Caught in the Crossfire: How State Laws and Federal Mandates Clash in Emergency Care
In the complex landscape of American healthcare post-Dobbs, emergency rooms have become a critical battleground where a physician’s federal duty to save a life clashes directly with restrictive state laws. This high-stakes conflict was the focus of "Emergency Care at a Crossroads: Shield Laws vs. EMTALA," a pivotal session at the CTeL Digital Health Summit on Capitol Hill. A panel of medical and legal experts used a powerful, real-world clinical scenario to dissect the untenable position providers are in, revealing a system fraught with legal ambiguity, professional risk, and life-threatening consequences for patients.
As of June 2024, 14 states enforce a near-total ban on abortion, while several others have restrictions based on gestational age, creating a confusing "patchwork of state laws" that providers must navigate in real-time (Guttmacher Institute, 2024). This session highlighted how that patchwork creates a direct conflict with federal law, leaving physicians and patients caught in the crossfire.
The Flashpoint: A Real-World Emergency Room Scenario
To ground the discussion, Dr. Nate DeNicola, Chair of the Telehealth Committee for the American College of Obstetrics and Gynecologists (ACOG), presented a common, life-threatening emergency.
A 28-year-old woman, pregnant for the second time but with no children, arrives at the emergency department with acute abdominal pain and vaginal bleeding. Her vital signs are mostly stable, but her heart rate is starting to trend high—a subtle but ominous sign in a young, healthy patient who can "tolerate a fair amount of distress before it really shows signs of emergency".
An ultrasound delivers a clear diagnosis: a right tubal ectopic pregnancy with cardiac activity present. The pregnancy is in her fallopian tube, not the uterus, making it completely non-viable and a ticking time bomb that, if it ruptures, could cause a catastrophic internal hemorrhage.
The Medical Reality of an Ectopic Pregnancy
Ectopic pregnancies occur in an estimated 1-2% of all pregnancies and remain a leading cause of maternal mortality in the first trimester (Winderman & Shamshirsaz, 2024). The standard of care is immediate treatment to remove the non-viable pregnancy before it ruptures.
However, in this new legal environment, the presence of cardiac activity becomes a "problem". Vague language in state laws creates a chilling effect. As Dr. DeNicola explained, providers are caught between their clinical judgment, which screams for immediate intervention, and laws that may require them to wait until the patient is at "imminent risk for death". He powerfully stated, "you wouldn't want to get anywhere close to that... point of death but... the law is more or less requiring you to go there".
Untangling the Legal Knot: EMTALA, Dobbs, and Shield Laws
The ectopic pregnancy scenario perfectly illustrates the legal and ethical chaos facing clinicians. It forces a direct confrontation between federal mandates, state-level restrictions, and emerging legal protections.
What is EMTALA?
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, is a federal law requiring Medicare-funded hospitals to provide all patients with a medical screening examination and necessary stabilizing treatment for an emergency medical condition, regardless of their ability to pay (U.S. Centers for Medicare & Medicaid Services, n.d.). The Biden administration had issued guidance clarifying that stabilizing treatment includes abortion when necessary. However, the panel noted this guidance was recently rescinded, a move that Rebecca Simone, a partner at Nixon Peabody, argued "only added more uncertainty to providers". This leaves the interpretation of a hospital's duty under EMTALA in a state of flux.
The "Chilling Effect" of State Laws
In the wake of the Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade, states were given the authority to regulate or ban abortion. The result is a confusing legal maze. Maggie Martin, Chief Legal Officer for the Oklahoma Hospital Association, described how Oklahoma has a 1921 law on the books, alongside newer trigger laws that were since invalidated by the state's Supreme Court. Yet, "if you pull up oklahoma's legal resource online those laws are still there... so it's really complicated and confusing for providers".
This legal ambiguity forces physicians to practice "defensive medicine," delaying care while they seek administrative or legal approval, all while the patient's risk of hemorrhage, infection, loss of fertility, or even death steadily increases.
Are Shield Laws the Answer?
In response, states with abortion access have enacted "shield laws." Dana Northcraft, Founder of RHITES, explained these laws are designed to protect clinicians who provide reproductive care—often via telehealth by mailing medication to patients in restrictive states. These laws can prevent a provider from being extradited to face charges in another state.
However, their protection is limited. Rebecca Simone highlighted a critical vulnerability: a shield law "can't protect the physician's license". A state like Texas could still revoke the Texas license of a provider practicing from New York, creating a "domino effect" that jeopardizes their licenses in other states.
The Human Cost: Physician Fears and Career Implications
The legal risks have profound, career-altering consequences, particularly for the growing telehealth workforce. Dr. DeNicola noted that most telehealth platforms require a physician to hold licenses in at least three states. The fear of losing a license in one state can effectively end a provider's ability to practice virtually.
Beyond professional risk, this crisis is taking a psychological toll. Studies have shown that physicians denied abortion care experience moral injury, burnout, and negative mental health outcomes (Harris et al., 2023). They are forced to reconcile their ethical and professional obligations with the threat of civil and criminal penalties, including the loss of their license and livelihood.
Conclusion: A Call for Clarity in a Time of Crisis
The CTeL Summit session painted a stark picture of a healthcare system in turmoil. The conflict between a federal duty to provide emergency care and a fractured landscape of state laws has placed providers in an impossible position. This legal ambiguity is not a theoretical problem—it is actively delaying life-saving medical care, harming patients, and threatening the careers of the very professionals tasked with protecting public health. Without clear, unambiguous legal and federal guidance that prioritizes patient life over political ideology, emergency rooms will remain a legal minefield, with both patients and providers bearing the devastating cost.
References
Guttmacher Institute. (2024). State responses to the overturning of Roe v. Wade. Guttmacher Institute. https://www.guttmacher.org/state-policy/state-responses-overturning-roe-v-wade
Harris, L. H., Morris, E., & Johnston, A. (2023). An untenable choice — Restricting abortion at the expense of high-quality care. The New England Journal of Medicine, 388(18), 1637–1640. https://doi.org/10.1056/NEJMp2301931
U.S. Centers for Medicare & Medicaid Services. (n.d.). Emergency Medical Treatment & Labor Act (EMTALA). CMS.gov. Retrieved June 12, 2024, from https://www.cms.gov/regulations-and-guidance/legislation/emergency-medical-treatment-labor-act
Winderman, K., & Shamshirsaz, A. A. (2024). Ectopic Pregnancy. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441922/