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.