“I spent years pursuing advanced training in family planning and reproductive health, which included learning to provide abortions because of my passion for reproductive justice. I practice in a state where it is likely that most of the clinics will be forced to stop providing abortions in the near future. I can’t travel to another state to provide care; should I just stop providing?” — a Midwestern abortion provider

As 2019 begins, abortion providers face restrictions that block patients’ access to clinic-based care: bans on abortion coverage in insurance programs such as Medicaid; logistical barriers such as waiting periods and unnecessary building modifications; and relentless threats and harassment. A more conservative U.S. Supreme Court means that additional barriers are inevitable and, in some states, could ultimately lead to elimination of abortion services, with disparate impact among the low-income, youth, people of color, and rural residents.

In the most restrictive environments, providers face a complicated ethical challenge. Many early- and mid-career clinicians invested time and resources to become experts in abortion care, understanding the critical importance of abortion access to their patients’ health, agency, and self-determination. Yet many currently work in states that will attempt to ban legal abortion in the near future.

And it is not just clinicians who will need to make difficult moral decisions. There is increased awareness that the abortion pill can be and is being used safely outside of a clinical setting. For some, the practice of self-managing an abortion expands the definition of “provider” to include community activists and supporters of those who choose to self-manage their abortion. Out of a commitment to both giving people options and recognizing that, for some, care with a clinician is already not an option, many others must also consider their role in the shifting abortion landscape.

These abortion providers, both clinicians and nonclinicians, face draconian choices. While proactive legislative action to protect access to abortion care will likely result in expanded abortion services in some states, these will primarily be on the West and East Coasts, where abortion care is already easier to access, rather than in the South and Midwest, where access is more restricted. Many clinical providers currently care for patients who simply cannot travel to a state with legal services, which may be hundreds or even thousands of miles away. While some of these physicians may be able to travel to provide care in other states, traveling long distances to provide in less restrictive environments may not be an option for many skilled abortion providers.

Additionally, many abortion providers feel a commitment to their own communities. As one family doctor told us, “I provide the full scope of health care to my patients, including reproductive health and abortion care. I practice in a state that has already passed numerous restrictions on access to abortion and it is likely that they will ban abortion next year. How can I refuse to take care of my patients who need this service when I provide care for them in every other way?”

The intersection of conscience and the law in the context of abortion provision is not new. In her 1995 book, scholar Carole Joffe coined the term “doctors of conscience” to highlight the skilled physicians who provided abortions before Roe v. Wade. Similarly, in his 2017 book Life’s Work, Willie Parker discussed his experiences growing up as a self-described evangelical child in the South and how, after practicing as an OB-GYN for many years, his thinking evolved to include a moral imperative to provide abortions for his patients in highly restricted environments. These publications document physicians’ internal conversations while deciding to provide abortion care in restricted or dangerous environments.

Before abortion became legal in 1973, many people were involved in providing support, referrals, and care to those with who needed abortions. Among the best known are the Clergy Consultation Service, a group of religious leaders who made referrals to safe services, and the Jane collective, a Chicago group of women’s rights activists who helped women find doctors to safely perform abortions. But many communities had anonymous networks of people who knew where safe providers were and helped people get the care that they needed. Both these networks and the doctors who provided abortion care pre-Roe faced legal risks.

In today’s political climate, if states move to ban abortion, clinician abortion providers will need to think carefully about whether and how they will share information about abortion pills. If the legal provision of abortion is banned in the majority of cases, or is unavailable in many states, clinician providers of conscience will have to grapple with ways to support patients, friends and families who are seeking abortion care.

Those who support people self-managing their abortions already face legal risk. Unfortunately, while abortion is still legal in every state, helping someone to use abortion pills outside of the health-care system can be legally risky and, in some cases, the practice (or even suspicion of their use) has been criminalized. For example, a Pennsylvania mother who obtained abortion pills online for her daughter was arrested and originally faced a potential sentence of up to seven years in prison and a $15,000 fine. According to the SIA Legal Team, there have been 21 prosecutions of people using abortion pills on their own. Communities of color, low-income people, and young folks often bear the brunt of this increased surveillance, prosecution, and punishment.

Given the legal risk, providers with and without clinical licenses are wrestling with their conscience. Those who support health access, reproductive justice and human rights—and who encounter people with unwanted pregnancies who cannot or choose not to travel to a clinic—are checking their internal compasses. The knowledge about how to use the pills and how to access them is held by many different providers, licensed and in the community, who can offer expertise. For each of these providers, the decision about whether to leave those with an unwanted pregnancy to find their own way or to offer assistance brings us face to face with this moral challenge.