Kate Cox, Damla Karsan, and Conscience in Post-Dobbs Medicine: Refusal, Provision, and Professional Integrity

“I don’t want to wait until I’m bleeding” — a bioethics case study

Author

Brendan Shea, PhD

Published

August 3, 2026

  • Who: Kate Cox, a thirty-one-year-old mother of two from suburban Dallas; Dr. Damla Karsan, her OB-GYN; Ken Paxton, the Attorney General of Texas.
  • What: In December 2023, Cox became the first pregnant woman since Roe v. Wade was overturned to sue in open court for the right to an abortion. A trial judge granted her request. Within hours, Paxton wrote to three Texas hospitals warning that anyone performing the procedure could still face prosecution. The Texas Supreme Court ruled against her. Karsan, the named physician-plaintiff, would have faced up to life in prison if she had gone ahead.
  • Where / When: Travis County and the Texas Supreme Court, December 2023. The broader question is national and ongoing.
  • Why it matters: The case forces a hard question about conscientious refusal and its mirror image, conscientious provision. When a clinician’s medical and moral judgment conflicts with the law of the state in which she practices, what does professional integrity require? Dobbs did not invent that question, but it inverted it.
  • Pair with: Abortion (The Law and Reproductive Rights)

The Case

In August 2023, Kate Cox saw a positive home pregnancy test and ran into the playroom where her husband Justin was wrestling on the floor with their two toddlers. The Coxes had always wanted a large family — three or four children. They lived in a Dallas-area bungalow with two child-sized lawn chairs in the backyard, two sippy cups in the sink, and an Olaf the snowman in the living room. Neither Kate nor Justin was particularly political. When the Supreme Court issued its 2022 decision in Dobbs v. Jackson Women’s Health Organization, returning the regulation of abortion to the states, the news barely registered with them. Texas’s strict ban, they assumed, would have medical exceptions that would cover anything serious.

At eighteen weeks, Cox’s obstetrician called while she was driving and asked her to pull over. Early screening tests suggested Trisomy 18. This is a chromosomal condition in which a third copy of chromosome 18 produces severe developmental abnormalities. Over the next several weeks of ultrasounds and maternal-fetal-medicine consultations, the diagnosis was confirmed. The fetus had malformations of:

  • The brain.
  • The spine.
  • The neural tube.
  • The heart.
  • The skull.
  • The limbs.

“Each time we had an ultrasound, there was more bad news,” Cox later told Time. The expected outcome was either death in utero or, if the baby survived birth, hospice care and death within hours or days.

Trisomy 18 (Edwards syndrome). Trisomy 18 occurs when a fetus has three copies of chromosome 18 instead of two. Roughly half of fetuses with the condition are stillborn. Among live births, most die within the first week. A small minority of children with mosaic forms live longer, sometimes into adolescence, generally with profound disabilities. There is no curative treatment. Standard care is “comfort care” — keeping the infant warm and free of pain — rather than aggressive intervention.

The diagnosis also created acute risks for Cox herself. Her two previous deliveries had been by Cesarean section. A third C-section, or an induced labor at term following a fetal demise, carried elevated risks:

  • Uterine rupture.
  • Hemorrhage.
  • Hysterectomy — meaning she might never be able to bear another child.

She had already been to the emergency room several times for cramping and elevated vital signs. Her physician, Dr. Damla Karsan, judged that termination of the pregnancy was the medically indicated course.

Texas law at the time forbade nearly all abortions. The statutes permitted a narrow exception when, in the “reasonable medical judgment” of the attending physician, the pregnancy placed the woman at risk of “a serious risk of substantial impairment of a major bodily function.” The exception was poorly defined. Karsan believed Cox qualified. She also believed that if she was wrong — or if a prosecutor disagreed — she could face severe penalties:

  • Loss of her medical license.
  • Fines of at least $100,000 per violation.
  • Up to ninety-nine years in prison.

The Texas medical exception. Texas’s overlapping abortion statutes (the Human Life Protection Act and Senate Bill 8) permit abortion only when, in the physician’s “reasonable medical judgment,” the patient faces a “life-threatening physical condition” or “a serious risk of substantial impairment of a major bodily function.” The statutes:

  • Do not list qualifying diagnoses.
  • Do not provide a pre-clearance mechanism.
  • Require the physician to make the call alone.

A prosecutor may second-guess that call afterward. The physician bears the burden of proving the judgment was reasonable.

On December 5, 2023, with Cox now twenty weeks pregnant, the Center for Reproductive Rights filed Cox v. Texas on behalf of Cox, her husband, and Dr. Karsan. They asked a Travis County district judge for a temporary restraining order — a court order blocking the state from prosecuting Karsan or her hospital if she performed the abortion. Two days later, Judge Maya Guerra Gamble granted it. From the bench, she said: “The idea that Ms. Cox wants desperately to be a parent, and this law might actually cause her to lose that ability, is shocking and would be a genuine miscarriage of justice.”

Within hours, the Texas Attorney General, Ken Paxton, sent letters to three Houston-area hospitals where Karsan held privileges. The letters made three points:

  • The trial court’s order did not insulate anyone from civil liability under SB 8, which authorizes private lawsuits for at least $100,000 per abortion.
  • The order also did not insulate anyone from criminal prosecution after the order was lifted, which Paxton was actively seeking.
  • The hospitals should consider their own exposure.

Paxton then petitioned the Texas Supreme Court for an emergency stay.

By the time the Texas Supreme Court ruled, on December 11, 2023, Kate Cox had already left the state. The court held that Karsan had not met the statutory standard. Her sworn declaration that Cox faced a serious risk of impairment of a major bodily function was, in the court’s view, an opinion — not the demonstration that the statute required. “Only a doctor can exercise ‘reasonable medical judgment’ to decide whether a pregnant woman ‘has a life-threatening physical condition,’” the court wrote. “A woman who meets the medical-necessity exception need not seek a court order. … But the law does not permit a court to grant a pre-authorization” (Supreme Court of Texas 2023). Cox obtained the abortion in New Mexico.

What follows turns on the physician rather than the patient. Damla Karsan had not been compelled to take Cox’s case. She could have referred Cox out of state — many Texas OB-GYNs did — and avoided the criminal exposure entirely. She chose instead to do three risky things:

  1. Put her name on the lawsuit.
  2. Swear under oath that the medical-exception standard was met.
  3. Publicly disagree with a state law she had to live under.

She was not refusing to participate in a procedure she found morally objectionable. She was insisting on participating in a procedure she believed she was morally obligated to provide. The question her case raises is whether the profession of medicine has room for that kind of conscience too.

The Argument Karsan Started

The classical debate about conscience in medicine was built around the figure of the refuser. Three examples:

  • A Catholic pharmacist who would not dispense Plan B.
  • An OB-GYN who would not perform elective abortions.
  • A nurse who would not assist with physician-assisted dying.

The debate asked when, if ever, the law should protect such refusals. Karsan’s case raises a stranger version of the question: when, if ever, should the law protect provision? The philosophical materials built for the first question travel awkwardly into the second.

The integrity argument for conscientious refusal

The foundational defense of conscience clauses, given its fullest form by the bioethicist Mark Wicclair, holds that being asked to perform an act one believes to be deeply wrong is being asked to damage one’s own moral integrity. Moral integrity is itself a basic human good that medicine should respect (Wicclair 2000). A pharmacist who believes emergency contraception ends a human life is not, on this view, merely expressing a preference. She is being asked to act against her core identity.

The Integrity Argument for Refusal

  1. Moral integrity — the consistency between a person’s deeply held moral commitments and her actions — is a basic component of human well-being.
  2. Compelling a clinician to perform an act she sincerely believes to be seriously wrong damages that integrity.
  3. The state and the profession should not damage a clinician’s integrity unless doing so is necessary to prevent serious harm to others.
  4. Therefore, clinicians have a defeasible right to refuse to participate in legal procedures they find morally abhorrent.

The disputed premise is the third, which depends on what “serious harm to others” amounts to. If a refusal merely inconveniences a patient who has other options, the right to refuse holds. If a refusal denies a patient timely access to legal, indicated care — particularly in a region with no alternative provider — the right runs out. That is where the principal reply lives.

Stahl and Emanuel’s reply: physicians are not conscripts

The bioethicists Ronit Stahl and Ezekiel Emanuel argue that the comparison to military conscientious objection breaks down at the point of voluntariness. Soldiers are drafted. Physicians are licensed. Medicine is a profession one enters voluntarily. The entry deal goes like this: a clinician accepts fiduciary obligations to patients in exchange for state-granted privileges. To accept the license and then refuse the obligations is to want the benefit without the burden (Stahl and Emanuel 2017).

The Stahl-Emanuel Reply

  1. Medicine is a public profession whose members voluntarily accept fiduciary obligations to patients in exchange for state-granted privileges.
  2. Those obligations include the duty to provide legal, professionally indicated care that the patient requests, regardless of the clinician’s personal moral views.
  3. Clinicians who cannot in conscience meet those obligations should leave the relevant specialty, not import their personal morality into the patient encounter.
  4. Therefore, conscience clauses that exempt clinicians from providing legal, indicated care are illegitimate.

The soft spot here is the third premise. It works smoothly for a young medical student choosing a specialty. It works clumsily for a thirty-year veteran of obstetrics whose state legislature changes the rules underneath her. The argument also threatens to swallow more than its authors may have intended. The same logic would seem to compel participation in:

  • MAID (medical aid in dying).
  • Capital punishment medical clearances.
  • Any other lawful practice the state designates as professionally indicated.

Brock’s counter-reply: the conventional compromise

The philosopher Dan Brock proposed, well before Dobbs, what he called the “conventional compromise.” A clinician may refuse personally, but must meet three conditions:

  1. Disclose the refusal in advance.
  2. Refer the patient to another qualified provider.
  3. Not abandon the patient mid-care.

The refusing pharmacist hands the prescription to a colleague. The refusing OB-GYN provides the name of a clinic across town. Brock then anticipated and rejected the “complicity” objection — that referring is itself moral participation — by arguing that the moral weight of a referral is too thin to constitute the kind of agency that integrity protects (Brock 2008).

The conventional compromise was, for two decades, the working consensus of American medical ethics. It held because it assumed a background condition: that a willing provider was somewhere. In a country where abortion was legal everywhere and contraception was available at any pharmacy, the refusing clinician could always point to a door. Dobbs removed the assumption. In a state with no in-state legal provider, the obligation to “refer” collapses into a duty to direct the patient to break the law, leave the state, or wait.

The reframing: conscientious provision

Here the question shifts from refusal to its mirror image, provision. The classical defenders of conscientious refusal — Wicclair, Brock, even the dissenters Stahl and Emanuel — were arguing about a different setting. In their setting, the contested care was legal, and the contested clinician was the one declining to provide it. Lisa Harris and her co-authors at the Hastings Center Report describe the post-Dobbs clinician as living under a “sword of Damocles.” The contested care is now criminalized. The contested clinician is the one who provides it (Harris et al. 2024). The integrity argument has not gone away. It has changed direction.

The strongest version of the inversion comes from Isa Ryan, Ashish Premkumar, and Katie Watson in the AMA Journal of Ethics (Ryan et al. 2022). They draw a distinction the classical literature mostly elides:

  • Personal morality — the convictions one holds as a private individual.
  • Role morality — the ethical obligations one takes on by accepting a professional role.

The pre-Dobbs conscience clause is a personal-morality protection. The pharmacist’s private view of emergency contraception is shielded from the role’s demands. Ryan and her co-authors argue that the post-Dobbs landscape now demands the role-morality analogue. Codes of professional ethics should protect clinicians who provide medically indicated care that their state has criminalized. That provision is what the role itself requires. In their words: “Codes of medical ethics should be updated to state that, where abortion is illegal, breaking the law to provide care for reasons of conscience is not unethical.”

The Argument for Conscientious Provision

  1. Personal morality grounds conscientious refusal: a clinician may decline care she sincerely believes is wrong, on the same integrity grounds the refusal tradition recognizes.
  2. Role morality grounds professional obligation: by accepting the role of obstetrician or emergency physician, a clinician takes on duties to her patients that are not reducible to her private moral views.
  3. When state law criminalizes care that role morality requires, role-based conscience generates the same kind of integrity claim as personal-based conscience does — pointed toward provision rather than refusal.
  4. Therefore, the profession should protect conscientious provision on par with conscientious refusal, including, where necessary, by recognizing that providing standard-of-care medicine in defiance of an unjust law is itself an ethical act.

A defender of the asymmetry will press on the third premise. Refusal, the objection runs, is a negative claim — leave me out of it — that can be honored without anyone breaking the law. Provision is a positive claim that, where care is illegal, requires law-breaking. That is too much to ask the profession to underwrite. Ryan and her co-authors anticipate the objection. They argue that the asymmetry is itself an artifact of the prior legal regime, not a deep feature of conscience. What the profession underwrites is not law-breaking as such. It is the role’s commitment to patient welfare when the law fails it.

One case from outside the United States shows what is at stake. In October 2012, Savita Halappanavar, a thirty-one-year-old dentist living in Galway, was admitted to University Hospital Galway at seventeen weeks of pregnancy with an inevitable miscarriage. Her membranes had ruptured. The fetus was not viable. Irish law at the time prohibited abortion unless the woman’s life was at risk. The medical team waited several days for the fetal heartbeat to stop on its own. Halappanavar developed sepsis. By the time the pregnancy was terminated, the infection was uncontrollable. She died on October 28, 2012. The case galvanized Irish public opinion and led to the 2018 referendum that repealed the constitutional ban. Damla Karsan, in Houston in December 2023, was practicing in a legal environment that posed the same demand Halappanavar’s physicians had faced in 2012: to wait until a patient was sick enough to qualify.

The move that hasn’t ended

What follows from the inversion is structural, not symmetrical. Pre-Dobbs conscience clauses protected individual clinicians from the demands of the profession. The new conscience question runs through institutions and jurisdictions — entities that classical bioethics did not theorize as conscience-bearers at all. Three current pressure points show the shape of the problem:

  • Catholic hospital systems. Roughly one in six U.S. acute-care hospital beds is now in a Catholic system, and in some states the share is much higher. Catholic hospital directives prohibit sterilization, most forms of contraception, and abortion even in cases like Cox’s. Clinicians who work in those systems are bound by institutional conscience whether or not they share its commitments.
  • State shield laws. A growing patchwork of state shield laws — New York, Massachusetts, California, and others — now protect clinicians who mail mifepristone into states that ban it. This poses the constitutional question of whether a state may reach across its borders to prosecute a doctor whose conduct is legal where she stands. It is no longer hypothetical: Dr. Margaret Carpenter, a New York physician, has been criminally indicted in Louisiana and hit with a six-figure civil judgment in Texas, while New York has refused extradition and, in October 2025, declined to enforce the Texas judgment. One physician is simultaneously a felon, a debtor, and a protected practitioner, depending on which state you ask.
  • EMTALA conflicts. The federal Emergency Medical Treatment and Labor Act, which requires hospitals to stabilize patients in emergencies, came into direct conflict with state bans — and the conflict was never resolved. The Supreme Court dismissed Moyle v. United States as improvidently granted in 2024, the federal government dropped the Idaho suit in March 2025, and HHS rescinded its EMTALA emergency-abortion guidance in May 2025. The question was not answered so much as withdrawn, leaving clinicians in ban states with less federal clarity than they had in 2023.

These are not problems Wicclair or Brock anticipated. Their framework was built for the individual clinician with a private moral commitment. It is now being asked to mediate between four very different parties:

  • State legislatures.
  • Federal statutes.
  • Religious health systems.
  • Clinicians whose oaths now conflict with their licenses.

The question that remains is no longer whether conscience matters in medicine. It is whose conscience the law should recognize when the conscience of a state, a hospital, and a physician all point in different directions.

Discussion Questions

  1. Write out the Integrity Argument for Refusal and the Argument for Conscientious Provision in your own words — premises first, then the conclusion. The two arguments share one premise. Identify it. Then say whether the post-Dobbs legal environment changes which side that shared premise now supports.

  2. Stahl and Emanuel argue that clinicians who cannot meet a profession’s obligations should leave the specialty. Does that response work for Damla Karsan — who completed her training years before Texas changed its abortion law? Give the strongest version of Stahl and Emanuel’s reply to Karsan. Then give the strongest version of Karsan’s reply back.

  3. Brock’s conventional compromise says a clinician may refuse to provide care she objects to, as long as she refers the patient to someone who will. Brock’s rule depends on one assumption about the world that has to be true for the rule to work. What is that assumption? Describe a present-day case where the assumption no longer holds. Does the compromise still work in some modified form, or does it have to be abandoned?

  4. You are a labor-and-delivery nurse in a Catholic hospital in a state with a near-total abortion ban. An ER patient is admitted at seventeen weeks. Her membranes have ruptured. The fetus still has a heartbeat, likely to stop on its own in a day or two. Her white-blood-cell count is rising — an early sign of infection. Hospital policy and state law both require waiting. Your professional judgment tells you the patient is heading toward sepsis. What do you do? Which argument from the case is doing the work in your answer?

  5. Catholic hospital systems describe themselves as institutions with a conscience. Many state legislatures describe their abortion statutes as expressions of the moral conscience of the people who voted for them. The integrity argument was built for individual people with consciences. Does it carry over to an institution or to a state? Pick one and defend your answer.

Further Reading

  • Charlotte Alter, “How Kate Cox Became a Reluctant Face of the Abortion-Rights Movement,” Time, March 27, 2024 — the long-form profile.
  • Lisa H. Harris et al., “Beneath the Sword of Damocles: Moral Obligations of Physicians in a Post-Dobbs Landscape,” Hastings Center Report, May–June 2024.
  • In re State of Texas, 23-0994 (Texas Supreme Court, Dec. 11, 2023) — the per curiam ruling, brief and worth reading in the original.
  • Kitty Holland, Savita: The Tragedy That Shook a Nation (Transworld Ireland, 2013) — the investigative account of the Halappanavar case.
  • Ronit Y. Stahl and Ezekiel J. Emanuel, “Physicians, Not Conscripts,” New England Journal of Medicine, April 6, 2017.

References

Brock, Dan W. 2008. “Conscientious Refusal by Physicians and Pharmacists: Who Is Obligated to Do What, and Why?” Theoretical Medicine and Bioethics 29 (3): 187–200. https://doi.org/10.1007/s11017-008-9076-y.
Harris, Lisa H., Daniel Grossman, et al. 2024. “Beneath the Sword of Damocles: Moral Obligations of Physicians in a Post-Dobbs Landscape.” Hastings Center Report 54 (3): 15–25. https://doi.org/10.1002/hast.1583.
Ryan, Isa, Ashish Premkumar, and Katie Watson. 2022. “Why the Post-Roe Era Requires Protecting Conscientious Provision as We Protect Conscientious Refusal in Health Care.” AMA Journal of Ethics 24 (9): E906–912. https://doi.org/10.1001/amajethics.2022.906.
Stahl, Ronit Y., and Ezekiel J. Emanuel. 2017. “Physicians, Not Conscripts — Conscientious Objection in Health Care.” New England Journal of Medicine 376 (14): 1380–85. https://doi.org/10.1056/NEJMsb1612472.
Supreme Court of Texas. 2023. In re State of Texas, No. 23-0994 (per curiam). Supreme Court of Texas. https://www.txcourts.gov/supreme/.
Wicclair, Mark R. 2000. “Conscientious Objection in Medicine.” Bioethics 14 (3): 205–27. https://doi.org/10.1111/1467-8519.00191.