DG: The latest data show clinicians provided nearly 900,000 legal abortions in 2017.

In health care, abortions are just a fact of life for many doctors, nurses, med students, insurers and hospital executives.

And then….

News clip: We begin tonight with breaking news.

News clip: An unprecedented leak from the Supreme Court.

DG:…came Monday night.

News clip: A bombshell new report suggests the Supreme Court is about to overturn Roe v. Wade.

DG: POLITICO rocked the country, publishing a leaked draft opinion that would overturn the landmark case.

If this draft becomes final, it would strip women of their constitutional right to an abortion.

States would now have the power to allow or to ban the procedure.

Unwinding Roe would disrupt the lives of women seeking abortions and upend 50 years of health care practice.

Today, how one doctor is determined to make sure her hospital is ready for a world without Roe.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, this is Tradeoffs.

******

DG: After a long weekend of meetings, Lisa Harris had just landed back in Detroit. 

Lisa Harris: The wheels had just touched the ground. And so I took my phone off of airplane mode. And a flood of headlines from CNN and New York Times flooded through my phone. And then a barrage of texts came through from colleagues and friends.

DG: Lisa is an OB-GYN in Ann Arbor. 

LH: I realized, wow, we really need to think through all the details about this.

DG: Lisa works for the University of Michigan’s hospital system, Michigan Medicine.

2.6 million patient visits last year, more than 1,100 beds, one of the state’s largest health systems.

LH: I walked off the plane, and I was just watching person after person after person, and nobody was alarmed. And I was looking around the airport and seeing hundreds of people going about their days. And I just had this deep sense that people don’t know what is coming. People don’t know what is about to hit.

DG: But Lisa did.

Over these last four months Lisa has carved out 10 hours a week to prepare her hospital for a post-Roe world.

She’s met 1-on-1 with her colleagues.

She’s given presentations. 

Her personal favorite: turning questions over and over in her head.

LH: Every morning I wake up and I think of something new that we need to account for.

DG: Lisa started this work soon after the Supreme Court held oral arguments in December in Dobbs v. Jackson Women’s Health where Mississippi asked the court to affirm its ban on all elective abortions after 15 weeks.

Reading the tea leaves, Lisa thought there was a reasonable chance the court’s new conservative majority might skip ruling on Mississippi and just overturn Roe.

And if that happened, abortions in many states would become illegal overnight.

News clip: In Alabama nearly all abortions would be outlawed.

News clip: Which would basically ban almost all abortions here in Miussouri

News clip: And that would trigger a law in Texas that would make providing an abortion a felony in the state of Texas.

DG: About half of the states, including Michigan, could quickly ban abortion if the Court strikes down Roe.

That’s why Lisa has been out front on this long before that draft opinion ever leaked.

Only around 4% of abortions in the U.S. happen in hospitals.

But Lisa says the people who get one there usually have a medical issue too complex for an outpatient clinic.

A 1931 state law makes performing an abortion in Michigan a felony, except when necessary to save the woman’s life.

Sounds clear, right? But Lisa says it’s not.

LH: What does the risk of dying from pregnancy need to be? Does it need to be 100% like that person who’s extremely ill in the intensive care unit and will die shortly? Or we see patients with cardiac disease where we might cite a risk of dying of maybe 25 or 30 percent if they were to continue the pregnancy.

DG: As Lisa and her colleagues bat around patient scenarios, they’re beginning to grasp the nuanced and difficult decisions they could have to face. 

Like people who have cancer. 

LH: Chemotherapy or radiation or surgery can cause harm, significant harm to a fetus or a baby. So they may want to end a pregnancy so they can start cancer treatment immediately, as opposed to wait months down the road, deliver, start their treatment, and maybe now already have more advanced disease that may not take their life immediately, but it might shorten their life a great deal.

So these are the questions that doctors and health care professionals are thinking about that I’m imagining legislators and justices have not thought about.

At some point, we will have to say, “We can justify taking care of these patients because, for example, the threat to their life is high enough that we will assume whatever risk we need to to take care of them, because that’s ethically and morally the right thing to do.” But there’ll be some point where we’re going to have to say to patients, “I’m sorry, we can’t help you. You can go out of state. You can go to Canada. You can drive several hundred miles.” And they will say, “But I can’t do that,” and we will need to say, “I’m sorry, I can’t help you.”

DG: As Lisa goes on, talking with her coworkers and putting together presentations, she’s realizing how much farther this goes beyond her own department. 

Primary care doctors need to think about this.

Specialists need to think about this.

The leaders of the hospital.

LH: I think I didn’t appreciate just how complicated it all is and how many legal questions there will be for which no one yet has an answer. And we don’t know what the answer will be.

DG: When we come back, the ripple effects at a health system that can no longer perform abortions and what Lisa wants policymakers to know about the work she does.

MIDROLL

DG: Welcome back.

All this year, Lisa Harris has been making the rounds, talking with people at her hospital about how the end of Roe could change their work. 

LH: It feels like throwing a grenade into a meeting every time I do it because legal abortion has been in the background through the lifetime of most people who are in practice now and it just doesn’t seem real to them.

DG: She recently met with a bunch of emergency department docs. 

She told them she hopes their main job would be reassuring nervous patients who used abortion pills at home.

LH: But there will be some people who didn’t have access to those safe medications and who used unsafe methods, who put something inside them, who took a poison or a toxin. Those people you’re going to have to jump and provide critical lifesaving care. 

DG: ER docs, she said, would have to get good at a new kind of triage: Is this person fine or do they need to be rushed into surgery? 

LH: And that’s a different skill set from what you’ve had to have before, because abortion complications are so rare and unusual that you’re not seeing a ton of it and you’re not making triage decisions like this.

DG: The ER docs hit her with lots of questions.

LH: Do I want to even know if they’ve tried to self manage an abortion? 

DG: How do you tell the difference between a miscarriage and a self-induced abortion? 

LH: Are they different? Would I know the difference? Do I need to know the difference?

DG: Could asking a patient about abortion put them or the patient at legal risk?

LH: Doctors traditionally want to know the more information, the better. And in this new climate, maybe that’s not the case.

DG: It’s more than just patient care Michigan Medicine must plan for.

Michigan has one of the top ranked OBGYN training programs in the country.

They have to be able to teach doctors-in-training how to perform abortions.

How do you do that if the procedure is all but outlawed?

​​LH: We’re beginning to have conversations with colleagues in other states that protect that care to figure out. OK, could you accommodate an extra learner at your site? What kind of contracts do we need to have in place? Where would they live when they’re out there visiting? How would they get there? How many days a week would they be there? So those are all the kinds of details that we’re working out.

DG: And the questions just keep coming.

How would the hospital handle the likely uptick in deliveries?

How will their contracts with insurers change if that happens?

LH: It’s all a big unknown right now. And I think the only thing that feels certain is it’s going to be messy and we’re going to learn as we go.

DG: What does seem certain — assuming abortion becomes illegal in Michigan — is that many people who want care will not get it.   

Lisa wishes folks, especially her state’s lawmakers and the Supreme Court justices, could glimpse what she’s seen over the past 20 years.

LH: They would see mothers. Most of the patients I care for already have children. They would see people drive through snowstorms and blizzards. They would see a lot of poverty. They would see people who, if they had more resources, would definitely continue their pregnancies. I think what you would see in a nutshell is all kinds of injustices and inequities all rolled into one that happens to manifest itself in someone requesting an abortion.

DG: Until now, it’s been helpful for Lisa and her coworkers to think about the systemic questions Michigan Medicine must address. 

It’s productive.

It’s a distraction, too. 

This work has helped keep the personal questions quiet. Questions like, “What happens if the care I’ve devoted my career to offering is outlawed?” 

LH: I literally got an email from a colleague today who said, I’m moving, I’m selling my house. I don’t want to stay here. I’ve been fighting this fight too long, and I’m going to go somewhere where I can make a different kind of difference.

DG: During our interview — the day after the opinion leaked — Lisa described herself as numb.

It’s hard to consider no longer doing what she’s done for so long. 

LH: There is stress and distress and pain that is very often woven into a decision to end a pregnancy. And when I think about needing to turn people away, when I think about people continuing pregnancies, they don’t want, giving birth when they don’t want to. I just see magnification of that pain and distress and injustice and inequity. And going there is just too upsetting. So right now, I’m just doing interviews all day long, asking questions about what is next. But to go there? That’s just too painful.

DG: Because it means what?

LH: Suffering. Witnessing suffering. There is not. Okay. You got me now. There’s not a lot much harder than witnessing other people’s suffering and being helpless in the face of that. And this will cause suffering, and I know I can help and I won’t be able to. And so I don’t want to think about that.

DG: There’s still a chance Lisa won’t have to witness the suffering she fears.

The Supreme Court could decide to keep Roe.

But if Roe goes away, Lisa is determined to help her hospital be as ready as it can be. 

Patients, she says, deserve nothing less.

I’m Dan Gorenstein, this is Tradeoffs.