The conservative push to limit abortion did not end with the recent repeal of constitutional protection in the United States last summer. The Supreme Court has affirmed and encouraged restrictive legislation in many Republican-led states. Antiabortion groups continue court work, and the current core fight centers on the use of mifepristone, the medicine most commonly used in medical abortions in the United States. The Supreme Court will decide the fate of this drug in the near term.
These are the key issues in the battle.
Medicine
Mifepristone received authorization in 2000 from the U.S. Food and Drug Administration. It is widely used around the world because it blocks the production of progesterone, a hormone that sustains pregnancy. It is normally used in combination with misoprostol, another drug that induces the expulsion of uterine contents. Misoprostol can be used alone, but it is less effective and carries more side effects.
Its use has grown since approval, and the drugs have been in clinical use for more than two decades. Data from the Centers for Disease Control and Prevention show that more than half of pregnancy terminations in the United States involve these medications.
Since 2016, the FDA has made changes to widen access to mifepristone, extending use to the first ten weeks of pregnancy, allowing mailing of the drug, permitting prescribing by nurses and midwives, and enabling telemedicine. Appointments were reduced from three to one to obtain prescriptions. By 2019, the combination had become the standard method for about two thirds of medical abortions in the United States.
Legal battle
Shortly after the Dobbs decision ended constitutional protections, antiabortion groups opened legal challenges against the FDA, filing lawsuits through offices in hostile states and with physicians who share their stance.
The case progressed toward federal courts, with Judge Matthew Kacsmaryk, a conservative appointee, presiding. On a recent Saturday, he issued a preliminary ruling suspending the nationwide distribution of mifepristone. His opinion included language that framed chemical abortion in moral terms and described the FDA as violating its mandate by approving the drug and downplaying safety concerns. The ruling noted a very small hospitalization rate among patients using the drug, while acknowledging broader safety data. The court emphasized concerns about the drug’s approval process.
Appeal
The judge gave seven days to file an appeal, and the government promptly challenged the decision, taking the case to the Supreme Court. A New Orleans-based court then ruled in a split decision on April 12, allowing continued distribution while considering further appeals. Judges appointed by former President Trump argued that too much time had passed to challenge the FDA consent, while another judge appointed by a different administration weighed against freezing access completely. The court allowed ongoing distribution but kept the door open to restrictions.
The appeals court also expressed that some FDA protections added since 2016 could be revised to improve access under supervision, while still maintaining safeguards.
Supreme Court
The Justice Department, under the current administration, filed an urgent appeal with the Supreme Court. Justice Samuel Alito, who signed a major ruling on the Dobbs decision, ordered an administrative pause on some restrictions while the matter is reviewed. Another deadline was set for public filings, with anticipated decisions by the following night.
There were additional filings challenging the federal court actions, arguing that the government should not be forced to rely on a single drug when a generic option exists. The broader regulatory framework faced questions about stability and nationwide access during a period of regulatory upheaval.
Reactions
The White House, proabortion groups, medical professionals, and the pharmaceutical industry condemned the lower court actions. They argued that the FDA should rely on its own independent assessment of drug safety and effectiveness, and that political interference risks compromising access to essential medicines. The American Medical Association stated that courts should not substitute their judgments for the FDA’s expertise, particularly when it comes to safe and effective reproductive health medicines. The ongoing debates have raised concerns about the potential loss of access for millions of women.
Analysts note that medical groups and regulators must base decisions on robust data rather than ideological beliefs. The debate focuses on how to balance patient safety with timely access to proven therapies that rely on established science.
What could happen
The Supreme Court decision could set a national precedent on how abortion drugs are regulated. A ruling favoring more restrictions might limit distribution to specific weeks or require in-person visits and a series of medical checks. Such rules would increase travel for some patients and require multiple visits to a licensed clinician before a prescription is issued. Conversely, a ruling that preserves broad access could stabilize nationwide availability, including mail order and telemedicine, while maintaining safety safeguards. The outcome will shape how doctors practice and how patients seek care, potentially affecting thousands of lives across many states.
Several Democratic-led states have begun to bolster stockpiles of the drugs in anticipation of different possible outcomes. There are ongoing lawsuits about access to information in various jurisdictions, reflecting how state-level policies interact with federal regulation in this evolving landscape.
The Supreme Court conservatives’ dilemma
The court’s conservative majority faces a difficult question about its role in regulating abortion. Historically, the court signaled that the decision should largely be left to states, yet recent debates test that path as lawmakers and activists push hard on drug-specific rules. Some justices have signaled a preference for stability and a cautious approach to altering drug safety evaluations, while others may push for a broader reexamination of how abortion services are regulated across the country.
Two years ago, the same conservative majority limited a pandemic-era rule that allowed prescribing without a doctor’s visit for a short period. Justice’s opinions have since underscored the need to respect the expertise of public health authorities while considering the consequences of rapid policy shifts on patient access and safety.