we need to come out and say “enough”

I’m still ruminating over the murder of George Tiller yesterday.

As one of the diminishing number of physicians who performed second trimester abortions, I can state unequivocally that it is never a procedure that is approached in a cavalier fashion. Not every gynecologist can perform it, even if trained appropriately. The sad thing is that we’ve done a really bad job at training the next generation of providers. I taught many residents, but of those, many will not provide abortion services for a variety of reasons. Part of why this is is that abortion has been marginalized. People don’t want to talk about it. My colleagues for the most part didn’t want to deal with it. Some couldn’t say the “a-word,” substituting euphemisms like VIP (voluntary interruption of pregnancy). Abortion is a very common procedure. It is a necessary procedure. But it will be an extinct, forgotten procedure if clinicians are not trained to do it safely and compassionately. We need to get it back into the hospitals so that it is again part of routine gyn practice. Abortion training must be made more widely available within residency training programs. It’s idiotic that many ob/gyn residency programs do not offer in-house abortion services, but must send “interested” residents to outside clinics, often on their own time during weekends.

When I was in practice, I did a lot of procedures in ob/gyn. Including abortion. Some of my most grateful patients were those for whom I performed an abortion. I never performed any abortion without being absolutely certain that the patient desired it and that it was her own decision. That’s what “choice” is about, after all. My abortion patients didn’t wake up that morning and decide “What the hell, I think I’ll have an abortion.” This was a very, very difficult decision for any woman to make. People who have not walked in their shoes should not be making judgments or regulations about this most private and personal of medical decisions.

All of us who either performed or continue to perform abortions need to finally stand up, be counted, and say “enough.” Abortion providers have this terrible stereotype of being slimy, scumbags in the margins of the medical profession. We’re not. A lot of us are academics. We’re honorable. Most of us have delivered babies. All of us provide or provided services that are challenging and that many physicians either can’t or simply won’t provide. Rather than honor abortion providers, society (including many physicians) treats them like criminals. This must change. While I recognize the potential danger in coming out as an abortion provider, there is strength in numbers. And just as the Gay community came out and took steps to remove the stigma of being gay, abortion providers should stand up, be proud, and demonstrate that we’re here to stay. Only when abortion is de-marginalized can we start addressing the onerous restrictions on the provision of abortion services and also combat the insidious demonizing of abortion providers. Such demonizing was absolutely behind the assassination of Dr. Tiller yesterday.

in memorium: dr. george tiller

I just read that someone assassinated Dr. George Tiller, an abortion provider in Kansas who was one of the few people who were skilled at and willing to perform abortions above 20 weeks’ gestation. Dr. Tiller was shot while attending church services near his home.

For those of us who perform or performed surgical abortion, Dr. Tiller, along with Dr. Warren Hearn in Colorado, epitomized the highest ideals of medical service. Regardless of one’s stand on abortion, Dr. Tiller was a true professional who performed abortion above 20 weeks despite many obstacles, including onerous regulations, overzealous protestors, death threats, a bombing and the shooting of both of his arms. He didn’t perform abortion for monetary reward; in general, there are far less dangerous ways to earn significantly more revenue as a physician. Rather, Dr. Tiller did what he did because it was necessary, and because midtrimester abortion is best provided by someone who has the patient’s best interests at heart.

This also demonstrates how critical it is that residents and other physicians get appropriate training in abortion services. While I provided second trimester abortion services while in practice here in Pennsylvania, I never performed one above 20 weeks to the best of my recollection, and as a resident would go to 24 weeks, but only using saline and prostaglandin amnioinfusion above 18 weeks. Dr. Tiller provided safe, legal surgical abortion up to, I believe, 28 weeks, which requires a great deal of art and skill to pull off without complications. Now that he is gone, there are far fewer people out there with that skill and experience. Only Warren Hearn comes to my mind, although I’m sure there might be a few others.

Dr. Tiller’s murder is another indication that we need to come together and find common ground. No one is more pro-choice than I am, period. I’ve performed many abortions, introduced medical abortion to my hospital in the days before mifepristone was available, lectured about abortion technique and taught many residents how to provide a safe surgical abortion in a compassionate fashion. I’ve never dissembled about my role as an abortion provider, and am very proud of what I did. Indeed, my patients for whom I provided abortion care were often among my most grateful patients. I’ve marched on DC twice in support of abortion rights, actively supported pro-choice candidates and have always been willing to donate money to the cause of reproductive rights. That said, I’ve also worked to find areas of agreement and cooperation with reasonable people on the pro-life side of the divide. I used to be a member of a local group called Common Ground, and it brought people together from both sides to have dialogue sessions on abortion-related issues. It was moderated with strict ground rules, so no one could interrupt or become disrespectful. In this fashion, people can talk with one another without coming to blows even when there is heartfelt disagreement. None of us were trying to convert one another, and indeed, conversion wasn’t possible. The pro-life participants were just as vehement about their side as those of us on the pro-choice side were about ours. But we got along and gradually had a better understanding and respect for the other viewpoint. It taught me that one can respect and even admire those with whom there is visceral disagreement.

We need more efforts like that. I remember the 90’s when several abortion providers were murdered along with volunteers and other staff. It seemed to be a reaction to having a pro-choice president in office, in that case, Bill Clinton. The murders can’t be justified, but I would suspect that they were born out of extreme frustration from not having a conservative administration in Washington, DC. Since January 20th, I suppose it was just a matter of time.

So I’m very saddened by the loss of Dr. Tiller. Unlike Warren Hearn, I’ve never personally known or communicated with George Tiller. But his work always meant a lot to me, and women who need a second trimester abortion are worse off due to his loss. However, the cause of reproductive freedom is very much alive, and will continue despite this terrible act of assassination. I hope that my colleagues, regardless of their personal stands on abortion, and medical organizations such as the AMA, come out and strongly condemn this murder. And even better if we can all learn from Dr. Tiller’s example and come together to try to find some common ground on a very divisive issue.

an enlightened attitude about abortion

I had dinner tonight with two Canadian colleagues, and near the end of dinner (after regaling each other with the usual gynecologic surgery “war stories”), somehow the topic of abortion came up. For starters, unlike some experiences I’ve had with gynecologists in my own country, I was not shunned nor was the conversation suddenly uncomfortable for the other physicians. Even better, I was told that in Canada, there are simply no laws regulating abortion; none whatsoever. Instead, it is considered something outside of the legal and legislative domains; it is a matter between a woman and her physician. 

Amazing. This was literally one of the few times I didn’t feel slightly ill at ease when talking about one of the most common gynecologic procedures with my fellow gynecologists. Usually someone looks at me when the subject comes up and says something to the effect of “Oh David, do we have to talk about that?” or “Mind you, I’m ‘pro-choice.’ Really. But I don’t do voluntary interruptions of pregnancy; they’re kind of associated with a certain reputation.“ Or else they just stop talking and politely find an excuse to walk away. These folks never mention the ”a-word.“ Every medical euphemism gets used instead: ”voluntary interruption of pregnancy,“ ”VIP,“ ”elective terminations.“ But never the word ”abortion.“ I think I have a scarlet ”a“ on my forehead, even a decade after stopping clinical practice altogether.

So it was refreshing that up here they wouldn’t interfere with the most private decisions, indeed some of the most difficult decisions, a woman makes in conjunction with her physician. They don’t determine, for example, when a fetus becomes a person. They also don’t legislate moral and religious questions such as when does life begin, questions that lack sufficient medical or scientific answers.

In a week when the Republican candidate can’t recall his previous vote against requiring insurers to pay for birth control (when they already cover Viagra) and then claims to not have thought about the issue at all, and a week when my candidate inexplicably claims that second-trimester abortion can be restricted by states when the indication is ”mental distress,“ it’s refreshing to be in a country, albeit temporarily, that at least recognizes that women have brains and should have control over their bodies.

Barack, just between you and me: my family and I are volunteers for your campaign in the Philadelphia suburbs. I am about as strong an Obama supporter as you’ll ever see. But with all due respect, what were you thinking? States should be able to prohibit second-trimester abortion unless there is a physical disorder that would result from the pregnancy?  I get it…you’re trying to pick up some right-wing voters. But good luck with that; they don’t trust you on abortion and probably never will. Worse: some of us progressives are now questioning your commitment to our issues in light of your FISA vote, your comments on abortion, and your sudden support for faith-based initiatives. Going to the center during the general election is one thing, but going into Rush Limbaugh-ville is scary. 

For starters, please stop using the phrase ”late-term abortion.“ There is no such medical term. A term pregnancy is 37-42 weeks in gestation. So isn’t late-term what we would usually call ”post-term pregnancy,“ namely 42 weeks and above? We don’t do abortions at that point. I don’t think I’ve done one above 20 weeks personally, and know of very few folks who do them even at 28 weeks (and those few generally do them in cases of severe fetal defects incompatible with normal life). Also, for anyone to suggest that a woman wakes up one morning at 24 weeks of pregnancy and decides then that ”What the hell, let’s go have an abortion” is both insulting and ridiculous at the same time. When we use the term “acute situational anxiety of pregnancy” as an indication for abortion, we’re talking about women who, after a complicated and very difficult decision process, clearly indicate that their lives would be abnormally and unduly burdensome due to a pregnancy. We’re not talking about a temporary inconvenience that some women are callously avoiding, much like the way that Corporal Klinger tried to avoid being in the military on M*A*S*H by faking a gender disorder. We’re talking about much more than that. To say that “mental distress” should not justify a second-trimester abortion is not within your purview as a presidential candidate, as an attorney and legislator, and most importantly, as a non-clinician.

I expect McCain to say something ridiculous vis a vis women’s rights, like trying to duck the fact that he voted down legislation to compel insurers to fund contraception. I expected Barack Obama to be much more sensitive to the rights of women when they are faced with an unexpected and undesired pregnancy, much like how I expected Obama to stand up for privacy rights and against the telecommunications companies that colluded with the Bush administration to spy on private communications. I’ll still vote for you and will of course continue to vigorously volunteer for your campaign as much as I can with limited free time. But please don’t disappoint me again. Do I have to visit Canada to encounter a more advanced attitude towards women? Can’t I at least expect this attitude in my own country as part of the change I can believe in? Right now I’m tired, and am not sure what to believe anymore.