Why does The Fulcrum feature regular columns on health care in America?
U.S. health care spending grew 9.7 percent in 2020, reaching $4.1 trillion — 19.7 percent of the gross domestic product. Over the long term this is clearly unsustainable. If The Fulcrum is going to fulfill our mission as a place for informed discussions on repairing our democracy, we need to foster conversations on this vital segment of the economy. Maximizing the quality and reducing the cost of American medicine not only will make people's lives better, but will also generate dollars needed to invest in education, eliminating poverty or other critical areas. This series on breaking the rules aims to achieve that goal and spotlights the essential role the government will need to play.
Pearl is a clinical professor of plastic surgery at the Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business. He is a former CEO of The Permanente Medical Group.
The Supreme Court’s leaked decision to overturn Roe v Wade, if finalized, would eliminate the constitutional right to an abortion, thereby handing over to states a choice that has been guaranteed to women for nearly 50 years.
Such a decision would not only cause major medical harm, but it would also turn tens of millions of women into instant criminals.
As a physician and health care leader, I side with the 80 percent of doctors who support the right of women to make choices about their own bodies. Medically, I concur with the scientific rationale provided in the Supreme Court opinions of Roe (1973) and Casey (1992) that fetal viability (when the child is “potentially able to live outside the mother’s womb”) establishes human life.
What’s been underappreciated in the debate over abortion are the criminal implications that would be created by defining human life at conception. Given the laws on the books, and those scheduled to go into effect should the Supreme Court overturn Roe, women in 22 states would be immediately in violation of child-abuse laws. I don’t believe doing so is what the Supreme Court justices intend or what the people of those states are expecting. But that is what will occur should the current draft become final.
To quote the governor of Oklahoma, who recently signed into law the nation’s strictest abortion ban: “From the moment life begins at conception is when we have a responsibility as human beings to do everything we can to protect that baby’s life and the life of the mother.”
Obviously, exposing fetuses to alcohol and the harmful chemicals in cigarette smoke would violate this prescription. Will law enforcement in the states that define human life at fertilization start prosecuting and potentially jailing any pregnant mother who smokes or drinks alcohol?
If a fetus is a living human, then smoking while pregnant would be equivalent to supplying cigarettes to a minor, punishable in most states by a large fine and possible jail time. Added to those penalties is the possibility of applicable child-endangerment laws. After all, nicotine dangerously reduces oxygen supply while smoke inhalation sends carbon monoxide directly to the fetus, both highly damaging. Prenatal heart defects, cleft lip and even miscarriage are just a few of the well-known consequences of smoking or breathing in second-hand smoke during the early part of fetal development. If such behaviors were to result in the death of a fetus, state prosecutors could see fit to charge parents with manslaughter or negligent homicide.
A similar concern applies to alcohol consumption. Currently, no states criminalize alcohol use during pregnancy, but supplying alcohol to a minor is illegal in every state. In many of them, it’s a felony when the crime results in serious injury or death. Self-reported studies reveal more than 1 in 9 women in the U.S. drink while pregnant. Among those of childbearing age, the prevalence of binge drinking is highest in many red states like Nebraska, Montana and North Dakota — places that are slated to institute abortion bans immediately following the ruling on Roe.
If it is determined that life begins at conception, so does the possibility of the enforcement of child-protection statutes. Any action taken by a pregnant woman that’s deemed harmful to the fetus could be child abuse, no different than if she were to intentionally harm a newborn, toddler or teenager. Research has shown that smoking and drinking in pregnancy negatively impact fetal development. The best approach to helping pregnant women abstain from alcohol and cigarettes are support groups and effective medical treatment programs.
For nearly a decade, attorney Lynn Paltrow has documented cases of pregnant women who’ve been arrested, tried and imprisoned for violating a range of anti-abortion laws, including examples of over-zealous law enforcement prosecuting women for potential harm to developing fetuses. The current Supreme Court draft would further empower such police actions.
I urge the Supreme Court justices to reconsider their preliminary opinions. As written the ruling would not only risk harm to the health of women but criminalize current law-abiding individuals. If the Supreme Court overturns Roe and allows states to define human life as beginning at fertilization, many unwarranted, unexpected and unfair prosecutions surely will follow.
image of U.S. President Donald Trump is displayed on a digital billboard in Times Square in New York on April 8, 2026.
Trump is stuck between two realities. Neither serves the American people
Normally, I worry that events may overtake a column. But not so with the Iran war.
I don’t worry about running afoul of a headline or Truth Social post from the president because what is said about the situation is no longer very relevant to the reality.
On April 8, Nick Catoggio, my Dispatch colleague, dubbed an earlier stoppage with Iran “Schrödinger’s ceasefire.” This was a reference to the famous thought experiment by the physicist Erwin Schrödinger, who was trying to explain the weirdness of “superpositionality” in quantum physics. A cat in a box is both dead and alive at the same time until you open the box. Schrödinger meant to illustrate the absurdity of the idea that particles aren’t any one thing, but a “cloud of probabilities.”
The Trump administration is stuck in a word cloud of probabilities of his own making. The war is over. The war is on. The war isn’t a war. We have a deal, but we don’t have a deal, but we’re about to have a deal. We destroyed Iran’s military. No, we left it intact. We want regime change. No we don’t. We already accomplished it. We “obliterated” Iran’s nuclear program a year ago. We had to go to war in February to prevent nuclear war. The Strait of Hormuz is open, closed, or something in-between. No deal without “unconditional surrender.” Let’s make a deal!
This everything-all-at-once vibe can be disorienting, particularly since most Americans didn’t have a war with Iran on their bingo cards until the shooting had already started. President Trump didn’t prepare the country or consult with Congress beforehand because he thought it would all be a smashing success in a matter of weeks.
The miscalculation that started it all: killing Iran’s Supreme Leader, Ayatollah Ali Khamenei, and much of Iran’s senior leadership, on the first day of the war. To “the great proud people of Iran, I say tonight that the hour of your freedom is at hand,” Trump announced on Feb. 28. “When we are finished, take over your government. It will be yours to take. This will be probably your only chance for generations.”
I support regime change in Iran and shed no tears for Khamenei or his goons. But when you start a war by killing the regime’s top leaders, it’s not unreasonable for the remaining ones to conclude that you really intend regime change.
Khamenei was a murderous fanatic, but he was a fairly cautious one. He liked to threaten closing the Strait of Hormuz or attacking our regional allies, but he was reluctant to actually do it, fearing it would invite a regime change war. The mullahs and IRGC goons believed, not unreasonably, that if they lost their grip on power, they’d be lynched by the Iranian people they’ve brutalized for decades.
By starting with a regime change war, Trump removed any reason for the regime not to go for broke. When you have nothing to lose — particularly when you are a millenarian religious fanatic — a Persian Alamo strategy makes a lot of sense.
So Iran closed the Strait of Hormuz and attacked its neighbors.
But it turns out this wasn’t the Alamo. In the contest of wills, Trump blinked. The Iranian regime’s tolerance for punishment proved — so far — to be greater than Trump’s and that of our gulf allies. Militarily we could finish the job, but that would require ground troops and much greater economic turmoil. In a conflict Trump launched unilaterally without the prior support of Congress, NATO or the American people, Trump doesn’t have the political capital for that.
But that’s only half the problem. Trump wants the war over, but he doesn’t want to pay — militarily, economically, politically — what that would cost. So he wants to make a deal that ends it. But there is no deal available that wouldn’t come at an equally undesirable cost. Any deal that looks like what President Obama struck with the Iranians would be too embarrassing to bear. But the Iranians are convinced that they can get just such a deal, and they’re willing to drag things out as long as it takes.
The result: Trump’s in a box of his own making. He thinks he can talk his way out by simply asserting a reality that doesn’t exist. When the financial markets get nervous, he announces a breakthrough that is, at best, a possibility. When the Iranians agree to a deal that looks similar to one Obama might negotiate, Trump goes back to his threats.
It can’t go on forever. But I’m sure it’ll last until long after this column is forgotten.
Jonah Goldberg is editor-in-chief of The Dispatch and the host of The Remnant podcast. His Twitter handle is @JonahDispatch.