The Social Medicine Portal

Honoring George Tiller by Improving Access to Reproductive Health Services

Last Tuesday’s Social Medicine Rounds (9/8/2009) was prompted by the brutal murder of family physician George Tiller on Sunday May 31^st 2009. While serving as an usher at the Reformation Lutheran Church in Wichita,  Dr. Tiller was shot in the head and killed.  We convened this Rounds to consider how we might respond to his death. Two issues dominated the discussion. The first was the failure of the American Academy of Family Physicians (AAFP) to condemn the murder.  The second was an examination of the ongoing barriers to abortion care that exist even in a relatively progressive state such as New York.  These problems were illustrated through 3 case vignettes.

The Death of Dr. Tiller

Dr. Tiller’s career as a family physician took a path he did not anticipate.  Like many conscientious physicians, his clinical practice responded to the needs of his patients.  Here is the story told in his own words (taken from the Physicians Voices section of the Physicians for Reproductive Choice and Health website):

In July of 1970, I planned to start a dermatology residency. On August 21, 1970, my father, mother, sister and brother-in-law were killed in an aircraft accident. My sister had a 12-month-old boy, Maurice. They had written out a will in longhand the evening before the airplane crash, that I was to raise Maurice. So we took charge of my sister’s boy and we moved back to Wichita. My game plan was to spend six months here, close out my father’s huge family medicine practice.

After I had been there for a little while, patients in the practice began to ask me if I was going to do abortions like my father did. I was outraged. Why would these nice people say that he was a scumbag kind of a physician?

I began to ask some of these women. And I found out that in 1945, ’46, or ’47, a young woman for whom Dad had already delivered two babies came to him pregnant again right away, and she said something to the effect that, “I can’t take it, can you help me?” That is apparently the way you asked for an abortion from your regular doctor before abortion was legal. Dad said, “No. Big families are in vogue, by the time the baby gets here, everything will be all right.” She had a non-healthcare provider abortion and came back and died.

I can understand how upset my father was. I do not know whether he did 100 abortions or 200 abortions or 300 abortions. I think it may have been something like 200 over a period of about 20 years, but I don’t know for sure. The women in my father’s practice for whom he did abortions educated me and taught me that abortion is about women’s hopes, dreams, potential, the rest of their lives. Abortion is a matter of survival for women.

When it became legal and my patients began to ask for it, I’d say, “Sure. It’s a legal process.” I was a service provider. I was a physician. The patients needed abortions, and I did them. It is my fundamental philosophy that patients are emotionally, mentally, morally, spiritually and physically competent to struggle with complex health issues and come to decisions that are appropriate for them.

We’ve been picketed since 1975. My office has been blown up. In 1993, I survived an assassination attempt. My kids were harassed in high school. I had to write letters of complaint to the City Council and the Board of Education. We had people who actually camped across the street from our house. I restrict where I go to eat, where I travel. You see a car following you, you think, “Ah-ha, let’s watch that.” You’re always on alert. You’re always looking around.

I was leaving the office. It was 7:00 in the evening. As I’m driving out, I have to slow down and I have to stop. Bang, bang, bang, bang, bang, bang, and I thought to myself, “That lady is shooting me with rubber bullets. I’m not afraid of rubber bullets.” Then I looked down and all this blood is all over the place. I thought, “She shot me. She can’t do that! I’ll get her.” I saw her running through some front yards. So I zipped down the street, turned in front of her to block her escape. She stops and reaches into this little fanny pack that she’s wearing in the front, and I thought, “She’s going for her gun again. She shot you once, George. She’ll shoot you again. You are in the wrong place at the wrong time.”

So then I drove off. Ended up back at the office, and I don’t remember anything for about 20 minutes. I remember trying to get into my car and drive myself to the hospital. I said, “Let’s not make this a big media event.” Well, I had lost 20 minutes and the TV trucks were there. I thought, “How’d they’d get here so soon?”

There was never any question in my mind that I was going back to work the next day. I belonged there and they were not going to separate me from my job and they were not going to separate me from my community. So I did go to work the next day, and we got everything done. People got taken care of, it took a long time. Arms hurt, bled a little bit, but so what? I am not going to be run over and I’m not going to run out. It’s just that simple.

I am a member of this community. Our DNA has been here since 1880. I belong here. The folks that come in from out of town, they are the intruders. Forty percent of all the people who were arrested here during the Operation Rescue in 1991 came from out of state. I intend to stay here. I am part of the fabric of Kansas and Kansas is part of the fabric of me.

I have more to be grateful for than I have to be resentful about. We have much more support in Wichita than we have rejection and castigation. If Wichita and our community did not want us to be here, I wouldn’t be here. But the vast majority of people in Wichita support, on a quiet level, what we do, which is help women and families.

Extensive coverage of the murder can be seen in this June 1, 2009 broadcast of Democracy Now.  This program includes an excerpt from a 2008 speech Dr. Tiller gave to the Feminist Majority Foundation in which he explained his social vision: “We’ve given war, pestilence, hate, greed, judgment, ego, self-sufficiency a good try, and it failed. We need a new paradigm that consists of kindness, courtesy, justice, love and respect in all our relationships.”

Non-Response of the American Academy of Family Physicians

Tiller’s death was clearly not a random act of violence.  As noted by Colorado physician Dr. Warren Hern:

I think it’s the inevitable consequence of more than 35 years of constant anti-abortion terrorism, harassment and violence. George is the fifth American doctor to be assassinated. I get messages from these people saying, ‘Don’t bother wearing a bulletproof vest, we’re going for a head shot.’

Tiller’s death was condemned in the strongest terms by American College of Obstetricians and Gynecologists:

The American College of Obstetricians and Gynecologists (ACOG) finds the murder of George Tiller, MD, deplorable and tragic. There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it. It is especially chilling and deeply disturbing that this violence has occurred at a time when the leaders of this country are committed to finding a common ground in the abortion debate.

ACOG extends its sympathy to the family of this dedicated physician who treated his patients with dignity and compassion.

As ACOG expressed in response to the 1998 murder of Dr. Barnett A. Slepian, “With each new incident of anti-abortion violence, the previously unthinkable becomes commonplace—that vandalism could turn to murder, that slayings could move from the clinic to inside the home.” The murder of Dr. George Tiller is even more horrific in that he was killed in a house of worship as he and his family attended church services.

There is no common ground when it comes to violence of this nature. All groups in the abortion debate, whatever their personal opinion on abortion, must condemn such brutality in the strongest possible terms. Failure to make such condemnation is acquiescence to violence and intimidation. Only by standing together can we ensure that acts of brutality end.

In fact, even some anti-abortion groups condemned the killing. Here are the words of Troy Newman of Operation Rescue from a June 3, 2009 editorial in USA Today:

The fundamental tenet of the pro-life movement is that human life has intrinsic value and is deserving of protection from the moment the seed and egg unite, until natural death. To take a life without due process devalues all life.

We at Operation Rescue were shocked to hear of the killing of late-term abortionist George Tiller and were among the first groups to denounce the cowardly act that took Tiller’s life. It was not justice, but vigilantism, which must be abhorred by a society that embraces the rule of law over anarchy.

With even the anti-abortion movement condemning the murder, how odd it seems that the American Academy of Family Physicians (Working for Family Medicine,  Working for You), of which Tiller was a member, refused to issue a statement.  A strongly critical commentary by Dr. Joshua Freeman (The Murder of George Tiller – Where is Family Medicine’s Response) in this month’s Family Medicine explored the reasons cited by the Academy for this refusal.  The AAFP pointed to a policy that it “does not comment publicly on a member’s death (regardless of how it occurred) but expresses condolences privately to the family.”  Of course George Tiller did not merely die.  He was murdered.  He was not simply murdered.  He was assassinated for carrying out his duties as a physician.  One cannot help but remember the comments of ACOG:

All groups in the abortion debate, whatever their personal opinion on abortion, must condemn such brutality in the strongest possible terms. Failure to make such condemnation is acquiescence to violence and intimidation.

Several State Chapters of the AAFP have introduced Resolutions condemning the murder to be considered at the next Congress of Delegates.  Truly, AAFP’s silence on this issue shames family medicine.

Barriers to Abortion Access in New York: 3 case studies

We then considered three case scenarios illustrating the barriers to abortion access in New York  State.  Each case came with a series of discussion points.  One point, considered in each of the cases, was the role of abortion in current health care reform proposals.  (All identifying information has been removed or altered in these cases).

Case 1: Teresa is a 22 year old woman, G1P1, who comes to your office for a refill of her Nuva-Ring. She reports that she had actually run out 4 weeks ago, but couldn’t afford the time off from work at the Post Office to get in any sooner.  She had unprotected sex 2 weeks ago.  Her pregnancy test is now positive. Teresa is sure she cannot afford to have another baby right now. She decides with you to have an abortion.  You give her the number to call Planned Parenthood to schedule it, and she calls you back later to tell you her insurance does not cover the procedure because she is a federal employee.

Discussion Points:

• The Hyde Amendment bans the use of federal funds for abortions except in cases of life endangerment, rape or incest.
• In addition, 32 states and the District of Columbia have prohibited the use of their state Medicaid funds for abortions except in limited cases allowed under the Amendment.
• What is your role as her primary care doctor in facilitating her timely access to abortion care?
• What are the implications for a universal federal health plan?

Case 2: Angela is a 31 year old woman G6P4, who works as a babysitter “off the books,” and comes to your office because she is pregnant and wants an abortion.  You know that she has Medicaid so you refer her to the local abortion clinic for care.  She calls you the next day to tell you she was denied care because her insurance does not cover abortion. You are confused because in New York Medicaid does cover abortion, so you call the clinic. They tell you that your patient has Fidelis (a Catholic HMO) and Fidelis does not cover abortion care.

Discussion Points:

• What is your role as her primary care doctor in facilitating her timely access to abortion care?
• What happens with Medicaid HMO’s that are “owned” by the Catholic Church?
• What does this mean about how our tax dollars are being spent?
• Can Angela use her Medicaid to pay for her abortion?
• Would she be covered by a federal health plan?

Case 3: Monica is a 16 year old woman, G0P0, currently attending Roosevelt High School. She was sent to you by her school-based health center because she had a positive pregnancy test.  Monica’s parents have insurance, but she does not want them to know that she is pregnant.  After talking to you, she decides she would like an abortion.  But she stresses the importance of not letting her parents find out.  She tells you that last year her 18 year old sister got pregnant and they kicked her out of the house.

Discussion points:

• What are the rules in New York State regarding confidentiality for teens around pregnancy care?
• Can she get other insurance to pay for her abortion?
• What are the systems issues around eligibility for Medicaid?
• What is your role as her primary care doctor in facilitating her access to abortion care?
• Would she be covered by a federal health plan?

Resources for Women needing Reproductive Services

The Portal has reported extensively on free and low-cost health care as well as free clinics in New York.   The New York City Free Clinic, located on 16^th Street in Manhattan, includes a Women’s Health Free Clinic in operation since February of this year.  The list of services provided at the Women’s Health Free Clinic includes Medication Abortion (up to 9 weeks).  It is a project of the Reproductive Health Access Project (RHAP) which offers detailed instructions on setting up free women’s health clinics.

Posted by Matt Anderson, MD