There are only four American doctors left who openly include third-trimester abortion in their practice. They're profiled in the new documentary After Tiller, which opens in New York tonight. All four of these doctors were close friends and colleagues of Dr. George Tiller, who was assassinated in Kansas in May 2009, and they take on significant personal risks in their fight to keep late abortion available; they believe in their work deeply, while understanding that many people view it as murder. Fewer than 1% of abortions in this country are performed in the third trimester. It's illegal in all but 9 states, and according to a 2011 Gallup poll, only 10% of Americans are in favor of the practice.
Susan Robinson is one of these four doctors. We spoke on the phone earlier this week.
You've been practicing medicine since the seventies as an OB-GYN, and you started off your career in a Catholic hospital. I'm guessing that there wasn't much talk of abortion there?
Oh, absolutely not. I did my fellowship and residency in perinatology, which is high-risk obstetrics, and we weren't ever supposed to discuss abortion. For example, if we were performing an amniocentesis and detected an abnormality, even a possibly fatal one, we were never supposed to even suggest the option to the mother. Instead we told them that the test was there to help them prepare for the reality of having that child.
Have you always been pro-choice?
I have. My sister had an abortion before it was legal, and it never occurred to me that there was anything morally wrong with what she did. It was a horrible time for her to be pregnant and it was horrible time for her to get un-pregnant. But, through medical school and residency, it never really came before my consciousness that I wasn't doing abortions personally. I never thought about it until David Gunn was shot in Pensacola, which is when I realized how actively people were trying to scare doctors out of providing abortions. I filed that thought away in my mind, sort of hoping that people wouldn't get pushed out out of the field; I didn't know yet that these doctors are very hard to scare.
Then I was living in the Boston area, and there were the shootings at Brookline, and that really knocked me off my chair. I said to the people I worked for, "I am going to do abortions at Planned Parenthood." And although we weren't supposed to do abortions in that practice, everyone there said, "I get it."
And now you've been doing abortion exclusively for thirteen years. You also teach in the field. How does abortion practice and education fit within the landscape of medicine?
Among doctors, I get two distinct reactions. I say I do abortion medicine, and they either say "Thank you so much for what you do," or they turn away in disgust. It's not like if you're a neurosurgeon or a perinatologist, and people go, "Oh really! How amazing," and they defer to you. In the hierarchy of medical specialties, abortion medicine is very low.
But the doctors who are pro-choice, and the doctors who tell you that they either would do it themselves if they could or dared to: they'll often go out of their way to express appreciation. I've had doctors tell me that they themselves had late abortions because of fetal abnormalities.
If I were a medical student and wanted to specialize in abortion medicine, would it be difficult for me to get training?
Not for first and second trimester abortions. I think about half of residencies in family medicine or OB offer first-trimester experience as either an opt-in or opt-out part of training. There are Ryan fellowships, also, for people seeking this training, and you'd come out of that knowing how to do second-trimester abortions. But if you wanted to learn how to do later abortion, you'd have to come to one of the three clinics that performs them, and ask them if they're willing to take on a trainee.
Do you get trainees? Are young people willing to commit to this profession?
Yes! We just finished a year of training with a family medicine doctor. Not only is she wonderful with her patients, but she's brilliant with her hands and so compassionate and smart. We were so happy to have her.
I read an interview with you recently where you talked about Aron Ralston, the mountain climber who cut off his hand in order to escape being trapped underneath a boulder. You said that women having third-trimester abortions need them the way that Aron needed to cut off his hand. Can you tell me more about that? What's the difference between how people perceive late abortions and what you see at your clinic?
I think that the public perceives first of all that late abortion could be completely eliminated if people would only get their act together and have their abortions earlier, which is completely untrue.
I also think that people assume that women do this casually—that they've known they were pregnant for thirty weeks and then were on their way down to the hair salon and they saw the abortion clinic and they decided to just walk in to avoid the inconveniences of motherhood. That also is completely untrue. No matter how available birth control and first-trimester and second-trimester abortion is, you are always going to have the need for later abortions. A woman would never do this casually. The procedure lasts three or four days, and is fairly disagreeable.
Three or four days, I had no idea.
Yes. It depends on what kind of a cervix you have, but in some cases it can go from Tuesday to Saturday.
Can you tell me more about the "these people need to get their act together" argument?
Well, a large percentage of our patients had no idea that they were pregnant. People go, "How could this possibly be?" Well, look at that reality show. It happens. Maybe you're a little heavy and you already have irregular periods, or you had intercourse once, several months ago, and the guy said he pulled out and there's no sex education in your school so you think everything's fine. Or you never have periods because you're very thin, or a doctor has told you you were infertile.
I could tell you a million reasons why women who are perfectly smart—and they are, these are not stupid women—don't come to know they are pregnant. They have no weight changes, they don't feel sick, they don't feel movement, or if they do they think it's gas. Suddenly someone says, "Hmm, your stomach's looking big, have you taken a pregnancy test?" And the person may have taken a test, and it may have come out negative—I've had women that only got a positive on their third test. And either way they think they just got pregnant. They have no idea they're in their 24th week. So they make an appointment for an abortion, and it takes a few weeks, and they have their ultrasound and find out that they're at 27 weeks, which is too far for an abortion anywhere. So then what happens? They either give up or have a baby, or they go on the Internet and they find us.
What's the farthest that someone's ever traveled to come to you?
I guess probably from Afghanistan. This was a woman in the US military, a woman who couldn't get leave to get her abortion until she was that far along. I've also had women from Saudi Arabia, where seeking or doing an abortion is a capital crime, and a couple people from the UK and France. We get them from Canada all the time, although the Canadians are very good with abortion care up to 24 weeks. And all the states, definitely; women have come to us from every state.
The decision on whether to carry out these abortions is up to you completely. In what sort of situation do you say no?
It gets tricky, of course. The further along a woman is with a fetus that's healthy—that's really where it gets hard. If someone finds out about a significant fetal anomaly that's bad enough that they want to terminate the pregnancy, then I believe that's their discretion. Some feel like, "Sure, I can take care of a kid with Down's no problem," and then two months later they're told that the baby also has an irreparable cardiac defect. They're told that the baby will have to have a dozen surgeries in its first year, with a very small chance that it will live past a certain age. And in those cases I see it as the parents' discretion, if they think their child's life will be filled with too much pain and suffering.
There's a disabled-rights side to this, and I don't doubt the ability of people with disabilities to find happiness and fulfillment in their lives, but what I have a problem with is the "I could have been aborted" line. Hell, I'm glad I wasn't aborted too! I just find that argument specious. When parents are saying, "We do not feel we can adequately cope with that issue," I believe them, and I don't think they'd have an easy time putting a child with severe disabilities up for adoption successfully.
So how do you draw lines in the case of a healthy fetus?
It's hard. Essentially I have to say to myself, "Is this a very compelling story?" And I feel very bad about that because who am I to say, "Well, it's compelling because you're 11," and then I see a similar case when the girl's 14 and I think, okay… but then, what if you're 15, what if you're 16? How do we draw these lines? What is the ethical difference between doing an abortion at 29 and 32 weeks? Is there a meaningful ethical difference? Can I justify it? Will I have to justify it, and to whom?
It comes down to a question of safety, many times. If I feel that there is a likelihood that there will be complications, and I won’t be able to finish the procedure in the office—and we’re an office, not a surgery center—I will only do the procedure if there is a fetal anomaly. Not for elective procedures. And I say “elective” as if the woman is choosing between pairs of shoes, and it’s not like that, not even close, but I will turn that patient down. For example, in the movie, I had a patient from France and she just desperately did not want to be pregnant—but she was 35 weeks, and gestational age is plus or minus three weeks, so she could've been at 38 weeks, and that’s just too far along. It wouldn’t be safe.
From the documentary, and from talking to you now, it seems like you evaluate each case one by one, along many dimensions; you seem really engaged with the specific difficulty of every case.
Yes. Absolutely. I also have to take other judgments into account. I might accept an 11-year-old incest victim even if I believe the procedure will be risky, because I’ll be able to trust that if I have to transport her to the hospital, people will understand why I accepted her as a patient, and it won’t result in the clinic getting closed down.
Do you often have patients that require emergency care like that?
Well, not often, but things go wrong when you do abortions. They don't usually go seriously wrong, but it’s a complex procedure. Still, if you compare abortion at any gestational age to childbirth, childbirth is significantly more likely to kill the mother than abortion, which is something that no OB-GYN will ever tell you.
I was really moved and amazed by the scene where you're writing down a baby’s name, noting the family’s request for a memory box and a viewing, showing the little ink footprints. Do families often want to engage with their baby like this after an abortion? How many people are ready to—as you say—say hello to their baby at the same time that they’re telling it goodbye?
With fetal anomaly patients, we ask them right up front if they plan to hold their baby after it's born. These patients, their emotional needs are so different from the ones who are looking at their pregnancy as an absolute disaster, who are just thinking, “Get it out of me, please, please, please.” Those patients—the maternal indications patients—they are not relating to their fetus as a baby, they’re relating to it as a problem.
But with a fetal indications patient—if she refers to it as her baby, I'll refer to it as her baby. If she’s named the baby, I’ll use the baby’s name too. I would say that most of these patients do decide to see and hold their baby, although many of them have a hard time dealing with the idea at first. We’ll take remembrance photographs, we’ll give them a teddy bear, the footprints. I mean, imagine being six months pregnant and finding out your baby’s missing half its brain, and you’ve got this nursery you’ve painted at home, you’re so ready—I don’t want them to go home from the procedure with absolutely nothing to remember and honor the baby, and its birth.
Wow. You’ll say “birth”?
Yes. I try to mirror what will be the most consoling to the patient. In general, these patients—fetal indications—do talk about giving birth, so I’ll say that as well.
What is it like watching these patients say goodbye?
It is very difficult. It’s the saddest thing on earth, I think sometimes. They cry, and I cry, and sometimes they’ll ask for a baptism or a prayer. I’ve got some little non-denominational prayers that I’ll say with the families.
To simultaneously sustain these ideas—that you desperately loved and wanted this baby that’s here in your arms, and also that you just committed yourself to ending its life—it's one of the most complicated emotional situations I can imagine. In these cases—I am sorry for this macabre question—the baby is dead, right? They never meet their baby alive?
That’s not macabre! That’s a good question. Yes, that’s the first part of the procedure. We sedate the patient and euthanize their fetus, their baby, with an injection. The fetus passes away, doesn’t feel anything.
What is harder for you, what you see on the inside of the clinic or the resistance you get from the outside?
Oh, of course, the inside. By far, it's the hardest and also the most rewarding. The total sadness of the fetal anomaly patients, the gratitude and relief of the maternal patients as they leave—the idea of being able to be with someone at a time of crisis and actually make it better for them. You can't solve their problems, you can’t erase what this pregnancy and this procedure is going to mean to them, but you can ease their pain and their transition by facilitating their saying goodbye, by being kind to them, by listening, by not interrupting, by not judging them for what they feel they need to do.
Are you afraid for your personal safety on a day-to-day basis?
I’ve had a lot of advice on security. I’ve had FBI, federal marshals, domestic terrorism people advising me. I don’t like to talk about what I do specifically to protect myself, but this is an aspect of the job, certainly. Put it this way, I’ve read Gavin de Becker’s The Gift of Fear a few times.
How do you see reproductive rights in the political arena right now?
I see things moving crazily to the right. I think that the extreme, right-wing, misogynist religious fanatics have basically hijacked the Republican party and are moving toward being able to hijack the Democrats too. I'm appalled at the hubris of these legislators who, one after another, think they can make more sensible decisions about a woman's personal, private reproductive decisions than the woman herself. They know nothing about these situations. They don't know a thing about later abortions, or why women seek them out, and yet they presume that they should be making these decisions.
I don't think this belongs in the legislature at all. The decision on abortion belongs to the woman, to her family, to her clergy person if she has one, to her doctor. Women don't ever need legislators telling them what to do with the contents of their uterus.
What do you hope people come away with after seeing the film, or reading this?
I really hope that they'll understand that these late abortion decisions are carefully made by these women. They have been thought out, wrestled with, agonized over. They are never casual. And the need for late-term abortions will never go away.