Joanna Erdman is MacBain Chair in Health Law and Policy at Dalhousie University’s Schulich School of Law.
Many of Canada’s doctors, a Globe and Mail investigation has revealed, are reluctant or simply refuse to prescribe the abortion pill, Mifegymiso. That report asks important questions of the formal health-care system: How many prescriptions have been written since Mifegymiso came onto the market? Who wrote them? Where were they written? And most importantly, why are doctors across the country – especially family doctors – turning away people’s requests and refusing to prescribe? Ethical objection, professional reputation, administrative complexity and plain unwillingness are offered up as explanations. Leadership, doctors stepping up to prescribe with the support and encouragement of their professional colleges, is offered in response.
The more obvious and primary barrier is left unaddressed: the prescription control on abortion pills, which creates this physician gatekeeping in the first place. Why not ask if any prescription needs to be written at all, rather than how many?
From a regulatory view, moving abortion pills off-prescription or over-the-counter is a research question to be answered by studies on label comprehension, self-selection and actual use. Can people follow written instructions on how to use the pills, know when they are appropriate for use, accurately date their pregnancy and actually use the pills to safely end their pregnancy, while seeking medical care when it is wanted or needed? Do we need prescription controls?
From a realistic view, the simple fact is that worldwide, the majority of abortion pills are already used without medical supervision, and outside formal health systems. People are increasingly self-sourcing pills in pharmacies, online and through local markets, and managing the abortion process themselves at home much as they would a miscarriage. So-called self-managed abortion is practised in criminally restricted settings, and also in places where abortion is lawful but services can’t be easily accessed or where people prefer to avoid interaction with the formal system. Strong public-health evidence shows that self-managed abortion can be practised safely when people are well-informed, resourced and supported.
Over the last decade, a global network of activist groups has emerged to support people in self-management. Through various channels – hotlines, apps, online counselling and in-person accompaniment – these groups provide people with reliable and accurate information on how to safely buy and use abortion pills, counsel and support people throughout the process of their abortions and help them navigate and access follow-up care. Increasingly, these groups are partnering with health researchers to document self-managed abortion as a safe and humane practice, and even as a positive, affirming life experience. Pain and bleeding, and risks such as ectopic pregnancy or inaccurate gestational assessment are not ignored or neglected, but normalized as features of abortion that people can and do manage with information and support.
While many of these activists call themselves providers of care, abortions are really self-managed with their care. They act in the belief that people have a fundamental right to think and act positively about their bodies, to use their bodies to protect their health and well-being and to decide whether and when to reproduce on their own terms. This marks a profound difference from abortion care in most formal health-care systems. The belief that abortion can and should be easy and convenient. Gone is the gatekeeper. This – the radical return of abortion to people – was the original promise of abortion pills.
The prescription status of abortion pills asks a fundamental question about control in our reproductive lives: Who’s writing the script? In legal terms, the prescription is an authorization – a permission slip – and in this way represents a continuation of, rather than a break from, our abortion past, with abortion as health care having long been overregulated and guardedly practised. Mifepristone was one of the first successful therapeutic agents where the company that developed it tried to pull it from the market because of public backlash and feared boycott. Strict administration and dispensing controls followed, adopted without evidenced need, which placed the pills beyond the reach of many. These were enacted in Canada, too, but these controls fell quickly after public outcry.
Real leadership from the medical establishment would be a reckoning with this past and a reimagining of its future. It’s time to build a health-care system where every person has the right to a safe and dignified abortion informed by the values and needs most important to them, and the right to access the means of realizing that right.
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