Corporate Citizenship and Institutional Responses Post-Dobbs — Critical Lessons from Two Restrictive States

“When Roe v. Wade was decided in 1973, a group of 100 U.S. professors of obstetrics and gynecology predicted that teaching hospitals would emerge as leaders in compassionate abortion care, creating outpatient clinics to meet the demand for legalized abortion. But most hospitals did not embrace abortion provision; many of them in fact adopted policies that were more restrictive than was legally required. Freestanding clinics instead emerged as the primary provider of abortion care, and this siloing was further reinforced by stigma, threats of violence, and the exclusion of abortion coverage by major health care payers. In 2020, hospitals accounted for one third of abortion-providing facilities but performed only 3% of the nearly 1 million abortions in the United States. [..]

The overturn of Roe forces us to reexamine the role of hospitals and teaching institutions in preserving and enhancing access to abortion. Under the principles of corporate citizenship, also called social responsibility, organizations share some of the rights and responsibilities of citizens, who are obliged to engage in social and political processes. Examples in health care include conscious efforts to reduce racial disparities in health outcomes, to serve underserved communities, and to engage in public health emergency preparedness. [..] Academic medical centers are well positioned to share their perspectives on abortion restrictions, given the effects on medical education, care delivery and staffing, and related reproductive health services. In states with bans, we believe that health systems have an obligation to maintain access to reproductive health care within the boundaries of the law, and patients reasonably expect access to legally protected care. Therefore, we see the responsibility for health care organizations to act as corporate citizens as extending to leading a coordinated response to restrictive abortion legislation. [..]

In Ohio, immediately after the Dobbs decision was released, state officials lifted the injunction on Senate Bill 23, which prohibited abortion in most circumstances after the detection of fetal cardiac activity. From the moment the state law changed, the institution where two of us (J.R.L. and A.R.B.) work launched a comprehensive response modeled on our health system’s emergency-response framework developed during the Covid-19 pandemic. We created an interdisciplinary Reproductive Health Task Force with representation from executive leadership, multidisciplinary physician experts, hospital legal counsel, and government affairs. This coordinated, centralized response provided clinical and legal guidance to health care professionals throughout the institution, mitigating confusion and reducing hesitancy to provide legally permissible care. Consensus was achieved regarding care in specific scenarios affected by the law, such as abortion in medical emergencies, miscarriage with fetal cardiac activity, and ectopic pregnancy.

[..] The institution also announced a policy of legal protection for clinicians in the event of an abortion-related lawsuit, fostering a supportive environment for caregivers. Task force leaders partnered with other hospitals in the state in developing a broad consensus on approaches to care, including in legal gray zones. Though the response did not alleviate all the anxiety or distress created by the new legal landscape, a coordinated response provided critical and timely support.

In contrast, the lack of an organized response in Tennessee — where one of us (L.Z.-S.) worked at the time — fostered an environment of chaos and confusion. Sixty days after Dobbs, a bill banning all abortion in the state without exception became law. Abortion providers attempted to engage the larger medical and academic communities to develop a coordinated response in order to standardize interpretation of the law, preserve access to lifesaving reproductive health care, and protect clinicians. These efforts, however, were met with resistance and resulted in minimal coordination among hospitals, which created anxiety and uncertainty for patients and clinicians alike. Each institution interpreted the law independently, and the result was a disjointed patchwork of care in the state. This lack of coordination led to the interstate transfer of patients for medically necessary, evidence-based care (including care for ectopic pregnancy), a sense of legal vulnerability among physicians, moral distress, and a chaotic practice environment that caused some physicians to leave the state. Without organized institutional responses, Tennessee patients continue to suffer as they receive disparate care at different institutions within the state, and clinicians are unable to uphold their ethical duty to provide appropriate medical care.

[..] We believe that a few critical lessons regarding corporate citizenship and reproductive health care have emerged.

First, a comprehensive and sustained institutional response to restrictive abortion laws is integral to maintaining access to legally permissible reproductive health care. Second, health care institutions have a responsibility for priority setting and resource allocation during public health crises, which includes leading the response to legal restrictions on abortion and reproductive health care. Third, health care institutions have a responsibility to protect their employees from undue risk, especially when standard-of-care medical practice is threatened with legal consequences. And fourth, an organized, multiinstitutional response to restrictive abortion legislation facilitates standardization of clinical practice in situations of legal uncertainty.

In the face of increasing maternal mortality and persistent racial disparities in obstetric outcomes, it is clear that health care organizations must provide care that improves the health of the patients and communities they serve. That includes all legal reproductive health care. Inaction and acquiescence will only increase morbidity and mortality among people with reproductive capacity, amplify health inequity and racial disparities, and further marginalize and stigmatize abortion. If institutions fail to fulfill their role as citizens, they risk disaffecting both their workforces and the communities they serve. Embracing corporate citizenship, as applied to reproductive health care and abortion, is foundational not only to the health and safety of our patients and communities but to the discipline of medicine itself.”

Full editorial, JR Lappen, L Zahedi-Spung and AR Brant, New England Journal of Medicine, 2023.5.11