They Support Choice If the Pill Kills but Not If It Saves

Dr Michal Pruski is a Clinical Scientist at the Cardiff and Vale University Health Board and a DClinSci candidate in Health Informatics at the University of Manchester (UK). He is academically trained in both basic and clinical physiology as well as in bioethics.

After the US Supreme Court’s reversal of Roe v. Wade, a number of states have immediately banned abortion. Pro-choice activists are responding by promoting medication abortions – a do-it-yourself form of abortion. Women can take pills at home to induce an abortion in the first few weeks of pregnancy.

The Biden Administration has backed the abortion pill, too. Attorney-General Merrick B. Garland and Health and Human Services Secretary Xavier Becerra both issued statements endorsing it.

“We stand ready to work with other arms of the federal government that seek to use their lawful authorities to protect and preserve access to reproductive care,” said the Attorney-General. “In particular, the F.D.A. has approved the use of the medication mifepristone. States may not ban mifepristone based on disagreement with the F.D.A.’s expert judgment about its safety and efficacy.”

As the New York Times has noted, this sets the scene for legal battles. The obvious one is: will anti-abortion states prosecute medication abortions?

But – based on experience in the United Kingdom — the use of the abortion pill could give pro-life doctors headaches as well.

In the past year, UK has witnessed the saga of two Catholic doctors who have been brought in front of the professional regulator, the General Medical Council, after accusations of professional misconduct. Their crime? They had supplied abortion pill reversal (APR) treatment to women. Accusations of this misconduct have been brought forward by pro-choice organisations.

The problem is that some women might panic when they discover that they are pregnant or are pressured to make a rash decision. They obtain abortion pills, often without seeing a doctor face-to-face, and soon after taking the first pill, they regret their decision.

Is it too late for them to save their pregnancy? Not necessarily.

A treatment developed in the US works about half the time. It involves the woman taking progesterone after the first abortion pill to counteract the abortifacient action of the drug.

Seventy-three women in the UK are reported to have taken a full APR course, of whom, 38 – more than half — successfully remained pregnant. Admittedly, the procedure is controversial, with pro-choice writers denouncing it as unproven, unscientific, and unethical.

This has triggered some healthcare practitioners and scholars to analyse the commitments of the pro-choice movement to APR. In a recently published paper in The New Bioethics, two colleagues, Dominic Whitehouse and Steven Bow, and I argue that those espousing a pro-choice worldview should actually support abortion pill reversal and that the current evidence indicates that they should actually be doing it.

While some pro-choice activists might be happy simply to expand women’s reproductive choices, some might also want to ensure that these choices are safe and effective at achieving the desired outcome, which in principle includes maintaining a pregnancy.

We then review the scientific evidence with respect to the ability of APR to halt an abortion, look at the potential impact of APR on mental health, as well as its procedural safety.

While highlighting that gold-standard evidence is lacking, we note that APR is associated with about two times higher rate of embryo survival compared to not completing the full early medical abortion course, that there is large agreement in the literature that women who are ambiguous about abortion are at risk of poorer mental health outcomes after abortion (and argue that women who request APR fall into this category), and highlight that there is no evidence that APR is more dangerous than abandoning an initiated early medical abortion.

The latter fact is important, as the results of the only randomised-controlled trial of APR have been at times misrepresented in the media, creating the impression that APR is not safe while most of the adverse effects occurred in the study group that did not receive APR.

As our paper argues, with respect to APR the two UK doctors were “champions of women’s choice and should be congratulated, not condemned, by pro-choice advocates”.  

While the cases against the two doctors have now been dropped (and there have even been accusations against a member of one of these pro-choice organisations that they pressurised a patient into complaining about one of the doctors and twisted their experience of the treatment), we argue that it is important to set-up systems to facilitate the future provision of APR to protect both patients and healthcare staff.

Our conclusion is that, while being open to any change in evidence, those espousing a pro-choice outlook should “support calls for an APR framework that will protect women and the healthcare professionals caring for them” “and certainly not oppose” APR. 

The debate over abortion pill reversal will be heading to the United States soon. It is quite possible that it will be denounced as dangerous misinformation. It’s not. But pro-life defenders should be prepared to defend their ground.