The supreme court on Tuesday seemed skeptical of arguments made by anti-abortion doctors asking it to roll back the availability of mifepristone, a drug typically used in US medication abortion. The arguments were part of the first major abortion case to reach the justices since a 6-3 majority ruled in 2022 to overturn Roe v Wade and end the national right to abortion.
The rightwing groups that brought the case argued that the justices should roll back measures taken since 2016 by the Food and Drug Administration (FDA) to expand the drug’s availability. A decision in the anti-abortion doctors’ favor would apply nationwide, including in states that protect abortion access, and would probably make the drug more difficult to acquire.
Medication abortion now accounts for almost two-thirds of abortions performed in the US.
Much of Tuesday’s arguments focused on whether the anti-abortion doctors who sued the FDA, a coalition known as the Alliance for Hippocratic Medicine, have standing, or the right to bring the case in the first place. The doctors claim they will suffer harm if they have to treat women who experience complications from mifepristone, an argument the Biden administration, which appealed the case to the court, has rejected as too speculative.
The US solicitor general, Elizabeth Prelogar, who defended the FDA, argued that the doctors do not come within “100 miles” of having the legal right to bring the case, arguing that their case rests on a “long chain of remote contingencies”. Under their argument, Prelogar said, a woman would have to face complications from a medication abortion that were so serious that she needed emergency care at a hospital – an unlikely scenario, given mifepristone’s proven safety record – and then end up in the care of an anti-abortion doctor who was somehow forced into taking care of her in such a way it violated the doctor’s conscience.
A number of the justices – even the ones who ruled to overturn Roe two years ago – seemed skeptical that the doctors met the threshold required to establish standing. Justices Amy Coney Barrett and Brett Kavanaugh seemed to seek assurances that the doctors represented by the Alliance for Hippocratic Medicine were already covered by laws that protect doctors from having to undertake cases that violated their consciences.
Justice Neil Gorsuch seemed to express concern over the sweeping implications of the doctors’ request of the court. “This case seems like a prime example of turning what could be a small lawsuit into a nationwide legislative assembly on an FDA rule or any other federal government rule,” he said.
The supreme court has historically rejected standing arguments based on such potential harm. However, Justice Clarence Thomas raised the possibility that perhaps the court’s own threshold for standing was too strict.
His fellow conservative Samuel Alito also seemed incredulous of Prelogar’s argument. “Is there anybody who can sue and get a judicial ruling on whether what FDA did was lawful?” he asked. “Shouldn’t somebody be able to challenge that in court?”
Since the fall of Roe in June 2022, more than a dozen states have banned abortion. The result has been legal and medical chaos. Dozens of women have come forward to say that they were denied medically necessary abortions. Abortion clinics in states that still allow abortion are overwhelmed by the flood of patients fleeing states with bans. More than 1m abortions were performed in the US in 2023, a record high.
The availability of medication abortions, which are usually performed using mifepristone as well as another drug called misoprostol, has helped soften the impact of the bans. Telehealth medication abortions, permitted by the FDA since the pandemic, helped ease some of the burden on abortion clinics; shield laws, passed in a handful of states, even allowed providers to offer telehealth abortions to people living in states with abortion bans.
But the accessibility of medication abortion also made it the next target of the anti-abortion movement after Roe was overturned. In 2022 the Alliance for Hippocratic Medicine challenged the FDA’s 2000 approval of mifepristone. The group, which includes anti-abortion doctors and is being defended by the Christian powerhouse legal firm the Alliance Defending Freedom, argued that the FDA overstepped its authority and that mifepristone is unsafe. (More than 100 studies have concluded that mifepristone can be safely used to terminate a pregnancy.)
A federal judge ruled in favor of the Alliance for Hippocratic Medicine, a move that could have yanked mifepristone off the market entirely. But an appeals court narrowed that ruling, deciding that it was too late to challenge mifepristone’s original 2000 approval.
Instead, the appeals court ruled to rewind later measures taken by the FDA that expanded access to mifepristone, including by removing requirements that abortion providers dispense mifepristone in person. A recent analysis found 16% of all US abortions are facilitated through telehealth.
Mifepristone’s availability has remained unchanged as litigation has progressed.
During oral arguments, Thomas and Alito also raised the specter of the Comstock Act, a 19th-century anti-vice law that bans the mailing of abortion-related materials. Long regarded as a relic, the Comstock Act has now seen a resurgence of post-Roe support among anti-abortion activists who believe it is the key to a de facto nationwide abortion ban.
“How do you respond to an argument that mailing your product and advertising it would violate the Comstock Act?” Thomas asked Jessica Ellsworth, a lawyer for Danco Laboratories, a manufacturer of mifepristone.
After some back and forth, Ellsworth told Thomas: “That statute has not been forced for nearly 100 years and I don’t believe that this case presents an opportunity for the court to opine on the reach of the statute.”
Regardless of what the supreme court decides, Americans will still be able to order mifepristone online from suppliers who help people “self-manage” their own abortions. A study released on Monday found self-managed abortions had soared since Roe fell.
Outrage over the overturning of Roe has turned abortion into a key election issue, since most Americans support at least some degree of abortion access. Voters in multiple states, including conservative strongholds, have voted in ballot initiatives in favor of abortion rights; roughly a dozen states are now expected to put abortion-related ballot measures to voters come November. Democrats are hoping that the issue will bolster turnout for their candidates, including Joe Biden.
The supreme court is expected to issue a ruling in the mifepristone case by the summer, just months ahead of the 2024 elections.
The case’s consequences could stretch far beyond abortion. If the justices greenlight attempts by ideologically driven groups to second-guess the authority of the FDA, the agency’s regulation of all manner of drugs – such as contraception and vaccines – could be challenged in court.
Ellsworth, the Danco attorney, argued that the doctors’ argument in the case “is so inflexible it would upend not just mifepristone, but virtually every drug approval”.
