The Pill Arrives

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RU 486

ALTERING THE DEBATE: A woman taking part in clinical trials at a Planned Parenthood clinic gets a dose of mifepristone

Did the landscape of abortion in America really change forever last week? Come take a tour. Dr. Stephen Grillot practices family medicine in Colby, Kans. In his town, a woman looking to end a pregnancy would need to drive 300 miles to Wichita to find the nearest abortion clinic. That's if she had the time and means to get away and was willing to pass the protesters to enter a building that has been bombed out and fired upon.

Last Thursday, when the Food and Drug Administration approved the sale of the abortion pill mifepristone--long known as RU 486--it put fewer restrictions on its use than anyone had expected. Virtually any family doctor or ob-gyn can now prescribe the two-drug regimen, provided he or she has some surgical backup arrangement if it fails to end the pregnancy or there are side effects. No more clinics; no more waiting until pregnancy is far enough along for surgical abortion. Just a series of pills taken over a period of days to induce a miscarriage. Advocates hailed it as the greatest breakthrough in women's health since the Pill and vowed to have mifepristone in doctors' hands within a month.

Grillot supports a woman's right to decide whether and how to end a crisis pregnancy. But he will not be offering this drug. Pro-life sentiment runs strong in his town. "My partners would have a fit if I used it in my practice," he says. "It will be used in the bigger cities. But in a small town like this, it would be hard. Everybody would know about it."

If only doctors in the big cities use it, what will really have changed? Last week's much heralded FDA decision--the denouement of years of controversy over a pill developed in France two decades ago--was not hailed as a triumph just for urban women who already have choices. Mifepristone proponents predicted that when it finally reached the market, it would privatize the whole experience of abortion, take it out of the streets and the courts and the Congress and into the privacy of the home and the doctor's office, enabling women to end a pregnancy before the embryo even resembles a fetus, much less a child. It would change medicine by offering a less invasive procedure; change politics by moving abortion earlier in pregnancy, when fewer people have moral qualms; change, above all, the access, since protesters wouldn't know where to set up a picket line if abortion became part of mainstream family practice.

Maybe the doctors who fell so silent last week in the face of such dramatic medical news were just waiting to learn more themselves, study the legal and financial implications, weigh the ethical ones, of offering a new kind of abortion to their patients. But for all the cheering of abortion-rights activists, it could be a long time before we really know what difference the marketing of mifepristone will make. Opponents vow to take to the streets in force, target the doctors who agree to prescribe it, gouge the conscience of anyone willing to wage chemical warfare on women and children. They call the drug baby poison and are enlisting allies in Congress to try to ban it, threatening boycotts of whoever makes it. As for the doctors faced with a decision, the greater the heat, the greater the fear. It's understandable that they could take a while to make up their mind--which means that what really changed last week may be more the promise of abortion in America than the reality of it.

Most people stay in the balcony of the abortion debate, looking down on the drama from the crowded middle seats. Their feelings tip and tilt according to circumstance and conditions: Was there a waiting period, counseling? If it's a teenager, do her parents know? Surveys find that 65% of people accept first-trimester abortion, but 69% oppose anything later than that. The laws reflect the public ambivalence of a country that wants abortion to be available but not easy. And pro-life forces have done everything in their power to make it harder, by focusing on the unimaginably hard cases. How can you abort a fetus developed enough to have fingernails, they ask?

In fact, for all the moral and legal wrangling, science has been the pro-life camp's best ally over the past decade, as doctors steadily moved up the point of viability, saving premature babies as young as 25 weeks, 24, 23. Sonograms as clear as Christmas cards let parents see their babies suck their thumbs in utero. Better prenatal testing has built greater awareness of how, and how quickly, a fetus develops--all of which may have fueled the discomfort with abortions that occur when a pregnancy is well along.

You could argue that the most important thing that happened last week was that science changed sides and put its power to work for the pro-choice team as well. The abortion pill shifts the focus from the latest stage of pregnancy to the earliest, when the entire embryo is the size of a grain of rice. For abortion-rights activists scarred by five years of fighting over "partial birth" abortions, that is where they prefer the public debate to take place.

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