On Friday, a Texas judge decided a case that may radically change abortion access in the United States. In his ruling, on a lawsuit brought by right-wing activists, the judge invalidated Food and Drug Administration approval of mifepristone, the first of two drugs used in a medication abortion.
The decision was issued by Trump-appointed Judge Matthew Kacsmaryk, one of the most conservative judges in the country, and will go into effect in seven days. If another court does not intervene in response to an appeal, the decision will have a dramatic impact on reproductive health care: More than half of U.S. abortions are performed with medication, and Kacsmaryk’s decision will apply even in states where abortion is legal.
However, the end of mifepristone in the U.S. does not mean the end of medication abortion.
There are currently two drugs used for the standard medication abortion. The second one, misoprostol, which was developed to prevent and treat gastric ulcers, is just as safe and nearly as effective at terminating a pregnancy. It is also easily available with a prescription at any pharmacy.
That doesn’t make the ruling any less an affront to human rights. Withholding a safe, effective medication from patients in order to pursue a political objective is barbaric, even if a secondary treatment remains. The lawsuit and Kacsmaryk’s decision falsely claim that the FDA rushed its approval of mifepristone and that the agency ignored the potential dangers of the medication. In actuality, mifepristone is safer than Tylenol, and it has been used without adverse effects by millions of people around the world. It has also been on the market for 23 years.
The drug blocks progesterone and stops a pregnancy from developing; it became known as “the abortion pill” because it is the only medication designed and prescribed solely for that purpose. But the truth is that it is not very effective on its own. So from the moment it was approved in France in the 1980s, it was prescribed in conjunction with misoprostol, which causes uterine contractions. Together, the two drugs will successfully terminate a pregnancy more than 95 percent of the time.
In countries without reliable access to mifepristone, misoprostol is regularly used alone. The World Health Organization recommends it as an alternative to the two-drug regimen when mifepristone is not available. And misoprostol’s widespread accessibility—it is sold over the counter in Mexico and is much less stringently regulated by the FDA than mifepristone—has also made it a popular choice for people managing their own abortions in the U.S.
Misoprostol has never been FDA-approved for use on its own as an abortifacient, but it is common practice for doctors to prescribe medications for off-label uses. Already, misoprostol is used every day by OB-GYNs across the country to induce labor, stop postpartum hemorrhage, and soften the cervix before gynecological procedures, even though the FDA has not approved the drug for those purposes.
And since misoprostol is an essential medication for other uses besides abortion, it is less susceptible to a blanket, politically motivated ban. In anticipation of this judicial decision out of Texas, abortion providers across the country have been preparing to pivot to a misoprostol-only protocol in the event of a mifepristone ban. Legal medication abortions will continue in the U.S. for the foreseeable future.
But the existence of an alternative protocol does not negate the inhumanity at the heart of this decision. Kacsmaryk, along with the anti-abortion activists who brought the suit, may end up compelling patients to undergo an inferior course of treatment when a more effective one—and one that can be less physically grueling—is available.
What does that actually mean for patients? Studies of misoprostol’s efficacy as a solo abortifacient have returned varying results. A systematic review of clinical trials found that taking misoprostol alone causes a complete abortion about 78 percent of the time. In the only study that has ever been done on self-managed abortion—that is, outside a clinical setting—with misoprostol in the U.S., 88 percent of participants reported a successful pregnancy termination without additional intervention.
Carafem, an abortion provider with clinics in four U.S. cities that also offers mail-order abortion medication, has offered misoprostol-only abortions to certain patients since 2020. (It is a less expensive option, in addition to being less vulnerable to legal restrictions, at least for now.) Melissa Grant, Carafem’s chief operations officer, said clinicians noticed that patients who used misoprostol alone were slightly more likely to report a continued pregnancy after treatment than patients who used it with mifepristone. Those patients had to take misoprostol again or undergo in-clinic procedures to complete their abortions.
In other words, banning mifepristone could mean more money spent, more mental anguish over lingering symptoms of an unwanted pregnancy, and more time spent arranging treatment and figuring out how to step away from work or family responsibilities. For people who live in states that restrict abortion, it could mean a second trip across state lines.
It will also mean more pain and suffering.
The experience of a medication abortion can vary widely from patient to patient, but it is generally not a pleasant undertaking. Patients will experience cramps and bleeding as misoprostol causes the uterus to contract and empty. Abortion providers often prescribe anti-emetic drugs and pain relievers along with the medication, to be taken just before ingesting it, because the drug can cause headaches, nausea, and vomiting, along with diarrhea.
One Scottish study of medication abortion patients who used the two-drug regimen found that 77 percent of patients experienced at least 1 of those 4 side effects, and the average worst-pain score patients reported was 6.7 out of 10.
But because it takes much more misoprostol to terminate a pregnancy without the assistance of mifepristone—three doses of four tablets, left to dissolve in the mouth, rather than a single dose of four—the physical toll can be harsher. Studies that have directly compared the misoprostol-only protocol with the two-drug course have found that “patients using misoprostol-only may experience more immediate, intense, and prolonged side effects than those using a mifepristone regimen,” according to an article published last month in Contraception, with a higher prevalence of diarrhea, fever, and chills.
If mifepristone becomes unavailable as a result of Kacsmaryk’s decision, every excess moment of pain or discomfort, every additional incidence of gastrointestinal distress, and every second try after an unsuccessful misoprostol-only abortion should be read as corporal punishment at the hands of the government.
There is not a single medical reason for any U.S. patient to have to settle for an inferior treatment plan for medication abortion. We are the wealthiest country in the world; even as the FDA has maintained excessive restrictions on how mifepristone is distributed and who can prescribe it, making it ludicrously overregulated for a drug that is as safe as it is, the medication has been widely distributed and safely used by millions of people. The only reason why any future patients will have to resort to a substandard drug protocol—one that is less likely to work and more likely to give them diarrhea—is because Kacsmaryk, the anti-abortion activists who filed the suit, and the conservatives on the Supreme Court want them to.
This is what it means for a public official to meddle in medicine, as all anti-abortion politicians (and all those seeking to curtail or criminalize transgender health care) strive to do. In the wake of the Supreme Court’s overturning of Roe v. Wade, the photographic negatives of all those abortion-rights slogans and clichés—“My Body, My Choice”; “decisions made between a woman and her doctor”—are looming into focus. It’s your body, but it’s the Federalist Society’s choice. The question of which medicine to prescribe is decided by a woman and her doctor, with ultimate veto power granted to the cruelest University of Texas law school graduate of 2003.
The ludicrousness of this arrangement has been highlighted time and again by reproductive rights advocates over the years, such that one might easily become numb to its horror. But everyday Americans and medical practitioners alike should be horrified anew by the prospect of an extremist judge forcing patients to accept a less effective, less comfortable treatment when a better one is available. Who is Kacsmaryk to sentence a patient to excess pain? How many additional women must vomit and ache to appease his political passions? If a doctor withholds the most effective treatment from a patient for no good medical reason, she may be accused of malpractice; when a civilian acts with the intent to cause another person physical suffering, we call it assault. When the Supreme Court and Matthew Kacsmaryk willfully obstruct access to medical care, with the intent of forcing patients into months of unwanted pregnancy, the pain and injury of unwanted childbirth, the torment of failed medication abortions, and the added discomfort of a medication that causes unpleasant side effects, what other word should we use?
To be clear, the difference between a misoprostol-only abortion and one with the addition of mifepristone is not vast. Using misoprostol alone is still extremely safe, physically tolerable, and very likely to successfully terminate a pregnancy. But refusing patients’ access to gold-standard medical treatment to satisfy a personal religious and political agenda is unethical at its core.
That barbarism is at the heart of the anti-abortion project; it feeds on the pain and suffering it creates. The more arduous an abortion seems to the public, the easier it is for the anti-abortion movement to argue, however disingenuously, that it is a dangerous, frightening, emotionally scarring ordeal from which women should be protected with severe regulations or outright bans.
The safety and efficacy of abortion medication threaten this objective. In fact, after mifepristone was approved in France and discussions about FDA approval were underway, anti-abortion activists were dismayed to find that the availability of the medication skewed the average abortion earlier in pregnancy and demystified the process for patients—which jeopardized the salience of abortion as a political rallying point. The Washington Post reported that anti-abortion groups worried about the “banalization” of abortion that the pill could induce. A Republican pollster fretted to a reporter that the drug could make pregnancy “a problem that can be easily taken care of”—suggesting that right-wingers wanted abortions to be as taxing and traumatizing as possible.
Now they’re getting exactly what they want.
In the recent Contraception article that noted the increased side effects of the misoprostol-only regimen, the authors observed that mifepristone’s safety and efficacy has been “conclusively established” during its 35 years of use across the globe. “From a medical perspective,” they wrote, “to prohibit use of this drug for abortion care is senseless.” That phrase, “from a medical perspective,” has stuck with me in the days since I read it. The medical perspective—reduced to just one perspective of many on the topic of medication, humbly submitted, to be readily discarded by an extremist judge and his friends on the Supreme Court for any reason, or no reason, at all.