Small-Town Doctors Weigh Principle, Pressure and Abortion Pill

It was hailed, or reviled, as revolutionary. But in South Dakota, Nebraska, Missouri--across the vast reaches of rural America--the abortion pill that became available this week may not change anything.

For the reality of RU-486 is this: In the very places where it could do most to improve abortion access--isolated towns like Rapid City--even physicians who strongly support abortion rights are afraid to use it.

Afraid not just of violence. Afraid more of being shunned. Of losing both their practices and their standing in the community.

“Word would get out,” says one family physician in a small South Dakota town. “And that would ruin my life here.”

There’s a reason why 86% of counties in the United States have no abortion providers. These are, by and large, conservative places. Religious values run deep. The first billboard on the way into Rapid City from the airport declares: “The gift of life. God’s special gift.” The local Planned Parenthood clinic draws pickets every weekend, even though abortions aren’t performed there.

An hour’s drive away, in a farm town of 700, the mother of a 15-year-old who is due to have her own baby next month explains the prevailing ethos this way: “The worst, most hateful, thing you can say about someone is that she had an abortion.”

That’s the atmosphere in which Dr. Marvin Buehner, a Rapid City obstetrician, struggles to decide whether to offer his patients RU-486, also known as mifepristone.

Buehner believes women have a right to end unwanted pregnancies. He thinks patient care suffers when the nearest abortion clinic is a six-hour drive away. RU-486 gives him a chance to put those convictions on the line. He could dispense the drug from his office, sparing patients not only the drive, but the surgery, the anesthesia, the fear of stretching out on the operating table of a doctor they’ve only just met.

Buehner knows the abortion pill’s promise.

But he also knows its peril.

He knows the pickets he would face, the boycotts, the threats if he ever dared dispense RU-486. “I guess I just have to figure out,” he says, “if the principle is important enough to outweigh the risk.”

At first, he says no way. “I do believe RU-486 should be available. And I don’t like to shy away from a fight. But you have to pick your battles,” he says.

Then he pauses. Continues, reluctantly, thinking out loud: “On the other hand, there is a principle here.”

He could prescribe RU-486 just to longtime patients, women he trusts to keep quiet. Some physicians in bigger cities have said they plan to do just that. But it feels like a cop-out to him. If you’re going to do it, he says, it should be in the open. And for all. “You should do it because you believe it’s the right thing to do.”

Point of fact: That’s exactly what he believes.

And yet:

Four years ago, Buehner offered an abortion to a patient, a mother of three, after an ultrasound late in the second trimester revealed that her baby had no brain. Word got out, as it always does. Next thing he knew, there were pickets and prayers outside Rapid City’s lone hospital. There was a guy dressed as the Grim Reaper, on stilts.

The hospital board decided--against the advice of all eight obstetricians in town--that even a fetus with a lethal deformity, a fetus doomed to die within days if not hours of birth, could not be aborted in Rapid City. Buehner’s patient drove six hours across the state to terminate the pregnancy in a Sioux Falls clinic.

So he can guess the reaction to mifepristone.

(For those who can’t, local activists are happy to predict: “If a doctor here were to prescribe it, I would expect hundreds of Christians out there picketing and praying at his office,” says Carol Harris, who’s active in an anti-abortion group. “It just wouldn’t be a fun time for him.”)

Buehner goes back to saying no way.

“I’m not a Don Quixote,” he says. “At least, I don’t want to be.”

Even in the most conservative communities, of course, there are many who support abortion rights. One 28-year-old single mom--a waitress in the nearby town of Spearfish--even suggests that it would be unethical for gynecologists not to offer the abortion pill. “They are medical doctors and that’s a medical procedure,” she says staunchly. “It should always be a choice.” But she, too, requests anonymity.

Although abortion-rights advocates around here say they would support a doctor who offered RU-486, they figure they would be, if not outnumbered, at least outshouted.

“The doctor who did it would never survive,” says Betsy Cordes, a dental hygienist in Spearfish, a pine tree-trimmed town of 7,000. “There’s no way. He would get run out.”

Edna Walton, for one, would volunteer to do the chasing. A mother of five out shopping for her grandchildren, she vowed to boycott any doctor who used mifepristone. Pickets, she thought, would not be needed. A few newspaper stories, a little community pressure--”voicing out,” she called it--would likely set the offending physician straight.

Some optimists in the abortion-rights camp feel certain that such social pressure eventually will ease, even in such places as Spearfish and Rapid City. They point out that prescribing birth control was once taboo. Over time, that stigma faded.

“I suspect that as more and more doctors come aboard and do medical abortions, it will evaporate as an issue,” says Dr. William F. Harrison, an obstetrician who performs abortions in Fayetteville, Ark.

So far, indications are mixed.

The National Abortion Federation already has trained 1,800 health care workers in the administering of RU-486, including 400 who do not perform surgical abortions.

And a recent survey by the Kaiser Family Foundation found that 31% of gynecologists who don’t perform abortions now were at least “somewhat” likely to offer mifepristone. But their enthusiasm flagged when they were told that patients using the pill require ultrasounds, multiple visits and extensive counseling.

There are other deterrents too. State regulations, for instance, can be onerous. Abortion providers may be required to have a shower on premises, or corridors 6 feet wide. They may need to examine and cremate all fetal tissue or report all abortions to the state. Such rules are designed for big clinics, but doctors who dispense mifepristone must follow them as well.

They also have to be prepared to perform surgery--or refer a patient to an available surgeon--in the 5% of cases in which the abortion pills fail. And they must be ready to counsel women through hours of bleeding and cramping, which can sometimes be severe.

Physicians who have tested RU-486 (which is combined with another drug to cause abortions) say patients appreciate it because it’s noninvasive, private and feels more “natural” than surgery. “I think it’s a wonderful thing for women,” says Laura Castleman, an obstetrician in the Detroit suburb of Troy, Mich.

But with the bureaucratic hassles, the potential medical complications and, above all, the fear of community backlash, “I don’t think the doors are going to swing wide open for women,” says Jim McCaul, an obstetrician who supports abortion rights but believes his farming community of Rolla, Mo., would turn on any doctor who offered the drug.

Indeed, most of the pills shipped out this week went to established abortion clinics, not physicians who have never terminated pregnancies.

As Ron Fitzsimmons, director of the National Coalition of Abortion Providers, put it: “This is not going to be the social revolution that some people had predicted.”

A South Dakota obstetrician had to agree.

Elective abortions make her uneasy. For moral reasons, she would never prescribe RU-486. But she does believe that some terminations are justified on medical grounds. And that opinion is just edgy enough in her rural community to give her qualms about speaking on the record.

“Here we are saying we’re not going to dispense [the abortion pill], and yet we’re still scared to be named,” the obstetrician says.

To her, that fact alone speaks volumes.