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Kylie Cooper has seen all the ways a pregnancy can go terrifyingly, perilously wrong. She is an obstetrician who manages high-risk patients, also known as a maternal-fetal-medicine specialist, or MFM. The awkward hyphenation highlights the duality of the role. Cooper must care for two patients at once: mother and fetus, mom and baby. On good days, she helps women with complicated pregnancies bring home healthy babies. On bad days, she has to tell families that this will not be possible. Sometimes, they ask her to end the pregnancy; prior to the summer of 2022, she was able to do so.
That summer, Cooper felt a growing sense of dread. Thirteen states—including Idaho, where she practiced—had passed “trigger laws” meant to ban abortion if Roe v. Wade were overturned. When this happened, in June 2022, some of the bans proved so draconian that doctors feared they could be prosecuted for providing medical care once considered standard. Soon enough, stories began to emerge around the country of women denied abortions, even as their health deteriorated.
In Texas, a woman whose water broke at 18 weeks—far too early for her baby to survive outside the womb—was unable to get an abortion until she became septic. She spent three days in the ICU, and one of her fallopian tubes permanently closed from scarring. In Tennessee, a woman lost four pints of blood delivering her dead fetus in a hospital’s holding area. In Oklahoma, a bleeding woman with a nonviable pregnancy was turned away from three separate hospitals. One said she could wait in the parking lot until her condition became life-threatening.
Idaho’s ban was as strict as they came, and Cooper worried about her high-risk patients who would soon be forced to continue pregnancies that were dangerous, nonviable, or both.
She was confronted with this reality just two days after the ban went into effect, when a woman named Kayla Smith walked into Cooper’s office at St. Luke’s Boise Medical Center. (St. Luke’s was founded by an Episcopal bishop but is no longer religiously affiliated.) Smith was just over four months pregnant with her second baby—a boy she and her husband had already decided to name Brooks.
Her first pregnancy had been complicated. At 19 weeks, she’d developed severe preeclampsia, a condition associated with pregnancy that can cause life-threatening high blood pressure. She started seeing spots in her vision, and doctors worried that she would have a stroke. The only cure for preeclampsia is ending the pregnancy—with a delivery or an abortion. But Smith had chosen to stay pregnant, despite the risks, and she was able to eke it out just long enough on IV blood-pressure drugs for her daughter to be born as a preemie, at 33 weeks. The baby ultimately did well after a NICU stay, one of those success stories that MFMs say is the reason they do what they do.
This time, however, Smith’s ultrasound had picked up some worrying fetal anomalies, raising the possibility of Down syndrome. “Okay, that’s fine,” Smith remembers saying. “But is our son going to survive?” The answer, Cooper realized as she peered at his tiny heart on the ultrasound, was almost certainly no. The left half of the heart had barely formed; a pediatric cardiologist later confirmed that the anomaly was too severe to fix with surgery. Meanwhile, Smith’s early-onset preeclampsia in her first pregnancy put her at high risk of developing preeclampsia again. In short, her son would not survive, and staying pregnant would pose a danger to her own health. In the ultrasound room that day, Smith started to cry.
Cooper started to cry too. She was used to conversations like this—delivering what might be the worst news of someone’s life was a regular part of her job—but she was not used to telling her patients that they then had no choice about what to do next. Idaho’s new ban made performing an abortion for any reason a felony. It contained no true exceptions, allowing doctors only to mount an “affirmative defense” in court in cases involving rape or incest, or to prevent the death of the mother. This put the burden on physicians to prove that their illegal actions were justifiable. The punishment for violating the law was at least two years in prison, and up to five. The state also had a Texas-style vigilante law that allowed a family member of a “preborn child” to sue an abortion provider in civil court for at least $20,000.
Because Smith had not yet developed preeclampsia, her own life was not technically in danger, and she could not have an abortion in Idaho. Merely protecting her health was not enough. Lawmakers had made that clear: When asked about the health of the mother, Todd Lakey, one of the legislators who introduced the trigger ban in 2020, had said, “I would say it weighs less, yes, than the life of the child.” The fact that Smith’s baby could not survive didn’t matter; Idaho’s ban had no exception for lethal fetal anomalies.
If she did get preeclampsia, Smith remembers asking, when could her doctors intervene? Cooper wasn’t sure. Idaho’s abortion law was restrictive; it was also vague. All Cooper would say was When you are sick enough. Sick enough that she was actually in danger of dying? That seemed awfully risky; Smith had a two-and-a-half-year-old daughter who needed her mom. She also worried that if she continued her pregnancy, her unborn son would suffer. Would he feel pain, she asked, if he died after birth, as his underdeveloped heart tried in vain to pump blood? Cooper did not have a certain answer for this either.
Kylie Cooper is an obstetrician who manages high-risk patients. (Bethany Mollenkof for The Atlantic)
Smith decided that getting an abortion as soon as possible, before her health was imperiled, would be best, even if that meant traveling to another state. She knew she wanted her abortion to be an early induction of labor—rather than a dilation and evacuation that removed the fetus with medical instruments—because she wanted to hold her son, to say goodbye. She found a hospital in Seattle that could perform an induction abortion and drove with her husband almost eight hours to get there. Unsure how much their insurance would cover, they took out a $16,000 personal loan. Two weeks later, Smith again drove to Seattle and back, this time to pick up her son’s ashes. The logistics kept her so busy, she told me, that “I wasn’t even allowed the space to grieve the loss of my son.”
If Smith had walked into Cooper’s office just a week earlier, none of this would have been necessary. She would have been able to get the abortion right there in Boise. But at least she had not yet been in immediate danger, and she’d made it to Seattle safely. Cooper worried about the next patient, and the next. What if someone came in tomorrow with, say, her water broken at 19 weeks, at risk of bleeding and infection? This happened regularly at her hospital.
As summer turned to fall, Cooper started to feel anxious whenever she was on call. “Every time the phone rang, or my pager went off, just this feeling of impending doom,” she told me. Would this call be the call? The one in which a woman would die on her watch? She began telling patients at risk for certain complications to consider staying with family outside Idaho, if they could, for part of their pregnancy—just in case they needed an emergency abortion.
Cooper described her feelings as a form of “moral distress,” a phrase I heard again and again in interviews with nearly three dozen doctors who are currently practicing or have practiced under post-Roe abortion restrictions. The term was coined in the 1980s to describe the psychological toll on nurses who felt powerless to do the right thing—unable to challenge, for example, doctors ordering painful procedures on patients with no chance of living. The concept gained traction among doctors during the coronavirus pandemic, when overwhelmed hospitals had to ration care, essentially leaving some patients to die.
In the two-plus years since Roe was overturned, a handful of studies have cataloged the moral distress of doctors across the country. In one, 96 percent of providers who care for pregnant women in states with restrictive laws reported feelings of moral distress that ranged from “uncomfortable” to “intense” to “worst possible.” In a survey of ob-gyns who mostly were not abortion providers, more than 90 percent said the laws had prevented them or their colleagues from providing standard medical care. They described feeling “muzzled,” “handcuffed,” and “straitjacketed.” In another study, ob‑gyn residents reported feeling like “puppets,” a “hypocrite,” or a “robot of the State” under the abortion bans.
The doctors I spoke with had a wide range of personal views on abortion, but they uniformly agreed that the current restrictions are unworkable as medical care. They have watched patients grow incredulous, even angry, upon learning of their limited options. But mostly, their patients are devastated. The bans have added heartbreak on top of heartbreak, forcing women grieving the loss of an unborn child to endure delayed care and unnecessary injury. For some doctors, this has been too much to bear. They have fled to states without bans, leaving behind even fewer doctors to care for patients in places like Idaho.
Cooper had moved to Idaho with her husband and kids in 2018, drawn to the natural beauty and to the idea of practicing in a state underserved by doctors: It ranked 47th in the nation in ob-gyns per capita then, and she was one of just nine MFMs in the state. But in that summer of 2022, she began to fear that she could no longer do right by her patients. What she knew to be medically and ethically correct was now legally wrong. “I could not live with myself if something bad happened to somebody,” she told me. “But I also couldn’t live with myself if I went to prison and left my family and my small children behind.”
At first, Cooper and other doctors distressed by Idaho’s ban hoped that it could be amended. If only lawmakers knew what doctors knew, they figured, surely they would see how the rule was harming women who needed an abortion for medical reasons. Indeed, as doctors began speaking up, publicly in the media and privately with lawmakers, several Idaho legislators admitted that they had not understood the impact of the trigger ban. Some had never thought that Roe would be overturned. The ban wasn’t really meant to become law—except now it had.
Frankly, doctors had been unprepared too. None had shown up to testify before the trigger ban quietly passed in 2020; they just weren’t paying attention. (Almost all public opposition at the time came from anti-abortion activists, who thought the ban was still too lax because it had carve-outs for rape and incest.) Now doctors found themselves taking a crash course in state politics. Lauren Miller, another MFM at St. Luke’s, helped form a coalition to get the Idaho Medical Association to put its full lobbying power in the state legislature behind medical exceptions, both for lethal fetal anomalies and for a mother’s health. Cooper and a fellow ob-gyn, Amelia Huntsberger, met with the governor’s office in their roles as vice chair and chair, respectively, of the Idaho section of the American College of Obstetricians and Gynecologists.
The results of these efforts were disappointing. The lobbying culminated in a bill passed in March 2023 that offered doctors only marginally more breathing room than before. It changed the affirmative-defense statute into an actual exception to “prevent the death of the pregnant woman,” and it clarified that procedures to end ectopic and molar pregnancies—two types of nonviable abnormal pregnancies—were not to be considered abortions. But an exception for lethal fetal anomalies was a nonstarter. And an exception to prevent a life-threatening condition, rather than just preventing the death of the mother, was quashed after the chair of the Idaho Republican Party, Dorothy Moon, lambasted it in a public letter. The previous year, the Idaho GOP had adopted a platform declaring that “abortion is murder from the moment of fertilization” and rejected an exception for the life of the mother; it would reiterate that position in 2024.
Cooper and Huntsberger felt that their meeting with two of the governor’s staffers, in December 2022, had been futile as well. It had taken months to schedule a 20-minute conversation, and one of the staffers left in a hurry partway through. “There was a lot of acknowledgment of Yeah, this is really bad. The laws may not be written ideally,” Huntsberger told me. “There was also no action.”
After the meeting, the two women sat, dejected, in a rental car across from the state capitol, Huntsberger having traveled more than 400 miles from Sandpoint, Idaho, where she was a general ob-gyn in a rural hospital. That was when Cooper turned to her colleague and said she had something to confess: She had just been offered a job in Minnesota, a state where abortion is legal. And she was going to take it. She had reached a point where she just couldn’t do it anymore; she couldn’t keep turning away patients whom she had the skills to help, who needed her help. “There were so many drives home where I would cry,” she later told me.
Huntsberger was heartbroken to lose a colleague in the fight to change Idaho’s law. But she understood. She and her husband, an ER doctor, had also been talking about leaving. “It was once a month, and then once a week, and then every day,” she told me, “and then we weren’t sleeping.” They worried what might happen at work; they worried what it might mean for their three children. Was it time to give up on Idaho? She told Cooper that day, “Do what you need to do to care for yourself.” Cooper and her family moved to Minnesota that spring.
Huntsberger soon found a new job in Oregon, where abortion is also legal. A week later, her rural hospital announced the shutdown of its labor-and-delivery unit, citing Idaho’s “legal and political climate” as one reason. Staffing a 24/7 unit is expensive, and the ban had made recruiting ob-gyns to rural Idaho more difficult than ever. Even jobs in Boise that used to attract 15 or 20 applicants now had only a handful; some jobs have stayed vacant for two years. The three other ob-gyns at Huntsberger’s hospital all ended up finding new positions in states with fewer abortion restrictions.
During Huntsberger’s last month in Idaho, many of her patients scheduled their annual checkups early, so they could see her one last time to say goodbye. Over the years, she had gotten to know all about their children and puppies and gardens. These relationships were why she had become a small-town ob-gyn. She’d never thought she would leave.
Two other labor-and-delivery units have since closed in Idaho. The state lost more than 50 ob-gyns practicing obstetrics, about one-fifth of the total, in the first 15 months of the ban, according to an analysis by the Idaho Physician Well-Being Action Collaborative. Among MFMs, who deal with the most complicated pregnancies, the exodus has been even more dramatic. Of the nine practicing in 2022, Cooper was the first to leave, followed by Lauren Miller. A third MFM also left because of the ban. Then a fourth took a new job in Nevada and a fifth tried to retire, but their hospital was so short-staffed by then that they were both persuaded to stay at least part-time. That left only four other MFMs for the entire state.
After the Supreme Court overturned Roe v. Wade, St. Luke’s Boise Medical Center started airlifting pregnant women with certain complications to other states to receive treatment. (Bethany Mollenkof for The Atlantic)
The departure of so many physicians has strained Idaho’s medical system. After Cooper and others moved away, St. Luke’s had to rely on traveling doctors to fill the gaps; the hospital was eventually able to hire a few new MFMs, but the process took a long time. Meanwhile, ob-gyns—and family doctors, who deliver many of the babies in rural Idaho—had to manage more pregnancies, including high-risk ones, on their own. The overall lack of ob-gyns has also had implications for women who aren’t pregnant, and won’t be: Idaho is an attractive place to retire, and the state’s growing population of older women need gynecological care as they age into menopause and beyond.
Anne Feighner, an ob-gyn at St. Luke’s who has stayed in Boise for now, thinks all the time about her colleagues who have left. Every day, she told me in June, she drove by the house of her neighbor and fellow ob-gyn, Harmony Schroeder, who at the moment was packing up her home of 20 years for a job in Washington State. She, too, was leaving because of the abortion ban. Across the street is the pink house where Cooper used to live and where her daughters used to ride scooters out front.
“I still have a lot of guilt over leaving,” Cooper told me. She had made the decision in order to protect herself and her family. But what about her patients in Idaho, and her colleagues? By leaving, she had made a terrible situation for them even worse.
Sara Thomson works 12-hour shifts as an obstetrician at a Catholic hospital in Idaho; she is Catholic herself. Even before the abortion ban, her hospital terminated pregnancies only for medical reasons, per religious directive. “I had never considered myself a quote-unquote abortion provider, ” Thomson told me—at least not until certain kinds of care provided at her hospital became illegal under Idaho’s ban. It started to change how she thought of, as she put it, “the A-word.”
She told me about women who showed up at her hospital after their water had broken too early—well before the line of viability, around 22 weeks. Before then, a baby has no chance of survival outside the womb. This condition is known as previable PPROM, an acronym for “preterm premature rupture of membranes.”
In the very best scenario, a woman whose water breaks too early is able to stay pregnant for weeks or even months with enough amniotic fluid—the proverbial “water”—for her baby to develop normally. One doctor, Kim Cox, told me about a patient of his whose water broke at 16 weeks; she was able to stay pregnant until 34 weeks, and gave birth to a baby who fared well. Far more likely, though, a woman will naturally go into labor within a week of her water breaking, delivering a fetus that cannot survive. In the worst case, she could develop an infection before delivery. The infection might tip quickly into sepsis, which can cause the loss of limbs, fertility, and organ function—all on top of the tragedy of losing a baby.
In the very worst case, neither mother nor baby survives. In 2012, a 31-year-old woman in Ireland named Savita Halappanavar died after her water broke at 17 weeks. Doctors had refused to end her pregnancy, waiting for the fetus’s heartbeat to stop on its own. When it did, she went into labor, but by then, she had become infected. She died from sepsis three days later. Her death galvanized the abortion-rights movement in Ireland, and the country legalized the procedure in 2018.
Doctors in the United States now worry that abortion bans will cause entirely preventable deaths like Halappanavar’s; the possibility haunts Thomson. “We shouldn’t have to wait for a case like Savita’s in Idaho,” she said.
Previable PPROM is the complication that most troubles doctors practicing under strict abortion bans. These cases fall into the gap between what Idaho law currently allows (averting a mother’s death) and what many doctors want to be able to do (treat complications that could become deadly). The condition is not life-threatening right away, doctors told me, but they offered very different interpretations of when it becomes so—anywhere from the first signs of infection all the way to sepsis.
No surprise, then, that the trigger ban provoked immediate confusion among doctors over how and when to intervene in these cases. Initially, at least, they had more legal leeway to act quickly: The Biden administration had sued Idaho before the trigger ban went into effect, on the grounds that it conflicted with a Reagan-era federal law: the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires ERs to provide stabilizing treatment when a mother’s health, not just her life, is at risk. The Department of Health and Human Services interpreted “stabilizing treatment” to include emergency abortions, and a federal judge issued a partial injunction on Idaho’s ban, temporarily allowing such abortions to take place. But Idaho appealed the decision, and when the U.S. Supreme Court agreed to hear the case in January 2024, it stayed the injunction. With that, any protection that the federal law had granted Idaho doctors evaporated.
Sara Thomson, an obstetrician at a Catholic hospital in Idaho, says the state’s ban has changed how she thinks about “the A-word.” (Bethany Mollenkof for The Atlantic)
Thomson was still working under these severe restrictions when I met her in Boise this past June. She missed the days when her biggest problem at work was persuading her hospital to get a new ultrasound machine. A former military doctor, she struck me as soft-spoken but steely, like the most quietly formidable mom in your PTA. At one point, she pulled out a Trapper Keeper pocket folder of handwritten notes that she had taken after our first phone call.
The cases that most distressed her were ones of previable PPROM where the umbilical cord had prolapsed into the vagina, compressing the cord and exposing the baby and mother to infection. When this happens, Thomson said, a developing fetus cannot survive long: “The loss of the baby is sadly inevitable.”
Previously at her Catholic hospital, she would have offered to do what was best for the mother’s health: terminate the pregnancy before she became infected, so she could go home to recover. Now she told patients that they had no choice but to wait until they went into labor or became infected, or until the fetus’s heart stopped beating, slowly deprived of oxygen from its compressed umbilical cord, sometimes over the course of several days. Thomson did not know that a fetus could take so long to die this way—she was used to intervening much sooner. She found forcing her patients to wait like this “morally disgusting.”
“Every time I take care of a patient in this scenario, it makes me question why I’m staying here,” she told me. It ate at her to put her own legal interests before her patients’ health. She knew that if a zealous prosecutor decided she had acted too hastily, she could lose years of her career and her life defending herself, even if she were ultimately vindicated. But if she made a “self-protective” decision to delay care and a patient died, she wasn’t sure how she could go on. “From a moral perspective, that’s something that you won’t recover from as a doctor.”
At St. Luke’s, the largest hospital in Idaho, doctors started airlifting some patients with complications like previable PPROM out of state after the trigger ban took effect. Rather than delay care to comply with the law, they felt that the better—or, really, less bad—option was to get women care sooner by transferring them to Oregon, Washington, or Utah.
After the Supreme Court stayed the injunction allowing emergency abortions for a mother’s health, in January 2024, Idaho doctors became even more cautious about performing abortions, and the transfers picked up. Over the next three and a half months alone, St. Luke’s airlifted six pregnant women out of state. Smaller hospitals, too, transferred patients they would have previously treated.
One woman described fearing for her life as she was sent away from St. Luke’s last year, after losing a liter of blood when her placenta began detaching inside her. “I couldn’t comprehend,” she later told The New York Times. “I’m standing in front of doctors who know exactly what to do and how to help and they’re refusing to do it.” Another woman whose water broke early went into labor en route to Portland, her doctor told me, and delivered her fetus hundreds of miles from home. Her baby did not survive, and she was left to figure out how to get back to Idaho by herself—a medical transport is only a one-way ride. Another became infected and turned septic in the hours it took her to get to Salt Lake City. She had to go to the ICU, says Lauren Theilen, an MFM at the Utah hospital where she was taken. Other patients were sick when they left Idaho and even sicker when they arrived somewhere else.
Where exactly was that line between a patient who could be transferred versus one who needed care immediately, then and there? “I have sometimes wondered if I’m being selfish,” says Stacy Seyb, a longtime MFM at St. Luke’s, by putting patients through medical transfer to avoid legal sanction. But no doctor works alone in today’s hospitals. When one of the first legally ambiguous cases came up, Seyb saw the unease in the eyes of his team: the nurses, the techs, the anesthesiologists, the residents—all the people who normally assist in an emergency abortion. If he did something legally risky, they would also be exposed. Idaho’s law threatens to revoke the license of any health-care professional who assists in an abortion. He came to feel that there was no good option to protect both his team and his patients, but that an out-of-state transfer was often the least terrible one. In Portland or Seattle or Salt Lake City, health-care providers do not have to weigh their own interests against their patients’.
In April, when the Supreme Court heard the Idaho case, the media seized upon the dramatic image of women being airlifted out of state for emergency abortions. Justice Elena Kagan made a point of asking about it in oral arguments. In a press conference afterward, Idaho’s attorney general, Raúl Labrador, pushed back on the idea that airlifts were happening, citing unnamed doctors who said they didn’t know of any such instances. If women were being airlifted, he said, it was unnecessary, because emergency abortions were already allowed to save the life of the mother. “I would hate to think,” he added, “that St. Luke’s or any other hospital is trying to do something like this just to make a political statement.” (St. Luke’s had filed an amicus brief with the Court in support of the federal government.)
Labrador’s comments echoed accusations from national anti-abortion groups that doctors and others who support abortion rights are sowing confusion in order to “sabotage” the laws. When Moon, the chair of the Idaho Republican Party, had rallied lawmakers against any health exceptions back in 2023, she’d also evoked the specter of “doctors educated in some of the farthest Left academic institutions in our country.” (Neither Labrador nor Moon responded to my requests for an interview.)
It is true that doctors tend to support abortion access. But in Idaho, many of the ob-gyns critical of the ban are not at all pro-abortion. Maria Palmquist grew up speaking at Right to Life rallies, as the eldest of eight in a Catholic family. She still doesn’t believe in “abortion for birth control,” she told me, but medical school had opened her eyes to the tragic ways a pregnancy can go wrong. Lately, she’s been sending articles to family members, to show that some women with dangerous pregnancies need abortions “so they can have future children.”
Kim Cox, the doctor who told me about a patient who had a relatively healthy child after PPROM at 16 weeks, practices in heavily Mormon eastern Idaho. Cox said that “electively terminating” at any point in a pregnancy is “offensive to me and offensive to God.” But he also told me about a recent patient whose water had broken at 19 weeks and who wanted a termination that he was prepared to provide—until he realized it was legally dicey. He thought the dangers of such cases were serious enough that women should be able to decide how much risk they wanted to tolerate. Because, I ventured, they might already have a kid at home? “Or 10 kids at home.”
Anne Feighner, an ob-gyn at St. Luke’s, has decided to stay in Boise for now. (Bethany Mollenkof for The Atlantic)
Megan Kasper, an ob-gyn in Nampa, Idaho, who considers herself pro-life, told me she “never dreamed” that she would live to see Roe v. Wade overturned. But Idaho’s law went too far even for her. If doctors are forced to wait until death is a real possibility for an expecting mother, she said, “there’s going to be a certain number of those that you don’t pull back from the brink.” She thought the law needed an exception for the health of the mother.
In the two-plus years since the end of Roe, no doctor has yet been prosecuted in Idaho or any other state for performing an abortion—but who wants to test the law by being the first? Doctors are risk-averse. They’re rule followers, Kasper told me, a sentiment I heard over and over again: “I want to follow the rules.” “We tend to be rule followers.” “Very good rule followers.” Kasper said she thought that, in some cases, doctors have been more hesitant to treat patients or more willing to transfer them than was necessary. But if the law is not meant to be as restrictive as it reads to doctors, she said, then legislators should simply change it. “Put it in writing.” Make it clear.
She does wonder what it would mean to test the law. Kasper has a somewhat unusual background for a doctor. She was homeschooled, back when it was still illegal in some states, and her parents routinely sent money to legal-defense funds for other homeschoolers. “I grew up in a family whose values were It’s okay to take risks to do the right thing,” she told me. She still believes that. “There’s a little bit of my rebel side that’s like, Cool, Raúl Labrador, you want to throw me in jail? You have at it.” Prosecuting “one of the most pro-life OBs” would prove, wouldn’t it, just how extreme Idaho had become on abortion.
When I visited Boise in June, doctors were on edge; the Supreme Court’s decision on emergency abortions was expected at any moment. On my last day in town, the Court accidentally published the decision early: The case was going to be dismissed, meaning it would return to the lower court. The injunction allowing emergency abortions would, in the meantime, be reinstated.
As the details trickled out, I caught up with Thomson, who was, for the moment, relieved. She had an overnight shift that evening, and the tight coil of tension that had been lodged inside her loosened with the knowledge that EMTALA would soon be back in place, once the Court formally issued its decision. Doctors at St. Luke’s also felt they could stop airlifting patients out of state for emergency abortions.
But Thomson grew frustrated when she realized that this was far from the definitive ruling she had hoped for. The decision was really a nondecision. In dismissing the case, the Court did not actually resolve the conflict between federal and state law, though the Court signaled openness to hearing the case again after another lower-court decision. The dismissal also left in place a separate injunction, from a federal appeals court, that had blocked enforcement of EMTALA in Texas, meaning that women in a far larger and more populous state would still be denied emergency abortions. This case, too, has been appealed to the Supreme Court.
Moreover, the federal emergency-treatment law has teeth only if an administration chooses to enforce it, by fining hospitals or excluding them from Medicare and Medicaid when they fail to comply. The Biden administration has issued guidance that says it may sanction hospitals and doctors refusing to provide emergency abortion care, and as vice president, Kamala Harris has been a particularly vocal advocate for abortion access. A Trump administration could simply decide not to enforce the rule—a proposal that is outlined explicitly in Project 2025, the Heritage Foundation’s blueprint for a second Trump term. If the emergency-treatment law is a mere “Band-Aid,” as multiple doctors put it to me, it is one that can be easily torn off.
EMTALA is also limited in scope. It covers only patients who show up at an ER, and only those with emergency pregnancy complications. It would not apply to women in Idaho whose pregnancies are made more dangerous by a range of serious but not yet urgent conditions (to say nothing of the women who might want to end a pregnancy for any number of nonmedical reasons). It would not apply to the woman carrying triplets who, as an MFM recounted to me, wanted a reduction to twins because the third fetus had no skull and thus could not live. She had to go out of state to have the procedure—tantamount to an abortion for just one fetus—which made the pregnancy safer for her and the remaining babies. And it did not apply when Kayla Smith, already grieving for her unborn son, worried about preeclampsia. Her family ultimately left Idaho for Washington, so she could have another child in a safer state; her younger daughter was born in late 2023.
Smith has joined a lawsuit filed by the Center for Reproductive Rights challenging the limited scope of exceptions under Idaho’s ban. A group in Idaho is also planning a ballot initiative that will put the question of abortion to voters—but not until 2026. In the meantime, doctors still want Idaho to add medical exceptions to the law. After the disappointingly narrow exceptions the state legislature passed in 2023, it did nothing more in its 2024 session. A hearing that Thomson was slated to speak at this spring got canceled, last minute, by Republicans, who control the legislature.
Still, Thomson told me she was set on staying in Idaho. She and her husband had moved their family here 11 years ago because they wanted their four kids to “feel like they’re from somewhere.” Having grown up in a Navy family, she’d moved every few years during her own childhood before joining the military for medical school and continuing to move every few years as a military doctor. When her son was just 14 months old, she deployed to Iraq. She got her job in Idaho after that. When she and her husband bought their house, she told him this was the house she planned to live in for the rest of her life.
In the past two years, she’d seriously wavered on that decision for the first time. The moral distress of practicing under the ban had sent her to see a counselor. “I was in a war zone,” she told me, “and I didn’t see a counselor.” This past fall, she came up with a backup plan: If she had to, she could stop practicing in Idaho and become a traveling doctor, seeing patients in other states.
But then she thought about all the women in Idaho who couldn’t afford to leave the state for care. And she thought of her kids, especially her three girls, who would soon no longer be girls. The eldest is 20, the same age as a patient whose baby she had recently delivered. “This could be my daughter,” Thomson thought. If everyone like her left, she wondered, who would take care of her daughters?
This article appears in the October 2024 print edition with the headline “What Abortion Bans Do to Doctors.”
About the Author
Sarah Zhang is a staff writer at The Atlantic.
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