The Case

Doyley had previously undergone three difficult cesarean sections, each complicated by excessive bleeding and post operative complications. For this fourth delivery, she requested a vaginal birth. The American College of Obstetrics and Gynecology guidelines advise against vaginal birth after more than two prior C-sections, and in states like Florida with fetal personhood laws, physicians who deviate from those guidelines face significant medical liability. Caught between that liability and the patient's wishes, her physicians sought a court order to compel a C-section.

The morbidity risk associated with vaginal birth after multiple C-sections is real, but as a doula, Doyley was familiar with the data and her complicated surgical history. She was not making an uninformed decision but one that should be decided between a patient and her doctor. Instead, it was decided in a virtual courtroom as she lay in labor.

Doyley ultimately had a C-section. She and her baby are healthy, but this case raises a question our society must grapple with: Should a judge decide a birth plan for a pregnant patient?

This case highlights how the Dobbs ruling on abortion is metastasizing into unrelated domains of healthcare. When the Supreme Court returned abortion regulation to the states in 2022, unintended or not, it set in motion a series of fetal personhood laws and liability frameworks that now govern a much broader range of pregnancy care decisions. Physicians in affected states report uncertainty about where clinical discretion ends and legal liability begins, and this indecision has a direct effect on patients.

The Reality of Racial Discordance

During the proceeding, Doyley, who is Black, raised concerns about her all-white care team and judicial panel. She asked whether she could see a Black physician. The concern was dismissed.

It should not have been.

Doyley's request was informed by data. Research consistently links patient-provider racial concordance with improved communication, trust and health outcomes. Black women in the United States are three times more likely than white women to die from pregnancy-related causes. This disparity persists across income and education levels. Black women are also approximately 20% more likely than white women to undergo cesarean sections, even in low-risk pregnancies. Accounts from Black women who have experienced poor maternal outcomes consistently describe feeling dismissed and unheard by their care teams.

"My first reaction to her story is that she wanted to be seen and heard," said Dr. Lisa McLeod, a Black board-certified OB/GYN specializing in high-risk pregnancies. "She wanted someone to listen to her concerns." The growing demand for doulas is a response to this concern. When patients do not feel seen or heard by their clinical teams, they seek advocates.

The court’s failure to recognize the documented relationship between patient-provider concordance and health outcomes underscores why workforce diversity in medicine warrants attention and investment.

The Erosion of Autonomy

This case also raises questions that extend beyond reproductive rights. In medicine, a competent adult has the legal right to refuse treatment even when a physician believes the treatment is necessary or life saving. This principle applies to a patient with terminal cancer who declines chemotherapy, a Jehovah’s Witness who refuses a blood transfusion for religious reasons or an ICU patient who declines resuscitation or heroic measures. Treatment refusal does not require a physician’s approval or agreement.

When physicians face liability for honoring a patient’s care refusal, the dynamic of the clinical relationship may shift, particularly if communication is poor and trust is not fully established. Physicians and patients might together discuss the clinical history, data and preferences and arrive at a shared decision, but if that decision falls outside black-and-white guidelines, liability exposure can override clinical judgment and when it does, the courts can step in. In this situation the physician becomes less advocate and more adversary due to the interpretation of the law.

Dr. Carrie Carda, a board-certified OB/GYN in Missouri who manages high-risk pregnancies, described the bind plainly. "ACOG does not support vaginal birth after three cesareans, so a doctor would be putting her career at risk because of medical liability." The Dobbs ruling has cultivated these clinical stalemates and this legal environment in maternal healthcare. Now that we are here, is this what we want? is it what we intended?

A Path Toward Better Outcomes Through Trust

This case is instructive for physicians, healthcare administrators, politicians and legal scholars and patients. To avoid similar clinical ordeals, three policy shifts are warranted.

• First, clinicians need unambiguous legal protection when honoring a patient’s clinical wishes.
• Second, workforce diversity must be treated as a patient safety intervention with investment and outcomes data to ensure accountability. Ms. Doyley’s request for a Black physician was not coincidental. It was informed by her experiences and data.
• Third, the doctor-patient relationship must be legally insulated from state politics that have no place in clinical care delivery.

For Black women like Ms. Doyley, trust in the medical system has been eroded historically and confirmed by data. But physicians have power to address this. When I asked Dr. McLeod what it would take to prevent cases like this one, her answer was simple. “Honestly, we need to sit down, listen and have these collaborative discussions early. It is our job to ensure patients are well-informed long before they are in labor.”

That is not a high bar. It is exactly how we should support patients and is what bodily autonomy and basic dignity in healthcare require.