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And even though mifepristone has won federal approval, the current patchwork of state laws still applies. Some states require any doctor who performs abortions to register with the state and report every procedure he does. Some have rules about the design of offices where abortions occur or require that the fetal remains be examined by a doctor. In North Dakota, the law requires that remains be buried or cremated.
Apart from the logistical and legal hurdles, there are the moral and psychological ones. Doctors who don't do abortions on principle are not likely to change their mind based on the method. Those who approve of abortion under certain circumstances will still want to see how mifepristone works, how widespread its use becomes and whether a backlash could endanger their entire practice. Dr. Thomas Purdon, president-elect of the American College of Obstetrics and Gynecology, spoke with a lot of his colleagues last week after the news broke and found them both receptive and cautious. "The medical abortion is less traumatic and done so much earlier in a pregnancy that physicians can rationalize the fact that they are not disrupting a more advanced pregnancy," he said. "The emotional and ethical barriers are easier to cross."
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.