“So we’re all doing pelvic exams on this patient?” I asked.
“Yes.”
“Without her permission?”
He stared at me.
“We’re all really supposed to do this?”
“Quit asking questions,” he said. “Scrub in and get with the program.”
I refused, turned around, and went directly to the department head.
“I can’t believe we are expected to do this,” I said. “It is a terrible violation.”
“These women have come to a teaching hospital,” he replied. “They understand that medical students are present and need to learn. They’ll never know it anyway.”
“Are you proud of this teaching institution?”
“Of course,” he replied.
“Then you’ll have no problem when I go to the local paper and discuss this teaching practice.”
I knew very well that this could mean the end of my medical education, but if this was what it meant to become a doctor, I had no desire to go any further. After a heated discussion, the department head agreed to put a halt to pelvic exams on anesthetized women, and I agreed not to go to the papers with the story.
In spite of the fact that almost half of the women in this country have an abortion at some time in their reproductive lives, abortion was not acknowledged, discussed, or described during my ob-gyn rotation. When I asked to be taught the procedure, I was met with total resistance. It was simply not a program option. This refusal only made me more determined.
Shouldn’t a physician be able to at least intelligently discuss all the options for women with unplanned pregnancies?
I was finally able to arrange, on my own, an elective reproductive health rotation at another institution. There I was able to learn about the various methods of abortion and observe procedures.
Memories of my own abortion kept creeping in, memories too painful to talk about, but I had been in enough medical situations by then to realize that my experience was not the norm. I was anxious to see how procedures were done in a legitimate, well-run clinic.
The first abortion I saw during that rotation was for a woman who was halfway through her pregnancy. The fetus had an abnormality incompatible with life. It had started out as a very planned and wanted pregnancy. When the abnormality was diagnosed through an ultrasound, the woman chose to end the pregnancy instead of going full-term, delivering the baby, and having it die immediately.
Most abortions done at this stage are for similar reasons, or to save the life of the mother, but knowing the circumstances did not soften the visual reality of a twenty-one-week fetus. Seeing an arm being pulled through the vaginal canal was shocking. One of the nurses in the room escorted me out when the color left my face.
Not only was it a visceral shock; this was something I had to think deeply about.
I had been about eight weeks pregnant when I had my abortion. I knew from my embryology classes in the first year of medical school that an eight-week embryo is about the size of my thumbnail. It cannot feel pain or think or have any sense of being. I have never regretted that abortion.
Confronting a twenty-one-week fetus is very different. It still cannot feel pain or think or have any sense of being, but the reality is, this cannot be called “tissue.” It was not something I could be comfortable with. From that moment, I chose to limit my abortion practice to the first trimester: fourteen weeks or less.
Over the next six weeks I met eight to ten women in the clinic almost every day, women who had come to end pregnancies for a variety of reasons. For some it was financially motivated. Others had educations to finish or careers they had just started. Some were in abusive relationships and did not want that connection to the man. There were women with chronic illnesses whose lives would be in jeopardy if the pregnancy continued. And there were women carrying fetuses with genetic abnormalities or anomalies incompatible with life. Many had been using a form of birth control that failed.
Never once did these decisions seem easy or casual. Every one was the product of tremendous personal struggle. Anyone who claims otherwise is either very ignorant or unkind or both. Anyone who says that women use abortion as a method of birth control or as a simple matter of convenience should spend a day in a clinic where abortions are performed. No honest person would ever make that statement again.
Equally important and revealing is the fact that women who have abortions come from every level of education, every income bracket, and every age from puberty to menopause. They are Catholic and Jewish, Protestant and Buddhist, agnostic and atheist. Every race and every ethnic group. Every possible woman. They are, in truth, our sisters, aunts, grandmothers, music teachers, neighbors, and best friends.
By the end of six weeks I had become steadfast in my belief that abortion has to be legal and available for all women, even when the pregnancy is into the second trimester. Women cannot be forced to bear children they are unable to care for physically, financially, or emotionally. Women cannot be forced to continue with a pregnancy that may cost them their lives. The bottom line, as expressed by my friend Liz Karlin, is, “Women have abortions because they want to be good mothers.”
What struck home more than anything during that rotation was how drastic and tragic it would be to have this choice taken away from women. By the end of it, I had learned that abortions could be performed with compassion and respect, just as I had suspected. It was an experience I had been denied, but one I vowed not to deny any woman who became my patient.
From there I went on to another elective rotation in Salt Lake City, Utah, to study infertility, in vitro fertilization, and embryo transfer. It might initially seem strange for a doctor who wants to do abortions to enroll in both those rotations. But true choice is a matter of understanding and weighing all the options, and then being free to carry out the most appropriate one.
While I was leaning toward a specialty in some aspect of women’s reproductive health, I was still weighing other options. I found genetics fascinating, for instance, and was intrigued by the career possibilities in forensic pathology.
Before I had learned to do abortions and was still early in my training, I met a woman whose circumstances illustrated the life-and-death reality of choice. I didn’t know it then, but her case would be the turning point in my medical career.
When I encountered her, I was one of many students, interns, and doctors doing prenatal care in a low-income clinic. Most of my time was spent getting initial information from patients, keeping charts, taking medical histories—the grunt work of the process.
This woman, when I first saw her, wouldn’t look at me directly. She seemed heavy with defeat. She moved slowly and spoke slowly. I was the first person in the system she had seen. I began working on her chart, getting her ready for the exam. “I can’t have this baby,” she blurted out.
“What do you mean?”
“I can’t have it,” her voice was hushed, frightened. “He’ll kill it if I do.”
“Who? Who will kill it?”
“My man. The county already took my two girls because he beat them. I already lost my two girls. I can’t lose another. He’ll kill it. I know he will!” She was looking at me now, beseeching, her voice strident.
“Have you had counseling?” She shook her head. “There are shelters for abused women. Places you can get help, where you can get away from him.” She kept shaking her head.
“I can’t have this baby. He’ll kill it.”
I began making inquiries over the next few days. The social service agencies were aware of the case, knew the history, but couldn’t be mobilized. They wouldn’t agree to take the child after birth until there was evidence of abuse. The woman had no money. $350 for an abortion might as well have been $350,000.
When I saw her again, I asked her about adoption, but she adamantly refused.
I felt completely helpless. This woman’s predicament seemed insurmountable. The rest of the medical personnel in the clinic were no help. I s
aw her periodically throughout her pregnancy. Eventually she stopped pleading with me, but in her eyes I read deep fear and reproach. I was her first connection to the clinic, the one she chose to confide in, a person she thought had real power, and I was impotent.
The night she delivered was incredibly busy on labor and delivery. I scurried from patient to patient, prepping, comforting, coaching, assisting doctors. Her birth was one of many, an uncomplicated procedure lost in the confusion of a hectic night. Her “man” was not there. She had no visitors.
When we sent her and the baby on their way in a taxi two days later, she wouldn’t meet my eyes.
“Be safe,” I said, as I closed the cab door. She rode away, out of my life. I thought about her from time to time, but things careened on. Only the present demands stayed in focus.
Nearly a week later my pager went off, and all I could hear was my name and the words “emergency room.” When I walked through the swinging doors, there she was again. I saw her holding her infant son. ER staff surrounded her, trying to get her to hand over the baby, but she was holding the limp body tightly.
When she saw me, she held it out, shaking with emotion. “It’s your fault!” she cried. The baby, this infant, just born and already dead, lay across her arms like an accusation. “It should never have been born.” The woman’s face was twisted in anguish and hatred. “It’s your fault.”
I stood with my hand over my mouth, frozen in place. Now I was the one unable to meet her eyes. I felt a surge of mingled guilt and frustration and anger. Guilt for not being more persistent in finding her the help she had asked for. Frustration with a system that doesn’t protect the weakest and poorest and most vulnerable. Anger at the father for all the obvious reasons. I also felt utterly inadequate.
For a long time I felt it was indeed my fault. Her face haunted me. Her words echoed in my head. Even now her face still confronts me. At that moment I knew with absolute certainty that I had to learn to do safe, legal abortions. I had to be able to offer that service to my own patients. Abortion is about life: quality of life for infants, children, and adults. Everywhere and in every sense of the word. Life, not death.
The self is not something ready-made, but something in continuous formation through choice of action.
—JOHN DEWEY (1859-1952)
chapter four
Just weeks before my graduation from medical school in 1987, Randy and I were married in a private ceremony. Two good friends, Sonja, and Flower Grandma were the only people in attendance. Then, after graduation, we held a huge family party to celebrate both events. My parents were embarrassingly proud. I remember dancing with Dad to the “Blue Skirt Waltz,” closing my eyes and pretending I was ten years old again. Within days we were packing up for my ob-gyn internship in Portland, Oregon.
Before we left, though, I had one stop to make in St. Paul. I tracked down Hal, the man who had first put the crazy notion in my head that I could be a doctor.
Coming up his front porch steps, I wasn’t sure that he would even remember me. His broad grin and open arms reassured me that he had not forgotten the hippy mom on a bright afternoon more than seven years earlier. His eyes asked the question, and my nod gave the answer. I made it! I was a doctor! This man whom I had only met once in my life had changed everything for me.
We sat on his front porch. He wanted all the details. I told him Sonja was now ten. He recalled the “blond giggler” tearing around with the other kids at the party. Before I left, I promised I would do for others what he had done for me. I would listen, believe, and empower those least likely to believe in themselves. I would plant seeds.
The internship year is a book in itself. Everything people say about the rigors and stresses of medical internships is true. That year was the most painful, draining, and grueling period in my life. For a hundred hours a week, or more, I was immersed in labor and delivery, assisting with surgeries, outpatient clinics, internal medicine, and on call for the emergency room. Randy and Sonja were largely on their own.
I was only rarely able to include Sonja in my daily routine. The chief resident and I had daughters about the same age. If our overnight call coincided on weekends, we’d bring our kids to work.
One morning on rounds, a group of us came around the corner to find Sonja and her playmate dressed in oversized scrubs, wearing hospital booties, holding clipboards, and walking in purposeful circles.
“What are you two doing?” one of the attending physicians asked.
“We’re making rounds,” they announced, as if that was pretty plain to see.
As part of my internship training I observed procedures in the abortion clinic and learned from skilled, caring, and compassionate doctors. One day our chief resident introduced me to a patient and told her I would be doing her abortion. I remember sitting down at the foot of the bed and flashing back to my own awful procedure.
I pushed back from the bed and stood up. I asked the patient to sit so we could talk. She had already received thorough counseling, but we talked more about the procedure, its alternatives, the risks, and possible complications. I wanted to make sure she understood everything and had all her questions answered. I wanted to make sure she was clear in her choice. I was, of course, imagining myself when I had been in need of these very same things.
The procedure went well, though I know I was slow. I did three more procedures that day, learning from each one. With a growing confidence, I saw that I could do this and do it well.
At the end of one year, I left the program, certified as a general practitioner. As quickly as we could, Randy, Sonja, and I packed up to return to the Midwest.
Randy had begun taking courses toward an engineering degree in Portland, and we agreed that he should complete his degree in the Twin Cities. We chose to move to Cambridge, Minnesota, an hour away from Grantsburg, Wisconsin, where much of our family lived. I’d have to commute to the job I’d accepted at the Grantsburg clinic and hospital, but Randy would have a shorter commute to school in St. Paul.
It was the summer of 1988, and I was a bit apprehensive about returning to work in my hometown. I considered it a temporary situation while Randy finished school. There were two full-time physicians in Grantsburg, with a third, Dr. Hartzell, moving into retirement. Dr. Hartzell had been there since 1949; he was a loved and respected fixture in the community.
My first weekend on call was the Annual Water-Skip contest. Grantsburg bears a sign declaring a population of 1,462, but on that weekend it swells with 10,000 spectators and participants for the insane activity of racing snowmobiles across open water. Inevitably, there is too much drinking, too many accidents, and a little hospital emergency room set on overdrive.
Dr. Hartzell lived just up the street and stopped by to see how things were going more than once that weekend. Miraculously, we found time to sit and chat for a few minutes. I remembered him coming to our home when I was six years old and very sick with rheumatic fever. Later, when I took a fall off the neighbor’s pony and broke my arm, he set the break and was the first to sign my cast.
He had been our family doctor in the truest sense of the word. Dr. Hartzell had stuck with the community for years when other doctors had come and gone. Finally I was able to bring the conversation around to what I really wanted to discuss: abortion.
Throughout the United States in the years before abortion was legal, there had been a network of clergy connecting women who wanted abortions with doctors they knew were safe. Dr. Hartzell was one of them. He told me that he always believed that these decisions had to be handled between individual women and their doctors.
When women came to him, whether they were referred from out of the area or local women he had known for years, he would schedule the operating room for a “D & C.” D stands for dilation, and C stands for curettage. It refers to a method of opening the cervix and cleaning out the uterus. It is usually a therapeutic procedure in response to abnormal uterine bleeding. It can also be a diagnostic procedure to gather uter
ine lining, looking for dysplasia or cancer.
The patients coming to Dr. Hartzell for D & Cs, however, were pregnant. The procedure would remove the pregnancy early in the first trimester. The word “abortion” would never appear on the chart. No one asked the obvious questions, but he told me that “there were starting to be some rumblings in the community” about it.
We were both concerned about what this would mean for me, as I planned to continue the practice but would now chart it as an abortion. It was, after all, 1988, and abortion had been legal in the United States since 1973. There was no need to hide, and hiding it only contributed to the negative spin some people try to put on it.
The hospital board had other ideas. Under pressure from a few community members, they had a closed meeting to set into effect a policy that forbid all elective abortions at the hospital. I was furious, but my hands were tied. Dr. Hartzell was retiring and not ready to fight this battle with me. I went to the next open board meeting to try to discuss the issue. I was told that “unwanted pregnancies don’t happen in this community” by one of the board members. As I looked around the room, I personally knew that abortion had been a choice made by family members of at least two of the people sitting on the board. I kept quiet, but I wondered if they even recognized their hypocrisy. Over and over, I tried to make my case, but they would not budge.
For the next few months I referred patients with unwanted pregnancies to a clinic in St. Paul, a two-hour drive away. Then one day a woman I had known since we were children came to me. She already had two kids, was living on a shoestring budget, had no health insurance, and was pregnant. She and I talked a long time about the options, and she was clear in her decision to have an abortion. She asked me to do it. She was adamant about not going to a doctor she didn’t know, and she did not want to travel to St. Paul.
My choices were clear, but none of them were very good. If I sent her away, I was failing as her doctor and as her friend. If I did the abortion openly at the hospital, I would likely get fired. I chose instead to risk my job and my credibility, but it was a choice I made for that patient and for a number of others over the following year. It was a choice mandated by circumstance, much like Dr. Hartzell’s decision had been to perform procedures in a clandestine manner. A decision forced by a difficult reality.
This Common Secret: My Journey as an Abortion Doctor Page 3