Tag: clinic

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T

he sky above Boulder was dark when the abortion doctor picked me up for dinner. I had to squint to recognize Warren Hern in his thick aviator glasses and fur-trapper hat.

At the restaurant—a kitschy Italian spot along a pedestrian mall—Hern ignored the table the waiter offered us, pointed at one in the corner, and clomped over in his heavy hiking boots. He’d like to order right away, he said: the osso buco and a glass of Spanish red. How long will that take?

Hern spent the next two and a half hours of our dinner correcting me. A baby is a fetus until it is “born alive,” he told me as I chewed my bucatini. His dear friend, the Kansas physician George Tiller, was not “murdered” in 2009, he was assassinated. The activists who scream outside his clinic are not “pro-life,” they are fascists.

Pausing, Hern sighed. He is very busy, he said, and there are many things he’d rather be doing than talking to me. “But I can’t complain that the pro-choice movement has completely failed” at communicating, he said, “and then turn down an opportunity to communicate.”

Read: What winning did to the anti-abortion movement

I’d met Hern before, so I wasn’t surprised by his gruffness. The 84-year-old can be a curmudgeon—he’s obstinate, utterly certain of his position, and intolerant of criticism even as he dishes it out. Useful qualities, perhaps, for someone in his line of work.

Hern is now nearing his fifth decade of practice at his Boulder clinic; he has persisted through the entire arc of Roe v. Wade, its nearly 50-year rise and fall. He specializes in abortions late in pregnancy—the rarest, and most controversial, form of abortion. This means that Hern ends the pregnancies of women who are 22, 25, even 30 weeks along. Although 14 states now ban abortion in most or all circumstances, Colorado has no gestational limits on the procedure. Patients come to him from all over the country because he is one of only a handful of physicians who can, and will, perform an abortion so late.

During the first 13 weeks of pregnancy, when about 90 percent of abortions in America are carried out, the fetus’s appearance ranges from a small clot of phlegm to an alienlike ball of flesh. At 22 weeks, though, a human fetus has grown to about the size of a small melon. The procedures that Hern performs result in the removal of a body that, if you saw it, would inspire a sharp pang of recognition. These are the abortions that provide fodder for the gruesome images on protesters’ signs and the billboards along Midwest highways, images that can be difficult to look at for long.

Many of the women who visit Hern’s clinic do so because their health is at risk—or because their fetus has a serious abnormality that would require a baby to undergo countless surgeries with little chance of survival. But Hern does not restrict his work to these cases.

The phone at Hern’s clinic rings constantly these days. Since the overturning of Roe and the corresponding blitz of abortion bans, appointment books are filling up at clinics in states where abortion remains legal. Women who have to wait weeks for an appointment may end up missing the window for a first-trimester procedure. Some book a flight to Boulder to see Hern, who is treating about 50 percent more patients than usual.

These later abortions are the less common cases, and the hardest ones. They are the cases that even stalwart abortion-rights advocates generally prefer not to discuss. But as the pro-choice movement strives to shore up abortion rights after the fall of Roe, its members face strategic decisions about whether and how to defend this work.

Most Americans support abortion access, but they support it with limits—considerations about time and pain and fingernail development. Hern is reluctant to acknowledge any limit, any red line. He takes the woman’s-choice argument to its logical conclusion, in much the same way that, at this moment, anti-abortion activists are pressing their case to its extreme. Hern considers his religious adversaries to be zealots, and many of them are. But he is, in his own way, no less an absolutist.

In May of 2019, an envelope landed on my desk at work with a nature calendar inside. The photos—an arctic tern landing on a hunk of ice, a shock of mountain maple in the Holy Cross Wilderness, two sandhill cranes taking flight—were all credited to Hern. I’d interviewed him a week earlier for a short article about abortion-rights activism, and it amused me that a working abortion doctor was making wildlife calendars and express-mailing them to journalists. This past December, I flew to Boulder to meet him.

The Boulder Abortion Clinic is a single-story, yellow-brick building, partially hidden from the road by a wooden fence. Someone tried to shoot Hern once, back in 1988, so now the front windows are made of bulletproof glass. You have to show ID to gain access to the waiting room, and the blinds are usually drawn, leaving the whole place slightly dim. Stepping inside is like going back in time: The office is a maze of wood paneling, vinyl chairs, and faded green carpet.

The first day I visited, no protesters were chanting outside; it was a Monday, and they tend to show up on Tuesdays, which is patient-intake day. Hern’s staff sat me in an office near the front desk, where I could hear calls coming in. I listened as a receptionist told a patient named Lindsey that it was okay to be anxious; she paused a few times while Lindsey cried.

“The fee will be about $6,000,” the receptionist said. Late abortions are expensive because they are medically complex. For patients who need financial aid, the National Abortion Federation may cover some of the cost, and local abortion funds often contribute. The receptionist told this to Lindsey, and offered her the organization’s number. “You can do partial cash and credit card, yes,” she said. Often, if a woman cannot afford to pay for her hotel, her transportation to Boulder, or some part of her procedure, Hern will foot the bill himself, staff members told me.

Hern stopped performing first-trimester abortions a few years ago; he saw too much need for later abortions, and his clinic couldn’t do it all. The procedure he uses takes three or four days and goes like this: After performing an ultrasound, he will use a thin needle to inject a medicine called digoxin through the patient’s abdomen to stop the fetus’s heart. This is called “inducing fetal demise.” Then Hern will insert one or more laminarias—a sterile, brownish rod of seaweed—into the patient’s cervix to start the dilation process.

From the May 2022 issue: The future of abortion in post-Roe America

When the cervix is sufficiently dilated after another day or two of adding and removing laminarias, Hern will drain the amniotic fluid, give the patient misoprostol, and remove the fetus. Sometimes, the fetus will be whole, intact. Other times, Hern must remove it in parts. If the patient asks, a nurse will wrap the fetus in a blanket to hold, or present a set of handprints or footprints for the patient to take home.

I interviewed half a dozen of Hern’s former patients. Most of the women who agreed to talk had wanted a child. But they’d received serious diagnoses late in pregnancy: disorders with disturbing names such as prune-belly syndrome, trisomy 13, Dandy-Walker malformation, and agenesis of the corpus callosum. Some said they considered their abortions a kind of mercy killing.

“I put my baby down,” Kate Carson, who’d gotten an abortion at Hern’s clinic in 2012, told me.  She’d been 35 weeks into a much-wanted pregnancy when her doctor diagnosed multiple brain anomalies. Carson’s daughter, the doctor said, would have trouble walking, talking, holding her head up, and swallowing. “It’s euthanasia. That’s the kind of killing this is,” she said. “But I would do it again a million times if I had to.”

Amber Jones, who terminated her pregnancy at about 24 weeks in 2016, told me that her baby’s diagnosis meant he would not survive. Hern reassured her, she said, that she “shouldn’t be made to carry the pregnancy. That it’s bullshit, and we have the right to access health care.”

Carson and other patients described Hern as brusque. But they seemed to take comfort in that brusqueness, as though Hern’s fierce assurance helped them feel more sure themselves. “I wouldn’t say he has a great bedside manner,” Carson told me. But “the degree of respect that I felt from him was enormous.”

Abortions that come after devastating medical diagnoses can be easier for some people to understand. But Hern estimates that at least half, and sometimes more, of the women who come to the clinic do not have these diagnoses. He and his staff are just as sympathetic to other circumstances. Many of the clinic’s teenage patients receive later abortions because they had no idea they were pregnant. Some sexual-assault victims ignore their pregnancies or feel too ashamed to see a doctor. Once, a staffer named Catherine told me, a patient opted for a later abortion because her husband had killed himself and she was suddenly broke. “There isn’t a single woman who has ever written on her bucket list that she wants to have a late abortion,” Catherine said. “There is always a reason.”

The reason doesn’t really matter to Hern. Medical viability for a fetus—or its ability to survive outside the uterus—is generally considered to be somewhere from 24 to 28 weeks. Hern, though, believes that the viability of a fetus is determined not by gestational age but by a woman’s willingness to carry it. He applies the same principle to all of his prospective patients: If he thinks it’s safer for them to have an abortion than to carry and deliver the baby, he’ll take the case—usually up until around 32 weeks, with some rare later exceptions, because of the increased risk of hemorrhage and other life-threatening conditions beyond that point.

Even within the abortion-rights community, Hern’s position is considered a hard-line one.

Frances Kissling, the founding president of the National Abortion Federation, the professional association for abortion providers, admires Hern and his commitment to women. But she has misgivings about his work. “Later-term abortions are more serious, ethically, than earlier abortions,” Kissling, who left NAF after a few years and went on to lead Catholics for Choice, told me—and only more so in cases that involve women who have not received any serious fetal diagnoses. “My ethics are such that I would say to them, ‘I’m terribly sorry, but I cannot perform an abortion for you. I will do anything I can to help you get through the next two or three months, but I don’t do this,’” she said.

Hern bristles at the label abortion doctor. Too simplistic, he says. He will correct you if you use it. He is a physician, he says, who happens to specialize in abortion. Worse still is abortionist. He remains angry about a 2009 story in Esquire in which the author referred to him that way, again and again. It’s a pejorative, Hern says. He is more than his profession, he needs you to know. He is many things: an anthropologist, an epidemiologist, an adopted son of the Shipibo Indians in Peru. Abortion was never the destination for Hern, he insists; it was a detour.

As a child growing up in the suburbs of Denver, Hern dreamed of studying diseases in faraway places. During medical school, he worked as the unofficial doctor at a mining camp in Nicaragua, where he learned to speak Spanish. He spent six months in Peru, studying the culture and practices of the Shipibo. In 1966, the Peace Corps sent him to Brazil, where he learned Portuguese and trained under physicians who had started a family-planning association. Hern toured a maternity ward where one room was full of women recuperating from childbirth. Two other rooms held patients suffering from complications related to illegal abortions; at least half of those women ultimately died. This, he says, was formative.

From the June 1969 issue: The right of abortion

In 1970, Hern accepted a job at the now-defunct Office of Economic Opportunity in Washington, D.C., where he led the effort to open family-planning clinics across the country and launched a voluntary-sterilization program for adults in Appalachia. Given the link between the eugenics movement and the early birth-control movement, the word sterilization can carry an ominous ring. Hern says, though, that his work was intended to give low-income people choices and reduce their financial hardship. “Families like these,” he wrote in The New Republic at the time, require housing, clean water, food, and sanitation. “But one of the most important needs is freedom from the tyranny of their own biology.”

In 1973, Hern was back in Colorado—the first state to decriminalize abortion in some circumstances—acting as a consultant for family-planning programs when the world shifted. Sarah Weddington, a lawyer friend of Hern’s from D.C., had won the Roe v. Wade case before the U.S. Supreme Court, and abortion was now legal in all 50 states. Hern wrote op-eds defending the decision and an explainer about the procedure for The Denver Post. One day, he got a call from a Colorado group that wanted to start a nonprofit abortion clinic in Boulder. Would Hern be their medical director? Of course, he told them. Absolutely.

The Boulder Valley Clinic opened in November of that same year. Hern designed the medical protocols and performed all of the abortions himself. Although one major battle for abortion rights had been won, a larger war was just beginning. Demonstrators began gathering outside the new clinic. Two weeks after it opened, Hern received his first death threat—a late-night phone call at his secluded cabin in the mountains. The man on the phone said he was coming for Hern. The doctor began sleeping with a rifle next to his bed.

In 1975, Hern took out a loan and started his own practice. He named it the Boulder Abortion Clinic—avoiding euphemisms like women’s care because he wanted patients to be able to find him. At the time, Hern had never performed any second-trimester abortions, for which the standard procedure then was to inject a saline solution into the uterus to induce labor. But Hern had read about another method in a textbook that explained how Japanese doctors were using laminarias to end abnormal or dangerous pregnancies. The method took longer, but it was safer. Hern studied the technique, ordered laminarias, and got to work.

Soon, Hern had published the first research paper on this multiple-laminaria method in American medical literature. Other clinics adopted the procedure, with modifications, and it’s been the dominant method for second- and third-trimester abortions for nearly 50 years. Hern and his staff carry out up to a dozen such terminations every week.

Hern was 34 when he performed his first abortion, a year before Roe v. Wade would be decided. A friend in D.C. who ran a local clinic invited him to come learn the procedure. Hern’s patient was 17 and in her first trimester of pregnancy. She wanted to be an anesthesiologist, he remembers.

Hern had learned how to do a dilation-and-curettage abortion in medical school, but still, he was terrified—and so was she. He recalls that after he finished and told her she wasn’t pregnant anymore, she wept with relief. He did too. “I was overwhelmed by the significance of this operation for this young woman’s life,” he told me. “This was a new definition, for me, for practicing medicine.”

But the work sometimes got to him. He would often retreat to his office to compose himself after an abortion. Partly, it was the high-stakes nature of the procedure. But he also needed time to process how the dead fetus looked, how removing it felt. Sometimes he’d sit in his office and think, What am I doing?

He had bad dreams too. In the 1970s, physicians did not induce fetal demise during abortion, and once or twice, during a procedure at 15 or 16 weeks, he used forceps to remove a fetus with a still-beating heart. The heart thumped for only a few seconds before stopping. But for a long while after, a vision of that fetus would wake Hern from sleep. He could see it in his mind, the inches-long body and its heart: beating, beating, beating. In one dream, Hern angled his own body to shield his staff from catching a glimpse.

Other people might have decided that this work wasn’t worth the haunting images, the pricks of conscience. They might have quit. But for Hern, the psychological stress of the work was the necessary cost of helping patients. He saw it as his job to carry some of the emotional weight. Over time, that stress became easier to manage. He stopped needing to compose himself between procedures. The bad dreams went away.

In 1978, Hern presented a paper before the Association of Planned Parenthood Physicians in San Diego titled “What about us? Staff Reactions to D&E”—dilation-and-evacuation abortion—in which he concluded that, though medically safe, surgical second-trimester abortions are clearly more emotionally difficult for providers than earlier ones.

I quoted that paper during a conversation with Hern, as we sat shoulder to shoulder at a bar in downtown Boulder. He was nodding before I finished. Many of his colleagues were annoyed by what he’d written, he said. The abortion-rights movement isn’t exactly eager to talk about these visuals, mostly because it gives fodder to the opposition. Hern’s comments about “destruction” still appear on a number of anti-abortion websites as evidence of the horror of the procedure.

But the point of his report was to be honest, Hern said, and he stands by it. Why not face the truth that abortion late in pregnancy is, at least in one way, destructive? He still believes that such destruction can be a profoundly merciful act.

Annie Lowrey: American motherhood

Regardless of the circumstances of pregnancy, in Hern’s view, a woman’s life—her humanity, her wishes—isn’t just more important than her fetus’s. It is virtually the only thing that matters. That approach is diametrically opposed to the view of anti-abortion advocates, for whom pregnancy means motherhood and, often, self-sacrifice.

Hern understands that few share his total conviction. “This is a grotesque conversation to many people,” he said at the bar. “But this is a surgical procedure for a life-threatening condition.”

During that conversation and the ones following it, I prodded for cracks in Hern’s certainty. At one point, I thought I’d found one: Hern had told me about a woman who’d sought an abortion because she didn’t want to have a baby girl. I thought he had refused. But when I followed up to ask him why, I learned that I had misunderstood. Hern said he had done abortions for sex selection twice: once for this woman; and once for someone who’d desperately wanted a girl. It was their choice to make, he explained.

“So if a pregnant woman with no health issues comes to the clinic, say, at 30 weeks, what would you do?” I asked Hern once. The question irked him. “Every pregnancy is a health issue!” he said. “There’s a certifiable risk of death from being pregnant, period.”

Hern met the Kansas abortion doctor George Tiller at a National Abortion Federation conference in the late 1970s. The two talked on the phone nearly every week for 30 years. Tiller was the opposite of Hern—gentle, soft-spoken, churchgoing. “George was a normal person,” Hern told me once. “That distinguishes him from me right away.” Yet Tiller was murdered for doing the same work.

The phone rang at Hern’s house one morning in May 2009, and Jeanne Tiller was on the line. “George is gone,” she told Hern. An anti-abortion fanatic had shot her husband at church, where he was serving as an usher. Hern flew to Wichita for the funeral, and helped carry his friend’s casket down the aisle of the packed College Hill United Methodist Church. Sixty federal marshals stood guard at the service, he said. They told him that he would likely be the next target. Later that week, Hern performed abortions for all of Tiller’s remaining patients at his clinic in Boulder.

Thirteen years after Tiller’s death, Hern and I stayed up late talking in the restaurant of my hotel. Hern was speaking so loudly—about Donald Trump, fascism, and anti-abortion violence—that the bartender had begun to stare. Opposition to abortion has long been “the hammer and tongs to power” for the Republican Party, Hern was saying, “because of their allegiance to the white Christian nationalists and white supremacists.” Christianity, he told me, not for the first time, “is now the face of fascism in America.” That moral arc of the universe bending toward justice? “That’s the belief, but I don’t believe it.”

David Frum: Roe is the new prohibition

I asked Hern whether he ever worried that now, in a post-Roe world, he might have an even bigger target on his back. I wondered whether it was a bit reckless for him to be so outspoken with reporters like me. Actually, it’s the opposite, Hern replied. Being so vocal “increases the political cost of assassinating me.”

“That’s dark,” I said.

He simply shrugged. “This is what I have to think about.”

Suddenly, he remembered that he’d brought me something. He dug around in his coat pocket, and pulled out a fridge magnet he’d made from a photograph he took a few years ago near the island of South Georgia: penguins diving off an iceberg into the deep blue ocean.

Hern is known for presenting such gifts to people—and for regularly mailing out his latest published works. In addition to the magnet and the calendar, Hern sent me a copy of his poetry collection and his new book on global ecology. In the latter, titled Homo Ecophagus, he compares mankind to a cancer on the planet, writing that our unrelenting population growth will ultimately lead to the demise of every species on Earth. To view human beings as a scourge seems a rather ominous perspective for a man who ends pregnancies for a living. Could he see his work as, even subliminally, a form of population control? When I asked about that, Hern shook his head vigorously, waving my question away, as if he’d been ready for it. “Being concerned about population growth is consistent with the idea of helping women and families control their fertility on a voluntary basis,” he said.

Hern lives in a modest gray split-level cluttered with landscape photographs, Shipibo pottery, and mounted fossils. Some of the photographs were taken by his wife, Odalys Muñoz Gonzalez, who is 27 years his junior and whom he refers to as “mi amor.” Gonzalez is originally from Cuba, though they met at a conference in Barcelona in 2003. Back in Spain, Gonzalez directed her own abortion clinic. Now she works at Hern’s, performing nonmedical tasks and translating for Spanish-speaking patients.

Gonzalez sometimes worries that Hern comes across as too intense. “I always tell him, ‘Don’t look like Bernie Sanders,’” she told me, in her thick Cuban accent. Part of her hates that he can be so angry, so severe. “But another part of me loves,” she said. “Because how many people do you know that live with the level of passion that Warren does?” Still, Gonzalez wishes he would retire so that they could have more time to travel together and photograph wildlife.

During my stay in Boulder, I did occasionally look at Hern and wonder: Would I want you in charge of my complex medical procedure? Next month, he’ll be 85, and when he shuffles around the clinic in his turquoise scrubs and white lab coat, he looks it.

Younger providers have opened a handful of new late-abortion clinics in recent years. Some of these providers and others in the field argue that Hern’s abortion procedures take longer than they need to, and that his methods are out of date. Hern should have retired decades ago, these critics say. “Being 84 and doing procedures is problematic,” one physician, who requested anonymity in order to speak candidly about Hern, told me. (When I asked Hern about the criticism of some of his methods, he said he has always emphasized patient safety and will alter his procedures if they make the abortion safer. “If people don’t agree with me, I don’t really care,” he said. “I don’t give a shit.”)

Hern is working with two other doctors in the hope that eventually they will take over the clinic. But he’s hard to please. “I have to find the right people, train them, get them to know what needs to be done,” he says. “Finding physicians willing to do this work—who will do it well, do it carefully—is difficult.”

One morning during my visit, Hern and I climbed up the hill behind his house. The ground was muddy, and, thanks to a recent skiing injury, Hern was unsteady on his feet. I briefly wondered if this hike might bring about the end of one of America’s most famous abortion physicians. At the top of the hill, Hern pointed up toward a grassy crest of land above us called the Dakota Ridge. A big problem with modern society is that we’ve forgotten that we’re part of all this, he said, waving toward the ridge. The Bible says to “go forth and multiply and dominate the Earth and blah-blah, but that is exactly the wrong advice.”

He’s read the Bible a few times, he said. But he’s not religious; he’s spiritual. “The natural world, the forest, is my cathedral,” he said. To watch the sunrise, to see a wild animal, “just to be there, that’s a spiritual experience for me.”

And then, suddenly, Hern was connecting it all, drawing everything together: religion, Republicans, the Supreme Court, the future of American society. “These people believe stuff that’s out of the medieval times. The Pleistocene!”

He sighed. “I’m holding back,” he said, not holding back at all.

On my last day in Boulder, a few of the clinic staff gathered in the kitchen for an unofficial Christmas party. They’d finished the week’s procedures, and all of the patients had been sent home. Now it was time for eggnog. Gonzalez poured some into mugs, and the clinic administrator offered to spike it with a bottle of his homemade rum. They passed around a box of chocolate cupcakes that someone had brought in.

Hern congratulated his staff on a good year, and they listened, amused, while he explained that he wasn’t able to find any good Audubon calendars at Barnes & Noble for their annual staff Christmas gift. He made a joke that he’d already told me more than once: “I could just give you the calendars from last year to pass on to your Republican friends,” he said, with a laugh. “They won’t notice for about 300 years that they’re out of date.”

Read: The Roe baby

A dozen Christmas stockings hung on the bulletin board, each displaying a staff member’s name in glitter glue. Buttons were pinned on the board, too, including some emblazoned with George Tiller’s face. You will be greatly missed, one said. Someone had propped open an outer door for circulation, and a stack of papers near the phone rustled—instructions for how to talk to someone calling with a bomb threat. “TAKE A DEEP BREATH,” they read. “Questions to ask: When is the bomb going to explode? Where is it right now?”

Hern seemed not to notice the strange juxtaposition of it all—the eggnog and the abortions, the cupcakes and the bomb threats. The buttons with the image of his murdered friend and the fact of his own stubborn survival. Of course he didn’t. He has spent five decades living with these contradictions.