'Strange times’: Prescribing methotrexate legally ‘low risk’ post-Roe

PHILADELPHIA — Rheumatologists are unlikely to be held liable under a state’s anti-abortion laws for prescribing methotrexate for a rheumatic disease, according to a law professor who spoke at ACR Convergence 2022.

“It is strange times when a law professor is speaking at a rheumatology conference,” Greer Donley, JD, John E. Murray Faculty Scholar and associate professor of law at the University Pittsburgh Law School, told attendees.

Donley reminded attendees that methotrexate can only be an abortifacient if it is prescribed in high doses.

“I would tell you that continuing to [prescribe it] in a state that bans abortion is fairly low risk,” she said.

These considerations are part of what Donley referred to as the “new legal landscape” for physicians, including rheumatologists, following the June U.S. Supreme Court’s ruling in Dobbs v. Jackson ruling, which overturned the decision in Roe v. Wade and ended federal abortion protections. Just 2 weeks after the Dobbs decision, anecdotal reports began to emerge of patients being denied methotrexate prescriptions because the drug has been used to end ectopic pregnancies.

According to Donley, the key is that abortion in most states refers to intent, meaning abortion is defined as performing a procedure or prescribing a drug with the specific intent to end a pregnancy.

“You are not causing an abortion if you are not intending to,” Donley said. “You are not going to be liable under a state’s abortion laws if you are prescribing the drug for arthritis or some other condition.”

However, if the clinician knows that the patient is pregnant and continues to prescribe methotrexate, the clinician could be held accountable for intent, according to Donley.

“You should not be prescribing methotrexate in a patient who is known to be pregnant,” she said.

Donley additionally offered advice for providers practicing in states where abortion is illegal, who may find themselves counseling patients who need or want an out-of-state abortion.

Donley urged caution in this scenario.

“In this new reality, no lawyer can tell you this conduct is 100% safe if you live in a state that bans abortion,” she said. “But if you live in a state that protects abortion, you have no reason to change your practice. Nothing has changed.”

Donley stressed that counseling patients about out-of-state abortions is “a much more high-risk activity.”

She highlighted Texas state law SB8, which can punish a provider who performs an abortion after a fetal heartbeat is detected.

“It is likely that more states are going to pass laws that follow in Texas’ path,” she said. “If you live in a state that bans abortion, it is really worth paying attention to what your state is going to do in the next year.”

However, Donley added that even in states with strict laws, an abortion may be performed if the mother’s life is threatened.

Donley also encouraged rheumatologists to counsel all patients on the potential fetal complications associated with teratogens. For clinicians practicing in states where abortion is banned, if the patient finds out that the drug has caused potential disability to the fetus, they may want to have an abortion.

“The more you can do to stress to your patients about these risks, and how to prevent them, and how to ensure that they won’t happen, the more you are going to reduce your liability,” she said.

Offering a brief comment on ethics and the law, Donley suggested that every rheumatologist must decide where their own avoidance of legal repercussion ends and the ethical duty to their patient begins.

“This is a decision for each of you to make on your own,” she said.

Donley called on organizations like the American College of Rheumatology to guide rheumatologists through this territory.

“This is one of the areas where your professional society should come out with standards to guide your conduct,” she said.