I have to know the subtle shades of difference between “I want,” “I need,” and “I should” for each patient on every day, no matter what else is going on to complicate or confuse the issue.
It was one of those confusing issues, and my lack of attention, that resulted in an abortion I will always regret having done.
The patient and her husband came together to the clinic. It was during one of the first years I was working full-time, and that clinic did not have an ultrasound. We estimated the stage of a patient’s pregnancy based on her last normal menstrual period (LMP) and by pelvic exam to determine the size of the uterus.
When the patient and I reviewed her medical history prior to the abortion, I asked my usual question, “Are you absolutely sure of your decision to have this abortion?” She was obviously sad, but very clear in her decision and had the complete support of her husband.
“Yes, I want to do this,” she said. “There is no way I could possibly carry this pregnancy full term. I just cannot have this baby.”
With hindsight, I should have asked a few more questions. “Why can’t you have this baby?” for example. I knew there were no medical reasons, but what was driving her? There were no clues in the notes from the counselor, and I didn’t probe further.
The patient was a large woman. Due to her size, the pelvic exam was difficult and less accurate than I liked. Her history suggested she was about eight weeks since her last menstrual period. I could tell that we were within two weeks of that. She was certainly no more than ten weeks, and probably less. I continued with an uneventful abortion. The procedure took about five minutes, and she handled it well.
We moved her to the recovery room, and the tissue we removed from the uterus was taken to the lab for evaluation. We always examine the products of conception (POC), both to confirm the stage of pregnancy and to look for any abnormal tissue. On examination of the POC, it was obvious that she was actually around ten weeks LMP, meaning she had conceived at least two weeks earlier than expected by her history. I always tell the patients if we find something unexpected.
Upon entering the recovery room, I sat down next to the patient and asked how she was coping.
“Fine. Total relief, really. If I had given birth to that baby, it would have been a constant reminder of the rape. I have always been very against abortion, but in this case it was the only thing I could do.”
I was holding my breath. This was new information to me. Was the embryo we just aborted the rapist’s or her husband’s? I stifled a gasp. Questions raced through my head. When was the rape? I had to tell her what I had found, but what if . . . ?
“Mrs. P., I don’t know when the rape was, but after looking at the tissue that came out of your uterus, I need to tell you that you conceived at least two weeks earlier than we had estimated.”
The color drained out of her face. The lines around her eyes and mouth began to change and contract. She kept moving her eyes from me to the door, as if she was about to bolt.
“What? What do you mean? When did I get pregnant? I got pregnant from the rape, right? Right?”
I tried to stand, to go to the desk to get the wheel that we use to determine weeks of pregnancy and most likely conception dates, but my legs wouldn’t work. I broke into a sweat. The nurse sitting at the desk had figured out the situation and handed me the wheel. She and I looked at each other, trying to hide the look of horror in our faces.
Together we went over the facts, the date of the rape, the stage of the pregnancy as evidenced by the POC. The pregnancy was clearly not a result of the rape.
“Oh my God, what have we done?” she choked.
Mrs. P was inconsolable. I had another staff member get her husband from the waiting room, and I had to tell him what we had learned. In a gesture that would have horrified a malpractice lawyer, I apologized over and over. The three of us cried together. This pregnancy, this baby, would have been very welcomed and loved had they known it was theirs. But now it was ended, and I felt responsible. I was responsible.
We spent lots of time, the three of us, trying to comfort each other. Before they left, we exchanged home phone numbers, promised to talk again soon. They never blamed me or threatened legal action against me or the clinic. We all had counseling to deal with the guilt and sadness over the event. More than anything, I learned to never assume anything, to always ask the questions in my heart, to listen to what wasn’t said, to pay attention to my intuition, and to never do an abortion without having an ultrasound first.
Another thing I learned from that patient and her partner: how great is the gift of forgiveness. I was still trying to forgive the doctor who did my abortion years ago. Not because I had any regrets, but because of the terrible way I was treated. Every single day I worked, and with each patient I treated, I remembered that abortion. At the core, I was determined to make my patients’ experiences better than mine had been.
A clinic facility that expressed my priorities, my values, and my style was taking shape in my imagination when I flew into Bozeman. The plane banked over the Bridger Mountains. The broad Gallatin River valley spread below, surrounded by mountain ranges. I could barely contain my excitement.
Two summers before I had visited Montana for the first time, joining a group of friends for a horse pack trip in the Bob Marshall Wilderness. I had spent eight days in the backcountry. Eight days free of protesters. Eight days away from television, away from news of the outside world. There, I gained a sense of peace I had never known before. I recognized that the mountains offered me a refuge, a place where I could renew myself, and I had dreamed of that possibility ever since. In Bozeman I could do the work I loved and have the solace I needed out my back door.
The airport had just two gates. All the faces were friendly and open. Walking from the plane into the main building I could feel the cold, dry air—a welcome change from the thick humidity in the Midwest. I felt as if I were home, as if the mountains were holding their ridges out to me in an embrace.
Dr. Balice met me at the baggage claim. A small man with a big grin and a cowboy hat, he was gracious and talkative and excited. We drove right to the clinic, and I immediately saw some of its advantages. It was in a building with many other offices: a dentist, an accountant, a few doctors, the American Red Cross, a surgery center, a pharmacy, and a medical lab. Being in a building with other businesses would prevent the clinic from becoming an isolated target. Protesters would have a harder time singling out women entering the building for abortion services. The activity and variety would make it difficult for them to harass and pinpoint the staff and patients. From the first, I liked it.
When I walked through the door, I noticed a stained glass panel made by Dr. Balice. But then I looked past everything else and started to sketch in my own clinic. I could imagine the comfortable chairs and alternative magazines in the waiting room. I could see Carol Griggs’s prints on the walls and hear Tracy Chapman music. I would have coffee and juice and snacks available. Everything would be arranged to help calm and reassure patients, encouraging them to be informed partners in the process.
The clinic was small. As I walked through, I brain-stormed the layout I’d design. A room with nice windows had great potential for a counseling space. I would furnish it with a small couch, a rocker, and a small desk. Maybe I’d install a fish tank for a focal point when discussions were tough. The view out the third floor window framed the peaks of the Bridger Range, and that high up, curtains wouldn’t be needed.
Two other rooms would be the exam and procedure rooms, with a small lab adjacent. I could see remodeling possibilities that would provide a separate entrance/exit into the recovery room for patient privacy. I would get overstuffed couches that pushed back into recliners so patients could get comfortable while recovering. It would be a quiet room with more to eat, lots to read, and an ambiance designed to provide support and healing.
Within twenty-four hours of my arrival, Dr. Balice and I had come to an agreement on terms an
d timing. I would come back shortly after Christmas. I planned to open my doors in February of 1993. I was beside myself with excitement, leavened with more than a little apprehension.
Neither Randy nor Sonja had any intention of being uprooted, and until we knew the clinic would actually be a success, it didn’t make sense for them to move anyway. Randy had just finished college and begun an engineering career. Sonja had more than two years of high school left. She was completely engaged in her education and friends. My work had asked so much of her already. The last thing I could expect was for her to leave home.
I needed a place to live in Bozeman three nights a week. The other days I would come back to the Midwest and continue to work at two clinics I had been serving for four years. I’d get one day a week with my family, if everything went without a hitch.
The month of January was crammed with preparing for my own medical practice—legal considerations, writing protocols, gathering medical supplies and equipment, and finding a place to live. For a time I felt, and in fact was, incredibly isolated. I had few friends or contacts and lived a kind of obsessive existence in which my clinic became my central and only focus.
In mid-January I found a small apartment just six blocks away from the medical building. I took every precaution I could think of to keep the location a secret. I never walked directly to the apartment. I’d walk a circuitous route, usually heading out in the opposite direction, making stops along the way, coming and going at different times. Sometimes I’d duck into a restaurant, sit alone at a table for an hour, then leave by the back door. I never spoke to any of the other tenants in the apartment complex, which is completely contrary to my nature. I longed to make small talk, meet people who smiled as we passed outside the building, find out about the town, live normally.
Often as not, the easiest thing was to spend the night at the office. I was afraid to walk home alone after dark. I had so much to do. I slept on the recliner in the recovery room. Staff would bring me coffee and bagels in the morning.
Most of Dr. Balice’s staff stayed on to help me get things up and running, but did not intend to stay long term. That meant hiring new people. The responsibility of handpicking my staff was as exciting as it was daunting. The first position I filled was the clinic manager. The woman I hired was perfect. Stacy was dedicated, professional, determined, and excellent with patients. She also had a great instinct when hiring other new staff, and soon we had a team assembled I felt comfortable and confident with.
Mountain Country Women’s Clinic opened its doors on February 2, 1993. From the start, counseling formed the core emphasis of patient care. I had always been at my best with one-to-one interactions, and I had hired staff who were intuitive and committed to the same style. We worked as a unit, sharing responsibilities from front desk to lab to clean up, with counseling being a focus for all of us.
No patient was turned away for financial reasons, but each staff member had complete veto power regarding the provision of services for any individual patient. Often we spent hours on a single patient before ever getting to the procedure. Sometimes we never would get to the procedure.
In counseling sessions, immersed in women’s stories and dilemmas, we heard over and over again about the real difficulties and choices they faced. With each case, each situation, we also learned about ourselves. Most important, we began to understand that above all, we simply had to listen.
As always, the patients kept me strong. Within weeks of opening our doors, there was already a handful of women whose experiences and circumstances reaffirmed my philosophy. I had a business to run, and the financial burden kept me awake some nights, but I knew I was doing everything I possibly could to keep our patients both physically and emotionally safe. It became the most important and rewarding part of my work. I knew, from my own experiences, how essential it was to be fully informed, and I could see daily, in the looks of gratitude and relief, what it meant to the women we served. That was the bottom line that mattered.
It wasn’t uncommon for a woman to return three or four times before she’d feel comfortable with her decision. In the first month of my new practice I handled one such patient: forty years old, a successful career woman, torn between her ticking biological clock and the present circumstances of her life.
“Deep down I think I’ll regret having this abortion,” she said at one point during her first visit. “I know I’m getting to an age where I have to decide about having children. But then when I think about everything else—my relationship, my work—I can’t imagine having a child.”
As soon as she said that, I knew we wouldn’t be doing an abortion, not that day anyway. But we talked nearly an hour longer. Everything about her body language communicated her indecision, her ambiguity.
“Do you think it’s the situation, your circumstances, that you’ll regret, or is it the abortion itself?”
No response. A shrug of shoulders.
“That’s a big distinction. You need to sort that out. This is not the time for a snap decision. Work it through more. Give it the time you need.”
“I feel so terribly irresponsible!” she said.
“Look,” I said, taking her by the shoulders, “it’s the people who don’t think things through, who make no plans and ignore reality until they’re really stuck and then can’t cope—they are the irresponsible ones.
“You’ve met us now. You’ve seen the clinic and how we work. Take your money and go sort this out. Come back if you need to.”
Two days later she returned.
“I just want to do it,” she said. “All this thinking is driving me crazy. Let’s just do it and be done with it.”
“No. This is irreversible. We never ‘just do it.’” I sent her on her way again.
But when she returned a third time, a week later, I could see the difference in her even before she said a word. Gone was the cocoon she had wrapped herself in earlier. Gone were the nervous, fidgety mannerisms, the hesitation before tough questions.
“I’m absolutely sure now,” she told me. “I regret my situation, but this is the right choice.” Her eyes held mine.
“Is this your head talking now, or your heart?” I asked, although I already knew the answer.
“My heart,” she said, with absolute certainty in her voice and in her manner.
I had devoted three counseling sessions to this single patient. Three unpaid sessions, from a business point of view. But there is more than one consequence in these cases. The financial one pales in comparison to the human, emotional one.
That patient expressed her gratitude when she left the clinic. “Thank you for making me wait and work through all the things I was struggling with on this choice,” she said. “I’d have been a wreck if you had done the abortion the first time I came in.”
Many times the counseling involves more than just the patient. Parents, boyfriends, or husbands are frequently very involved in the dialogue, but the decision is still ultimately the woman’s.
Another day I spent nearly an hour on the phone with the mother of a young pregnant girl. She had been calling all the clinics in the region to get a sense for which would be the best for her daughter.
They lived in a small Wyoming city. Their daughter, the way the mother described her, reminded me of Sonja. She was a responsible kid, at the top of her school class, active in sports and other activities, busy with her friends.
“She went to a movie one night,” the mother told me. “We always insisted that she walk home with friends in the neighborhood when she was out late, and she always did. But this one night her girlfriends were in a hurry, and my daughter told them not to bother. It was only a few blocks. She knew that if she called we would come and get her . . . ”
After a silence, the mother continued. “She was raped in those few blocks. On the way home my daughter was raped.
“But worse than that, she felt so terrible and so guilty, as if it were her fault! She couldn’t bring herself to tell us this awful
thing. She couldn’t tell us.
“Last week I noticed that the supplies for her period hadn’t been touched for a while. I really wasn’t sure how long. When I asked her if something was wrong with her period, she broke down in tears. It was only then that she told me, and by that time she knew she was probably pregnant.”
I could hear the emotion in her voice, threatening to break through. “How overdue is your daughter?” I asked, moving us on.
We discussed in detail the process our clinic went through with each patient. By the time we finished she had decided to make an appointment. I insisted, however, that the daughter make her own appointment, stressing that we do abortions at the request of the woman, not a parent or husband. The mother understood what I was saying and put the daughter on the phone.
We had a brief discussion, long enough for me to confirm the things the mother had told me, and for me to be convinced that she indeed wanted to end this pregnancy. She had, in fact, been making calls herself, inquiring about how to get an abortion.
“Is it all right if my parents both come?”
“Of course it is. That is the way it should be,” I replied.
They arrived within days, after a six-hour drive. All three of them were well dressed, neatly groomed, polite, exuding an air of prosperity and a careful control over their emotions.
While the daughter began her counseling with one of my staff, and with her permission, I asked her parents to join me in my office.
“I know you are concerned,” I began. “And I want to fully explain the procedure your daughter will go through, if that’s her decision.” The man looked a little startled at the possibility his daughter might not elect the abortion. “It sounds, in this case, as if Ellen is pretty clear. But it’s very important that we reach a complete understanding with each patient, and that the choice is an informed one.” He nodded.
I went through the technicalities of the procedure, at one point drawing a diagram of the uterus on a notepad to illustrate the stage of her pregnancy. I could feel the father’s growing agitation as I continued. I wondered how much a part of all this he had been, whether he had fully dealt with his own feelings.
This Common Secret: My Journey as an Abortion Doctor Page 8