The Pill Arrives

  • JAMES WORRELL FOR TIME

    RU 486

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    RALF-FINN HESTOFF--SABA FOR TIME
    AWAITING WORD: Participants in a seminar for clinicians who would administer the pill, just before the FDA announcement

    But he and others still found that many doctors simply don't want to get involved in a battle that has left the country divided and some of their colleagues dead. They have heard of the doctors and nurses who, when they arrive for work at a clinic, confront protesters who refer to their children by name. "Many doctors feel if someone else provides it, why bother? Somebody else will do it," observes Dr. Lisa Tucker, who works at the Florida clinic where Dr. David Gunn was murdered seven years ago. Experts liken this debate to the one over physician-assisted suicide: "A lot of doctors believe in it but say they won't do it themselves because they don't need the hassle," says George Annas, a medical ethicist at Boston University School of Public Health. "They don't want to get involved in a public debate."

    There are already cautionary tales arising from the early clinical trials. A family doctor in a rural, conservative town in the Northeast had a pregnant 18-year-old patient who wanted an abortion. He did not do surgical abortions, but he did offer her a medical alternative, using not mifepristone but the cancer drug methotrexate, which was also being tested in trials as an abortion inducer. The doctor, knowing that his nurses opposed abortion, administered the drug himself. That was in January 1998, and by Easter, the nursing staff had heard what happened and a nurse resigned. The local church got involved; at the Easter service the pastor asked worshippers to "pray for the doctor and the other souls" at the medical center. Soon petitions poured in. The state medical board investigated and found nothing wrong but issued a reprimand anyway. Insurers informed the clinic it was not covered for abortions, although the only classification was for surgical abortions. Some patients dropped the clinic, and some donors stopped providing funds.

    Even if more doctors offer mifepristone, there remains the question of how many women will choose it. The women who took part in clinical trials represented a cross section of society, with a range of reasons for opting for the drug. Asian women were twice as likely as others to choose mifepristone because they considered it safer; white women were twice as likely to use it as nonwhites because they considered it more natural. More educated women chose it because they wanted to show support for broader choices and because they wanted to avoid surgery. Nearly all the women in the study found the drug highly acceptable and would recommend it to others.

    Yet the women in the trials were a self-selected group. For the general population, the pill is a new option, but not an easy one. It is not likely to be less expensive than surgical abortion, given the number of doctor's visits and the possibility that the pills will sell for $200. And it is not as though you take a pill and the baby disappears. Medical abortion, as opposed to surgical, is a multistep process, requiring three visits to the doctor over a period of two weeks. The first visit is to make sure the pregnancy is still early enough for the pill to be used safely, which will automatically exclude many women who don't realize they are pregnant until more than 49 days after their last period. Two sets of pills are required--first mifepristone, then, two days later, misoprostol, to trigger contractions and expel the fetal tissue--and that can cause nausea, heavy bleeding and painful cramping. After about 12 days, a woman must return to the doctor to confirm that the abortion was successful.

    Some doctors see a psychological advantage to the new procedure by giving patients the sense that the process is more natural because their body is doing the work, not a surgeon's vacuum. "My patients are usually under a lot of stress and are trying to find the appropriate action to take," says Dr. Carolyn Westhoff, a professor of obstetrics, gynecology and public health at New York's Columbia University, who has conducted many of the mifepristone trials. "For someone who feels backed in a corner, it is good to feel you have a choice."

    That is not to say mifepristone makes abortion morally simple. In fact, some doctors argue the opposite. Carole Joffe, a sociologist of reproductive health and visiting professor at Bryn Mawr College, believes mifepristone could make abortion "more emotionally wrenching because women who take mifepristone experience something like a miscarriage, where they have to confront the product of conception." Women who undergo surgical abortions don't usually see the fetus. With mifepristone, a woman typically passes large blood clots in the toilet within 24 hours after taking the second pill.

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