HEALTH CARE/Joan Retsinas

When States Play Doctor with Abortion: A Cautionary Tale

Sometimes state legislators yearn to play doctor. They want to don those nifty white coats, like super-heroes, and protect hapless women, otherwise doomed to suffer from their ignorant physicians. And, flexing their new-found medical wisdom, these legislative physicians have targeted abortion.

This cautionary tale from Ohio highlights the fallout when legislators –who can’t distinguish an MRI from an ultrasound, who think the Islets of Langerhans are in the Indian Ocean, and who don’t know precisely what a statin is - step in as ersatz physicians, to safeguard women from their real physicians.

The tale begins with mifepristone and misoprostol – the two ingredients familiar to scientists at the FDA, unfamiliar to the legislators in Ohio. But no matter. Ohio legislators plunged down the pharmaceutical hole anyway, to emerge with an edict.

Briefly, mifepristone and misoprostol are the key ingredients in a two-part abortion pill. Sixteen years ago, when the FDA first approved the pill, it set dosages for each pill – one to follow the other. At the time, the FDA required women to see a physician for each pill, to help physicians monitor the effects of the pill, which include cramping and bleeding. The FDA also prescribed a safe effective dosage. With the pill, women did not need to seek out a clinic, but could substitute out-patient visits. The pill would work in the early stages of pregnancy (before seven weeks).

Five years ago, Ohio legislators, along with their counterparts in Arizona, Arkansas, North Dakota, Ohio, Oklahoma and Texas, required physicians and women to abide by those 2000 FDA guidelines. On first glance these laws seem strange. For diabetes, hypertension, pulmonary disease, arthritis – the list goes on – the legislators didn’t rule on treatment. On second glance, this law seems benign. Why not abide by the FDA guidelines? What is the harm?

The harm lies in the mismatch between legislation and science. The science of the day – or at least what we know at the moment, which is all we can know — changes, more quickly than state legislatures. Over time, physicians recognized that lower doses, with milder side effects, would work as effectively, that women could take these pills on their own, without sitting in a physician’s office, that they could take them as late as 10 weeks into pregnancy. In states where physicians were free to prescribe “off label,” they prescribed the abortion pill in lower doses, to be taken at home. In those states, women seized on the abortion pill – a useful option at a time when the number of abortion clinics was shrinking.

In Ohio, the legislature tied women and their physicians to an outdated regimen. Researchers (from Advancing New Standards in Reproductive Health at the University of California-San Francisco) analyzed the results. Women were forced to take higher doses of this potent pill. Women suffered more side-effects; they were more likely to need follow-up care; they paid more for the higher dosages, the additional visits. And, crucially, women were less likely to use this option.

In March the FDA revised its guidelines, reflecting clinicians’ experience. The FDA now calls for lower doses, to be taken at home, up to 10 weeks into pregnancy. And Ohio’s law (along with laws in North Dakota and Texas) in calling for adherence to FDA guidelines, is in sync with medical wisdom. (Courts nixed the laws in Arizona, Arkansas and Oklahoma.)

But when physicians play doctor, ostensibly to protect patients, by requiring ultrasounds, waiting periods, specific surgical procedures, those physician-legislators are not protecting patients, but simply restricting abortions.

In their quest for abortions, women face a formidable foe in state legislatures. States could effectively lower the demand for abortions by assuring women sufficient income to raise their children, safe housing, and good schools. States are unlikely to do that. Look at states’ reluctance to raise the minimum wage or expand Medicaid.

States’ crueler tactic has been to restrict supply by blocking women’s access through a myriad of edicts. Ohio legislators were not saving women from their physicians, but blocking women’s access to “medical” abortions, leading women to greater complications.

Ironically, these ersatz physicians were violating a cardinal rule of medical ethics: first, do no harm.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, October 15, 2016

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