Patients are being denied emergency abortions. Courts can only do so much.

Every state abortion ban has an exception to save a mother’s life. But what qualifies as a life-threatening medical emergency in Texas may not be enough for a doctor in Idaho, and even hospitals within the same state can look at an identical case and reach different conclusions.

The legal and medical murkiness has physicians around the country begging state officials to clarify when they can terminate pregnancies without risking legal peril. And as they await guidance from states, stories of pregnant patients turned away from hospitals in medical emergencies or forced to wait until their vitals crash have become emblematic of the confusion unleashed when the Supreme Court’s Dobbs decision ended the federal right to an abortion in 2022.

The conflict is a key part of a case this week at the Supreme Court focusing on the clash between federal protections for patients in medical crises and Idaho’s near-total abortion ban. Lower courts, state attorneys general, legislators and medical boards are also grappling with how to give doctors and hospitals the leeway to save pregnant patients’ lives while complying with state laws, many of which include vague and unscientific terms like “serious,” “major” or “substantial.”

“There’s not a line in the sand where someone goes from being totally fine to actively dying,” said Dr. Nisha Verma, a consultant for the American College of Obstetricians and Gynecologists and an OB-GYN in Georgia, which has a six-week ban. “It’s a continuum and it’s often unclear when in that continuum we can intervene. … I know how to decide with my patient at that moment, taking in their specific situation, but what does the attorney general or some politician intend?”

Joe Biden’s presidential campaign, which is seeking to make abortion a centerpiece of the election, has honed in on this tension, elevating stories of women denied abortions after their wanted pregnancies suffered complications that jeopardized their lives or health, and arguing in ads and speeches that they illustrate the “legal and medical chaos” unleashed by the Supreme Court’s Dobbs decision.

Former President Donald Trump has touted his role in overturning Roe v. Wade while arguing the issue should be left to the states — even as some allies plan for federal abortion restrictions should he win in November. The Trump campaign did not respond to a request for comment.

Abortion opponents, meanwhile, accuse doctors of willfully misinterpreting laws, and say giving physicians greater discretion would open the door to more abortions that aren’t medically necessary, including in non-emergency situations.

“[Abortion-rights groups] have sown confusion to justify their agenda for unlimited abortion,” said Kelsey Pritchard, the director of state public affairs at Susan B. Anthony Pro-Life America. Doctors who have acted “recklessly with women’s safety” by denying care, she added, “are instances of medical malpractice. That’s not due to the pro-life laws.”

Doctors say they fear that following their medical judgment could cost them their license or land them in jail. And they argue that broader exemptions and clearer guidelines would help but not fully solve the problem, as they believe any limit on abortion restricts their ability to make judgment calls in time-sensitive situations. Absent the freedom to make those decisions without fear of being second-guessed in court, many providers are waiting until patients are on the verge of death to perform abortions.

“If you make standard medical care a crime when folks in all kinds of difficult medical situations present, especially in emergency situations, we are always going to see some type of delay,” Caitlin Gustafson, an OB-GYN in Idaho, told reporters on a recent call. “Because it’s criminalized care, physicians are going to naturally hesitate.”

Freestanding ERs, small clinics and rural hospitals have an especially hard time navigating this minefield, as many lack the medical expertise and legal resources that large academic hospitals have to make a call about when an abortion is permissible in an emergency.

Verma said she and her colleagues — who have the backing of a task force staffed with legal experts and high risk pregnancy specialists — regularly treat patients “in not-great conditions” who were turned away by other facilities.

“A lot of folks in the state don’t have any guidance or any level of protection,” Verma said. “And their response is to not want to take care of people that are experiencing OB complications or needing abortion care at all.”

Only a handful of red states have made statutory changes to their bans — all of which target abortion providers, not the pregnant person — but many have allowed other types of clarifications. In South Dakota, the state’s GOP supermajority legislature passed a bill earlier this year requiring state health officials to produce a video to explain when doctors can perform abortions in emergency situations. The Texas Medical Board has put forward draft rules to do the same. And in Oklahoma, the state attorney general released guidance last year saying that doctors should be given “substantial leeway” to use their medical judgment to make calls on whether an abortion is necessary to save a pregnant patient’s life.

Lawsuits spearheaded by the Center for Reproductive Rights in Idaho, Oklahoma, Texas and Tennessee are also seeking legally binding rulings guaranteeing patients’ right to an abortion in emergency situations before they become life-threatening.

But providers worry none of those moves — not even a decision from the nation’s highest court siding with the Biden administration in the Idaho case — will resolve their concerns.

“I can’t take [doctors’ fears] away,” said Dr. Sherif Zaafran, president of the Texas Medical Board. “It’s not something we can control. … We have to operate within the constraints of what the law allows us to do. There are certain things that cannot be answered unless it’s answered legislatively.”

Several Idaho physicians, afraid of violating state law, have turned away patients even when they believed they needed emergency abortions, including people experiencing preterm premature rupture of membranes, which carries a high risk of infection, according to an amicus brief from medical groups filed to the Supreme Court.

The case the justices will hear Wednesday hinges on the chasm between Idaho’s near-total abortion ban, which allows the procedure only when the mother’s life is in danger, and longstanding federal laws that require hospitals to provide stabilizing treatment including abortion to patients whose life or health is threatened.

While a ruling, expected in June, will apply only to Idaho hospitals, advocates on both sides agree it could set a precedent for other states with abortion bans and trigger a new wave of litigation.

Gail Deady, a senior staff attorney for the Center for Reproductive Rights who is leading a separate lawsuit on behalf of pregnant patients in Idaho, said that even if the Supreme Court rules in favor of the Biden administration, physicians will likely remain confused about what they are allowed to do and when.

She noted that such a ruling would only apply to “people who are presenting to emergency rooms and who qualify as having a sufficient emergency to need immediate stabilizing abortion care” but not address pregnant patients with “conditions that were life and health threatening, but … didn’t require immediate abortion care to prevent their deaths.”

Because the expected narrow ruling from the Supreme Court is likely to leave physicians around the country in legal limbo for the foreseeable future, many doctors and patients grappling with that reality have decided their best chance for a remedy is at the state level.

Some are plaintiffs in state court lawsuits seeking broader medical exemptions, including Kate Cox and Amanda Zurawski in Texas, who Biden and other Democratic candidates have cited as examples of what could increasingly befall patients nationwide if Trump wins in November. Both women were denied abortions when pregnancy complications put their health and future fertility at high risk. Cox left the state for the procedure while Zurawksi received treatment in Texas after several days of delay that caused permanent damage to one of her fallopian tubes. The Biden campaign featured Zurawksi in an ad hitting back at Trump’s call for abortion to be left to the states, and the president invited Cox as a guest to his State of the Union address in March.

Anti-abortion groups acknowledge some patients have suffered harm, but are still urging GOP legislators to resist calls to broaden exemptions, which they believe would undermine the goal of protecting fetal life.

“Several of the women in the Zurawski case did have medical emergencies that they should have received treatment and care for under our law, and it’s not right that they didn’t,” said Rebecca Weaver, the legislative director for Texas Right to Life. “It’s not the law that’s the problem, it’s the implementation.”

However, the Texas Supreme Court ruling from December, which said Cox did not qualify for an exemption to the state’s ban, called on the state medical board to offer more guidance on how to interpret the state’s abortion laws. The board has since solicited public comments on draft rules on what kind of “medical emergency” would make someone eligible to receive an abortion.

But Zaafran, the board’s president, said there is no way to provide an “exhaustive list of conditions.” He argued, for instance, that what qualifies as an emergency situation in one part of the state might not qualify in another area.

“It all depends on the circumstances,” he said. “What’s more important is what you believe is an emergency and documenting that way.”

Pritchard, the state public affairs director at Susan B. Anthony Pro-Life America, said her organization is encouraging other states to produce videos, similar to what South Dakota did.

“We want to make sure if there is confusion — anywhere — that we clarify that and provide this education,” she said. “If there is a doctor who is just genuinely, honestly unsure, this guides them in the right direction so they know that they can continue to act as they always have.”

Doctors remain skeptical, arguing that as long as there is a threat of criminal charges, no amount of guidance will give them the confidence they need to follow their medical judgment in sensitive situations.

“These laws are an effort to make people feel better without actually creating any significant change in the care environment,” Verma said. “There’s no way to highlight every situation that could occur or all of the complexity of medicine. So there’s still confusion on the ground, but I think it then makes it easier to put the blame on the physicians who are trying to still practice in this really confusing environment.”