Beyond the Realm of Hypotheticals: Dobbs and the Future of U.S. Reproductive Rights

https://doi.org/10.56927/69073

Minsoo Kwon*, James Jolin*, Sarosh Nagar*

*All authors contributed equally to this article.

On May 2, 2022, news outlet POLITICO publicized a leaked draft opinion penned by United States Supreme Court Associate Justice Samuel Alito in February 2022, indicating that the Court is poised to repudiate the constitutional right to an abortion.¹ Unprecedented within the Court’s history, the leaked opinion represents an initial draft of the Opinion of the Court in Dobbs v. Jackson Women’s Health Organization, a case for which the Court held oral argument in December 2021.² Dobbs, one of the most high-profile and contentious cases on the Court’s docket, considers the constitutionality of Mississippi’s prohibition on most abortion procedures after 15 weeks of pregnancy, effectively barring some abortions prior to the point at which a fetus becomes viable outside the womb.³ Such a pre-viability proscription stands in opposition to the Court’s holdings in Roe v. Wade (1973) and Planned Parenthood v. Casey (1992), both of which maintain that abortions prior to viability cannot be restricted.^4,5 Consequently, Dobbs not only asks the Court to consider the narrow question of Mississippi’s laws constitutional permissibility but also of Roe and Casey’s status as binding precedent.

On this latter, weighty question, the Dobbs draft ruling does not prevaricate. The draft opinion’s text — which Chief Justice John Roberts has since confirmed is authentic — is blunt and unequivocal: it categorically rejects the Court’s holdings Roe and Casey, arguing that Roe was “egregiously wrong” from the outset and that both holdings must be “overruled.”^1,7 The implications of a Dobbs ruling conceived in the image of the leaked draft are, to be sure, striking: not only does the draft upend the long, complex legal history of abortion rights, but it also threatens to disrupt maternal health in the United States and stoke the flames of the socio-legal battle over abortion rights across the nation.

The Leaked Dobbs Ruling’s Place in Legal History

The leaked Dobbs draft ruling is one of few opinions in history to ever escape from the Court’s furtive, hallowed chambers.⁸ The draft opinion is equally unprecedented in its holding. The Supreme Court has rarely overturned one of its precedents, only doing so approximately 232 times in the last nearly two centuries.⁹ The Dobbs draft opinion, indicating an imminent overturning of Roe and Casey, is poised to join this short list, despite the Court’s longstanding precedent on constitutional abortion rights. Indeed, the Court’s abortion jurisprudence over the past half-century illuminates how deeply entrenched Roe’s central holding is and what Dobbs is likely to upend: in many ways, Roe’s pre-viability prohibition on abortion restrictions is “precedent on precedent.”¹⁰

At issue in Roe was a Texas statute barring abortion procedures, with the exception of when “medical advice” deemed the procedure necessary to protect the life of the mother.⁴ After brushing aside Texas’s historical justification for its abortion restriction, the Roe Court turned to Griswold v. Connecticut (1965) — along with a long line of cases affirming personal privacy in marriage, procreation, contraception and child rearing — to conclude that Texas had run afoul the right to personal privacy in placing severe restrictions on abortion.⁴ As many conservative political commentators have observed recently, abortion appears nowhere in the Constitution, but that fact was immaterial for the Roe Court.¹¹ Instead, the Constitution’s implicit right to privacy, per the Court, was broad enough to encompass the decision for a birthing person to terminate a pregnancy. Even so, the Court’s ruling was not categorical; it identified two key interests involved in the decision to undergo an abortion — in the health of a woman and the potential life of a fetus — both of which grow in importance and become compelling as the pregnancy progresses.⁴ In dealing with these interests, the Court promulgated a scheme based on the trimesters of pregnancy, prohibiting abortion restrictions in the first trimester, allowing some maternal-health-related restrictions on abortion in the second trimester, and permitting outright bans on abortion in the final trimester — when the fetus was thought to reach “viability” outside the womb.⁴

The 7-2 majority opinion in Roe gave the perception of consensus, but the decision was not without dissent. Justice Byron White’s dissent, for instance, inveighed against the Court’s alleged overstep into the legislative realm, a point Alito broaches in his draft Dobbs ruling. Roe functionally fashions a new constitutional right, per White — one with sufficient substance as to wrest legislatures’ ability to establish abortion regulations through the political process.⁴ Nonetheless, Roe has remained largely intact, even when challenged by Planned Parenthood v. Casey (1992). In Casey, the Court considered five provisions of Pennsylvania’s 1982 Abortion Control Act, which did not bar abortion outright but placed numerous restrictions on the procedure, including a requirement that a woman furnish evidence that she had notified her husband of an intended abortion.⁵ The relatively conservative Casey Court, in a 5-4 decision, naturally upheld most Pennsylvania’s restriction — with exception to spousal notification — but notably, it largely affirmed Roe’s central holding in doing so. The Casey Court engaged in an extensive stare decisis analysis of Roe, finding that even two-decades later individuals had come to rely and “organize[] intimate relationships” on the basis of the 1973 ruling’s guarantee of legal abortion.⁵ Casey admittedly rejected Roe’s rigid trimester abortion restriction framework but upheld its “central holding”: that fetal viability represents the point before which states could not restrict abortion.⁵ Replacing Roe’s trimester framework, the Court applied an “undue burden” inquiry, which searches for whether a “state regulation has the purpose or effect of placing a substantial obstacle in the path of a woman seeking an abortion of a nonviable fetus.”⁵ Reasonable, state-sponsored tactics to persuade a pregnant person against obtaining an abortion were permissible; outright bans on pre-viability abortions were not.⁵

Yet another nearly two decades later, the Court affirmed this Roe-Casey hybrid “undue burden” standard and strengthened its fact-finding power when assessing abortion cases.¹² Even so, debate over abortion rights in the U.S. certainly persists: what exactly constitutes an “undue burden” or “substantial obstacle” to abortion are chief among that which remains unresolved. But, these debates aside, the Court’s approximately 50 years of precedent command, with uncharacteristic clarity, that the discourse move past the constitutionality of pre-viability abortion. Viability, indeed, remains a proverbial line in the sand. The leaked Dobbs draft ruling reopens this closed chapter of the Court’s abortion jurisprudience and relitigates the stare decisis inquiry at issue in Casey. Only time will tell if the draft becomes binding precedent, but its sharp language looms large. In a matter of months, Roe and Casey — precedents largely affirmed time and again — might become things of the past.

Immediate Implications for Reproductive Rights

The leaked Dobbs ruling’s significance is not only relegated to legal abstractions, however. The immediate implications for reproductive health — encompassing access to contraception and abortion — has been the center of grave concern due to an arguably indomitable demand.

A vital distinction lies between safe and unsafe abortions, the latter of which can involve either an outdated method or an untrained provider, resulting in the ingestion of ineffective caustic substances or “traditional concoctions.”¹³ Current methods regarded as safe — vacuum aspiration (procedural removal of uterus contents through suctioning tube), medication abortion, and, dilation and evacuation — are the abortions to which accessibility will drastically be curbed if Roe is overturned.¹³

States’ “Trigger” Laws are characterized as such because of the immediacy with which such states intend to enforce abortion bans upon the overturning of Roe. To date, 23 states have laws that restrict legal status of abortion: these are the places where an expected drastic restriction in abortion accessibility looms as a likely consequence.¹⁴ In the absence of Roe, 33.6 million U.S. women — over half of the nation’s women of reproductive age — will lose access to an abortion.¹⁵

In recent years, prior the leaked Dobbs ruling, medication abortion has been the center of much legal discourse: the FDA approved in 2000, what is commonly called a “medication abortion,” is in actuality a sequential administration of two medications: Mifepristone and Misoprostol.^16,17 Such administration can only take place until about 10 weeks of pregnancy.¹⁷ This safe-abortion method is subject to the same abortion laws at both state and federal levels, as until rather recently, FDA’s in-person dispensing requirement for Mifepristone meant that patients had to find access to an in-person clinic.¹⁷ However, in 2017 the ACLU filed a lawsuit challenging the FDA’s REMS (Risk Evaluation and Mitigation Strategy) requirements for Mifepristone, which was then overturned in December 2021.¹⁶ Thus, the in-person dispensing requirement removal by the FDA opened the possibility of mailing such abortion medication in states that do not restrict telehealth for medication abortion.¹⁷

Whom will such immediate changes in access to abortions affect the most? Notably, not all who seek abortions identify as women. However, current data suggest that the overturning of Roe will disproportionately affect people of color and low-income communities’ access to the procedure.¹⁸ CDC data on abortion surveillance in 2019 shows that women in their twenties had the highest rate of abortions, which accounted for more than half of the abortions in totality. Among these women, rates were the highest among adolescents under 19 years of age.¹⁹

Disparity in demand extends beyond age brackets and into race and socioeconomic status: in Mississippi, although black women are just 42% of the child-bearing population, they comprised 74% of the women who received an abortion.¹⁵ In fact, unsafe self-managed abortions were three times higher among black woman compared to their white counterparts.²⁰ Behind such statistic are an alarming number of black women whose lives were potentially in grave danger due such unsafe abortions.

In 2014, women paid an average of $535 for an Early medication abortion, a financial burden which is not covered by any government subsidy or even most privately funded insurance programs due to the Hyde amendment — a statute barring the use of federal funds to pay for abortion unless its to save the carrying individual’s life, or if the pregnancy arises from incest or rape.²¹

Despite such exceptionary clauses in the Hyde amendment, however, a study conducted by the Government Accountability Office in 2019 found that 14 states’ Medicaid programs “do not cover Mifepristone even in the cases of rape, incest, and life endangerment as is required by the Hyde Amendment.”²² For abortion-seeking individuals in states where it is illegal, out of state travel may be the last resort for a safe abortion. However, such out of state travel is expensive and risky, posing additional limitations on financially disadvantaged individuals. Faced with a financial burden one cannot afford, and now a slendered accessibility, a person seeking an abortion faces seemingly impenetrable legal and logistical barriers to a safe abortion. Unsafe abortions and unsafe self-managed abortions — which may be the last remaining option for some — pose grave health and legal risks.

To be sure, access is only one part of abortion legality. The criminalization of abortion stirs additional controversy. Many, if not most, cases of arrests for self-induced abortion consist of a similar frame of someone seeking emergency medical help and consequently coming to the attention of notified law enforcement.²³ In Texas, Legislature S.B.8, commonly known as the “Texas Heartbeat Act” enforces a “civil liability for violation or aiding or abetting violation,” meaning that anyone who “knowingly engages in conduct that aids or abets the performance or inducement of an abortion” faces criminal charges and statutory damages in no less than ten thousand dollars.²⁴

Increasing conversation regarding the ethics of abortions has shone a brighter light on a life after birth in the United States. How does the United States currently support life after birth compared to other wealthy countries? The United States is one of the only OECD countries that lack a federally mandated paid parental leave policy.²⁵ Foster care children experience and develop Post Traumatic Stress Disorder at higher rates than soldiers, as “30% of youth in foster care will experience PTSD symptoms, which is twice the rate of U.S. war veterans.”²⁵ Such alarming evidence — mounted against proper quality of life for children and families — raises the question of the bounds of pro-life and whether such fervent defense of life envelops lives after birth.

The Long-Term Outlook of Reproductive Rights in America

What does the future hold? In the short term, the overturning of Roe and the leaked opinion in Dobbs will result in the abortion issue to the states, as suggested by Justice Kavanaugh during oral arguments over the case.^1,2 However, in the long-term, overturning Roe is likely to lead to a wide variety of legal and political battles that will continue for years to come — and which are not likely to remain at the state level either. Furthermore, from a legal perspective, the overturn of Roe may lead states to pass laws designed to challenge other cases which depend on the precedent set in Roe, though whether these other challenges will succeed is unknown.

Chiefly, the overturn of Roe is likely to trigger a wave of political action at the state level. Pro-choice groups will likely attempt to pass laws or executive orders guaranteeing access to abortion, while pro-life groups will instead attempt to pass laws that restrict or ban abortion outright. In addition to the wide variety of state trigger laws discussed earlier, these laws may include efforts to limit access to the abortion pill. In the most extreme cases, candidates may even seek to ban access to birth control, as proposed by some highly conservative candidates nationwide, such as state representative candidate Jacky Eubancks in Michigan.²⁶ Beyond these laws, the overturn of Roe means that in most states, aforementioned trigger laws or previous laws on abortions (those that were in effect prior to Roe) will go into effect — however, these old state laws are likely to be challenged by both pro-life and pro-choice groups.¹⁵ For example, in Michigan, one law predating Roe bans abortion and has triggered litigation that resulted in state judges blocking enforcement of the abortion ban.²⁷ Furthermore, at a legal level, these new state laws on abortion are likely to make abortion a critical issue in the 2022 midterms and beyond. Already in Pennsylvania, for example, Democratic gubernatorial candidate and Attorney General Josh Shapiro has made abortion access a key issue in his campaign against highly conservative pro-life candidate State Sen. Doug Mastriano.²⁸

At a broader level, the implication of these legal and political battles will be a patchwork of abortion regulations that will vary across state lines. The result will mean a loss of access to abortion services in more Republican-leaning states, while pro-choice protections may remain in Democratic-leaning states.¹⁵ Swing states may be left in a rather confusing position, as they may see repeat changes in abortion status in as little as two years, depending in large part on the national political environment.²⁸ This oscillating patchwork will likely create significant uncertainty for many women seeking to get an abortion. While companies and other organizations have also already announced plans to provide and fund abortions for employees who need them and who live in states where abortion is banned, poorer individuals whose jobs do not provide these services may be left unable to access abortion services in turn.²⁹

However, any who suggests that this renewed abortion debate will remain at the state level is likely mistaken. The end of Roe and Casey does not preclude the possibility of national-level efforts to either codify or block abortion access, and in fact, it is far more likely that both parties will incorporate such legislation into their platforms. In particular, the Democratic Party is likely to support bills like the Women’s Health Protection Act (WHPA) and other laws to codify access to abortion, while Republicans may attempt to enact a national abortion ban or implement other restrictions on abortion.30 It is worth pointing out, however, that the WHPA currently lacks the votes to pass, and similarly, the likely prospect of a Republican House combined with a Democratic White House makes it highly unlikely that any major abortion legislation will pass through 2024.³⁰

However, from 2024 onwards, it is conceivable that either party may try to pass their desired abortion legislation if they achieve legislative control of the government. Senate Democrats have already attempted to pass the WHPA, and Senate Minority Leader Mitch McConnell (R-KY) has already suggested he may be open to a national abortion ban in the future.³¹ However, given the difficulties involved with predicting the far future, it is nigh impossible to predict which side will emerge victorious in this national struggle.

From a legal perspective, the strike-down of Roe and Casey will fuel a proliferation of litigation for a number of different reasons. First and most immediately, the Court’s decision is likely to lead to court challenges to other precedents beyond abortion, which either depend on the right to privacy established in Roe or rely on similar privacy-related justifications. While some of these cases, like Loving v. Virginia (1967) on interracial marriage, are non-controversial and unlikely to see significant challenges, prospective litigants may be more likely to target two potential cases — Lawrence v. Texas (2003), which decriminalized sexual relations between individuals of the same sex, and Griswold v. Connecticut (1965), which guarantees access to contraceptive services.³² Both cases are dependent on the privacy precedent set in Roe or similar justifications, and given that several more extreme polticians have expressed opposition to same-sex marriage and contraceptive access, it is possible that these cases may be future targets of litigation. In response to this concern, Justice Alito’s draft opinion claims that the Court’s overruling of Roe does “not undermine them” in any way because these other cases do not deal specifically with abortion.^1,2 However, given that this explanation lacks a detailed precedential analysis to support it, and given that the proposed draft opinion does contradict any assertion of an implicit right-to-privacy in the constitution, it is likely this justification will not deter future judicial challenges to these associated cases.

Furthermore, beyond a pure precedential analysis, the Court’s decision to overturn Roe due to Dobbs has illustrated the efficacy of the legal strategy performed by the State of Mississippi — namely that states can pass laws that may be considered illegal in order to strike down existing legal precedent. In this case, for example, Mississippi’s abortion ban was a clear challenge to Roe and Casey, and yet its' implementation led to the end of Roe. This outcome leaves it conceivable that future states could enact similar laws in order to overturn precedent in the future.³³ Such a strategy may be applied to several cases — with perhaps the most vulnerable being Obergefell v. Hodges (2015) on gay marriage, since, as hinted in Justice Alito’s statement to deny certiorari in Davis v. Ermold (2020), it is conceivable that some on the Court may believe that Obergefell was wrongly decided.³⁴ However, given the popular support enjoyed by Obergefell as opposed to other cases, it is questionable whether such strategies will succeed in cases beyond Roe. Nevertheless, a wave of legal challenges in the style of Dobbs may be likely to come.

An Unclear Future

Despite the potential scenarios outlined in this article, it is re-emphasizing the incredible uncertainty surrounding the future of abortion in a post-Roe and Casey world. After all, even the draft opinion itself is exactly that — a draft – which may change before the decision is released later this month. The resulting changes may alter the precedents’ outlined in the opinion, in turn implicating what a post-Roe world may look like. Further unexpected events in both the political and legal realms are also likely to alter how the opinion in Dobbs may be implemented, or for how long it may even last. Nevertheless, this article provides the HHPR’s best effort to discuss what a post-Roe and Casey world may look like, focusing on the political, legal, and health-related implications of overturning the 50-year old decision. Throughout all our analyses, however, only one fact remains certain — the battle over abortion is far from over, and will play out in the decade to come.

About the Authors

Minsoo Kwon is in the Harvard College Class of 2024-2025 and is an Associate Editor. James Jolin and Sarosh Nagar are in the Harvard College Class of 2024 and are both Senior Editors of the HHPR.

Author Contributions

MK: Conceptualization, Writing — Original Draft, Writing — Review and Editing; JJ: Writing — Original Draft, Writing — Review and Editing; SN: Writing — Original Draft, Writing — Review and Editing.

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