Reddit reviews Willing and Unable: Doctors' Constraints in Abortion Care

There's a really, really excellent chapter in Lori Freedman's Willing and Unable: Doctors' Constraints in Abortion Care that discusses miscarriage management in Catholic hospitals- basically, what happens when a woman comes into the hospital actively miscarrying a pregnancy prior to viability and is potentially at risk of infection, but the doctors' hands are tied by the Catholic Church's Directive 47. One story I've transcribed before and can easily copy and paste here to share:

>The restrictions that Catholic hospitals place on reproductive services bothered Dr. Smits, but the catalyst for his quitting came about through an issue that he had, until working in St. Mary’s, seen as relatively uncontroversial in the world of obstetrics: miscarriage management. As a perinatologist, much of his work revolved around trying to save high-risk pregnancies. But for previable fetuses (less than approximately twenty three weeks old), little can be done to save the pregnancy if the membranes of the amniotic sac are ruptured. After that point, it is only a matter of hours before infection can threaten the health of the pregnant woman. Therefore, using the same procedures by which abortions are performed, the physicians of this study were routinely trained to facilitate spontaneous abortion (evacuate the contents of the uterus) when a woman showed up at the hospital who was less than twenty-three weeks pregnant, bleeding and cramping, and had ruptured membranes. This means the pregnancy is over. The woman can either continue to labor as she would in childbirth to deliver the previable (or nonviable) fetus, often with the help of pain and labor-inducing medications, or, if a physician with the appropriate training can be found, the woman can choose a surgical procedure in order to expedite spontaneous abortion and to reduce the risk of infection. The surgical procedure in the second trimester typically takes between fifteen and thirty minutes to complete and, in contrast with the hours (or sometimes days) of labor, is often seen as an easier and more comfortable option for a woman experiencing a miscarriage.

>A problem arose for Dr. Smits when he took care of a patient whose fetus had not yet died, even though her membranes had ruptured and she was infected and sick Because the fetus was still alive, the Catholic hospital ethics committee viewed evacuation of the uterus as an abortion, and it would not approve the procedure. Dr. Smits recounted the details of the case: “I had this one situation where- I’ll never forget this, it was awful- where I had one of my partners accept this patient at nineteen weeks And the pregnancy was in the vagina. It was over. But she [the patient] wanted everything done. And so he takes this patient and transferred her to [our] tertiary medical enter, which I was just livid about, and, you know [sarcastically] ‘We’re going to save the pregnancy.’” Dr. Smits was angry because the pregnancy was only nineteen weeks along, and given the extent to which the patient had already begun to expel the pregnancy, there was really no chance of fetal survival. Therefore, he saw the fact that she would occupy a coveted hospital bed and physician care in the tertiary medical center- a specialized enter for high-risk pregnancies- as wasteful of time and resources that could be allocated to the management of other precarious but viable pregnancies. He continued: “So of course, I’m on call when she gets septic, and she’s septic to the point that I’m [using medication] to keep her blood pressure up and I have her on a cooling blanket because she’s 106 degrees. And I needed to get everything out [of the uterus]. And so I put the ultrasound machine on and there was still a heartbeat, and [the hospital ethics committee] wouldn’t let me [do the procedure] because there was still a heartbeat. And this woman is dying before our eyes.

>. . .

>Returning to Dr. Smits, his concerns were comparatively straightforward compared with those of Dr. Gray. He needed to save the life of his miscarrying, now dying patient. His attempts to gain approval for uterine evacuation from the ethics committee had failed, so like Dr. Gray, he took matters into his own hands: “And so I went in to examine her, and I was able to find the umbilical cord through the membranes and just snapped the umbilical cord and … ‘Oh look. No heartbeat. Let’s go.’ And she was so sick she was in the ICU for about ten days and very nearly died. And I said, you know, I can’t do this. I just can’t do this. I can’t put myself behind this. This is not worth it to me.” And so he quit his job at the Catholic hospital and joined a secular academic medical center. When I asked Dr. Smits how the hospital administration and ethics committee had responded to the bad medical outcome of the case, he told me they saw it as a problem of a “bad transport”: “Nobody thought that the hospital did anything wrong. I think that the biggest issue was that they took this nineteen-weeker on transfer … They just said that she didn’t need to be in the tertiary medical center . . The point is that for a nineteen-week pregnancy, you’re not going to be able to do anything to save the pregnancy anyway.”

>When I asked what ultimately happened to the patient, he said: “She was in DIC, which means that her coagulation profile was just all out of whack. So they bleed internally And her bleeding was so bad that the sclera, the whites of her eyes, were red, filled with blood … She actually had pretty bad pulmonary disease and would up being chronically oxygen-dependent, and as far as I know, [she] still is, years later. But, you know she’s really lucky to be alive.”