Legal Uncertainty after Dobbs and Its Impact on Clinical Practice

Abstract

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Introduction

The US Supreme Court’s 2022 decision to overturn Roe v. Wade sparked widespread scrutiny due to its far-reaching legal, medical, and societal consequences. In the immediate aftermath, numerous states enacted or enforced abortion bans that triggered the rapid closure of abortion clinics. These closures have led many patients to travel long distances to obtain care, often encountering significant delays that disproportionately burden low-income individuals, rural populations, and racial and ethnic minority groups.^[1]

Yet focusing primarily on access — as much of the public health literature and advocacy research has done — obscures another significant long-term impact of Dobbs: the introduction of legal uncertainty into routine clinical decision-making.^[2] Legal scholars and clinicians began documenting these risks immediately after the decision was issued.^[3] This form of uncertainty reflects the ambiguity in how statutory restrictions are interpreted and applied in clinical settings. In states with abortion restrictions, physicians must consider potential legal ramifications with each medical decision, often under extreme, high-pressure conditions and with limited information. This has reshaped how care is delivered across a variety of clinical settings, so the health consequences of the Dobbs decision cannot be fully understood by focusing solely on abortion and miscarriage.

Researchers and clinicians increasingly report that abortion restrictions have destabilized standard medical practice beyond access to abortion itself.^[4] Bans have complicated the evidence-based management of miscarriages and obstetric emergencies, delayed or denied fertility treatments, constrained cancer therapies, and introduced uncertainty into the prescribing of medications with teratogenic or abortifacient potential, including methotrexate, misoprostol, and mifepristone.^[5][6] Abortion restrictions have affected multiple aspects of standard health-care delivery, creating uncertainty for patients and clinicians.

Delays Due to a Need for Legal Advice

As a result, clinicians may seek legal counsel before making decisions.^[7] However, much of the existing medical literature has focused on disruptions in abortion care rather than on how legal ambiguity affects routine clinical practice. Delays in treatment are a well-established source of harm, particularly in obstetric and emergency settings.^[8] When clinicians must delay intervention until conditions worsen, patients face higher risks of infection, hemorrhage, and long-term morbidity and mortality. Investigative reporting and case analyses have documented instances in which doctors turned away patients seeking emergency medical care for a miscarriage multiple times, even as some patients developed severe sepsis.^[9]

Emerging evidence indicates that legal uncertainty is already associated with worse clinical outcomes. A study of Texas hospitals following the implementation of Senate Bill 8, a near-total ban on abortions after approximately six weeks of gestation, reported delays and denials of care for patients with pregnancy complications, including in instances where abortion was the standard of care.^[10] A subsequent analysis found that Texas abortion restrictions delayed care and significantly increased maternal morbidity.^[11] These findings raise concerns that the state laws restricting abortion in the aftermath of the Dobbs decision may be influencing patient outcomes.

Qualitative research further illustrates the impacts. This new form of defensive practice, termed “hesitant medicine,” occurs when providers delay, withhold, or modify care to avoid legal scrutiny.^[12] Physicians described prioritizing legal defensibility alongside clinical judgment in urgent scenarios. Legal ambiguity in other restrictive states has produced similar patterns.^[13]

Crucially, this phenomenon extends beyond abortion treatment. Emergency departments, inpatient services, outpatient clinics, and specialty practices all exist within the same legal environment. A lack of legal clarity can influence a multitude of related decisions (e.g., management of miscarriage, ectopic pregnancy, sepsis, cancer treatment). In a multi-state qualitative study, clinicians reported delaying or avoiding first-line, teratogenic therapies for reproductive-age patients who were not pregnant due to concern that a subsequent pregnancy could require abortion.^[14] These effects extend to wanted pregnancies and clinical care in other specialties.

Contribution to Physician Shortages

There are also broader implications for the capacity of health systems nationwide. Whether through limiting the scope of practice, declining to provide certain services, or leaving restrictive areas altogether, legal threats are accelerating existing workforce and infrastructure challenges. A national analysis showed reductions in residency programs in states with abortion bans following the Dobbs decision, raising concerns about future access to care in such areas.^[15] Reports also suggest that some physicians have left or are considering leaving restrictive states, potentially further exacerbating workforce shortages. These shortages may exacerbate pre-existing gaps in care in the most vulnerable areas.

Conclusion

Ultimately, the uncertainty about criminal liability impacts clinical practice. The constant need to analyze legal risks in routine, everyday decision-making produces downstream consequences that extend well beyond abortion care.

Research focused solely on reduced access to abortion complements research on the legal uncertainty itself and its impact on many areas of clinical care. While some researchers and organizations focus on access to abortion care, it is crucial also to consider the impact of a fear of liability on clinical care beyond abortion, and even beyond pregnancy.

Laws governing reproductive care that do not allow clinicians to act on medical judgment in good faith — without fear that appropriate treatment will later be construed as criminal conduct — risk undermining not only abortion care, but the integrity of clinical practice.

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[1] Fuentes, L. (2023, January). Inequity in US abortion rights and access: The end of Roe is deepening existing divides. Guttmacher Institute. https://www.guttmacher.org/2023/01/inequity-us-abortion-rights-and-access-end-roe-deepening-existing-divides

[2] Bearak, J., Popinchalk, A., Ganatra, B., Moller, A.-B., Tunçalp, Ö., Beavin, C., Kwok, L., & Alkema, L. (2020). Unintended pregnancy and abortion by income, region, and the legal status of abortion: Estimates from a comprehensive model for 1990–2019. The Lancet Global Health, 8(9), e1152–e1161. https://doi.org/10.1016/S2214-109X(20)30315-6

[3] Dobbs Reingold, R. B., Gostin, L. O., & Goodwin, M. B. (2022). Legal risks and ethical dilemmas for clinicians in the aftermath of Dobbs. JAMA, 328(17), 1695–1696. https://doi.org/10.1001/jama.2022.18453

[4] Buchbinder, M., Arora, K. S., McKetchnie, S. M., & Sabbath, E. L. (2025). Social Science & Medicine, 369, 117856. https://doi.org/10.1016/j.socscimed.2025.117856;
Joffe, C., & Kimport, K. (2025). Journal of Women’s Health, 34(6), 754–759. https://doi.org/10.1089/jwh.2024.0589

[5] Kimport, K., & Kaller, S. (2025). Contraception, 151, 111043. https://doi.org/10.1016/j.contraception.2025.111043;

[6] Zia, Y., Somerson, E., Folse, C., et al. (2024). Reproductive Health, 21, 171. https://doi.org/10.1186/s12978-024-01908-9

[7] Buchbinder, M., Arora, K. S., McKetchnie, S. M., & Sabbath, E. L. (2025). Social Science & Medicine, 369, 117856. https://doi.org/10.1016/j.socscimed.2025.117856

[8] Gerdts, C., et al. (2016). "Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas." American Journal of Public Health, 106(5), 857–864. https://doi.org/10.2105/AJPH.2016.303134

[9] Arey, J., et al. (2022). A preview of the dangerous future of abortion bans—Texas Senate Bill 8. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMp2207423

[10] Arey, J., et al. (2022). A preview of the dangerous future of abortion bans—Texas Senate Bill 8. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMp2207423

[11] Nambiar, A., Patel, S., Santiago-Munoz, P., Spong, C. Y., & Nelson, D. B. (2022). American Journal of Obstetrics & Gynecology, 227(4), 648–650.e1. https://doi.org/10.1016/j.ajog.2022.06.060

[12] Lilly, A. G., Newman, I. P., & Bjork-James, S. (2024). Social Science & Medicine, 350, 116912. https://doi.org/10.1016/j.socscimed.2024.116912

[13] Buchbinder, M., Arora, K. S., McKetchnie, S. M., & Sabbath, E. L. (2025). Social Science & Medicine, 369, 117856. https://doi.org/10.1016/j.socscimed.2025.117856

[14] Physicians for Human Rights. (2025). Cascading harms: How abortion bans lead to discriminatory care across medical specialties. https://phr.org/our-work/resources/cascading-harms-how-abortion-bans-lead-to-discriminatory-care-across-medical-specialties/

[15] Association of American Medical Colleges. (2024). States with abortion bans see continued decrease in U.S. MD senior residency applicants. https://doi.org/10.15766/rai_dnhob2ma