Abortion, a doctor's story
 by Elizabeth Kaye: 1988

  She's the surgeon, a healer, a counselor.  She cried when she delivered her first baby.  But there's another aspect to her practice she does abortions.  
  She is 35 years old and she is a doctor, a gifted practitioner who understands the exacting discipline of medicine and the uncharitable meanderings of the human heart.
  Her specialty is on obstetrics and gynecology.  The first births she attended made her weep with joy.  Since then, she has performed about 500 abortions.  She sees no dichotomy in that.  
  Even now, when she describes the baby being born, she gets tears in her eyes.  Describing abortion to anyone other than colleagues or patience is another thing, and something she vowed, on a night many years ago, to avoid.  
  She had been at a party, when a man began questioning her about the procedure.  She tried to evade his questions but she was young, and he was insistent, demanding that she be specific, and graphic.  Later that evening he got drunk.  She was talking to someone else.  He glared at her and began shouting, "Don't listen to her.  She tears up babies."
  When she recently agreed to discuss what she calls "the most loaded issue there is," it was with the stipulation that she not be identified, and in the hope that women might benefit from what she has to say.  As any opinions are, hers are founded not only in ideas but also in feelings that are directly related to experiences in her own life.  
  When she was 20 she nearly died from a ruptured tubo-ovarian abscess, caused by a Dalkon shield, and intrauterine contraceptive device commonly used in the early '70s.  She was a premed student then, staunch and idealistic, absolutely determined to become a doctor.  In the time she lost to illness, she found an empathy that no trading could have provided.  "I really understood what it was to be a patient, how disruptive and painful and frightening it could be.  I identified with women not understanding what's happening with their bodies because they aren't told and don't know to ask."
  While in the hospital, she had consented to undergo a surgical procedure known as an exploratory laparotomy.  Before surgery, she told a nurse and she knew from premed courses her leave she was not to be having a hysterectomy.  The nurse gave her a peculiar look.  "I'd better get your doctor," she said.  Only then did the doctor explained that what she had actually given him permission to do was to go inside, see what was wrong, and remove anything that might cause a problem-- including her uterus, if necessary.  It wasn't necessary, as it turned out.  
  Still, the experience permanently influenced her approach to medicine. "There's a tremendous need and opportunity to educate," she says. " Even the most sophisticated women often have no idea what is happening under that drape over their knees.  When a woman comes in for an annual exam it's nice to be able to teach them, to have diagrams and say, ' This is what a pelvic is, this is what we're looking for in a Pap smear.' "
  The same instructive methods apply when she does an abortion an operation, she prefers to call a pregnancy termination, for the word abortion strikes her as needlessly judgmental seeming to apply that a pregnancy that should have continued to has been stopped.  In her view, one of the most significant aspects of a termination is the patient psychological preparation.  “If a woman is really well-educated in advance about what to it's going to be like, how long it will take, what is going to happen to her, you can help her and not startle of her in any way.”
  The conversation that follows was not easy for her.  “It required a lot of emotional energy to decide whether or not I could do it, how I've really felt about it, whether I could let down all the things the done to handle this over the years and to reach my current philosophy.  It's like I build up all the stuff and now on supposed to let it down.”
 

 Your initial impulse to become a doctor was based on a desire to heal, to make well.  Did learning to do pregnancy terminations seem opposed to that?
  Not at all.  I saw them of something I needed to know how to do because I consider them part of a woman's total health care that I’m committed to making available in a safe way.  
  Which presupposes you believe that there are times when a pregnancy should be terminated.
  It presupposes that there are times when that choice will be made and I am the facilitator of that if I choose to do it.  
  Have you ever chosen not to do one?
  On occasion.  There was a woman--she was not my patient--who came into my office angry and started complaining about the office itself, and the woman at the reception desk, and I immediately started to feel angry myself. ‘And I said you know we don't have a very good interaction here.  I don't think it would be a good idea for me to take care of you.” She said, “But you just have to.  I just took the whole afternoon off from work and now I'm here and you have to do this.”  And I just said, “I don't have to do anything.  I'm going to find you another doctor.  Excuse me.”  And I left.  In other words, I do have a choice and if it's someone I don't have rapport with or if I think her affect is totally bizarre or that she doesn't know what she is doing, I won't do it .  I'm not just hands that people can put into motion.
  Describe an instance of a woman coming to you for a pregnancy termination who, as you put it, didn't know what she was doing.
  With one woman, who was actually my associates patient, I noticed that every time she had an appointment she would panic and either come late or cancel and rescheduled.  She went on for two weeks like that and it was getting late--and at some point we just decided that she was not someone we wanted to take care of.  She had really serious psychopathology, she wasn't your average neurotic--she had major borderline psychotic issues that were triggered by this pregnancy.  Adoption would probably be a better option for somebody like that.  You just don't want to go into surgery was someone who's going to change her mind at that point because it is an intervention--if you leave things alone, the pregnancy is going to go ahead.  But if she can't even decide before that point, then abortion is not a good option.  
  What are more typical cases?
  The average patient is in the first trimester of pregnancy.  She misses her period at six weeks, thinks it over, and comes in around the eighth week, which is a fairly safe time.  It's actually a lot safer than having a baby in terms of the risk of mortality and concerns like that.  She has the procedure, there are no complications, and she comes back and says she feels very relieved and goes on with her life.  My experience has also been that usually once they make up their minds, they want to do it in a fairly short period of time.  Once they know, they know, and they want to be done with it.  
  What if it isn't clear cut? What if a woman is extremely conflicted about whether to terminate her pregnancy?
  Nobody feels great about it.  Most women usually have lot of conflict.  One woman came in for abortion and then told her husband had called just before she left, and said, “Don't do it, let's have the baby.”  So we did an o.b. interview, and then she rescheduled a week later to terminate the pregnancy.  And even though she was relaxed and sure when she came in, I'm sure that there was a lot of arguments over the dinner table and a lot of soul searching.  
  Would you counsel a woman not to terminate?
  I've helped women realize they don't want to do it, but I haven't ever said don't do it--I have sometimes said I wouldn't do the procedure for them because I didn't feel comfortable enough that they had formed their opinion about it.  
  Have you ever told someone that you thought they should go ahead and have the baby?
  I think I would do that with a friend.  I wouldn't do it with a patient.  I don't feel it's my right to force--to even have opinions about what's right for them.  
  Then how do you see your role in this process?
  My role is to make sure that they’re is sure as they can be.  If you let them talk, they reach their own conclusions.  So I usually just listen... if you listen, people tell you what's going on.  
  What if it became clear to you that a woman is in a state of conflict that goes far beyond the norm?
  One woman came in and made an appointment to interview me to be her obstetrician and then started asking me about abortion and it just didn't jibe.  As we talked it became apparent that she really needed to sort out her feelings about the pregnancy.  
  And how did you help her do that?
  I said, “You don't seem to have made up your mind about this,” and she cried and said, “No I really haven't.  I really want this baby, but my husband doesn't.  I don't know what to do.” Then I told her how much time she had during which it was still safe to terminate to become clear about what she really wanted.  This particular woman ultimately decided to keep the child.  
  If a woman does decide to terminate, what is her state of mind once your action in the room, ready to start the procedure?
  Patients are sedated and kind of sleepy and easily relieved that they’re there.  They usually have very supportive significant others who come with them for the procedure.  If they don't, I always have a staff person come in and hold their hands and talk to them while it's going on.  The main thing is a sense of relief that it's over because the anticipation is usually worse than anything.
   And what about your mood?
  I don't know what my mood is.  
  Do you allow yourself to have a mood?
  I don't think I do.  I look at it strictly technically, making sure that I'm as certain as I can be that she's prepared, that she's relaxed, that she knows what's going on, doing my best to make sure that she won't have to come back for a repeat procedure.  I do feel glad that women can come to me and feel safe and be well taken care of.  
  What are the most difficult situations you ever been involved in?
  When I had been in practice about a year and a half, my best friend got pregnant.  Initially she had thought that she would keep the pregnancy and I had talked to her during that stage, trying to imagine her with the child.  It would have meant major modifications in everything she and her boyfriend were doing, but they decided it was worth it--and then decided it wasn't.  They realized the time was not right.  
  She came all the way across the country to have an abortion and asked me to do it because she really trusted me.  Initially I was going to, but I decided that I really didn't want to be attached to that lost.  Because she was going to marry this man, and I didn't want to go through the years with that... I don't know, like Lady Macbeth... that blood on my hands. To be a participant in what I knew was a really hard decision for them. I did go to the abortion with them, with her and her fiance I held her hand through the procedure.  And it was really difficult.  It felt different.  It made me realize that I have something that I do: I have a distancing thing that I do when I’m the doctor doing the procedure.  But in this case it was no longer a procedure.  It was them.  And this potentially being that ceased to exist in that very room.  I don't usually think that way about it.  I don't think I allowed myself to think that way.  But I couldn't do that with her.  It was just different.  
  Was this the first time you had allowed yourself to be fully aware of what was going on?
  Well, I've thought it through in the abstract.  But this made me cry.  Afterward we all did.  We were sort of laughing and crying.  We were all said.  Yet we all knew it was definitely the right thing to do.
  Maybe when something is that sat and yet that right all you can conclude is that sometimes bad things need to happen, that they're part of reality.
  I agree with that.  But I think doctors often deal with that idea by not dealing with it--by not allowing ourselves to become totally absorber in it, by not allowing ourselves to be the women on the table in every case.  Because she couldn't do it.  You couldn't handle it.  You have to distance yourself.  But don't want to end up sounding like a pro-life advocate...
  The fact the terminations are difficult isn't an argument for the pro-life movement.  It doesn't mean they shouldn't be done, it just means they're hard to do.
  Without distancing yourself.  Yes.  But it's hard to do any medical procedure without distancing yourself.  Hard to cut open an abdomen or do brain surgery.  
  And you don't have to be a right-to-life advocate to feel some uneasiness and misgivings about abortion.
  But I want to be professional about it.  I want to say its another procedure I do, like a hysterectomy or a removal of a cyst.  And I don't like to talk about how it's done or what it looks like, or all that gory stuff of the pro-life people splash on huge posters outside clinics.
  But don’t you think it's valid to say that abortion should be available to women, but that doesn't mean there's not sorrow in it?
  There should be sorrow in it.  I like people to acknowledge that this is a heavy-duty thing, that it's a very heavy, responsible choice the people have to make.  People should acknowledge that some time during the process.  
  Have you had experiences where you have done an abortion and really sensed the sadness?
  A friend of a friend of mine came in. She's a very aware person, in a profession where she gives all lot of other people advice, and she really had thought carefully about it.  She was late in coming to me and rescheduled a couple of times--all those little messages that she was very ambivalent--and I talked to her at length because I was afraid she would change her mind when it was too late.  I wanted to be sure she was clear, and she was clear.  We had discussed all the options.  But it was a hard choice.  And she was said.  And it was awful.  
  Awful for both her and you?
  Yes. But you know, there are lots of children in the world, and studies have shown that there are far fewer repercussions from an early pregnancy termination then there are from rearing an wanted child.  So it away, it's incredibly compassionate to terminate a pregnancy and not bring a child into a set up where the parents might resent the child.  
  I agree.  But the underlying fear in a termination must be that later a woman will feel she made a mistake.
  I don't think people make mistakes.  I don't believe in the mistakes.  People do what they do, and there's a whole set of things that has led them to that point.
  I have a couple of fertility patients who have had terminations in the past, and they can't get pregnant now and--they're just beating their heads against the wall.  They say, “Oh, if I'd only known that that was going to be my only chance.  That's a sad thing.  But the reality is still that at the time, that was the choice that they needed to make.  It's a tough one.  
  How do  you feel about women who repeatedly have abortions?
  If someone took it lightly or dismissed it or came in five or six times, I think I would start to have difficulty, as much as I would dislike myself for feeling that way.  Because that woman is as much entitled as anyone else.  But I start to the problems with that.  That doesn't happen often if patients are counseled.  
  I imagined the things most people have trouble with are second-trimester abortions.  I would think many people have a different attitude about a pregnancy that's gone on to that point.
  Luckily.  Because I have trouble with that, too.  Although the women's having them tend to be very, very young--a sixteen year old who just can't believe this has happened to her and finally calls her big sister who brings her to a doctor.  By then, she's four months pregnant.  
  And by then it's a different issue.  It's a different thing being taken out of you.
  Is it really?
  Well, once its baby-shaped, it does seem different, yes.
  Except, if you look under the microscope its baby-shaped pretty early.  That's the question: What are you really doing, and how do you make a cutoff at any point?
  How do you?
  You can't.  If women are going to have reproductive freedom, then it's up to them to choose what form it will take.  That is what’s nice about Catholicism, which teaches that the whole thing is wrong no matter what.  Because when you start drawing these arbitrary lines, saying contraception is okay but abortion is bad... or abortion is okay but it's not okay once you can feel the baby move... or abortion is okay for women who were raped or if the baby's abnormal, once you get involved in that, it's a big, yucky mess.
  So you're saying that a woman either does or doesn't have control over her reproductive life.  And you either except that or you don't.
  Right.  
  And you allow no graduations in how you think about it?
  I allow them, but I feel bad for allowing them.  I feel guilty for allowing them.  Obviously I formed my own opinions, and certain other opinions can make me a little uncomfortable or angry, but then I get angry with myself because I'm making value judgments when the issue to me is very clear.  
  And is what?
  That women should be allowed to choose.  
  Well, it may be impossible to establish a cutoff point, but I think individual cases might feel their own cut off point.  A woman might feel that if she stays pregnant into the second trimester, she must want the baby or simply feel what it's just too late to terminate at that time.
  Unfortunately not everybody thinks that way.
  When you do a termination, you have to look at the matter that you've removed?
  Yes.  
  And what is the like for you?
  Well, first of all, in the first trimester there's basically nothing to see.  There's placenta tissue.  You don't see a fetus that early.  You just make sure that it looks like you've got all of the... it's called products of conception... you want to be sure that you got it, though you can usually tell as you do the termination.  You could feel the uterine cavity shrinking.  Then you double check the tissue to make sure it looks like pregnancy tissue.  
  But after three months you can see something that is baby shaped?
  Yes.  At four months from a woman's lost period it's probably about 3 inches big.  And to be sure you have the whole fetus, you have to look at it.  
  That must be painful.  Or is it just scientific?
  ( Doesn't answer for a moment. ) There are certain blocks there. Yes, I imagine that would be painful.  It requires the ultimate detachment which I have not mastered.  
  The biggest problem was second trimesters is that the risk goes up substantially.  It's an almost totally different procedure.  You're dealing with a large, soft uterus that can be perforated easily, and you’re the best hands with someone who does them regularly. I stopped.
  You obviously have a very different feeling about terminations in the first trimester as opposed to termination's after that, and you don't think you should have it.
  ( Doesn't respond. )
  Well, maybe there really is a difference between placental tissue and an inch-long baby.
  Fetus.  It's not a baby until it comes out.  Or we like to think of it that way.  You know, if you start getting into what second-trimester fetuses looks like, that's where the right-to-life people really jump on the wagon.
  I guess the issue is when you think life begins, and that's an impossible debate.  People see it so differently, and I doubt its legislatable.
  The question of whether or not there's a right to abortion is not even legislatable  because the right exists, and if you don't let women do it legally they'll stick a coat hanger in their uterus.  So they obviously think they have a right.  
  That's the bottom line, isn't it? And when you look at a fetus under a microscope, that's probably when you most need to remind yourself of what you just said.
  Of the alternative.  Yes.  I live with that awareness.  And I hear about all the time.  One doctor who knew I was doing this interview said, “Don't forget to mention that my grandmother died in 1930 after an illegal abortion.”  Probably her uterus was perforated and she got peritonitis.  They didn't have antibiotics then, so she suffered and eventually died.  This is been going on for centuries.
  I trained with a woman who was just a few years older than I, who was trained before abortion was legal.  And she saw women rolling into the emergency room with perforated uterus, and 17-year-olds dying on the spot.  People who saw that it believe so strongly in abortion and are very committed to making it available.
  And I really worry that abortion will be made illegal again.  The right-to-life people are very powerful.  What really makes me sick is this concept that if you make it illegal, it will stop happening.
  It seems to me that the strength of your position comes from the fact that though you really have to pull yourself together to look at a fetus under the microscope, you're still committed to making abortions available because you believe that it's the right thing to do.
  What's right is hard to define sometimes.  But you have to go with what you think about it. There's nothing else you can go by.
  How do you feel about becoming pregnant yourself?
  I want to have children, and especially after what I've been through medically I was so terrified I wouldn't be able to.  I certainly didn't want to put my fertility at any futher risk.  So for a while I went crazy with my birth control.  I was really careful because I didn't ever want to have to decide.  I knew it wasn't time to have a baby, but if I had gotten pregnant I think that I would have been so grateful to know I was fertile.  I think.  But you don't know till you get there.  
  What if you were there? Your single. You have a demanding job. If you got pregnant what would you do?
  Oh God.  It would be so hard.
(Web site editor's note: Education is the key)

This article was written by Elizabeth Kaye a free-lance writer based in New York City in 1988.
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