Inside a Hospital’s Abortion Committee

Sarah Osmundson knows how to talk about abortion. She’s learned over the course of her career as a maternal-fetal medicine doctor that some patients are comfortable with the option, and others would never consider it. Osmundson deals with hard cases: Her patients are women with preexisting conditions that make pregnancy dangerous, women who develop life-threatening conditions during pregnancy, and fetuses with conditions that are not survivable. She’s trained and practiced in different parts of the country where different religious norms prevail. She knows about agonizing moral dilemmas and understands the patients who make extraordinarily difficult decisions—such as choosing to deliver a baby who might live only a few hours.

When she learned that the Supreme Court would overturn Roe v. Wade, Osmundson knew her life would change. Tennessee passed one of the strictest abortion bans in the country “and so right away, I knew we would be at the center of this,” she says. “I don’t think I really understood what that fully meant at the time.”

Vanderbilt University Medical Center, where Osmundson works, created what is informally known as an “abortion committee,” a group that meets to decide whether to permit doctors to offer an abortion in challenging cases. The Tennessee law allowed an exception “to prevent the death of the mother,” but that left a moral chasm difficult for doctors to navigate alone: Did death have to be possible? Probable? Imminent? The committee was created so that doctors felt a sense of safety in numbers.

In this episode of Radio Atlantic, Osmundson talks about her experience on the committee. She started out hopeful and then began getting emails from fellow doctors saying, for example, that they were not “brave enough” to go ahead with an abortion for a patient who was begging for one when she found out her baby would not live. Normally doctors on these committees do not reveal their inner workings. We are in touch with Osmundson thanks to Kavitha Surana, a reporter at ProPublica who first spoke with her as part of her reporting on the landscape post-Roe. You can find more of Surana’s work here.

Listen to the conversation with Osmundson here:

The following is a transcript of the episode:

Hanna Rosin: Sarah Osmundson is an obstetrician in Tennessee, specifically a maternal-fetal medicine specialist, which means that if a pregnant patient is referred to her, the blissful, stress-free pregnancy of their dreams is probably off the table.

A typical case of hers might be a woman who comes in with preeclampsia, a serious complication that often manifests as high blood pressure.

Sarah Osmundson: With preeclampsia, we generally counsel women that this is a pregnancy-associated condition. It starts from the placenta, and when the placenta is no longer inside of you, also known as delivery, the preeclampsia will go away. And so the cure for Mom is to deliver—it’s always to deliver.

But we have a second patient that we are concerned about, and that second patient is the baby, or the fetus. And so we are trying to walk this line of delivering early enough to prevent complications for Mom but also late enough that the baby doesn’t have serious long-term complications related to prematurity.

Rosin: The pregnant women she sees might have diabetes, organ transplants, heart disease, or the fetus might have such severe complications that it’s very unlikely to survive. And with each case, she has to think about both patients. Osmundson does not perform abortions, but sometimes she has to bring up the option with her patients.

In over 10-plus years, she’s developed a way of bringing it up: giving her own medical advice but also hearing out the patients on what they value.

Osmundson: You know, I had really come to kind of a place of peace with that—that, you know, we were honoring patients’ decisions even if they’re not the decision that I personally would make or that I would recommend.

Rosin: And then, the whole balancing act got upended. June 24, 2022, the day of the Dobbs decision, when Roe v. Wade was overturned, Tennessee Governor Bill Lee signed one of the strictest abortion laws in the country: No elective abortions at any point in the pregnancy. Limited exceptions to protect the life and health of the mother.

And Osmundson had to figure out how to take care of her patients without breaking the law.

Osmundson: The exception says, and I wrote it down because I always get this wrong a little bit, but it says that you can perform an abortion to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function.

To me, even from the beginning, this was very gray, because what does that mean? Where is that risk? It is a continuum of risk. Where is the cut point that we have to decide some aspect of risk is too high? And so right away, I knew we would be at sort of the center of this. I don’t think I really understood what that fully meant at the time.

[Music]

Rosin: This is Radio Atlantic. I’m Hanna Rosin. Today, we get a view into how some abortion decisions are made behind closed doors, and the terrible pressures that that places on doctors.

When is the risk to a mother serious enough for the new law? A 2-percent chance of death? Ten percent? Does the patient have to be at death’s door? And how can an individual doctor make that decision, given that they could get prosecuted for getting it wrong?

Osmundson hoped to figure it out by not doing it alone. Vanderbilt University Medical Center, where she works, created what was informally known as an abortion committee. Her hope was that by working together, doctors could protect themselves and their patients and figure out how to operate in this new landscape.

The existence of these hospital committees, much less their inner workings, is something that few people know about. Even the patients whose cases they decide often don’t know about them. We are aware of them thanks to Kavitha Surana, a reporter at ProPublica who has been tracking the impact of Dobbs around the country. She connected us to Osmundson, a rare doctor who was willing to speak openly with her how this committee was impacting her work—which at the very beginning was kind of positive. It made her feel safer.

Osmundson: You know, I think many of us were very scared and felt some comfort and safety in numbers and felt like having a group of people who could talk through these issues and make decisions was the right way to go.

We don’t want to do anything that might even appear that we are performing an abortion that does not meet the exceptions in Tennessee, because we do not want a prosecutor to come after us. None of us want to poke a bear and see if it bites us. And, you know, it seemed all of a sudden like we were in the position of poking the bear with everything that we did medically.

So we were sort of all like, Hey, if, you know, a group of us says this meets the exception clause, then they have to come after the entire group, not just an individual.

You know, we’ve invested—I’ve invested 15 years of my life in training. I have taken out substantial loans to complete my medical training. Risking that for this seems, like, terrifying.

[Music]

Rosin: So you’re on the committee. What was the first case you encountered that the committee had to deal with?

Osmundson: You know, I think I would say a lot of the cases in the beginning, I think, were very clear-cut cases, like where Mom has a serious cardiac problem, and there’s lots of data that those patients will get very sick with pregnancy and may not make it to a point of pregnancy where they can have a live birth.

I think those are very, I don’t want to say, easy decisions, but they’re very—I think all of us sort of look at them and say, Well, obviously, this is going to prevent her death—very real risk of death and the serious risk of substantial and irreversible impairment.

Rosin: Mm-hmm. So those were more clear cut.

Osmundson: Yes. But, you know, as time went on, we ended up getting more of the cases that are much more gray. So, in the beginning, I should say, another type of case that we’d have is someone with type 1 diabetes who has a very high A1C level, which means that their diabetes is not in good control. And we know those patients have a high risk of losing the pregnancy early, of developing kidney failure in pregnancy, and having all sorts of complications.

But what happens when you see a patient who has diabetes and it’s well controlled and they also have, you know, another autoimmune condition that’s pretty well controlled? Plus, you know, they have some kidney disease at baseline. But again, it’s not horrendous kidney disease.

You know, these are the kind of cases where we’re really trying to guess at: What is their risk of death or serious morbidity? And even when I see these patients in the office, like, I can’t sit down with them and say, Your risk is X percent. I don’t have data to drive that individual case. Maybe their risk of serious problems in pregnancy is like 5 percent.

I take care of people who don’t get an amniocentesis, which is like a needle in the abdomen to check on the baby’s chromosomes. They don’t undergo that procedure because there’s a one-in-1,000 risk of a complication. And so we don’t do certain things because of very low risk. How am I to say that a risk of 5 percent is too low of a risk?

[Music]

Rosin: One day, Osmundson emailed her colleagues on the committee that a patient was 14 weeks pregnant and learned that her fetus had no skull and would not survive. This meant that the woman might develop excess amniotic fluid, which posed a risk of killing her.

Osmundson thought the risk was high enough to meet the Tennessee law’s exception. But the other doctors on the committee did not join in agreement. As we know from ProPublica’s reporting, one doctor on the committee wrote back that they were not , quote, “brave enough.” Another wrote that, given the Tennessee law, an abortion in this case could be seen as, quote, “cavalier.”

Osmundson: I feel like I’m making a decision thinking about: How would our attorney general interpret this? How would the optics appear? And it makes me feel really uncomfortable, as a physician, that I’m considering care for the optics, rather than for what is right and best for the patient.

Rosin: They kept making decisions, worrying about the optics, until one day something happened. It wasn’t a case before the abortion committee. It didn’t even involve the possibility of an abortion. But it made it much harder for Osmundson to accept what they were doing.

Osmundson: I had a patient who had a really normal, healthy pregnancy and highly desired pregnancy—went through, you know, fertility treatments and everything. And then she had a very sudden and rare complication at the end of pregnancy that caused liver failure. And even in those circumstances, I’ve seen us bring people back from the brink of death and survive, and she didn’t.

And, I mean, it’s devastating. Like, I was just shocked, actually, when I came—like, she was very sick in the morning. I expected her to pull through, and then I was shocked to hear that she had died.

[Music]

Rosin: Right. So, in this case, even though an abortion wouldn’t have changed anything, wouldn’t have changed the outcome, did the death of that patient—did it change anything for you on the committee?

Osmundson: I think it really solidified the fact that denying an abortion to a patient who has medical complications is at odds with my medical judgment. And that made me realize that, like, when we’re debating these issues, we are trying to interpret a law from a lawyer perspective.

And, like, I’m actually really not qualified to do that. Like, I’m very qualified to give you my medical judgment, and I’m very qualified to talk to a patient and help them walk through that decision-making process. I am not qualified to read, you know, 15 words in a law and try to interpret it.

And, in some ways, it’s like, Why am I second-guessing my medical judgment? Obviously, this patient who has diabetes and lupus—obviously an abortion, if she wants an abortion, an abortion is the right thing for her to do, because, you know, even in the lowest-risk circumstance, somebody can die from pregnancy.

Rosin: Right. Oh, I see. Because you’d probably had to—I mean, maybe it’s just a mental trick we all do—but you’d have to set aside, when you were denying people an abortion, you had to basically tell yourself, Okay, maybe this person won’t fall on the wrong side of the risk calculus. Like, maybe I’ll just get lucky, and this will be okay.

And when someone dies, it’s a reminder that, no, you don’t always get lucky, and you are correct in thinking, through your experience, that people can die.

Osmundson: And even if this patient’s risk of dying is 5 percent, right, that’s a 95-percent chance that she’s going to come through pregnancy fine. Right? Seems like a no-brainer—she doesn’t need an abortion. But you know, 5 percent is actually—we make a lot of decisions not to do things because the risk of death is 5 percent. Why am I telling a patient that she shouldn’t have an abortion for, you know, a hypothetical risk of 5 percent?

Rosin: Right, because 5 -percent risk of death is actually quite high.

Osmundson: It’s quite high.

[Music]

Rosin: After the break, Osmundson begins to see much more clearly how this law is putting her and other doctors in an impossible position.

[Music]

Rosin: After this young patient with an otherwise healthy pregnancy died, Osmundson stopped being able to put the obvious aside: Pregnant women died. As a doctor, she knew that, and she’d always known that. And now, she was failing to give her patients the full range of options to not die, because she felt like she was interpreting a law that she had no qualifications to interpret. And so she started talking about that. A lot. Out loud. On the committee.

Osmundson: I actually, in sort of joking one time when our hospital lawyer was there, I said, Could we just call up Bill Lee or call up, you know, our attorney general and ask them? Like, give them the case and say, What would you like us to do?

And it’s sort of tongue in cheek, but it’s not, right? Like, they’re the ones who are going to decide whether they want to prosecute me. So why can’t I call them up and say, Do you think this makes the exception? Why am I being asked to kind of guess at whether this is a prosecutable action?

Rosin: And was there a moment when you thought, Oh, I don’t want to be on this committee anymore?

Osmundson: Yeah. And I’ve thought through that. I mean, I think, you know, a natural sort of question is, Well, just quit the committee. And, you know, the problem with that is, at this point, like, the other maternal-fetal medicine physician we had had left—had moved out of state. You know, like, I think it’s really important for a maternal-fetal medicine physician to be involved in the care. I still think there’s a lot of benefit in thinking through these complex issues collectively.

I just feel that the decision-making—like, the moral culpability—shouldn’t be put on physicians to make these decisions. Like, I didn’t come into medicine to practice medicine for how it appears to a lawyer or to a judge or to the governor. I came into this to help patients and to help them through these processes. And the idea that I would consider what my governor or my attorney general thinks about a situation, like, that’s very practical in some ways, but it’s just wrong.

Like, do you want your cancer doctor to be considering the opinion of an attorney general when they’re making recommendations about your cancer care? Why would you want those kind of external things involved in your care during pregnancy?

Rosin: Right. Right. I think the illuminating thing about what you’ve been through is that we do tend to talk a lot about elective abortions, but not so much about this circumstance, where these are absolutely desired and wanted pregnancies. And the decisions you’re making are purely for medical reasons—like, really scary medical reasons. I mean, are you just not going to do it anymore?

Osmundson: I don’t know what the right answer is. I will just say that I’m still sort of figuring out what is the right answer.

One scenario is to say, like, I will give you my medical advice and tell you all the medical circumstances that can happen. The people who have to say yes or no, maybe they should be lawyers in our hospital.

Rosin: Ooh, like, if you followed your thoughts to the logical conclusion—you know, protect the purity of your profession—this is a legal situation. What you’re saying is correct, and yet it still feels like—like, wouldn’t it feel like abandoning your patients?

Osmundson: It does. I mean, and I think that’s like—I’ve talked about this with other members of the committee, and I think they feel like we all feel conflicted, right?

And I don’t fault anybody who’s on this committee or fault anyone who says, you know, I am too scared that I’m going to be prosecuted, and I’m going to tell this patient we should not do an abortion here. Like, I don’t fault them for doing that.

This is like, I mean, a risk of jail time and, like, huge fines. That’s crazy. So, I mean, maybe there’s some safety in saying, like, I’m going to say yes, you can have an abortion, but other people will probably say no. What happens when all of us say, We feel uncomfortable denying care to somebody.

I don’t know what fully is the right answer, other than getting rid of these horrendous laws or really making it clear that these are doctor-and-patient decisions.

You know, I have had personal patients of mine that have died in pregnancy, which are horrible and, I mean, I remember every single one of them. But, you know, I will say, most of those patients are patients that had serious complications at the beginning, where I talked about abortion as an option. I was transparent about every single thing. And while I feel horrible about the end result, I don’t feel morally culpable for it, because I did every single thing that I could, including offering an abortion.

But in these circumstances, I feel like we will be morally culpable for the care that we don’t provide, and I struggle with that. And, you know, so who should bear the weight of that? I don’t know. You know, I don’t think the lawyers want to bear the weight of it. But the idea that we police ourselves is also just, like, a little bit repugnant when, like, the decisions we make are not the medical decisions that we would make.

Rosin: Oh, I fully see it now. I see what you mean. Because you are culpable. Like if, in the past, a patient dies, it is terrible—

Osmundson: Right.

Rosin: But it’s probably important for you to continue and value your own profession and your own expertise to be able to look back at the course of that relationship and say, I did do everything I thought was medically necessary. Like, you guys are talking and making a decision, but if you don’t, then, I mean, you are culpable in a way.

Osmundson: Right. Right. And that’s—I think that’s where I feel like, as physicians, we are being co-opted into a repugnant system. Like, we are being used to be these, like, arbiters of judgments, which conflict with our medical judgments. And I don’t want to be a part of a system that is going to potentially make judgments that, you know, if somebody has a complication or dies in pregnancy as a result of that—like, I am a part of that decision-making process, and I am culpable in what occurred, and that feels morally untenable for me.

You know, ultimately, my hope is that these laws that really interfere with healthcare will go away. And that’s really what we need. Like, I know that everybody at my institution and everybody who is on this committee wants the absolute best for patients and patient care and wants to do what’s right.

And we are struggling with what is right. And, you know, the ultimate culpability lies in the legislators who enacted these laws and haven’t done anything to clean them up.

Rosin: Right. Right. You’ve mentioned a few colleagues who’ve left and gone to practice elsewhere. Has that thought come into your head?

Osmundson: I mean, it has. But I actually feel like since Dobbs, I almost feel a stronger calling to be here, to provide care. Like, I know I will give patients all the options available to them.

I worry that you have a circumstance where all the doctors that would do that leave, and you are left with doctors who will not talk about those things. And that—that is actually very scary.

You know, I mean, there is reason to hope that there will be some change in the state that lets us care for patients better.

Rosin: Well, you have a lot of complicated decisions ahead of you—personal and medical and professional—and I really, really, deeply appreciate your willingness to air the challenging parts of your life right now.

Osmundson: Yeah. No, I appreciate the opportunity to be able to talk about it. And, you know, we really do think that, you know, most people actually are closer on these issues than we are far apart. I think it kind of gets portrayed differently, but I really hope that, you know, our public can understand these better and, you know, I hope that there will be some change in the laws that are here.

Rosin: Yeah. Thank you.

[Music]

Rosin: This episode was produced by Kevin Townsend and edited by Claudine Ebeid. It was engineered by Rob Smierciak and fact-checked by Yvonne Kim. Claudine Ebeid is the executive producer of Atlantic audio, and Andrea Valdez is our managing editor.

Thank you also to Kavitha Surana and ProPublica. A link to her story is in our show notes. To read more of her reporting, go to ProPublica.org.

I’m Hanna Rosin. Thank you for listening.