do we have um rights guaranteed in the state constitution, but they've repealed many of the problematic laws uh which occurred prior to um DOS, but I also think to myself, why didn't we pass that in 20121 in retrospect or why didn't you know like it's a voter initiated ballot initiative? We could have passed it at any year, you know, and many of the laws which have been passed since dos could have been passed before before DOBS also. Yeah, I I mean well a lot to say there. I will I'm going to take a moment to plug our Massachusetts law to say that like >> we have experienced this evolution in 2020. We had a big push um in part knowing something like DOBS was probably coming in 2022. We had another big change to our laws in reaction to DOS. It was like July of 2022. And then just this year we actually last week um >> yeah to your credit >> with many other people with many other people were able to repeal the remaining gestational age restrictions. Um, and I have to say that I don't know what makes it the right time and the right place to to sort of have things happen because if you had asked me six months ago, I didn't think that this I don't know. I see my friend Taylor from Reproductive Equity Now nodding in the for we um, you know, it it moved fast when it moved and so sometimes it is the right place, the right time, but you do have to have a critical mass. Yeah. >> And a and a big enough coalition. Can you talk a little bit about how you built that coalition in Ohio? >> Yes. Yes. Um, you know, the the whole process at the beginning for the ballot initiative was uh fraught. You know, I um you know, the strange thing about the ballot initiative was it was going on while I was writing the book, you know. Um so, in fact, you know, I working full-time as a doctor still as a division director. um I have kids and then um there was the um campaign for the ballot initiative and then I was trying to write a book at the same at the same time. >> That's a lot of yes. >> That's a lot of yes. Um, so yeah, to some extent that was that was a strange experience too because the the campaign was sort of like floating over the book and one of the hard parts about writing this book is the reproductive landscape changes on a month-by-month ba basis, you know, and you know, I finished writing this book at least a year ago, probably a little bit more than than a year ago. And you know, it took at least like two years to write the book. So it's not like you're writing about George Washington crossing the Delaware or some like event which is in the past. It's actually very difficult to write a book about a historic event which is continuing to unfold in front of you. At some point actually I had a hit a time point and be like okay the book is over at like this date because otherwise I'd be revising it forever. But yes, I was writing it during the campaign itself. But um there were a lot of um debates. You know, getting the coalition together for the campaign was quite fraud and I give enormous credit to everyone involved that we were able to get it off the ground. You know, the two major debates were putting in a vi viability limit. Um and then whether or not to go forward in 2023 versus 2024, that's a whole different um topic. But um you know the interesting thing and I write about this in the book you know when you do a ballot initiative it's sort of interesting and I guess this is obvious but the ballot initiative can say anything you want. You know if you have like a politician running for office you have to find a human being and human beings are complicated and they often have you know flaws. If you're having an election for the ballot initiative it's like you're you know constructing it. I mean you again this is somewhat obvious but you write as you can make it say whatever you want. So you write them to try to get them to exactly pass. So we did have a lot of debate about whether or not to put in the viability lang language in it and it was a tough choice because you know you don't know if without it it wouldn't pass with you know voters. We would definitely prefer um not to have it. I always wonder if like 20 years down the road in some sci-fi but not implausible future viability with advancing neonat neonatal technology may be far lower and I may have ended up handicapping you know my colleagues you know when I'm retired 20 years from from uh now but then what if it didn't pass you know but these are the examples of complicated choices that you have to make you have to choose one road or the other just like we do in medicine then go down the road you choose. >> Yeah. I I think one of the and I'm really interested in what you think about this, but our one of the reasons that I have felt so compelled to speak in the in the sort of last four to six years um is that we have a fair amount of privilege and that the pregnancies we take care of are generally the kinds of abortions that are easy to talk about or somehow easier for the to to explain. why and they feel um for lack of a better way to describe it like good abortions. There's a lot of discussion in in like I think the the reproductive equity community about like how do we talk about abortion and how do we make it clear that bodily autonomy is a right regardless of the circumstances. And um I know you wrestled with that a lot and you talk about that in the book. Um you sort of talk a little bit about like high risk low risk and why why MFMs get to talk about this somehow um in a way that >> Yeah. No, I >> feels weird. >> Yeah. Yeah. Yes. No. No. Total to totally the same. So we are MFM. So if we want to write a book, it's going to be about high risk of statetrics and high risk of is a critically important part of what's been going on since DOS and is also complicated and warrants being explained. But it is a little bit of a double-edged sword. There has been a disproportionate amount of media attention on high-risisk versus low lowrisk pay patients post you know dos. A lot of the stories which have emerged after dos that you know most pull on the heartstrings and they genuinely should are you know the patient with a lifelimiting birth defect who's forced to continue the pregnancy which is still going on right now. I mean, we fought against our ban in Ohio, but that's still like going on right now all throughout the United States, which is still just absolutely insane. That is something that happens, you know, and those are for multiple reasons, you know, among the most sympathetic patients. And there were many of those stories that came out in the early days after DOS or the patients who are forced to continue against harrowing, you know, medical problems. But those getting the line share of the attention post jobs can be problematic. You know, also because you are trading what most pulls on the heartstrings for a subpopul of the abortion story which is not representative of of the whole. You know, I I always like to think what if you had two patients and one had a serious or lifelimiting fetal birth defect and the other one was just a healthy 20-year-old who just didn't want to be pregnant pregnant and it just wasn't the right time in her life. And if you could only provide abortion services to one, I would probably choose the 20 year old, you know, like as tragic as the other story is, if you look at the totality of the impact on that person's, you know, and that's the lion share of what our colleagues in complex family planning do, that's the lion share of, you know, statistically most patients seeking abortion. And the problem to some extent is that if you you focus on high risk obstetrics and of course we're both high risk obstitricians it's like my wife does pediatric cancer if you're like you know most kids don't have cancer don't focus on that focus on you know all the kids with like colds in the offices but you know the issue is potentially one of a um the expression which is often used as the higher hierarchy of deser urbaness or you know dividing into sort of good patients and had patience. And so I I do wrestle with that and talk about that in in the book too. >> Again, sort of describing the gray in a very very clear way. I think the the phrase you used, which I wrote down because it was so um it was so uh powerful to me was that um exceptions are the the crumbs of autonomy that legislators uh bestow or withhold from us. Right. There are a couple times in the book where I guess I do get a little writery. >> No, it's great. It's great. I was like, >> and there are a couple higher vocabulary words in there, too. So, I, you know, >> but but I think that really is what it, you know, like who gets to decide who has autonomy and who doesn't? And, um, >> and I think as MFMs sometimes if we're not very explicit with >> we mean this for everyone. Yeah. Not just our patients. Um I I think we all are conscious of that risk and running that risk and at the same time because we are not family complex family planning physicians who only do abortion care and contraceptive care we sort of have carry this privilege to be able to talk about it in a way that is um more public often or feels safer >> and that's why the goal should be what you've managed to achie achieve here in in the last week. you know, the the the ideal number of laws that regulate specifically abortion should be zero. You know, I mean, medicine is obviously surrounded by laws. You can't do anything in medicine without laws. And that's not bad. You know, laws are fundamentally usually more more good than bad, but you don't need laws that are specific to one thing, you know. Um, and so yeah, you know, if we would prefer in our state that we wouldn't have viability limits, we still actually have a 22- week law with the the funny thing, it's not that funny, but our 22- week law in Ohio, it's actually written as a 20week ban, but if you read the fine print, it's 20 weeks after consion, which is >> or the pregnancy has existed. Yes, yes, that's what our former language, >> which is 22 weeks. I think someone didn't understand the birds and the bees when they when they wrote the law. So, you know, >> Yep. that's uh that that was also a conversation here when we had a gestational age ban in place. Um I guess you know we've obviously been really focused on high-risisk pregnancy but I think there is a broader question which your book does a really good job of explaining which is like the the role of all physicians and all specialties and how important it is for them to know about um abortion and obstetrics and gynecology more generally women's health in general. Um but uh can you say a little bit like were you thinking about other physicians as an audience for this? Oh yes. Yes. Well, I don't know what the Well, I think for many OBJ Joans in states with bands after Doss, we had a flood of non OB Joan do doctors all of a sudden coming coming to us, you know, and I think hopefully it has shown the entire field of medicine that obstetrics isn't like ensconced within some sort of magical, you know, shield. Um, we're always, you know, in maternal fetal medicine specifically, and this is one of the things I like so much about our field is that I'm always talking to the neurosurgeon, the opthomemologist, the dermatologist, you know, because we see patients who are pregnant with heart heart disease, kidney disease, you know, things along those lines. And, you know, obstetrics overlies the global um total of medicine also. So you know you all of a sudden after dos and under abortion bans with criminal jeopardies the oncologist has the question of do I give this pregnant patient you know chemo you know if we are performing a DNA there's an anesthesiologist involved in the case if it's potentially a criminal case is your anesthesiologist or co-conspir spear ritter radiologist used to started to call me up and be like you know do I have to worry about radiation which you don't in general you know that's a overflow concern as it as it is and um er docs you know a lot of the litigation post jobs even cases that have gone up to the Supreme Court have involved in Tala and the question of you know what do you do if a pregnant patient especially as we start to get more and more obstetric deserts you know yes >> more and more counties where you don't get um OBS where it's the ER do with the people walking through through the door, you know. >> Yeah. And I think a lot of the cases that have been, you know, the anecdotes that are out there floating around around real tragedies in the posts era have um s like circled around people being afraid to give care. >> Yeah. Um, can you say a little bit about you you talk about decision paralysis and and that being an issue for physicians, which I think doesn't apply just to our our specialty, but maybe applies broadly in the postdabs era. >> Um, what what do you you know what thoughts do you have about how do has impacted physician behavior in general? >> Yeah, and that that's one of my goals in the book, too. So, you know, when I was trying to figure out how to write a book and what I wanted this book to look like, one of the books that I read was Dr. Daniel Offrey's What do doctor Doctors Feel, uh, which if if you haven't read it is a great book, but it obviously explores the emotional half of being a do doctor. And um you there's a certain hypothesis that if patients understand the emotional landscape of doctors and that'll also be better for pa patient care. You know if doctors are not viewed as clinical logic machines but as you know humans who have the potential to fall into fallacies you know can fall into decision paralysis traps can potentially feel anger or shame. If patients themselves understand that and have a better sense of how doctors think, then that actually can help patients navigate health health care because you can know what warning signs to look out for. And this is all the more so after DOBS, you know, when doctors in states under bans are experiencing emotions and situations that you never thought we would and they never, you know, should. But, you know, if you're the patient, it benefits you to understand that the doctors are potentially feeling um fear, you know, and what is it emotionally to stare into potential criminal bands? And I feel like a lot of doctors feel potential senses of shame, you know, and moral in injury if you can't provide a patient the care you want to care, you know, to provide because of a law. And, you know, following the law is a choice. You know, that's that's what makes it moral injury as opposed to just watching something awful which occurs. You know, if if you're not providing the patients with the care that they need because you choose to follow um the law, that is fundamentally yourself choosing to follow the law, which means at the end of the day, it's you. And that may be a reasonable choice, but it may be a choice that generates a tremendous amount of shame. So I hope that in the book by illustrating the emotional landscape if you will of doctors and colleagues in states under bans it will then help patients guide their own care especially if they have to act in their own bea best defense you know if you have the doctor who's not making a choice because if if you look to in many of the reported tragic cases it's obviously in retrospect the patient needed a DNC you know but they were getting infected they were bleeding And we don't really know because we don't know all the the informationation in these cases from behind the scenes and health care systems can be you know complicated webs but like something wasn't moving forward >> right >> you know like we don't know what was it indecision was it a minute but we need patients to recognize that we need patients to ask questions we need them to realize what may be going on under the hood in their doctor's brain because a lot of patients now have to fight for themselves Right. Right. I guess that leads me to my my next question, which is um for us in the room, you have a sympathetic audience of a number of physicians and physicians in training here. >> Yes. Um >> I figured that would be a lot of >> Yeah. >> So, we have a lot of we have a lot of Massachusetts privilege when it comes to abortion um and abortion uh well and legislation in general. um what can we be doing to support our physician colleagues? You know, having worked since you've been in a restrictive state and changed it successfully like what what could we be doing to support colleagues better the real human beings doing this care in restrictive states? Yeah, you know, one of the many things since doss is that it took our field of OB Joan, it took our fields of MFM and we were suddenly split into those in Stays Under Vands and those with states, >> the red and blue side of the room, >> the red and blue uh side of the room. Um, I would say one thing. So, um, you know, in our state, the ban came down the very first day and we were all just like totally stressed out and we were staring into this this black hole of potential criminal jeopardy >> and people from non-ressearched states started to try to recruit my faculty away. >> You know, that happened all across the United States. I think so many, you know, I mean, we're both division directors. We need to recruit people, right? I think there's, you know, um, so yeah, don't don't do that. And we still we we need people to work in the the rest restrictive states. And I think one of the things that's been fascinating with the some of the data that's emerged over the last couple months is we don't seem to see the numbers of people leaving the restrict restricted states. you know, I mean, we were all braced for like everyone to start to leave and then early on Idaho lost like 20% of their OB/GYN. So, you know, which I think is interesting because logically the people in restrictive states should leave and go to other, you know, states. But, you know, just within the last couple months, you know, a number of papers have come out showing that the the net movement actually appears to be very small. And I think we both know people who I mean we certainly know people who have left states under bans, you know, but we also know a lot of people who have stuck it out in those in those states. And you know, enormous credit to the people who who do and enormous credit to the people who go to restrictive states, you know, cuz they are going uphill but still serving the needs of patients who need care. you know, there's still patients in all these states that need care, and if everyone leaves, we're just going to make everything >> everything worse. But I would say that the best thing that people in um states such as Massachusetts can do for us in uh restrictive states is do exactly what you're doing in terms of making your own laws as beneficial as they can. you know, that's both beneficial to the patients here. But, you know, if we take my state for example, we still have a um you know, 22- week limit, which we would ideally rather not have. We still have um viability um language in the um ballot initiative, which you know, we'll never know for sure if that was the right call there or not. I'm we'll probably struggle with that one for uh ever. But that means that we have states, you know, patients after 22 weeks that we need to send to other states. So if other states are able to pass the laws that you were able to pass here, you know, and 24-hour waiting periods, too. You know, when our ban first came down, we did have friendly states around us where we could send our patients. Many of those had 24-hour waiting, you know, periods. They were, you know, they had Democratic governors. There were states that overall supported abortion rights, but they just had these 24-hour waiting periods on the book. And if you're sending a patient across state line, those 24-hour waiting periods became became a huge deal. It's basically 24 hours of someone's, you know, life sitting there in another state. So I guess you know we're doing our best in the red the red states you know but the more the people are over able to overturn any and all laws in the other states such as what you guys did here >> and I will say like you know there's an there's a narrative that you know is very much I don't want to repeat too much of the sort of anti-choice rhetoric but but just to say that um really The argument has been to get legislators out of the care we're providing and let let us do our jobs. Like we are actually trained to do this. Let us do our jobs. Um I have one more minute. Right. So which which sort of we've touched on it a little bit, but exceptions. You talk a lot about exceptions and how hard it is to legislate exceptions. >> Yes. >> U many states have bans with exceptions. But I actually didn't know about the MS one. Can you talk a little bit about the exception list? It was a list of conditions that included multiple sclerosis and like how that came about. >> So So when when our bill passed uh when our ban came down, so it had five exceptions. It then had a handful of things such as rape, incest, and birth defects, which were whatever like banned. You know, you you just can't can't do it for those at all. Everything else fell into the middle of what was known an affir affirmative defense which for the sake of time I I talk talk about it in the book but the five named except exceptions it was uh prom bleeding diabetes preeacclampsia multiple sclerosis randomly like there was there's only five and there's these five named ones you know and so you go through the list you know as I'm presuming a lot of people here are obgyns they make sense you know, bleeding, you know, diabetes, bleeding, infection, >> and then you get to MS. And I remember reading the law and I'm like, multiple sclerosis, why is that one of the five, you know, and in fact, >> at one point while we were under the ban, you know, in maternal fetal medicine, BC patients, there was a patient with MS that I was seeing, you know, and the pregnancy was going fine. Abortion wasn't an issue. I didn't even bring it up, but I kind of thought to myself, you're one of the few patrons in the state right now who could potentially um but then I don't know why and I've always wondered why that was one of the five. >> I have to assume it was something personal by someone who had the power to put it in the law. Like there's there's no other way, >> you know, like it's not random, you know, they didn't pick these five by throwing darts at a medical textbook, you know, which meant that there was someone there at the table who knew about abortion in complicated cir circumstance and had some they must have had some personal connection to that disease. And of course, multiple sclerosis is a terrible disease and of course we should support, you know, abortion rights. But what always bothers me is like that also must have been the limit of their world worldview. You know, like whatever they knew personally, they used their power to carve out something for that one disease. And all of the other diseases, and not just all the other diseases, whoever that person was signed off on a bill that had no exceptions for rape. >> Yeah. >> And incest or children or birth defects. But the one disease that they knew, they worked their way into the law. >> Yeah. Well, and I think it highlights just sort of how ridiculous any list of exceptions, no matter how comprehensive it seems, ends up at the end of the day. >> Um it's a a very clear way of explaining something that's hard for us to talk about and explain. >> Yeah. And and it seems like, you know, um legislators will go to the people and they'll be like, can you give us a list of the ex exceptions? like if we wanted to make this abortion ban better, can you give us can can you spell out like 20 things for us? And the answer of course is like no, right? >> You know, because first off, it gets back to the lowrisk high high-risk >> issue. you know, we shouldn't have rights for the patients with diseases and no rights for the patients who who do not, you know, but also you just can't. I mean, there's so many I mean, you go to medical school and there's a lot of diseases, >> you know, when you when you go to take your medical board, it's it's not just five things or like 20 things. It's like uh >> humans, they get a lot of things. >> Humans get a lot of things in new ways. >> Yes. Every day I learn a new way actually. Well, and I think again that was where you used the the the crumbs of autonomy and I think it's true. Um anytime somebody else is deciding what's worthy and what's not. >> Yes. >> We we run this risk of of sort of um leaving a lot of people out. >> Yeah. >> Leaving a lot of people behind. >> I'm keep I'm being mindful of time because I was given a time. >> Oh yeah. I think we should probably switch to audience questions. Yeah. Uh questions, anyone? >> How did how do you sort of in general balance the personal fear that you have of being an advocate? I guess both of you um of putting yourself out there and having a target on your back, especially if you are in a restricted state as somebody who's going to be moving to a restricted state from Massachusetts having trained >> to the restricted state. >> Kudos. How sort of how do you balance like you know doing the advocacy in your everyday work for your patients but also wanting to do that extra step of putting yourself out there working on legislation and other things like that >> at risk of a jinx I you know because now I have like a book that's coming out so maybe I I at least don't get a lot of harassment and problems you know um some of it is that I think I'm a white male, you know, um, so other people get harassed, you know, a lot more. I don't have to tell, you know, uh, you know, people that, but I'm also not, you know, I'm very involved in advocacy. I don't have a big like I don't have like a huge social media, you know, presence and things along those lines either. So, this may be specific to myself. I don't find I I'm always surprised that I don't tend to get harassed that much. During the campaign, I got weird mail. Um, but it was innocuous. It was um envelopes that had Bible quotes on it printed out on a piece of paper, you know. So, that's the most I've ever gotten. And I think so obviously like harassment for OB/GYNs and abortion providers is a very serious, you know, problem. Um, but I think a lot of people in abortion live happy lives, you know, like we're not all running around in Kevlar dodging bullets, you know, people have families and serve on PTAs and, you know, so and I think at the end of the day, you just have to do the appropriate things to be brave to live the life as you want to live. I don't know if that's a good answer or not. I'm also, you know, the the risks that I face are different than the risks that other people face. And the harassment that I face or don't face is extremely different than the harassment that other people may or may not face, too. So, >> um I'm wondering if you could talk a little bit about the changing landscape of like trainees in OBGYn and how you're like guiding medical students and residents as they're kind of approaching this part of their training and >> yeah. Um I I don't know if you have thoughts on that one that one too. >> Yeah, I mean I have I guess I have a lot of um concern that we are quickly evolving into two different fields almost like it is it is not possible that trainees here in Massachusetts are experiencing the same training as people in a restrictive state or a banned state. um you know trainees here are I think it's part of our everyday discussion um and so I think they see a lot more counseling we're obviously trying to provide opportunities you know and thinking about what can we do as a as a supportive state what can we do to support the future of OBGYn um but I do think it's an active conversation with no good answers at the moment um and I I do know that everyone in meded is worrying about it um and thinking about how we support that future. Um, but I I think another piece of it is is, you know, I've been trying to use all of my various platforms to advocate for a lot of clarity around how we talk about the role of abortion care in everyday medicine and health care and in everyday sort of like what does it mean to provide pregnancy care if you're for example a level four maternal center? like can can you do a D& within X amount of time? Do you have somebody on your staff that can do that? And you know maintaining a workforce and an entire system that can support kind of the sickest patients that has to be done all everywhere in the country, not just in supportive states. So where opportunities for us to talk about how important just the skills are um as a way to to sort of maintain that education like it's still part of your education. >> Yeah. And you know in states under bans um a lot of D& still o hoer because they're going to hoer you know uh when we were under the several months of our ban in Ohio and our banan did have an explicit exception for prom you know um and prom was was spell spelled out so all the patients would still come in with pretty vi viable prom we would still oh for the I I guess I shouldn't assume it's an entire audience of doctors. No, no, no. Definitely not >> prom is when the bag of water breaks ear early. But um so I you know even from my understanding in the states that have far more draconian bands than what we had in my state for several um months. You know there's still providers there who do DNA and are doing DNA and can train their trainee in DNA. But of course that's that's only one one piece of the puzzle, you know. But yeah, you do worry you if you look at the national numbers, we're not seeing the doctors leaving the restricted states that we thought that we would in terms of the total numbers, but the more there are many OBJs who support abortion bans, >> right? >> You know, and there are OBJ trainee who support abortion abortion bans. You know, obviously the great line share of us do, but like any field, we're not homogeneous, you know, either. So what you're likely seeing is you are seeing people selecting the state where they go into, you know, work and you can have the states that are under bans post jobs. Um, but it could be that their numbers are staying stable because they're having a shift. You know, I was also surprised post jobs that a lot of OBGYn's didn't care and it didn't affect them. You know, there there was a number of us, you know, you have the people who are like directly involved in family planning. There was us in maternal fetal medicine. There were objeans who, you know, just generally supported abortion rights and were but there was just also just this giant cohort of, you know, docs in practice who did low risk and they just didn't seem, you know, even if they weren't like anti-abortion, it just it just didn't affect them, you know, on a on a day-to-day, you know, basis. You would think the whole field would be up in arms, but uh like a lot of things as crazy as it is, there's sort of a bell-shaped curve or maybe it's biodal, I don't know, but there's some range of waves that people feel. So, >> um, in general, I was wondering if you could speak a little bit to this idea of perhaps harm reduction in policym or advocacy versus your ideal or absolute and what you would like to have and and obviously there's, you know, the moral quandry there and and you've had to experience it. But I I could imagine um as you know a future advocate or policy maker or other positions um or experts in the field deciding maybe to make that list of 20 exceptions um thinking that 20 exceptions better than zero. And so I was just wondering if you could expand a little bit about what you you know on this topic. >> Yeah I mean the fundamental problem is that people shouldn't be going to the ballot to vote on other people's rights. You know, I mean, right should be part of the law. You know, we des desperately needed in our state to advance the ballot initiative. The ballot initiative has been tremendously positive since being passed. But like, you know, you shouldn't have a mass of people in Ohio going to the ballot voting on the rights of other people. And ballot initiatives can be a double-edged sword. You know, when I was a resident in Ohio back in the early 2020s, there was a ballot initiative to ban gay marriage in the state and that passed and and that was out outlawed for for a period of time. You know, having the fundamental rights of others be held to a 50th percentile of like a ballot is is fundamentally a problem. You know, with regards to the language of the ballot initiatives, you know, basically for a ballot initiative to move forward, it needs millions and millions of dollars from major donors. The major donors are only going to release the money if you can show polling showing that more than 55% of people support the ballot. You know, because like there there's no reason ever advancing a ballot initiative if more than 55% of people don't support the ballot. You know, because again, you you can write it to be whatever whatever you want. You you know, so you write it was actually a fascinating process to learn about. You you write a whole bunch of different versions with with with a whole different bunch of different tweaks and then it all goes through um polling and f focus groups. And you can never get generally above 60% cuz more than 60% of humans don't agree on you know anything. And when it comes to reproductive rights you know if you don't have enough freedoms in there then you if you if you have too few restrictions and some people will start to turn against it. Um, I'm sorry. If Yeah, if if you go the other way, you know, then abortion right supporters may unreasonably start to not support it, you know, either. So, it's actually hard to get the language of a ballot initiative that will hit the sort of 55 to 60%, you know, threshold. But you basically need a wording that'll hit the 55 to 60% threshold for the donors to release the the money, you know, cuz if you can go to the people who donate to campaigns and you say like this is the the language of our ballot initiative and it polls at 57% then they'll be like, I'm going to support that because it's going to um because it's going to pass. All of which just becomes a problematic calculus for us as doctors because our medical decision-m shouldn't go through a process like that. You know, it's it was like and then you know cuz you know the language and the rules that would you know survive that process and end up going to the ballot is not medically you know what we're going to want. And you know, it's definitely not going to be the ideal of what we would want from a reproductive freedom standpoint, too. I don't know that actually answered your question or not, but >> I do think that there's an active discussion about it. And I know that um our professional organizations have actually taken a much more active role in the last couple of years of sort of like how do we support folks in band states who are trying to at least be in the room to decide help decide um because that is a calculus too. like you can say, "Well, we want we want these three things have to be in the law, and maybe you're not in the coalition anymore, you know, like like and maybe you don't actually get to influence any of it." And so, um, I think that there's been a lot more support to like how do we think about if if exceptions are the thing that's going to happen no matter what, how do we do harm reduction in that way? Um, and I don't think folks have a good answer, but there is an active attempt to support colleagues and and sort of learn from what other folks have done um and acknowledging that it is not good. >> Yeah. And my >> and puts us in a terrible position. >> The opinion of many is that you know a specific list of exceptions for specific medical problems at least in my opinion and the opinion of most like we just can't have that. I mean I understand the argument for harm reduction but you know if if we start to compromise on basic rights you know we just can't and most people in America support fundamental abortion you know rights. So in theory in a representative democracy we should one day get to where we need to to be you know >> and maybe that's hopefully that answers your question.