Overly Strict Drug Regulations Are Causing Me Moral Injury

Growing up, I always knew I wanted to be a doctor. But when the FDA needlessly placed an age restriction on over-the-counter levonorgestrel (Plan B) for emergency contraception, I decided I needed to become a lawyer too. I reasoned that political interference in healthcare meant my future patients might not receive the care they needed, and that as a physician-attorney, I could help advance evidence-based policy.

In the 20 years since, levonorgestrel-based emergency contraception and daily oral contraceptives have become available over the counter with no age restrictions. Recent conversations, however, have made clear that we are facing newfound but similar threats to misoprostol and mifepristone (Mifeprex), drugs commonly used for medication abortion. The situation is causing harm to patients and physicians alike, and we have a moral obligation to fight back.

I recently attended the “All In: Wellbeing First for Healthcare” leadership collaborative, where a theme emerged that I couldn’t shake: friction points in our healthcare system — whether policy decisions that block necessary care, prior authorizations, or an inbox overloaded with non-clinical administrative tasks — cause real harm to physicians. They are, themselves, a source of moral injury.

Sitting there, I started thinking about mifepristone and misoprostol. As an emergency physician, I have lost count of the patients with early pregnancy loss under my care who needed these medications and couldn’t get them. I’ve done everything within my control: I’ve obtained risk evaluation and mitigation strategy (REMS) certification at all the hospitals where I work; gotten mifepristone on formulary at inpatient and retail pharmacies; and helped colleagues get REMS-certified. And still, again and again, I take care of patients who cannot receive the care I know they need.

During a recent shift at a community hospital, I had a patient who needed mifepristone. I knew the main campus of the same system had it on formulary, but frustratingly, I found out this site didn’t stock it. I then called the local CVS, where my REMS certification is on file, only to learn they couldn’t deliver it for 3 days because of the upcoming long weekend. Next, I called an OB colleague upstairs to find out where they send these prescriptions. The answer: they don’t.

“We know it’s standard of care. We just don’t do it.”

Adding mifepristone to miscarriage management gives my patients a 15% better chance of completing without additional procedures. Yet, all too often, the system simply won’t let us get there.

Weeks later, a Walmart pharmacist called to tell me they would not dispense misoprostol to a patient. The reason: an internal policy against dispensing medications for abortion, and the diagnosis code on the prescription read “missed abortion.” This patient, who was actively experiencing a pregnancy loss, was turned away and stigmatized at a pharmacy counter by someone who didn’t understand their own policy, let alone the clinical reality in front of them.

Sitting in that “All In” leadership collaborative lecture hall, I finally named what I had been experiencing. Every one of these moments, knowing exactly what my patient needed and being blocked from providing it, had been quietly and persistently contributing to my stress, my burnout, and my moral injury.

This brought me back to another conference I had attended weeks earlier: “Moral Leadership in Medicine,” an event focused on the moral leadership required to support clinicians providing reproductive healthcare in the face of changing laws. The central theme was that physicians delivering reproductive healthcare are subject to serious moral harms by laws that are not grounded in evidence, and that healthcare leaders have a moral imperative to address the systems causing those harms. That conference focused largely on the consequences of abortion bans, but the call to action is the same. Just as abortion bans interfere with the delivery of standard of care for pregnancy complications, so do laws that restrict access to medications like misoprostol and mifepristone.

And those restrictions are growing.

In 2024, Louisiana became the first state to schedule misoprostol and mifepristone as controlled substances. A colleague and I warned publicly about the harms that would follow, and a subsequent public health study confirmed those predictions. Retail pharmacies stopped carrying misoprostol. Patients began experiencing delays in accessing miscarriage care. It is not hyperbolic to say that at some point, someone will die as a result of these laws. Several states have since introduced similar legislation. South Carolina’s proposed bill goes further, also adding methotrexate — which is used for ectopic pregnancy — to the list of scheduled drugs.

I recently gave an interview with a radio station in Columbia, South Carolina focused on keeping the Black community informed about local politics. The host rightly asked whether restricting methotrexate access would harm their community — one that already faces reduced healthcare access and worse maternal health outcomes. The answer was an unequivocal yes. These laws harm patients and will continue to do so when time-sensitive, lifesaving care is locked behind poorly conceived legislation.

After 20 years of fighting for contraceptive access, I somehow find myself focusing on abortion drugs that were already accepted as safe and effective. Birth control remains under threat too, and that fight is far from over. But I am convinced that the overregulation of mifepristone and misoprostol, driven by the stigmatization of abortion care both inside and outside of medicine, is causing measurable harm to physicians and patients.

As leaders and advocates, we have a moral obligation to reduce barriers to access: by ensuring our hospitals stock these medications and by showing up in statehouses and courthouses to counter the proliferation of restrictions that have no basis in evidence or ethics.

Kimberly Chernoby, MD, JD, is an emergency medicine physician and reproductive rights lawyer. She is Chief Legal Officer of the FemInEM Foundation.

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