The Assassination of Dr.Tiller: The Marginality of Abortion in American Culture and Medicine

C. Joffe and T. Weitz: Abortion After Tiller

ON SUNDAY May 31, 2009, George Tiller, an abortion-providing physician in Wichita, Kansas, was assassinated in his church by an anti-abortion extremist. This event was not entirely surprising to observers of the abortion conflict in the United States. For years, Tiller had been the most high-profile and polarizing abortion provider in the country. He was reviled by the anti-abortion movement, and had endured previous attacks on his life. At the same time, Tiller was a revered figure within the close knit abortion-providing community–fondly called by his peers “Saint George”–not only because of his steadfastness in the face of the endless attacks of his opponents, but also because of his willingness to accept their most challenging cases, often at no charge to poor patients.

Tiller’s murder, and the attention this event brought to his controversial practice, illuminates the deeply embattled status of the abortion issue in American culture that still exists more than thirty-five years after legalization. The murder, most obviously, reveals the staying power of the extreme violent wing of the anti-abortion movement, at a time when many thought the worst of the violence had subsided.

The initial reporting of the murder in the media also illustrates how little understanding there is of why the contested later abortions provided by Dr. Tiller are necessary. Most significantly, his death and the subsequent closing of his clinic brings to light the striking lack of options for a small but significant portion of abortion patients: those women needing abortions for medically indicated reasons, but whose pregnancies are past the deadline at which most facilities in the United States perform this procedure.

Dr. Tiller’s Practice: Women’s Health Care Services in Wichita
George Tiller did not start his medical career intending to be an abortion provider. He was a flight surgeon in the Navy when a family tragedy in 1970–the death of his parents and other family members in a small plane crash–brought him back to his home town of Wichita, Kansas to take over his father’s general medical practice. Upon assuming this role, Tiller was surprised to learn that his father, a prominent local physician, had been quietly providing illegal abortions among the many other medical services.

Tiller took up abortion provision and eventually, in a not uncommon pattern in a country with a chronic shortage of abortion providers, this procedure began to overwhelm the rest of his medical practice. His office became a specialized abortion clinic and renamed itself Women’s Health Care Services. When he died, his clinic was one of only 1,787 facilities in the United States that provided the approximately 1.2 million abortions performed each year.

Tiller ultimately became a specialist in later abortions—that is, those occurring after twenty weeks of pregnancy. Women seeking abortions after this time make up only about 1 percent of the abortions occurring in the United States each year (nearly 90 percent of all abortions in the United States occur within the first twelve weeks of pregnancy). But for the thousands of women needing these later abortions, especially those that occur in the third trimester, options are severely limited. Tiller was one of only two or three of abortion providers who openly offered abortions after twenty four weeks of pregnancy. Patients came to him from all over the United States, and from foreign countries as well. Many came with referrals from their own obstetrician, or their local abortion providers who were unable to help. Other patients found Women’s Health Care Services on the Internet.

Although the majority of abortions that Tiller provided occurred in the first and early second trimester of pregnancy, it was the later abortions, especially those after twenty four weeks, that were the most controversial. These later abortions are subject to much confusion and misunderstanding. Indeed, one of the great ironies of the public debate over abortion is the apparent incongruity between the circumstances under which Americans support abortion and their opinions about when abortion should be illegal.

In numerous polls, respondents consistently show more support for earlier abortions than later ones, with a majority believing abortions in the third trimester should be illegal. At the same time, polls reveal greater support for abortions when the status of the fetus was compromised or when the health of the pregnant woman was jeopardized–conditions that are often not diagnosed until later in the pregnancy. There is also increased support for later abortions in cases of rape of incest.

These abortions are commonly referred to as “late-term abortions,” a definition that is not part of the medical literature and that implies, by use of the word “term,” that the procedure is occurring at the very end of a pregnancy. The confusion is compounded by the fact that there is no consensus within the medical community as to precisely when the “viability” of a fetus is reached, and regulations governing the performing of later abortions vary not only from state to state, but from hospital to hospital.

In the case of Tiller, his later abortions consisted of two groups: abortions performed when the fetus was severely compromised, and abortions performed on a viable fetus to preserve the health or life of the pregnant woman. The women who came to Tiller for these later abortions were typically in the most harrowing of situations, carrying wanted pregnancies that had gone terribly wrong or with life-threatening conditions facing the women themselves. Some of these women had fetuses with heartbreaking anomalies that were discovered only later in pregnancy, such an anencephaly, a lethal birth defect in which most of the brain and parts of the skull are missing. Other women had themselves become very ill in the course of a pregnancy, such as the onset of cancer, which demanded a course of chemotherapy.

These later abortions called for specialized medical and counseling services, which Tiller pioneered. Unlike the outpatient services characteristic of the vast majority of earlier abortions, these later procedures took place over a several day period. Patients (and their partners) often stayed in local Wichita motels for up to a week. Women’s Health Services offered patients in-depth counseling as well as the opportunity for group counseling with other women and couples in similar situations.

Tiller himself was a deeply religious man and attending to the spiritual needs of his patients was a high priority. The clinic had a special “Quiet Room,” where patients could grieve after their abortions, sometimes holding the blanketed remains of their fetuses. The chaplain on the clinic’s staff helped interested patients choose among various options for baptisms, funerals, and burials.

The Opposition Mobilizes
Tiller’s provision of later abortions drew massive attention from abortion opponents, both local and national. In 1985, his clinic was bombed, and in the summer of 1991, thousands of demonstrators from around the country descended on Wichita, blockading the clinic entrance and leading to more than 2,500 arrests over the course of the 46-day protest. In 1993, Tiller was shot in both arms by an anti-abortion extremist (though not seriously wounded).

Several years later, Operation Rescue, one of the most militant anti-abortion groups, moved its national headquarters to Wichita with the announced purpose of shutting down Women’s Health Services. Women coming to his clinic were met each day by a gauntlet of screaming protestors. Opponents also refined the tactic of bringing pressure on all those in the Wichita area who did business with the clinic–motels, cab companies, plumbers, food suppliers and so on–to stop these services. The names of those businesses which refused to comply were posted on anti-abortion Web sites.

Tiller’s home and those of his employees were also targeted by his opponents. At one point, with his driveway blockaded, the doctor and his wife had to be helicoptered out of their house to attend one of their children’s wedding. Tiller was under the protection of federal marshals for several years and routinely wore a bullet proof vest.

The campaign to shut down Tiller’s practice also took place in the courts. The former Attorney General of Kansas, Phill Kline, a fervent opponent of abortion, was a particular foe, whose political career was largely based on prosecution of abortion providers in general, and Tiller in particular.

Also, as Kansas laws permit grand juries to be convened by citizen petitions, Operation Rescue officials were able to launch two grand jury investigations. Tiller’s opponents claimed the doctor was violating the Kansas law that permits abortions of viable fetuses to save a woman’s life or because continuing the pregnancy would cause her “a substantial and irreversible impairment of a major bodily function”–a clause that the state’s legal authorities have interpreted to include both physical and mental health.

It was this mental health clause that most enraged his opponents. Tiller did not accept all those who requested later abortions, but he was known to perform abortions on very young patients—ten and eleven year olds, for example, who were typically the victims of incest—even when no physical health issues were present. He argued that forcing these children to continue their pregnancies would likely lead to severe mental health consequences, and thus their abortions conformed to Kansas law. Tiller made a similar argument in defending his decision to perform abortions on some women whose fetuses had severe non-lethal anomalies, pointing to the mental health consequences for a woman of continuing a pregnancy that would result in the birth of a child who would suffer great pain and eventually die, as occurs, for example, with various chromosomal abnormalities.

The state’s law also demands that a second doctor approve all abortions on viable fetuses and Tiller was accused of violating this provision as well, with the prosecution arguing that the physician signing off on these late abortions was “too close” to Tiller. In each of his numerous trials, Tiller was acquitted. In the most recent one, in March 2009 (attended by Scott Roeder, who would assassinate him two months later), the jury took less than a half hour to render its verdict. Though Tiller was consistently vindicated, such legal challenges inevitably took a large emotional and financial toll.

The enduring stigma of abortion
Tiller’s history as an abortion provider in Wichita and the events surrounding his death make very clear the extent to which abortion endures as a particularly stigmatized and divisive element of American society. With respect to abortion-related violence, this assassination–the first of a provider since 1998–suggests a pattern in which the most extreme violence associated with this issue occurs during pro-choice administrations. All seven previous murders of members of the abortion providing community took place during the presidency of Bill Clinton. The eight years of the George W. Bush administration saw a reduction in the worst acts of abortion violence, presumably because abortion opponents felt they had a sympathetic figure in the White House and anticipated the eventual overturn of Roe v. Wade.

The aftermath of the slaying also revealed the imperfections in the systems set up to deal with anti-abortion violence. Scott Roeder had twice in the week prior to Tiller’s murder (including the day before) been seen vandalizing another abortion clinic in the state. In each instance, clinic staff called both police and the local FBI office with Roeder’s license plate information, but there was no follow-up from law enforcement.

In theory, there should have been such follow-up from the FBI. By his actions–Roeder was seen attempting to glue the clinic’s locks–he was in violation of the FACE (Freedom of Access to Clinic Entrances) Act signed by President Clinton in 1994, which makes it a federal crime to prevent individuals from receiving or providing reproductive health care.

Most important, however, is that the killing of George Tiller and the subsequent closing of his clinic reveals the marginality of abortion provision from mainstream medicine. As mentioned earlier, with the closing of Tiller’s clinic, there remain only one or two additional doctors in the United States who openly provide late abortions.

The reality that there are only a handful of abortion providers currently in the United States who openly perform later abortions does not mean that occasionally these procedures do not occur elsewhere. In hospitals across the country, many other physicians provide this care on a case-by-case basis in order to save a woman’s life or because the fetus is incompatible with life. These doctors, often maternal fetal medicine specialists, do not consider themselves to be “abortion providers” nor do they consider what they do “abortions.” Quite possibly, in the wake of the Tiller murder, these physicians will be even more selective about the late procedures they choose to do.

The post-Tiller era, therefore, is not unlike the situation of the pre-Roe v. Wade era when the availability of a late abortion depends heavily on having a relationship with a sympathetic physician or having the resources to travel elsewhere.

Finally, what will the killing of Tiller mean for the social movements on both sides of the abortion divide? For the mainstream anti-abortion groups, for example, the National Right to Life Committee, this murder quite likely will have some negative consequences. In spite of the NRLC’s quick condemnation of the murder, the organization has reason to fear that the public will not be able to adequately distinguish between different elements of the antiabortion movement.

Operation Rescue, which has long been considered one of the most aggressive anti-abortion groups, also took pains to reaffirm its commitment to non-violence and specifically disavowed any connection to the killer. This claim, however, was hard for many to believe given that Roeder (when apprehended) had the phone number of an Operation Rescue official on the dashboard of his car and had previously made a donation to the group and posted on its website. As a result, this event is arguably a public relations disaster for the movement, and the murder may well lead to a drop in new recruits and donations.

In contrast, the killing has already brought some degree of heightened public sympathy for the plight of abortion providers and their patients. However, the major–and extremely serious–loss to abortion-rights forces may be a continued decline in the number of physicians willing to perform abortions, a field already faced with a chronic shortage of providers. Certainly, in the short run, there will be considerably more difficulties for those women needing later abortions.

Carole Joffe is the author of the forthcoming Dispatches from the Abortion Wars: The Costs of Fanaticism to Doctors, Patients and the Rest of Us (Beacon Press).

Tracy Weitz is an assistant professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, and the Director of the Advancing New Standards in Reproductive Health (ANSIRH) program at UCSF.