00:00:21.140We are on the road, as it were, and we're coming to you today with an episode about
00:00:28.220mifepristone, the little pill that causes a big fuss. Adrian, what do you know about mifepristone?
00:00:34.000I know that it is sometimes called an abortion pill. And it's the main way in which people can
00:00:39.160control their own pregnancies in states that have otherwise outlawed abortion because it is
00:00:44.860available through the mail. And that has made it the next flashpoint in the rights war on
00:00:50.840reproductive freedom. Yeah. So sometimes it's called the abortion pill. Usually when people
00:00:55.780say the abortion pill. They're talking about mifepristone, although there's actually two
00:00:59.920different kinds of pills used in a medication abortion, five pills total. Right. One of
00:01:04.700mifepristone, one of misoprostol, which we're necessarily going to touch on a little bit today.
00:01:08.840But today we're really focusing on mifepristone because this is the pill that gets most of the
00:01:14.080controversy and most of the opposition. It's also sometimes called by its like research lab name,
00:01:20.620Its codename from when it was being developed in 1980, RU486, R as in Robert, U as in Ursula, 486.
00:01:29.060When I was a young internet feminist back in the olden days, there was like one user whose screen name across all the different platforms was IAM486.
00:02:03.380And it's why the number of deaths and illnesses caused by illegal abortions in red states has not gone up as much as it otherwise would have.
00:02:11.960That's because of this pill, because the pill is ubiquitously accessible and pretty easy to take and pretty reliably safe and effective.
00:02:23.680So Mifepristone is also, as you can imagine, the subject of a lot of controversy, right?
00:02:28.720It is the object of attacks from the anti-choice movement as they regroup after their Dobbs victory and set about their longer term goal of ending abortion entirely.
00:03:06.060But it probably won't be around forever or it might not be around forever. The future of mifepristone is uncertain on several grounds, right? Because Trump judges or the Trump FDA might not allow the drug to continue being distributed by telemedicine.
00:03:23.280They might say it has to be dispensed in person, which will make it much harder to get, especially in red states. That's one legal question.
00:03:28.940Right. There's also the question of whether the Trump DOJ or any of the Trump aligned justices on the Supreme Court will keep allowing abortion medications to be sent through the mail. Right. Or whether it will be banned entirely or whether sending it through the mail will be banned, not just by the FDA, but under the like 1873 Comstock Act.
00:03:47.880We still got to do a Comstock Act episode.
00:03:50.660Yeah, Comstock, the guy who won't die.
00:03:54.320There's another issue of like whether the FDA, which is now controlled by Trump appointees, will find a way to say that Mifepristone is like unsafe or unfit for the U.S. market and like pull it from the shelves entirely.
00:04:09.120Yeah, to be fair, it does not contain the currently FDA mandated quantity of beef tallow.
00:04:14.200So shocking little beef tallow in American abortions these days.
00:04:20.400Also, horses that they give it to tend to still have worms.
00:04:23.480So how safe and effective is it really?
00:04:26.420And then, you know, in the long term, of course, it's unclear that the Supreme Court will keep allowing states to decide to make abortion legal within their borders.
00:04:35.140Right. Abortion could be outlawed nationwide under this court.
00:04:38.660So post-Dobbs, we're in a bit of an interregnum period with abortion politics.
00:04:43.620Wait, Moira, I heard that the court's actually more of a 3-3-3 court. I've heard that they would never do that. The person who told me that is that they would also never decide Dobbs or kill the VRA. I sold them a bridge. It's a nice one. It doesn't work, but, you know, I got rich.
00:04:58.880But like right now, we are in a bit of an interregnum period, right? The right one on Roe, but they haven't yet won a nationwide ban.
00:05:08.280And so it's still unclear how they will go about seeking a nationwide abortion ban, what steps they will take along the way. All that's up in the air. But it is clear that this drug, mifepristone, is going to be central to that coming battle.
00:05:27.080So as we said, mifepristone is one of two drugs used in medication abortions, which now account for a very solid majority of abortions in the U.S.
00:05:34.340And together with misoprostol, which is originally an ulcer drug, but it's used off-label in abortions, mifepristone is over 97 percent effective in terminating a pregnancy.
00:08:03.300So the standard medication abortion, just so you know, like, what it's like, goes something like this.
00:08:10.000MIFI, mifepristone, comes first and you just take one pill, right?
00:08:15.640And mifepristone is a hormone blocker.
00:08:18.100It works by blocking progesterone, the pregnancy hormone.
00:08:22.000And blocking progesterone does a few things.
00:08:23.940It stops the development of the fetus, but it also helps to dilate the blood vessels in the uterus, which helps break down the uterine lining.
00:08:32.080And it helps to soften and open the cervix, which makes it possible for the contents of the uterus to move out.
00:08:37.380So you take one of those pills and you just swallow it.
00:08:40.66024 hours later, the patient takes MISO, usually four pills.
00:08:45.040And those have to dissolve instead of being swallowed.
00:08:48.100Right. So you can put them in your cheek. You can put them under your tongue. Some people use them as like a vaginal suppository because they don't like the way they taste.
00:08:55.460Oh, that all works. And some people might be told to take more miso, like further doses of four pills of miso, like a few hours later, either because they have a higher body weight or in rare instances because the initial dose doesn't complete the abortion.
00:09:10.220But what happens is that the miso then like causes contractions of the uterus. Right.
00:09:15.900So MIFI starts to break down the contents of the uterus, sort of like soften all of that stuff, and then MISO squeezes it out, and that's a miscarriage.
00:09:24.280Generally, this combination works really, really well, and it almost always works the first time.
00:09:30.300So MIFI has cut off the progesterone and started to open the cervix, and then 24 hours later, MISO induces contractions of the uterus, which expels the contents out through the cervix.
00:09:40.760This is how together the drugs induce miscarriage.
00:09:43.540Patients will experience cramping and bleeding that will be intense for about 6 to 12 hours.
00:09:49.000And then, like, lighter bleeding that continues for, like, up to two weeks.0.99
00:09:53.640But then they're not pregnant anymore, right?0.51
00:10:16.200But in the United States, there was an intense pressure campaign by anti-abortion forces to keep the drug illegal, not just out of the U.S., but like not imported.
00:10:27.340But after an extremely long, drawn out, unusually thorough and rigorous approval process and a ton of pressure from the pro-choice movement in the U.S., federal regulators finally approved MIFI for the U.S. market in 2000.
00:10:44.060And then it was formally allowed in America.
00:10:46.840And it completely revolutionized how abortions happen.
00:10:49.020Yeah. So I think it might be useful for the context of like how MIFI has made illegal abortions post-Obs very different from illegal abortions pre-Roe. It might be good to know that like before the invention of MIFI, and it's like introduction to the U.S. in 2000, most abortions were surgical abortions, DNC or DNE procedures. And those are abortions that are performed manually with surgical instruments inserted through the vagina and through the cervix into the uterus.
00:11:17.720So like the cervix, which acts as kind of like a gateway between the vagina and the uterus, got dilated manually with these like long metal rods.
00:11:25.960And then the uterus was scraped out with a curette, right?
00:11:47.420It's also, by the way, the standard treatment for an involuntary miscarriage.
00:11:50.680It's just like the basic way to empty the uterus.
00:11:53.580But D and C abortions can also be kind of onerous.
00:11:56.380You have to go to a clinic to get them.
00:11:58.580And after Planned Parenthood versus Casey, the 1992 Supreme Court decision that allowed states to place lots of restrictions on abortion in the name of like protecting health.
00:12:09.220You often had to go more than once, right?1.00
00:12:10.920You had to go a couple of times before you could get your actual abortions.
00:12:13.860Yeah, the first time the doctor had to, like, talk to you about how beautiful babies are.
00:12:18.020The second time they had to read, like, five Bible verses to you.
00:12:20.580And the third time you had to measure just how large the hallway between all the different rooms was in the clinic to make sure that it was actually up to code.
00:12:28.440Yeah, and you would also have to have, like, sorry, like a transvaginal ultrasound.1.00
00:12:31.720Like, the state would mandate that they shove something into your vagina.1.00
00:12:34.280Like, it's really, really an unpleasant, onerous procedure with a lot of medically unnecessary institutionalized humiliation mandated by law.0.99
00:12:42.340And also, like, clinics have been made into unpleasant places.
00:12:45.940They're often, like, long waits because there's not a ton of clinics that perform abortions.
00:12:51.120There's screaming protesters outside that you have to endure the humiliation of walking past.
00:12:55.820So, like, abortions in clinics are safe, but they're also uncomfortable.
00:13:01.820No, having biked by the Planned Parenthood in San Francisco, even in San Francisco, I've been like, oh, wow, like, this does not seem fun.
00:13:08.540And like, look, it's not like a walk in the park physically, right? It's not the kind of thing that's going to knock you out, but is the kind of thing you want to wear sweatpants and carry some Tylenol for, right? So Miffy was really a revolution in privacy and inconvenience.
00:13:25.040When it first came onto the market, you still had to go in person to get it prescribed, right?
00:13:30.000So often you still had to make multiple trips to the clinic, depending on state laws.
00:13:33.480You still had to have, like, a ultrasound.
00:13:36.320You still had to get a lecture about how you're, like, a bad person killing a baby, etc.
00:13:40.340But you got to have your actual abortion at home, in your own house, surrounded by your own stuff, your pets, your friends, your couch, your kids.
00:13:49.860And crucially, you got to do it in private.0.62
00:13:51.900I was going to say, privacy and convenience, two things that Republicans don't seem to think women deserve, largely.0.91
00:14:10.260So, they would bleed at home, and they'd cramp at home, and those intimate, uncomfortable aspects of an abortion would be more dignified by being done in private, right, and more comfortable by being done at home.
00:14:21.440Yeah. The MIFI wouldn't have any immediate results, right?
00:14:25.520No, it would probably, and we're going to get into this, it would end a pregnancy, right?
00:14:29.100You can't just take MIFI and stay pregnant, really, although that will become the object of some anti-choice propaganda.
00:14:35.100There's some studies on MIFI-only abortions, but generally you don't want to do that.
00:14:38.380You want to have an additional step to empty the uterus.
00:14:41.160But I guess what I'm trying to figure out is, like, would there be any discomfort that early on, or would you take it in front of your physician and then walk out?
00:14:47.480Some people report cramping, but you take it in front of your position and walk out, and then you take the MISO 24 hours later, and that's when the cramping really starts. It's abdominal pain. Yeah.
00:14:56.540Right. So MIFI also really revolutionized the practice of abortions for clinics. The privacy, the convenience, all of that was good for patients. But I think it really gets undersold how good MIFI is for providers because a surgical abortion in a clinic is a really resource intensive process, even if it doesn't take very long.
00:15:20.040You need other staff's time to assist and supervise.
00:15:22.880You need equipment and you need to be able to sterilize it.
00:15:26.100You need drugs to dilate, drugs to anesthetize, drugs for preventative antibiotics.
00:15:30.980You need a procedure room and then you need a chair and a recovery room.
00:15:34.620The pill, by contrast, gets rid of like a lot of that overhead.
00:15:38.320It's a lot less resource intensive and labor intensive for providers.
00:15:41.880You just hand it over and she swallows it.0.99
00:15:44.280So in the pre-Dobbs but post-Casey era of abortion law, when there were a ton of restrictions, but technical legality, that's when Miffy enters the scene.
00:15:54.580And there were already a lot of onerous, medically unnecessary, like time-consuming restrictions that providers had to comply with, right?
00:16:01.020All that compliance, getting the admission privileges at the local hospital, ensuring the facility is up to like ambulatory surgical center standards, doing an ultrasound on every single patient, observing waiting periods.
00:16:13.780all of that really did take up a lot of time and a lot of money.
00:17:07.100Midwives in the 19th century sold abortifacients made of things like pennyroyal, people would drink turpentine, there was like ergot, Spanish fly, all of which were like medicines that worked on the idea that they were poisonous, but if that you took just the right dose, it could cause your body to induce like a purging response.
00:17:28.400So, like, vomiting, diarrhea, and as a, like, immunoresponse, emptying of the uterus, right?
00:17:34.120And the idea was that you get, like, just the right dosage to prompt that response without killing you, right?
00:17:39.720But as you can imagine, these had their downsides.
00:17:42.480Yes, yes, I feel like you've just said all of them.
00:17:45.760Yeah, it could be dangerous. It could also be unreliable, right?
00:17:48.840These were not as reliable or as effective as Miffy is.
00:18:53.400People did die kind of all the time in the pre-Roe era because of these vulnerabilities that are inherent to the surgical method.
00:19:00.880There's just a lot more ways to get hurt when you're having a black market surgery than there are if you're merely taking a black market pill.
00:19:48.140So we're going to go into more detail about the regulatory history of Mipristone, but for now suffice it to say that in 2021, after Biden came into office, but before the worst of the pandemic had sort of abated, the Biden FDA lifted this longstanding requirement that Miphy be distributed only in person and allowed the drug to be dispensed via telehealth.
00:20:12.380Nominally, this was about COVID safety, right?
00:20:14.620Like, OK, fewer people going in person to abortion clinics to retrieve their pills from a provider in the same room meant that there would be fewer chances of COVID exposure.0.89
00:20:24.860But really, this was a nod to the sort of like coming post-Roe future.
00:20:29.960Donald Trump had put three justices on the Supreme Court just during his first term.0.90
00:20:34.420A test case was already winding its way through the federal courts.
00:20:37.720And the writing was on the wall for the national abortion right.
00:20:40.700Like, Roe was going to be overturned. Everybody knew this by 2021. This is a bureaucratic thing that the Biden administration actually did right, I think.
00:20:48.940I was going to say, that's pretty smart.
00:20:50.360Yeah, they had a way to expand abortion access without needing congressional approval, and they went for it. And they made that rule change permanent in 2023. So you used to have to go in person to get your mifepristone prescription. Now you don't. Now you can see somebody on the Internet, right? You don't need an ultrasound. You can just get your pill.
00:21:09.960And that has made it very, very easy to get mifepristone.
00:21:14.520That means it's now legal for providers to prescribe mifid to patients they are not physically present with.
00:21:20.100And what has emerged in the years since Dobbs is a vast system in which providers living in democratically controlled states with quote-unquote shield laws,0.68
00:21:29.180which are like laws that forbid state or local authorities from cooperating with abortion investigations from red states,
00:21:36.000They go online and they prescribe MIFI to women living in red states.
00:21:41.400And sometimes this comes after a telehealth appointment, like a Zoom meeting.
00:21:45.060But sometimes it's just like patients just fill out a form online and then the pills are shipped.
00:21:51.180And some providers will only ship the pills to a place where abortion is legal.
00:21:54.160So a patient living in like Arizona might have to have their provider in like San Francisco ship their pills to a P.O. box on the state line that the patient has to find a way to get to.
00:22:06.840But more and more providers are simply shipping the pills into the red states to these women's houses from the blue states.0.61
00:22:13.240Sometimes women will order pills through like third party pharmacies located in other countries.0.95
00:22:20.180So say a doctor located in like Spokane, Washington or upstate New York will order pills in from a pharmacy in India to be shipped to a patient in New Orleans.0.82
00:22:31.060It's a series of like really elaborate workarounds.
00:22:34.660Right. Because all the laws in red states targeting abortion provision really are entirely concentrated on the United States, the international picture.
00:22:43.300I don't think there's a law that says you can sue a doctor in India for providing this stuff. Right.
00:22:47.580I'm sure somebody will try, but it's mostly an intrastate battle right now.
00:22:53.160And in fact, like one of the ways that I think they might attack this system is attacking the constitutionality of those shield laws and saying, no.
00:23:00.900So, like, right now there's a woman named Maggie Carpenter who is a New York state-based gynecologist who has made it her job to ship these pills into red states to women who need them there, right?
00:23:13.760And she cannot physically leave the state of New York because New York has a shield law that prevents her from being extradited to the places like, I believe, Louisiana and Alabama both have warrants for her arrest.0.69
00:23:53.020So there's a lot of these like kind of elaborate workarounds that are merging what is technically legal with what seems like arguably legal or hasn't been declared illegal by the courts yet.
00:24:05.480And there's a lot of like shades of gray based on what risks providers are willing to take.
00:24:10.920There are doctors who only do this now, who have warrants for their arrest, like Maggie Carpenter.
00:26:09.580So this might be a good time to take a step back and look at the history of Mifeprestone.
00:26:14.280Because while the medication is under attack now, the fact is that the anti-abortion movement has been fighting tooth and nail against this medication and against the ways it has made abortion safer and easier for decades.
00:26:25.720So as I mentioned, Mifepristone, which was originally called RU486, was developed by the French pharmaceutical company Roussel-Ucloff.
00:26:34.460I'm going to necessarily have to butcher a lot of French names for the next couple minutes.
00:26:39.160Adrian, do you want to help me with this? How do you say this?
00:32:43.380The cheeses, the government forcing pharmaceutical companies to actually help people.
00:32:47.780Yes. You know, I think this is like maybe a moment to like pause and be like, look, medical authority has often not been the friend of feminism. Right. From psychoanalysts to obstetricians. Right. There's a lot of ways that doctors and the authority of doctors has been wielded against women's freedom. This is a place where scientific innovation, if not medical authority itself, is wholly on the side of women's advancement. Right. It's an unmitigated good.
00:35:02.260So not only can you not give this to American patients, you can't even do research on it at an American biochemistry lab.
00:35:09.760But so explain that to me, because for George H.W. Bush, this is like clearly an easy way to make good with the anti-abortion movement in his own party with minimal cost.
00:35:22.420Right. People don't miss something they've never experienced in the first place.
00:35:26.560But what on earth would possess Roussel ou Cleff?
00:35:29.580What are they afraid of bending over backwards so far in order to accommodate the Bush administration policies there?
00:35:35.640Yeah, you know, I'm not really sure what their thinking was.
00:35:37.520Maybe they were trying to secure favorable regulatory environment for their other products.
00:36:09.660So that research ban and that ban on importation is when this story turns from like a politicized but ultimately kind of banal story of corporate and regulatory bureaucracy into like the plot of a heist movie, at least for a little bit.
00:36:26.380Because have you ever heard of a guy named Lawrence Ladder?
00:36:28.960You're telling me we're leaving the Michael Clayton portion of this movie and going into the George Clooney and Ocean's Eleven portion of this story?
00:36:36.940It's actually been compared to Ocean's Eleven a lot.
00:37:28.360But that group, NARAL, successfully campaigned for abortion law reform in the pre-Roe era, right?
00:37:34.480And it became this, like, passion that really transformed his life.
00:37:38.400So by 1992, Leder is already in his 70s, and he's leading this different pro-abortion group called Abortion Rights Mobilization, or ARM, which is aiming to be a little more militant.
00:37:49.620He starts looking around for a test case to challenge a George H.W. Bush ban on Mifid Pristone in the U.S.
00:37:55.660And to do that, to get a case through the courts and to challenge the ban under Roe, as he intended to, he needed somebody who was injured.
00:38:04.920That is, somebody who was pregnant, didn't want to be, and was willing to be the center of, like, public controversy about it, right?
00:38:13.160So that's when he gets connected to Leona Benton, who is a 29-year-old self-described anarchist.
00:38:21.160She's living in Berkeley, which is, you know, remember this is 1992 when anarchists and punks can still live in Berkeley.
00:39:23.160So this case shoots right up on the shadow docket because it's on an emergency basis because she is pregnant.
00:39:28.640And that means time is ticking, right?
00:39:31.040The court rules against her just a couple days before she's no longer able to use the pills to end her pregnancy, according to the Roussel-Ukloff guidelines.0.62
00:39:39.960I think the last day she could have done it was a Saturday and they rule on like a Thursday evening.0.81
00:39:53.320John Paul Stevens and Harry Blackmun, the justins who had written Roe and was still on the court at the time, they both vote in her favor.
00:40:01.100She returns to California where she gets a surgical abortion like the day after the ruling.
00:40:06.160And she's used a statement saying that the ban's claimed rationale or the court's claimed rationale about being like, you know, this is a health protection to ban the drug.0.98
00:40:27.340But what the case does accomplish is it brings a big amount of media attention to the issue of abortion pills in the U.S.
00:40:34.380Where honestly, like, as you mentioned, Adrienne, like, the average person doesn't miss something they never had, but they also didn't really know that they could have had it, right?
00:40:41.480Your average, like, busy voter and news consumer often didn't know that this pill even had been invented, let alone that it had already been banned, right?
00:40:49.900Yeah, plus, I mean, like, if people know abortion as a medical procedure, it makes sense that you do an inpatient visit for it, right?0.99
00:40:56.640If you told me, like, that for years now the French have had a pill against appendicitis and, like, people have been going under the knife for it, it's like, whoa, shit.0.85
00:41:04.640But, like, you wouldn't know that, right?0.97
00:41:08.060It sounds somewhat invasive, so it would make perfect sense that, like, you can't just take a pill, right?
00:41:13.380Yeah, I mean, it's a big part of abortion stigmatization that people think that abortion is a lot more medically serious as a procedure than it is.
00:41:25.420But like this is part of the misinformation, the stigmatization, the sort of like mystique of terror around abortion that really gets destigmatized when it's just taking a pill, you know.
00:41:36.940But like the upshot is that the Bush administration looks backward and they look repressive.
00:41:41.180And the abortion rights movement now has new energy among its rank and file.
00:41:44.740And they've got this like PR win, if not like a legal win.
00:41:47.620But the other thing that happens, and this is the part that's actually kind of insane, is that somehow Ladder sneaks in a second dose of the pills.
00:41:57.740So the ones that were described to Leona Benton and which are confiscated by customs to establish that text case, those are not the only ones they have.
00:42:05.860And it's still not clear how he got this extra set of pills.
00:42:15.660The French pharmaceutical company that owns it doesn't even want to lend it out to researchers in the U.S. That's how scared they are of backlash from the American Christian right. Nobody has it here. And now he does. And Larry later sneaks his Contradan pill off to a secret lab where he instructs the chemists to reproduce it. And bam, now this isn't a foreign drug anymore. It's something that's been synthesized in the U.S. It's an American-made drug seeking approval.
00:42:41.100And Miffin-Pristone has a second pathway to the U.S. market, whether Roussel Ucloff likes it or not.
00:42:46.360Yeah, that is called import your abortion drug or the bunny gets it, right?
00:44:24.660They don't want to distribute it anymore.
00:44:26.680It looks like with this new Clinton administration that comes in in 1993, there's going to be a more favorable regulatory environment in the U.S. for an abortion drug.
00:44:34.640But they don't want to be the ones to deal with it.
00:44:51.920It is an international non-profit that was established when a Rockefeller got worried about global overpopulation in the 1950s.
00:44:58.740Oh my God, yeah, that's exactly what I thought it was.
00:45:00.080Yes. These days, the Population Council funds research for and holds the copyrights to a lot of contraception and HIV treatments and distributes those to manufacturers on a non-profit basis explicitly because for-profit entities are reluctant to hold on to that kind of IP.
00:45:17.820In light of the uniquely high costs of battling lawsuits, fighting for market access, dealing with boycotts.
00:45:24.420These are kinds of drugs, like specifically contraception, abortion, HIV.
00:45:29.760I'm guessing that like some sort of like gender treatments, if they weren't so ubiquitous for cis people, would also have to be distributed in this kind of way.
00:45:38.300Because like the actual economics of trying to fight this many battles just to get something onto market into the hands of patients is so extreme and resource draining that for profit companies don't want to do it.
00:45:50.620Right. So now the Population Council basically acts as a clearinghouse to make this stuff available for nonprofit distribution.
00:45:57.760So they start looking for contract manufacturers. Right. Like who will be willing?
00:46:02.260We have this IP to this Mifepristone drug. The Population Council does.
00:46:06.920They're like, who will actually make it for us? And they kind of have a hard time finding takers.
00:46:12.420Everybody agrees to so much as, like, physically produce these pills, gets hit with a massive wave of anti-abortion threats, and a lot of these, like, pharmaceutical manufacturers just drop out.
00:46:27.040Well, like, a company will, like, sign a contract with the Population Council, be like, okay, we'll manufacture this drug for you, and then they'll get hit with a bunch of threats and lawsuits, and they'll be like, no, no, no, no, no, actually, we're dropping out.
00:46:36.860And the Population Council is trying to enforce these contracts by taking people to court.0.99
00:46:39.700Like you said, you would make this drug for us, and now you're chicken shit and you won't do it.0.99
00:49:22.580So MIFI comes to market, but it's got all these restrictions on it.
00:49:27.380The FDA begins requiring that Mifepristone only be distributed in a hospital in a clinic.
00:49:32.320That is, like, as we mentioned, you have to go in person for it.
00:49:35.240And that's in addition to other restrictions on abortion access, like the waiting periods, like the so-called mandatory informed consent lectures, where women are told falsely that abortion will increase their risk of cancer or suicide.
00:49:48.240Mandatory transvaginal ultrasounds, et cetera.
00:49:50.380Then the anti-abortion movement starts doing this thing they call abortion pill reversal, where they begin making these studies that say that, oh, if you take MIFI, but you haven't taken MISO yet, it can be reversed. It's kind of not true, but a lot of states begin requiring doctors to say that the pill can be reversed.
00:50:13.160So Arizona is the first state to require that beginning in 2015, and like at least 13 other states follow suit.
00:50:19.540So there's a lot of mandatory, like legally required disinformation about MIFI, and there's a lot of deliberate obstacles to access.
00:50:28.040And we should say that that's basically, as you were pointing out, having a dead fetus inside you is extremely dangerous.
00:50:34.520So this is medical advice that is in fact violating the Hippocratic Oath, isn't it?
00:50:38.260Yeah, I mean, there's a lot of stuff that doctors have to do because of the law.
00:50:43.160That is just untrue. Like doctors are required to lie to their patients by law because of these anti-abortion restrictions. It would hardly be the first time. Right. But even with all of this like antagonism towards Miffy in the U.S. market, it becomes more and more popular exactly because people really like the idea of having their abortions at home. Right.
00:51:02.040They're like, God, I don't want to have to, like, trudge past a bunch of screaming Christians in their, like, you know, braids and long skirts.0.99
00:51:10.020I don't want to have to trudge past the, like, inflated photos of, like, mangled fetuses.0.99
00:51:15.080I don't want to get called a whore, right?0.52
00:51:17.140I just want to be at home with my cats, probably named Miffy and Miso.0.76
00:51:23.060And I just want to have the privacy, right?
00:51:25.460And so it becomes more and more popular.
00:51:27.320When I went to grad school, the central courtyard at Penn was always a kind of a hotbed for people with these gigantic placards of fetuses.
00:51:36.680And got to tell you, like I wasn't walking anywhere to get an abortion, but walking past those people was a chore to begin with.
00:51:43.640Like if I was doing that and also, you know, contemplating some pretty serious life choices, it would suck.
00:51:49.320Yeah, I used to in another life when I was in my 20s, I used to do clinic escorting outside this like independent clinic in New York City every Saturday, which is when the protesters showed up.
00:51:59.860And there'd be like women walking and crying who didn't speak English and like getting screamed at by these protesters and their like husbands or boyfriends would be with them in broken English trying to be like there's no heartbeat.
00:52:10.300And then all of the protesters would leave at 10 a.m. because that's when the free parking ended.
00:52:14.120And I'm like, oh, it's murder, but it's not worth paying for parking over.
00:52:21.560Legal access to MIFI for abortions is curtailed in states that ban abortion, right?
00:52:27.340There's a lot of, like, flickering on and off of law in the two years following Dobbs
00:52:31.900as legal cases and popular referenda sort of, like, bring abortion access in and out of legality.
00:52:37.620I think of it as, like, a light bulb that's sort of, like, losing its juice and, like, you need to replace it.
00:52:42.780It sort of, like, flickers on and off a bunch.
00:52:44.140At this point now where we're sitting in 2026, those possibilities have largely been exhausted.
00:52:49.940And we basically know the world we live in, which is one where abortion is banned or very severely restricted in a like small majority of states.
00:52:58.080And it's legal or like mostly legal in a sizable minority of states.
00:53:04.040Louisiana actually moved to reclassify MIFI as a quote unquote controlled substance pretty quickly, which makes it harder for doctors to access like even an emergency in hospital.
00:53:14.840And it ups criminal penalties for those who are found in possession of it without authorization.
00:53:19.340We also know that the new status quo of red state access has emerged in this interim involves a lot of people, like, living in states with bans that are able to access MIFI and MISO abortions through telemedicine providers and through the U.S. mail.
00:53:35.660But the anti-abortion movement is, like, on a path to end all this, and they're trying several routes to get there.
00:53:42.560So they're trying to get rid of miffy access through saying that it's unsafe for women or other people and by saying that it kills babies.
00:53:50.120And then they're also taking like different procedural routes to banning it through like the regulatory state, right, through the FDA, but then also like through the judiciary.
00:53:58.140And why wouldn't they, given that like the Supreme Court keeps giving them everything they want?
00:54:11.040I mean, Alliance for Hippocratic Medicine sounds like exactly the kind of alliance-defending freedom shit that, like, tells you there's some true right-wing freaks at work.0.98
00:54:20.020Yes. It was a group of anti-choice doctors, some of whom were, like, dentists.0.98
00:54:25.260They'd never actually ever prescribed mifepristone.
00:54:28.400And they used this, like, fabricated evidence from anti-choice, like, fringe internet sites to claim that mifepristone was not safe, right?
00:54:38.700And on that basis, they asked the FDA to rescind its approval and remove it from the market.
00:54:43.920Let me guess, did this claim get taken up by a circuit court in Amarillo, Texas?
00:54:50.940Oh, wow. How did I know? Ding, ding, ding.
00:54:53.220This is like a federal district court where there's only like one judge.
00:54:57.140It's a guy, Matthew Kazmierich, who is a Trump appointee who, before he was a federal judge, used to work in anti-choice lobbying groups.
00:55:05.000Yeah. He's a Trump appointee's Trump appointee. Like this guy, they're all crazy, but this guy is truly fucked in the head. I mean, for people who are not from the United States, like this is what's called venue shopping, right? Where basically you can file, even if the lawsuit is about something that happens in a totally different state, even if it's something where the people withstanding don't reside in Texas, you can just go to Kaczmarek and like get him to rule reliably.
00:55:30.620Like the man is utterly predictable. Like he will find a way to rule in favor of any old shit you put in front of him as long as it's bad for gay people, bad for trans people, bad for women's rights, bad for Democrats, anything really.0.98
00:55:45.740Yeah, I mean, this tactic is why like a judge in Texas is ruling on the gender affirming care practices of a hospital in Rhode Island.0.99
00:55:56.000This is why E. Jean Carroll, you know, Donald Trump's sexual violence victim who lives in New York, is being investigated by the federal D.A. in Chicago.
00:56:07.620Right. The Trump administration and its allies will go to a forum where they have the best chance of getting the result that they want, even if the jurisdiction is somewhat lacking.
00:56:19.680So this is a group of doctors who never have prescribed this medicine, but say that, like, you know, having it available to be prescribed is a assault on their rights.
00:56:28.520Oh, it's the wedding website argument all over again, right?
00:56:31.720Yes. Yeah. You never actually had to do this, but there's some possibility that at some point you might.
00:56:38.340So Kazmieric issues a temporary restraining order back in 2024 that would have banned Miffy from the market entirely.
00:56:45.020He delays it by a week. So there's this like ticking clock. And SCOTUS steps in to stop that order from going into effect and preserve MIFI's market access. That happens in 2024. Then later, there was this other lawsuit seeking not to ban MIFI's FDA approval, the way Alliance for Hippocratic Medicine was, but to undo those 2021 regulatory changes that allowed it to be prescribed via telehealth.
00:57:08.600Yeah, I was wondering about that. That seems to be the biggest vulnerability, right? You say, oh, but that was a COVID era restriction. I'd like the VRA. Maybe it served its purpose.
00:57:17.140Yeah. That actually got approved by the Fifth Circuit Court of Appeals.
00:58:21.700Which is interesting if you actually think of Dobbs as being about states' rights.
00:58:26.520And with Thomas saying that telehealth abortion violated the Comstock Act.
00:58:30.760And calling those who prescribed and dispensed the medication, quote unquote, criminal enterprises.
00:58:35.900So these dissents, I mean, I think like the reality that the court allowed this order to go into effect at all, even temporarily, is a very, very bad sign.
00:59:25.320But these were like these dissents were signals to the anti-choice movement about the kind of arguments that these justices are amenable to.
00:59:34.280So the FDA is controlled by Trump appointees right now.
00:59:37.140The anti-abortion movement is really mad at the Trump administration that their FDA has not revoked Mifepristone approval yet or at least gotten rid of those 2021 changes that allowed for telehealth abortion prescriptions.
01:00:49.780But like the Trump FDA has been slow walking that review, I think because they're afraid of the political fallout in the midterms. Right. It caused a big rift with the anti-abortion movement. They really pushed for the FDA chief under Trump to get pushed out, which he eventually was. There's now a new FDA chief coming in who's supposed to be more friendly to the anti-choice cause. My guess is that we're going to see a revival of adverts to ban Miffy beginning in early 2027.
01:01:18.060Right. It's the kind of thing that they're going to smash on their way out, basically.0.95
01:01:21.840Yeah. Yeah, when there's fewer consequences.
01:01:24.700Like, MIFI is legal and accessible for now, but it is endangered.
01:01:28.580And really, the future of medication abortion is likely a MISO-only protocol.
01:01:33.720People really wanted to avoid this for a long time, people on the pro-choice side, because MISO-only abortions are A, more painful, and B, a bit less effective.
01:01:43.140The standard numbers cited are that abortions done with a combination of MIFI and MISO are about 97% effective, while MISO-only protocols, which use three doses of MISO instead of just one, are about 85% effective.
01:01:57.320Those were old studies. New research that was recently released by the New England Journal of Medicine, which was done with like just this kind of eye towards a post-miffy access reality, suggests that the effectiveness rate for a MISO-only protocol could be higher, but we don't really know.
01:02:14.860Cue RFK Jr. trying to figure out whether MISO is safe in the water supply.
01:02:20.900Yeah, you know, it's also like it's always a receding horizon, right?
01:02:34.860And it's just, it's a relentless assault on the safety and dignity of women and anybody else who can give birth.
01:02:42.660And it's just, it's not going to stop, but neither is the innovation and dedication of the pro-choice movement, which really does astound me.
01:02:51.820I mean, like, it's going to be an endless game of whack-a-mole when the moles are the dignity and health of women.1.00
01:02:57.080Yeah, you know, their plan, the anti-choice plan, relies on women ultimately, like, submitting to their subordination and just accepting being these, you know, vessels for other people's agendas.1.00
01:03:07.700And I just don't think that's a reliable plan.
01:03:10.000I think people are a lot more resistant to being used that way.