How Florida's abortion amendment is triggering tension across the state

Dr. Daniel Christie wears a pin on his white coat that says "Vote."

He doesn't want to get into politics with his patients, but he does want them to know he believes his job is on the line with Amendment 4 on November's statewide ballot, which would enshrine a right to abortion in the state constitution.

"If I can convince one patient coming through my clinic, 'Hey, you know what? My rights, my daughter's rights, my sister's rights, they're on the ballot this year. I'm going to vote. Then, you know what? Good," said Christie, an OB-GYN in Broward County who specializes in infertility.

Since May 1, when the Heartbeat Protection Act went into effect, some OB-GYNs in Florida say they are nervous to provide care that the state insists is legal under the law. The state generally prohibits, with exceptions, abortions after six weeks of pregnancy.

Amendment 4 would restore allowing abortion in Florida up to "fetal viability," usually around 24 weeks. If it doesn’t pass, providers told the USA TODAY Network-Florida that women will take dangerous risks to end their pregnancies.

How do they know? Because it's already happening, they say.

The six-week prohibition may as well be an outright ban, said abortion rights advocates, since many women do not know they are pregnant at six weeks. Anti-abortion supporters of the Heartbeat Protection Act argue that defending unborn life is a moral responsibility of the state, and detecting a heartbeat is a significant milestone that signals the presence of a distinct human life.

"If this passed, you would be able to have six months old, in the womb, a fully-formed baby, heartbeat, can feel pain, sucking its thumb, you see it on the ultrasound, you see the face, and that would be able to be snuffed out for no reason, whatsoever," said Gov. Ron DeSantis at a press conference surrounded by doctors in Jacksonville recently.

However, only 1% of abortions happen after 21 weeks, according to data from Pew Research Center.

Exceptions to the current abortion law include "fatal fetal abnormality" and rape, incest and human trafficking. While the state clarified that most of those exceptions have a cut off for 15 weeks, the state’s health care agencies do not say whether that applies to "fatal fetal abnormality."

The state has not yet charged a doctor for providing an abortion, but that doesn’t mean much to Dr. Alexandra Levy, who says ambiguity in the laws and current legislation in other states that potentially puts doctors at risk leaves legal departments advising “just do absolutely nothing, because you don't want to risk the wrath of an attorney general.”

Aside from the moral and religious factors in the abortion debate in Florida, health care providers already are saying – some publicly but most privately – that they're caught between patients and their legal risk managers. They're fearful that honest decisions about the best care may land them as defendants in lawsuits or worse – charged with crimes.

“We're all afraid. We're losing faith,” Levy said.

Doctors pile onto petitions on both sides of debate as DeSantis digs in

Florida's Agency for Health Care Administration and Department of Health have made clear that providers will not be criminally charged and an abortion is allowed at “any stage of pregnancy” to save the life of the mother.

The agencies also have said that the law does not include criminal penalties for women who get an abortion.

But some doctors and patients see hardline laws taking shape in other states and DeSantis’ fusillade of attacks against Amendment 4, and they worry.

Even with multiple attempts to reach providers, many would not even speak to the USA TODAY Network – Florida under anonymity because they feared repercussions from the state, their employers or both.

Elected officials in other states, like Idaho and Missouri, have attempted to pass legislation that would criminally charge women who get abortions or who help women travel to get one.

In 2023, Missouri lawmakers filed bills that would charge a woman with homicide on behalf of a victim who is an “unborn child at every state of development from the moment of fertilization until birth,” one of the bills stated.

The measure was later withdrawn, but providers in Florida wonder if a bill like that could be next.

“Nobody deserves to go to work and worry, ‘Is this the day that I get accused of murder and dragged out of here in handcuffs?’ ” said Levy, who has been practicing in Florida for two years.

Dr. Tamberly McCarus, an OB-GYN with Florida Physicians Against Amendment 4, disagrees and said Florida's law is “not ambiguous in any shape or form." She does not believe the Heartbeat Protection Act will lead to more extreme laws.

DeSantis has hosted a number of press conferences with doctors across the state, including McCarus, to condemn the ballot initiative.

The governor has pushed back hard against Amendment 4 since the beginning: fighting the amendment’s existence in Florida’s Supreme Court; hiring outside consultants to help craft a fiscal impact statement on the ballot; investigating the authenticity of the ballot initiative’s petition signatures; and sending cease and desist letters to TV stations threatening criminal charges if they didn’t stop running pro-Amendment 4 ads.

DeSantis and opponents to Amendment 4 argue the ballot measure's authors are "lying" to Floridians, and words used like "health care provider" and "viability" leave too much room for "outsiders" and unqualified practitioners to come to Florida and perform unsafe procedures.

But the terms they call into questions are defined in state law. “Viability” is defined as “the stage of fetal development when the life of a fetus is sustainable outside the womb through standard medical measures.” A “health care provider” must be licensed by the state.

Florida Physicians Against Amendment 4 boasts over 700 physicians' signatures who say loosening regulations on abortions would "usher in a substandard of care, and undermine their ability to care for women and girls," but a spokesperson declined to release the full list of names to a reporter. Seventy of those physicians, 10%, are OB-GYNs, according to Prudence Robertson, a spokesperson for the group.

One-hundred-and-thirty of the more than 850 physicians who have endorsed Amendment 4 are OB-GYNs, according to a list provided by the Yes on 4 campaign – or roughly 15%.

Lawsuit emerges to pull amendment from the ballot as some doctors fear for future in Florida

On Oct. 16, "four concerned Florida voters" who oppose abortion filed a lawsuit to pull Amendment 4 from the ballot. Alan Lawson, a former Florida Supreme Court justice and lead counsel for the plaintiffs, is alleging Amendment 4’s sponsor and elections officials illegitimately certified the measure for placement on the 2024 ballot.

One of the plaintiffs is a woman who said she was coerced into getting an abortion.

"I was pushed by my boyfriend into an abortion I didn’t want, and the abortion industry was eager to provide it. Tragically, my experience is far from uncommon," plaintiff Lorien Hershberger of Taylor County said in a press release from Lawson.

"For years I’ve worked with lawmakers on pro-life efforts to protect babies and moms; I won’t stand by and watch proponents of Amendment 4 use fraud to push an unpopular and extreme abortion policy on Floridians to erase all we’ve done," she added.

Christie, the OB who supports Amendment 4, said to limit abortion based on gestational age is "offensive" to women, as abortions at or after 21 weeks make up only about 1% of all abortions in the U.S. Moreover, 96% of all abortions occurred at or before 15 weeks gestation, while 3% occurred from 16 to 20 weeks gestation, according to health policy research group KFF. The state's previous ban, which went into effect in July 2022, kicked in at 15 weeks.

"These are not folks who wake up at 36 weeks and say, 'You know what? … I'm just gonna terminate. I don't think I really want to do this,'" Christie said. "These are unbelievably complex and tragic circumstances for the mother, for the fetus, or for both that have to be dealt with in the most horrific of circumstances."

Cherice Felix, an OB-GYN at Planned Parenthood in West Palm Beach, said she left Tennessee after the state banned abortion and “watched that system fall apart piece by piece.”

“Each restriction, each ban, it opened the door to a new way of restricting communication between doctors and their patients in the exam room,” she said during a Zoom press conference for the Yes on 4 campaign. “It restricted the care that we could give our patients, and then eventually it just flat out banned it. So I now live and work here, and watching similar things happen here in the state of Florida, it's really alarming.”

Five states, including Tennessee, have either enacted or are considering “abortion trafficking” laws. Such laws typically allow for criminal charges on an adult who is found to be “recruiting, harboring, or transporting” a minor to get an abortion, according to an Idaho law that was the first to go on the books.

In October, the Texas Supreme Court let stand a lower court decision that says hospitals are not required to provide emergency abortions.

Cases like this, along with the stories of two Georgia women whose deaths were linked to the state’s abortion ban, are frightening providers and especially patients, who have more questions now that they have fewer options.

“They are hearing wild and crazy things on social media, some of which are absolutely true,” said Cheryl, a midwife who practices in North Florida, who asked not to use her full name because of fear of professional repercussions.

During a routine third trimester checkup, one of her high risk patients came to her appointment with her husband and looked her in the eye and asked, “How are you going to decide if I have to die in order for the baby to live?”

Cheryl was stunned. “I said, ‘We're taking the best care of you and your baby,' ” she said, grateful it never came to that.

But critics of the amendment say such concerns are overblown.

Dr. Christina Pe?a, a Miami OB-GYN with Florida Physicians Against Amendment 4, said at a Coral Gables event with DeSantis, “Do not believe the lie. Women are not dying across our state because of lack of access to abortion under our current laws.”

Few Florida options for women seeking abortions beyond six weeks

For women in Florida who don't qualify under the exceptions and who seek to get an abortion after six weeks, there are few options. If the fetus' gestational age is lower than 11 weeks, they can get abortion pills, mifepristone and misoprostol, through the mail.

"It's better than the coat hanger days, but still, I wouldn't want my daughter to take mifepristone unmonitored," said Christie. These medications "are about as safe as you can get, but like any medication, there's complications, so I would want supervision."

Beyond 11 weeks, the pills may not be effective and could increase complications, Christie said. But women may still take the risk. Some already are.

"Did abortions happen prior to 1973? Of course, they happened. Did they happen completely safely? No, they did not. And that's where we are at this point. We're pre-1973," said Christie.

That year, the U.S. Supreme Court determined the U.S. Constitution protected a women's right to an abortion in Roe v. Wade. The current court tossed out that decision in June 2022, throwing the issue to the states.

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Now, if a woman wants to travel for an abortion, she will have to spend thousands of dollars to get to Washington, D.C., or New York City, some of the closest places that allow abortion with the fewest barriers.

While North Carolina allows abortion up to 12 weeks, the 72-hour in-person waiting period makes it difficult for many to make the somewhat drivable distance for an appointment.

The next closest is Virginia, where abortion is banned in the third trimester. But it's hard to find direct flights, the nearest abortion provider can be an hour from the airport and those clinics are already at capacity.

As previously reported by the USA TODAY Network-Florida, four out of the five organizations that provide monetary assistance for those seeking abortions in Florida say they have seen drastic increases in the number of callers and costs since May 1.

After abortion, some Florida doctors worry IVF is next

Some doctors worry that "heartbeat bills" could potentially affect embryos for in vitro fertilization, or IVF. For example, three states, including Georgia, have already enacted so-called fetal personhood laws. In Georgia, the 2022 LIFE Act states that "'unborn child' means a member of the species Homo sapiens at any stage of development who is carried in the womb."

And earlier this year, Alabama's Supreme Court ruled that frozen embryos are legally protected as children, which shut down IVF clinics across the state and rushed that state's legislature into fast tracking a law to backpeddle the decision.

McCarus, who opposes Amendment 4, said she doesn't believe Florida will go "extreme" and outlaw IVF.

“Cooler heads and medical scientists probably prevailed in that (Alabama) decision, so I’m actually relieved that that happened,” she said.

Yet earlier this year, a fetal personhood bill, Civil Liability for the Wrongful Death of an Unborn Child (SB 476), was filed by Sen. Erin Grall, R-Fort Pierce, the sponsor of the Heartbeat Protection Act. The bill, which never made it out of the Florida Senate Rules Committee, defined “unborn child” as “a member of the species Homo sapiens, at any stage of development, who is carried in the womb.”

This September, the governor's Faith and Community Initiative hosted an event with Attorney General Ashley Moody and Mat Staver, the founder and chairman of the Liberty Counsel, called "Your Legal Rights & Amendment 4’s Ramifications."

When the Alabama legislature passed the IVF protection law, Staver called it a "knee-jerk reaction."

"It is too bad legislators are moved more by political winds than in science and in the fundamental issues involving human life," Staver said. "Every human life begins as an embryo and has incalculable worth. Yet this law presents a double standard treating IVF embryos differently by removing their legal protections."

Every day, Christie has at least one patient who asks him if their embryos are safe in Florida, and their worries aren't unfounded, he said.

"I'm out of the game of guessing what this current Legislature is capable of. Because if you'd asked me two years ago, three years ago, would this be a conversation I would ever be having? Absolutely not," he said.

Ana Go?i-Lessan, state watchdog reporter for the USA TODAY Network – Florida, can be reached at [email protected]. 

This article originally appeared on Tallahassee Democrat: Abortion amendment on Florida ballot stokes tensions on both sides