Moral distress reaches clinicians in states that protect abortion

Clinical takeaway: Colleagues in protected states report moral distress from patient surges and strained resources, which the authors say institutions could address. 

Since the US Supreme Court eliminated federal abortion protections in 2022 in Dobbs v Jackson Women’s Health Organization, each state sets its own rules, from near-total bans to expanded access. Clinicians who provide abortion can now find that obeying the law means falling short of what their own judgment and professional standards require. Researchers call that conflict moral distress, knowing the right course and being barred from it, and earlier work tied it to burnout and attrition, with higher attrition among clinicians in ban states. 

Survey scores had already shown the highest distress among clinicians in ban states. Clinicians in protected states also described distress, especially where patient volume had climbed. What lay behind it in those states had gone undescribed, and may differ from what clinicians under bans face. This analysis of written accounts from clinicians extends that work by sorting the situations behind the distress in both kinds of state. 

Respondents in protected and restricted states both described moral distress, and their accounts fell into three groups: bans that barred care they were able to give, forced changes to how they practiced, and the national climate. Roughly a third wrote from protected states, a third from restricted states, and a third from settings the authors could not determine. 

In protected states, one described schedules filled by patients traveling from states with bans, patients turned away, and staff who were hard to keep. Another offered unfunded and out-of-state patients fewer options than insured in-state patients, such as operating room scheduling for deep sedation. A third said hospital policy kept care short of the gestational limit that state law allowed. 

In restricted states, bans forced some respondents to turn away patients they had the skills and equipment to treat. State counseling laws required others to tell patients that medication abortion can be reversed, which conflicts with the evidence. One respondent managed a pregnancy concerning for placenta accreta spectrum in an outpatient clinic because hospital care was out of reach, and the patient hemorrhaged. 

In protected states, distress extended to colleagues and patients under bans. Respondents in both kinds of state dreaded restrictions still to come, including pending bans and a mifepristone ruling. 

The analysis drew on written answers from 160 US physicians, advanced practice clinicians, and nurses who provide or have provided abortion care, surveyed from May to December 2023. Investigators coded the answers by theme and inferred the policy environment of each respondent from the text. The data cannot show how often any situation occurred. 

The surge distress resembles what clinicians reported during the COVID-19 pandemic, when patient volume strained resources and care slipped below standard. Anticipatory distress has also been described among clinicians providing gender-affirming care amid changing legal rules. Distress rooted in bans, the authors write, would take state or federal policy change to resolve. 

“In this qualitative study, abortion-providing clinicians, regardless of state policy environment, described their experiences of moral distress in the wake of the Dobbs decision,” the authors conclude. “Targeted approaches for alleviating moral distress among abortion-providing clinicians are imperative for improving health outcomes and addressing disparities in access to reproductive health care.” 

Source: Wascher J, et al. (2026 Nov 2) JAMA Netw Open. Moral Distress Among Abortion-Providing Clinicians After the US Supreme Court Dobbs Decision