Tangle - Can abortion pills be prescribed online?

Starting point is 00:00:00 From executive producer Isaac Saul, this is Tangle. Good morning, good afternoon, and good evening, and welcome to the Tangle podcast, a place where you can get views from across the political spectrum, some independent thinking, and a little bit of our take. This is associate editor, Audrey Moorhead, and today we're going to be covering the complicated legal battle surrounding the male order abortion pill. But first, just wanted to give you all a heads up on an interesting interview. that we released today. Back in March, you may have seen the headline. A 25-country study from the Pew Research Center said that Americans were especially likely to view fellow citizens as morally bad. In today's interview, Associate Editor Lindsay Canuth talks to one of the study's co-authors, Jonathan Evans, and Pew's Associate Director of Global Attitudes Research, Laura Silver, to talk about

Starting point is 00:01:03 Americans' national pride, partisan differences, and the state of professional polling. So after you're through listening to today's podcast, I definitely recommend checking that out. It's a fascinating conversation. With that, I'll pass it over to Will, who will tell you some more about today's story, and then you'll see me again for my take. Thanks, Audrey. All right, let's get into today's quick hits. Number one, Indiana held primary elections for the 26 midterms, and at least five of seven Republican state senators who opposed an effort to redraw the state's congressional map were defeated by challengers backed by President Donald Trump. One other race is too close to call.

Starting point is 00:01:50 Separately, entrepreneur Vivek Ramoswamy won the Republican nomination for Ohio's gubernatorial election. He will face former Ohio Department of Health Director Amy Acton in the general election. Number two, President Trump announced he is suspending a U.S. military operation to assist ships in their passage through the Strait of Hormuz. Saying the pause will allow for renewed discussions

Starting point is 00:02:13 over a potential peace agreement with Iran. Number three, the Spanish government said it will accept a cruise ship experiencing a hantavirus outbreak, which has killed three people on board and infected at least three others. The ship was previously denied entry by the African island nation of Cabo Verde, but will now travel to the Canary Islands to receive assistance. Number four, Russia carried out strikes across eastern Ukraine, killing at least 27 people. The attacks came hours before the deadline expired for a Ukraine-proposed ceasefire. And finally, number five, officials at the Food and Drug Administration reportedly blocked the publication of studies conducted by agency scientists

Starting point is 00:02:56 that supported the safety of vaccines for COVID-19 and shingles. An FDA spokesperson said the scientists drew overly broad conclusions that were not supported by data. The Supreme Court yesterday restored broad access to the abortion, pill, Miffapristone, blocking a lower court ruling. The order temporarily allows women seeking abortions to obtain the pill at pharmacies or through the mail without an in-person visit to a doctor. Those practices had been permitted for several years until a federal appeals court imposed new restrictions last week. The latest order will remain in effect for another week while the high court considers the issue more fully. On Monday, May 4th, the Supreme Court issued a temporary stay on a lower

Starting point is 00:03:51 court's order that Mifapristone, a drug commonly used in early term abortions, can only be prescribed and dispensed in person. The order pauses a Fifth Circuit Court of Appeals decision to prevent the drug from being accessed by mail. In a brief order, Justice Samuel Alito, who oversees appeals from the Fifth Circuit, paused that court's order until May 11th, restoring telehealth access to the drug and giving challengers until May 7th to respond. Miffa Prestone is a drug taken. to treat hormone disorders, manage miscarriages, and chemically induce abortions, in combination with another drug, misoprostol. From 2000 to 2022, more than 6 million patients in the U.S. used Mithoprestone, and 63% of U.S. abortions in 2023 were medication abortions.

Starting point is 00:04:40 Today, roughly a quarter of abortions are provided through telehealth prescriptions. And as of 2024, the FDA has reported 36 deaths of patients using Mithoprestone since 2000. The Food and Drug Administration, the FDA, has relaxed restrictions on MIFoprestone several times since its approval. In 2016, the FDA deemed Miphaestone safe to use to terminate pregnancies up to 10 weeks, and in 2021, it removed a requirement that it be prescribed in person. Finally, in 2023, the agency finalized rules allowing for drugs. drugs used in abortions to be accessed by male. Pro-life medical groups and doctors challenged the 2016 and 2020-21 rulings,

Starting point is 00:05:24 and the Supreme Court unanimously rejected that challenge in Food and Drug Administration v. Alliance for Hippocratic Medicine in June 24, saying they did not have the standing to sue. In October 2025, Louisiana sued the FDA, arguing its policies of allowing Mitha Prestone to be delivered by male was unsafe for women and allowed abortion to continue in Louisiana, despite a statewide ban. On May 1st of this year, the Fifth Circuit sided with Louisiana. Danko Laboratories and Gen BioPro, two manufacturers of the drug, challenged that decision on May 2nd, arguing that Louisiana did not have standing to sue. And Justice Alito issued the temporary pause two days later.

Starting point is 00:06:08 The Supreme Court's order is not a final decision in this case. After the challengers respond by May 7th, the court will decide whether to let the circuit court's decision stand, take up the case itself, or extend this day while it considers the arguments. The Supreme Court will decide how to proceed before the stay is lifted on May 11th. Today we'll get into what the left and right are saying about this case. Then Associate Editor Audrey Moorhead gives her take. We'll be right back after this quick break. Here's what the left is saying.

Starting point is 00:06:56 Many on the left suggest Mitha Prestone could create a political crisis for Trump. Some believe that the case is part of a national effort to restrict abortion access. And others say the Supreme Court is to blame for the uncertainty over Mithoprestone. In MS Now, Mary Ziegler suggested the Miffa Preston ruling could bring Trump's High Wire Act on abortion crashing down. In the 2024 presidential election, Donald Trump largely neutralized the abortion issue by simultaneously claiming credit for the end of row, and suggesting that if he was returned to the presidency, each state could continue to set its own abortion policy. After he was elected, anti-abortion groups rolled out a Make America Pro Life Again wish list,

Starting point is 00:07:40 much of it focused on eliminating access to Mitha Prestone. The Trump White House mostly ignored these demands, acutely aware of polls showing that most Americans opposed sweeping criminal laws and favored access to Mitha Preston. This equilibrium has worked for the president and the general. GOP, but changes to the broader landscape made it increasingly untenable in the long term. While Trump has continued picking judges with strong anti-abortion credentials, social conservatives have grown tired of waiting for the president. The Fifth Circuit ruling could bring Republicans'

Starting point is 00:08:12 High Wire Act crashing down. Trump is trapped between increasingly angry social conservatives and an electorate broadly approving of abortion rights and access. The Fifth Circuit's ruling could harm an already wounded Republican Party, and if it stands, bring home for the first time the reality of Rose End. In the Hill, Nikki Sapiro Vinkier said, an abortion ban won't happen all at once. Mifaprestone is just the next phase. In Trump v. Casa, the Supreme Court signaled that even when courts step in, they may not be able to block these kinds of restrictions nationwide. That means access may increasingly depend on where you live and whether a specific challenge has been brought in your state.

Starting point is 00:08:55 So even when access is restored, it is fragile, temporary, and inconsistent. At the same time, pressure is building from every direction. Federal lawmakers are introducing legislation aimed at revoking the FDA's approval of MIFA Preston entirely. Advocacy groups are pushing agencies to revisit decades of settled science. None of these actions exist in isolation.

Starting point is 00:09:16 They reinforce one another. The result is not one clear moment where abortion becomes illegal everywhere, but a series of decisions that slowly reshape access. The care is technically available, but the path to get it becomes more difficult, more confusing, and less reliable. Banning medication abortion outright is deeply unpopular. Anti-abortion extremists think they can change access quietly without people noticing and without having to own it. In Slate, Jill Filipovich wrote, abortion access is in chaos. Blame the Supreme Court.

Starting point is 00:09:50 Overturning Roe didn't resolve a contentious national argument and bring about an end of an era of considered debate followed by a democratic process to set abortion laws that reflect public opinion. It just made abortion rates far more fragile, including in the liberal states that seek to protect them. Instead of turning the issue back to the states, abortion opponents are now focused on ending abortion access nationwide.

Starting point is 00:10:14 Instead of providing clarity, the courts have created chaos. The provision of Mitha Preston via telemedicine is at the core of this most recent legal about-face that led the Supreme Court to temporarily allow telemedicine abortion to continue. But the court didn't issue a ruling on the issue itself. It did not say that telemedicine abortion is legal, case closed. It has just acquiesced to the status quo until it can decide.

Starting point is 00:10:38 In the meantime, the anti-abortion movement has pressured the Trump administration into forcing an FDA review of Mithoprestone, the results of which are supposed to come later this year. The movement's great hope is that the FDA will revoke the drug's approval entirely, and so women and their doctors remain in limbo. Now here's what the right is saying. The right supports restricting Mithoprestone because of its medical risks. Some expect the Fifth Circuit's ruling to eventually win out.

Starting point is 00:11:18 Others say the FDA must complete a thorough review. review of Mithoprestone. In the Wall Street Journal, Sierra Don McLean called Mithoprestone a tool of coercion. The Fifth Circuit's order has a sound basis. Miffaprestone poses clinical risks and is a potential tool of coercion and abuse. Its distribution without safeguards heightens these dangers. An in-person doctor's visit is the only reliable way to diagnose an ectopic pregnancy, a life-threatening condition in which an embryo implants outside the uterus. Because the symptoms of chemical abortion, abdominal pain and uterine bleeding can be similar to those of a ruptured ectopic pregnancy, a woman who doesn't get an ultrasound or physical exam

Starting point is 00:12:00 may mistake an emergency for a normal drug side effect. Pro-abortion groups say they champion women's rights, yet they promote a policy that endangers women. It is possible to hold divergent views on the legality and morality of abortion while still demanding a return to basic medical standards. The Fifth Circuit's order is a necessary corrective to the FDA's failures. The agency should use this pause as an opportunity to reinstate permanently in-person dispensing and physician-led follow-visits, which are necessary to protect women's health and freedom. In hot air, Ed Morrissey explored the Supreme Court's stay in the case. The Fifth Circuit shut the requirement for medical supervision

Starting point is 00:12:43 down three years ago, but the Supreme Court overruled it on the basis of standing. The panel attempted to address that challenge in anticipation of another appeal to the Supreme Court. This puts the new ruling on solid ground for standing, not to mention the FDA's acknowledgement of the use of incomplete data for its 2021 risk evaluation and mitigation strategy. Since the 2023 reversal, the state of Louisiana can also point to specific financial losses due to the 2021 risk evaluation and mitigation strategy, and the likelihood that those costs will increase in the future as more misuses occur. I'd guess that Alito issued a temporary stay to allow both sides to refresh the 2023 arguments overstanding. It makes sense to suspend the impact of

Starting point is 00:13:29 the Fifth Circuit ruling for a brief period while hashing this out, but if Alito thought the court would just follow suit from their earlier ruling, he would have referred the case to the full court for cert, along with a more substantive injunction against the ruling. This looks more like a quick way to reverse the previous ruling on standing, allowing the ruling to take full effect while Danko and Gen Biopro pursue an appeal the hard way. In National Review, Dan McLaughlin made the case for staying the FDA rule on the abortion pill.

Starting point is 00:13:58 The stay request that has advanced through the Fifth Circuit to the Supreme Court doesn't ask those courts to ban the pill entirely from the market, but simply to restore the pre-2020 rules for dispensing it, which required a single in-person doctor visit. The case isn't brought by doctors, so it doesn't have the same standing to sue issues that doomed a similar challenge in FDA v. Alliance for Hippocratic Medicine in 2024. Louisiana has laws against using the pill to commit homicide against an unborn child,

Starting point is 00:14:28 and allowing the pill to be mailed into the state without the participation of a Louisiana licensed doctor undermines its ability to enforce that unquestionably constitutional law. The Fifth Circuit found, unsurprisingly given the lack of studies and the fact that the current FDA isn't even defending the rule, that Louisiana is likely to weigh in its suit on the merits. That's always the most important factor in practice to granting an injunction, stay, temporary restraining order, or other emergency relief. Louisiana isn't asking to stop the FDA from asking the right questions or from answering them. It's just asking the courts to tell the agency to stop acting as if it has the answers before it even starts asking the questions. All right, that is it for what

Starting point is 00:15:12 the left and right are saying. Now I'll pass it back over to Audrey for her take. Thanks, Will. Here is my take. Let's rip the bias bandaid off. My most strongly held political conviction is my commitment to a pro-life ethic. Most of my other political convictions are downstream of my belief that the preservation of human life is the single greatest goal of a secular government and chief among those convictions is my view that abortion and physician-assisted suicide are the most pressing moral injustices in the United States today. The only non-tangle political work I've ever done is pro-life volunteering. With that said, I celebrated the Dobbs v. Jackson Women's Health Organization decision for two reasons.

Starting point is 00:16:06 First, and most pressingly, the court acknowledged that abortion is not a federal constitutional right. Second, it asserted that states had the right to regulate abortion. Opinions on abortion vary across the country because the interest in preserving children's lives and the interest in women's autonomy and security are in tension. And our constitutional system was designed to allow the states to represent that variance and how they govern themselves. Therefore, the state-by-state variance and the current map of abortion access across the country is constitutionally necessary.

Starting point is 00:16:36 Mail order access to Mitha Pristone and Mysoprostol, however, throws a wrench into the state-level gears, a wrench that staunchly pro-life states are trying to remove through legal appeals. In 2023, the FDA changed its risk evaluation and misconduct. mitigation strategies or REMS policy to remove the in-person visit requirement to access abortion drugs. That meant in practice that people in pro-life states gained the ability to order the drugs online from pro-choice states, where doctors aren't subject to restrictions on providing abortions. Additionally, several pro-choice states have enacted shield laws that protect in-state medical

Starting point is 00:17:12 providers from out-of-state civil and criminal enforcement. Pro-life states have challenged those shield laws by attempting to charge doctors in pro-choice states, but so far those challenges have failed. I have a few concerns with the FDA's REMS revision regarding Mithopristone and Miceprostal. For one, the FDA ordered the change without a significant new evidence suggesting further assurance of the drug safety. The last significant review of Miphrastone occurred in the early 2010s, and it resulted in no change to the in-person visit protocol out of an abundance of caution. The FDA temporarily allowed practitioners to bypass that requirement during the pandemic. But when it completely removed the in-person rule following the Dobbs decision in 2023, it didn't seem to conduct a new, completely

Starting point is 00:17:56 independent review. In fact, the agency only began such a review of the drug in 2025, and that review is ongoing. The FDA did cite some international evidence as part of its reasoning for relaxing the REMS. But I think the FDA was also motivated more by changing state policies in the wake of Dobbs, And I'm alarmed that it made this decision without conducting further review on its own. No matter which direction it comes from, that sort of federal agency politicization is not good for a few reasons. It reduces trust in the agencies themselves, and in this case, it undermines the state's ability to enforce their laws. Answering whether Miphypristone and Miceoprostol legitimately deserve the relaxed REMS standard is complicated by researchers' biased proclivities or by data itself. For example, the most significant studies on the topic include a 2013 study of Planned Parenthood's

Starting point is 00:18:48 agency reported data on adverse events following Mithapristone use. That data found a 0.65% rate of significant adverse events, which would support relaxation of the FDA rules. But one of the authors of the paper was Planned Parenthood's medical director. The study defined significant adverse events without including things like incomplete abortions. And some pro-life scholars have issued a study challenging, Planned Parenthood's numbers using FDA data obtained via Freedom of Information Act requests, though pro-choice organizations disputed the results of this particular study.

Starting point is 00:19:22 On the other side, pro-life think tanks have funded their own controversial research into the topic. The most recent such review, conducted by the Ethics and Public Policy Center, found that the FDA underestimates the dangers of the drugs. However, their research was not peer-reviewed. In one prominent controversy, a series of papers published by pro-life researchers, purporting to show increased health risks of Mipristone was retracted by the publishing journal in 2024, following concerns about methodology and conflict of interest, which the pro-life authors disputed. Some studies carried out overseas indicate that Mifapristone is generally safe, though it might need to be treated with caution. One UK study of telemedicine access to Mifapristone and mysoprostol found no significant safety issues from the drug.

Starting point is 00:20:08 But a 2009 finish study found that medication abortions had a higher incidence of, adverse events than surgical abortion, using a wider definition of adverse events than the 2013 Planned Parenthood study did. Much of the differences between various reports on Miphyprisone come from using different definitions of serious adverse events. And not only will different people reporting their issues define adverse events differently, but those effects may not necessarily be caused by the drug itself. That is, a causal connection between the drug and adverse symptoms is difficult to establish. And what's more, in the U.S., the FDA changed its practice of collecting adverse event data in 2016, so that prescribers only needed to report debts after use of the drug,

Starting point is 00:20:50 not other serious events, limiting our understanding of the complexity of the issue. While I acknowledge that some research supports the safety of this medication, I think that competing findings should at least have necessitated an in-house FDA review before the in-person restrictions were lifted. It's possible that that review would have turned to be. turned up similar results as seen in the UK, and their restrictions could have been lifted anyway. But instead, it seems like the rules were changed based on pressure from drug manufacturers and the apparent political climate. That said, even if the medication is reviewed and deemed safe for at-home use, that practice still creates issues, problems of autonomy that should disturb

Starting point is 00:21:28 pro-choice and pro-life people alike. There has been case after case, after case, after case, after case, after case, after case, of people, usually male partners, but sometimes family members, ordering the abortion pill regimen online, then tricking, coercing, or forcing their partners or children into taking them. Often these cases can involve the improper administration of the medicine. Some partners force-fed the pills beyond the 10-week gestational limit, which carries higher risk of complications. In some of those cases, the women lost their babies. In at least one case, a baby was born prematurely and has experienced developmental delays. In nearly all cases, the women experienced the many negative symptoms of taking abortion pills,

Starting point is 00:22:14 nausea, diarrhea, abdominal pain, and heavy bleeding. While some of these instances occurred while the FDA's in-person requirement was still in place, they can occur more easily absent any in-person requirement. And they're made especially easy by mail-order access across state lines, into states where these pills are ostensibly banned in the first place. Ultimately, though, I'm genuinely unsure how the Supreme Court will rule on the Fifth Circuit Court's order, pausing the 2023 standards update. I found Dan McLaughlin's argument in National Review, under what the right is saying, somewhat convincing, that the court could legitimately decide to ban remote access to Miffa Pristone.

Starting point is 00:22:52 Such a ruling would be consistent with the court's recent limitations on agency power. Even so, I think stepping in to restrict the use of a drug with agency approval is a bridge too far for this court, especially when the president and new agency director have had ample opportunity to reverse the rule and just haven't. That point actually brings me to what I think is probably the most interesting aspect of the pro-life movement at the moment. It's apparent standoff with President Trump. The Wall Street Journal recently ran a piece reporting that major pro-life organizations and leaders are beginning to break with Trump over his refusal to do anything related to abortion at the national level. Before Trump was elected, Project 2025 raised the prospect.

Starting point is 00:23:31 of enforcing the Comstock Act, an 1873 law banning the mailing of abortion-producing substances. But Trump has neither done that nor restored the in-person requirement on Miffa-Pristone access. If you ask me, though, pro-life movement leaders fundamentally misunderstand the president, and they misunderstand how pro-life activism needs to adapt to the post-Dob's world. I'd say President Trump is actually pretty pro-choice. He softened the abortion language in the 2024 GOP platform, which has been a party cornerstone since 1976. As a Florida voter in 2024,

Starting point is 00:24:04 he only said he'd vote no on an abortion rights ballot measure after he received backlash for appearing to support the measure in an interview. I don't think President Trump was ever committed to pro-life ideals. He was willing to bring injustices who might overturn Roe, sure, but I honestly think that had more to do with politics than principles. Once Roe was gone and abortion returned to the states, that calculus changed. National abortion bans have never been popular,

Starting point is 00:24:30 and support for abortion rights, as well as the number of abortions themselves, only increased after Dobbs. Trump is a savvy politician who's tapped into populist instincts, and since he was never thoroughly committed to a pro-life ethic to begin with, he seized the writing on the wall.

Starting point is 00:24:46 He'd much rather spent his political capital pursuing the agenda items he always cared about, immigration, tariffs, and his theory of foreign policy, than pursuing national pro-life legislation. The pro-life movement has been rudderless post-ops. It was designed as a national movement, not a state-level one. But now when pro-life legislation in states like Tennessee and Texas can be compared against pro-choice laws in California and Massachusetts, the pro-life movement needs to focus on making sure that maternal outcomes in pro-life states are competitive with or even better than pro-choice states.

Starting point is 00:25:18 As I said earlier, the interest of fetal life is often in direct tension with the interest of the mother's autonomy and financial stability. As long as those interests are in tension, and as long as fetal life and consciousness are debated, the pro-life movement will never be able to impose federal, top-down anti-abortion legislation. Likewise, the Supreme Court isn't likely to step in and provide those rules itself. Instead, pro-life advocates should turn their focus to setting up pro-family policies that address the demand for abortion, not rigidly prohibiting the supply. That's it for my take. With that, I'll pass it off to executive editor Isaac Saul with a staff dissent.

Starting point is 00:25:55 and then senior editor Will Quebec is going to be back to round us out. Thanks so much for listening. Thank you, Audrey. I'm just going to say I find Audrey's arguments here about the threats of Mifapristone unconvincing. She and many other conservative writers engage in what is called the misuse fallacy. The idea that because a product is misused by some people, it needs to be more heavily regulated. I can find cases of antifreeze being used to murder spouses.

Starting point is 00:26:27 or family members. Similarly, I can find cases of over-the-counter insulin being used in murder or manslaughter typically against spouses. There are many such examples. Should either of these substances require stricter access because of potential misuse? Mipipristone is a well-studied drug, and the FDA has real-world data from thousands and thousands of patients over more than 20 years to analyze in its decision-making process. I trust train regulators are taking a more even-handed approach than pro-life legal challenges, which have often been farcical concoctions downstream of the movement's success in striking down row. Ultimately, where Audrey sees a regulatory agency under political pressure, I see an agency that acted cautiously over more than two decades before making a

Starting point is 00:27:15 justifiable safety decision that made a popular drug more accessible. We'll be right back after this quick break. Here's today's Under the Radar story. On Tuesday, Meta, which owns the social media platforms, Instagram, and Facebook, said it will begin using artificial intelligence to scan users' photos and videos to determine if they are underage. People 13 years old and younger are not allowed on the platforms, and meta said the AI will look for, quote, general themes and visual cues, such as height and bone structure, to flag potential underage users. The system is currently operating in select countries, but meta plans to expand its use in the near future. The announcement comes after a jury ordered META to pay $375 million for violating New Mexico's consumer protection law and putting children at risk. And finally here is our Have a Nice Day story. In March, a New Zealander became separated from her dog, Molly, after falling down a waterfall during a hike.

Starting point is 00:28:31 The owner was rescued, but Molly, the dog, remained missing. A helicopter crew equipped with thermal imaging technology located Molly a week later, lying down at the base of a waterfall. And then a rescuer, accompanied by a support dog named Bingo, was able to reach Molly and airlifter to safety. Dog and owner have since been reunited. Stuff has this story with a video of the rescue. We'll drop a link to it in today's show notes and definitely recommend checking this one out.

Starting point is 00:28:59 All right, that is it for today's edition. Thanks for being with us as always. We will talk to you tomorrow. Until then, have a great rest of the day. And peace. Our executive editor and founder is me. Isaac Saul and our executive producer is John Wall. Today's episode was edited and engineered by Dewey Thomas.

Starting point is 00:29:18 Our editorial staff is led by managing editor Ari Weitzman with senior editor Will Kayback and associate editor's Audrey Moorhead, Lindsay Canuth, and Bailey Saul. Music for the podcast was produced by Diet 75. To learn more about Tangle and to sign up for a membership, please visit our website at retangle.com.

Tangle - Can abortion pills be prescribed online?

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