Warren Hern, America’s Abortion Doctor

Dr. Warren Hern is a physician whose career in reproductive medicine began before Roe v. Wade and continues today, after Roe's fall. Hern, who is eighty-six, founded the Boulder Abortion Clinic, and is one of the most high-profile abortion doctors in the country. For a long time, he has been one of the very few physicians who openly perform abortion in the second and third trimester. At the time of the 2013 documentary "After Tiller," which followed Hern and other abortion providers, there were only four such physicians; one has since died and the other two are retired. More clinics offering late abortion, procedures done at twenty-one weeks or later, including the DuPont Clinic and Partners in Abortion Care, have opened in recent years. Late abortion is wildly misrepresented by politicians and misunderstood by the public; it is rare, but the need for it has increased as state bans make it harder for pregnant people to seek care.

Hern has written a memoir , "Abortion in the Age of Unreason: A Doctor's Account of Caring for Women Before and After Roe v. Wade." The book is partly a firehose of pure screed, demonstrating the radical commitment necessary to sustain a career under unique duress. Hern received his first death threat two weeks after his clinic opened, in 1973, and has spent fifty years under constant harassment from people who view him as a mass murderer. His op-eds from the past several decades, republished exhaustively in the memoir, show Hern hitting the same notes over and over, warning of a future of draconian abortion regulation and pregnancy criminalization that has now come to pass.

The book also provides an answer to the question that has tended to hover over his profession: What kind of person would choose this line of work? In Hern's case: a hippie with a wife and child, who still takes great solace in hiking and skiing and wildlife photography, whose focus on reproductive medicine comes in part from decades of fieldwork in epidemiology and global health. One of the only regrets Hern mentions in the book is that he never made the time to study jazz piano under Ahmad Jamal , who once agreed to tutor him. A more significant regret comes from his stint in the Office of Economic Opportunity's family-planning division, in the early seventies; his office launched a voluntary sterilization program in Appalachia, which expanded across the country. But medical abuse followed: two young Black sisters, aged twelve and fourteen, were sterilized involuntarily by a doctor who regarded them as mentally disabled. Hern later testified in Congress that his proposed guidelines for the program were suppressed.

I wanted to talk to Hern in part because I'd seen the profound impact his work had for just one of his patients—a woman named Erika Christensen, whom I interviewed , in 2016, about her third-trimester abortion, and who became an activist instrumental to the passage of New York's Reproductive Health Act . I also found his candor in the book to be remarkable. The memoir begins with a description of a pregnant patient whose placenta had separated from the wall of the uterus, causing the swift death of the fetus and a coagulation syndrome that caused the patient to start "bleeding everywhere within her body and from all orifices." Hern methodically walks the reader through what late abortions can entail: dismemberment of the fetus; intentional cranial collapse. In the early years of his practice, knowing that he had to personally prove that abortions could be performed safely, he would, after a dilation-and-evacuation procedure, "empty the cotton sock in the suction bottle of its contents, spread the tissue out on a glass plate, and look at it carefully over a light box" in order to insure that no parts of the embryo remained within the patient to cause infection. Even after reading the memoir, it is hard for me to fathom what it might have been like to confront life and death at this scale for fifty years.

Hern and I spoke on Zoom. He was wearing aqua-colored scrubs, sitting in a wood-panelled office with old photos on the wall. He has a vigorous manner, but looks like a man in his eighties who should by rights be retired. I was expecting him to be impatient, because journalists tend to describe him this way. But even if Hern's answers tended to run toward political rant, he spoke as if, contrary to the reality that encroaches from every direction, he had plenty of time. Our conversation has been edited and condensed.

I want to talk about what late abortion is and is not. The anti-abortion movement has created a false image: as if late abortions involve the death of a nearly full-term baby, the size and age and shape of a newborn. Even the phrase "late-term abortion" implies this.

For the sake of clarity, do abortions ever take place close to or at full term?

No. There are situations where, in a desired pregnancy, a catastrophic event occurs in the middle of the third trimester. For example, a woman came to me and she was over thirty-five weeks. Her doctor sent her to me because the fetus had a stroke that destroyed the brain. The fetus was not going to be able to survive, and if it did it would not have a life.

She was terribly grieved about this. She came to me. I did the injection [that stops the heart of the fetus in utero]. Her fetus was delivered in her hospital with her doctor and her husband present. Do you want to call that an abortion? I don't call that an abortion. It was an interruption of a pregnancy that was hopelessly complicated. There was no point in forcing her to carry for another month, and then have a dead baby. That is cruel. It may have been necessary two hundred years ago, but it is not necessary now.

What you're describing, though, is abortion care. To me, that story illuminates something people are learning at great cost now: that abortion is often procedurally indistinguishable from miscarriage management, stillbirth management.

It is a fundamental, essential part of reproductive health care for women.

But, in discussing late abortion, we're talking about very rare cases. About 1.3 per cent of abortions take place at or after twenty-one weeks, which is halfway through the second trimester. Still, this is the type of abortion your clinic specializes in, and performs almost exclusively.

Right after Texas passed S.B. 8 , and then after the Dobbs decision , we were flooded with patients who needed late abortions because they were being turned down everywhere else. We couldn't see patients who were earlier in their pregnancies, because we were just too busy taking care of the more difficult patients. We have seen some earlier patients now, but our special interest is in helping women who are having abortions later in pregnancy because they have the most difficult circumstances. They're at the end of the line. They can't find anyone else to do this.

What other misperceptions about late abortion have you encountered in your career?

People have the idea that a woman just decides she doesn't want to be pregnant. She wants to get a new dress, or she wants to go to prom next week, so she decides to end the pregnancy. But women take this decision very seriously. Obviously, the operation is highly stigmatized. Many women, right after Trump was elected, thought that abortion was illegal and were afraid to even make the phone call, much less come in. And now abortion is functionally illegal in about twenty states, and we have situations where women come in, have their abortion, and are afraid to go to their own doctor or any doctor in their home state for a follow-up exam, which they need to have—because they're afraid to be arrested and sent to jail. That is not a complete fantasy; there are threats to that effect.

In terms of popular speculation about late abortion, there was the partial-birth-abortion meme, which was set up in the nineties when an anti-abortion group took some fragmentary information from a presentation at one of [the National Abortion Federation] meetings and turned it into a weapon. People believed that this was a way that late abortions were being done. And there were a few people doing a few of these procedures, but it was never the principal way things were done. It has been a very damaging bit of psychological warfare.

Yes, I only learned fairly recently that partial-birth abortion, which I heard so much about as a child in the nineties, is not a term that appears in medical literature, and is not really a procedure that is performed in any standard way. In your memoir, you write that doctors had specific reasons for performing this type of abortion, sometimes called intact dilation and extraction: sometimes it was a medical need, sometimes essentially a spiritual need—so that the baby could be delivered intact and held by the parents afterward.

There were actually two doctors who were doing something like this [initially]—delivering the fetus intact, and then destroying the brain, which killed the fetus as it was coming out. I did not agree with this procedure, but the doctors were doing it sometimes for the woman's safety, or so the geneticist could make a study of fresh tissue and diagnose the problem.

The standard of care for later abortions involves an initial injection of a medication into the fetus that stops the fetal heart. But that was moot in this discussion.

You're referencing the congressional hearings about partial-birth abortion, and the federal law banning it. You were not allowed to testify at the hearings—no doctors who performed late abortions were. But you submitted written testimony, in 1995, in which you wrote that a law banning a political construct could render illegal many other individual late-abortion procedures that physicians perform because of specific medical and personal needs of the patient. You wrote about women who were airlifted into your clinic, on the brink of bleeding out on your operating table: "I didn't have time to consult with the Senate on the proper method of performing the abortions." It presaged our current reality, where doctors are withholding life-saving care out of fear of prosecution and women have died as a result.

I wonder if you can talk about the ways that a late abortion, a late miscarriage, a stillbirth, a spontaneous early delivery that ends in a baby who dies an hour after birth—the way that all of these things can resemble one another from the standpoint of medical procedure.

These are not separate events. It is a spectrum. It is a continuum. There are elements of each of these events in all of the others, which is why it's incredibly stupid for politicians to try to regulate them. These things are so complicated, and they change instantly, and they are highly personal family matters.

Back to what late abortions actually are: I think people tend to think, If you're that far along, just keep going. Why is abortion sometimes a safer choice medically, even when the fetus or baby is near or past the viability mark, than continuing a pregnancy?

The basic fact is that if you're pregnant, you're at risk of dying from that pregnancy. Doesn't matter whether you're happy about being pregnant. If having the abortion at any point in pregnancy is between fifteen and twenty times safer than carrying the pregnancy to term, what is the possible justification for forcing a woman to continue the pregnancy if she doesn't want to?

Well, a lot of people would say, "The justification is the life of the unborn." But this is why I was asking about the medical circumstances that lead women to choose late abortion. I don't think it's women coming in at eight months saying, "I've decided that giving birth is riskier than abortion, so I choose an abortion."

For fifty years, I have seen women have a desired pregnancy, and not find out until late in pregnancy that there's a catastrophic problem that does not permit the fetus to survive, or that will give the fetus nothing but suffering to experience. The woman doesn't want her baby to suffer. She wants to end the pregnancy before that happens. Abortion is a clear therapeutic treatment of the condition of pregnancy where the woman is not going to have a healthy baby. There's going to be tremendous suffering all around, and it is simply pointless to continue, especially when the pregnancy itself is a threat to her life. You can imagine a scenario where the woman has an amniotic-fluid embolism—which is almost impossible to predict—in the delivery room, and dies.

You also perform elective late abortions, meaning that there are no urgent medical concerns—

All abortions are elective, and all abortions are therapeutic. But take that hypothetical example: a woman walking in at eight months saying, "I just don't want to do this." Well, I have to make a judgment about that. I have to ask, is it safer for me to end a pregnancy in my office or let her go to term? Quite aside from the fact that I don't want to do an abortion at eight months; I don't feel comfortable doing it.

I am not an abortion-dispensing machine. I'm a physician, and there are things I will do and things I will not. I will do a late abortion for someone who has a serious fetal abnormality or a twelve-year-old kid who's been raped, but I would not do it without that indication.

I still want to talk about the cases where there's no urgent medical requirement for the abortion. A patient choosing to get a late abortion for a nonmedical reason often means that the patient had no idea she was pregnant, which happens often with young girls and teen-agers, or that she has been trying to get an abortion and hasn't succeeded.

One of our recent patients was a young woman who thought she might be pregnant, and she went to an anti-abortion fake clinic . They told her several things that were not true, including that it was too late, that abortion was illegal. They delayed several weeks before she got the information about how far along she was in pregnancy. And by the time she got to a real clinic, which was full, she was too far along to be seen there. My office was the third clinic she came to.

And in Texas you have this situation where the state government has shut down the birth-control clinics. [In 2011, targeted funding cuts caused twenty-five per cent of publicly funded family planning clinics in Texas to shut down.] So the woman who can't afford to travel to the next town can't get birth control. She gets pregnant. She has three kids. She doesn't have time for child care; her husband's unemployed. She doesn't have money to go to the next town to get an abortion. And that clinic closes. She can't afford to leave her family and go to another state. And whether she leaves or whether she has the baby, she's going to lose her job.

How did you react to watching Donald Trump speak about late abortion in the debate ?

The thing about Donald Trump, quite aside from the fact that he is completely disassociated from reality, is that his MAGA people believe everything he says. Other people don't, but they don't have enough information to know that what he's saying is a lie, if often with a grain of truth.

The "baby execution" line referred to something concrete—not actually abortion but, rather, the practice of declining to provide invasive care to a baby or fetus when the pregnancy ends prematurely owing to medical issues. These are situations where a baby can't survive, in which the physician and family make the decision together that they're not going to intubate a baby that weighs three-quarters of a pound, and prolong their life for maybe one agonizing hour. Is that right?

Yes. That's a highly personal family choice, and it is a legitimate choice. I know of many cases where women have a catastrophic diagnosis, they want to continue the pregnancy, they want to have their baby, and they want to comfort it until it dies. That's a legitimate moral choice for people, but it is cruel and stupid to impose it on other people who don't want to do that.

It is also cruel to remove that choice—to prevent a person from simply holding their baby, as peacefully as possible, for however many minutes they're going to get. And, in fact, you often walk your patients through something similar, after an abortion.

About fifty per cent of my patients are women who have desired pregnancies. They want to have their baby, but they've decided to end the pregnancy for these reasons that are medical, social, emotional, all the rest. So they may want viewing, and, when it's possible to have an intact delivery, my staff takes the fetus, cleans it up, puts baby clothes on it, with a little cap, and puts it in a basin with a blanket to take a picture that can be given to the parents. Sometimes, people want pictures with it. Sometimes, people bring little toys. This is part of their grieving, a family event. Often they want footprints, handprints. They might want a lock of hair.

You write that your staff often accommodates religious ceremonies.

Forty years ago, even, a Native American woman, a highly educated professional who was deeply connected to her roots, had to end a pregnancy, and she conducted a Native American ceremony in one of my rooms with my staff. We were in tears at the end of it. It was beautiful.

You have not shied away, in your career, from acknowledging the violence that abortion can entail. You wrote, in 1978, about later abortion, "We have reached the point in this technology where there is no possibility of denying an act of destruction. It is before one's eyes. The sensations of dismemberment flow through the forceps like an electric current." For obvious reasons, this was controversial.

I think about reproduction as inherently violent: every pregnancy ends in an act of violence, whether it's abortion, miscarriage, stillbirth, delivery—and that violence is transformed when it's a form you choose. But I think pro-choice people have a hard time acknowledging that abortion can involve violence, and I wanted to talk to you about that. You wrote that performing late procedures was difficult for you, emotionally, early on.

The procedure that I developed in the seventies [involving multiday dilation and evacuation] for late abortion was safer for the women than [the previously common methods of] saline abortion or hysterotomy, but it transferred the stress of the experience to the doctors and nurses. But we were putting abortion in the context of health care for women, which, in a way, goes in conflict with our entire evolutionary experience over millions of years. We have this ingrained, wired desire to support small, helpless creatures. That is one of the reasons late abortion is difficult, and why it is very useful for the anti-abortion people. And the most dangerous thing about the anti-abortion stuff is not necessarily the beliefs but the exploitation of those beliefs for political power.

I think of late abortion as a bellwether for reproductive rights generally—I don't think we can reckon with the full complexity of abortion without including late abortion, and I don't think abortion rights are secure without a full understanding and inclusion of late abortion. But it's politically unpopular—only about twenty per cent of people believe third-trimester abortion should be legal. Were you disappointed that Kamala Harris did not defend it directly in the debate?

As Lyndon Johnson said, you've got to get elected before you can be a statesman. Kamala has to deal with the fact that there are a whole lot of people that don't like her position on abortion. So, just with my political judgment, I understand that that's a bridge too far for her.

But what we need is a constitutional amendment that says you cannot interfere with a woman's access to health care, including reproductive health care. The idea of replacing Roe v. Wade is hopeless, because it has these poison pills in it that say we can regulate abortion after viability. What is viability, exactly? What is the definition of viability? If the woman's life is at risk, the viability of the fetus is irrelevant.

You write about disliking the phrase "abortion on demand," which has become a popular slogan among both the pro-choice and anti-abortion camps. You write that a woman cannot walk into your office and demand an abortion.

You can, but I'm not going to do it.

You also write over and over about the importance of trusting women. Between those two things is your judgment. Under what circumstances do you turn a patient away?

There are circumstances, and the circumstances can change. For example, early in my career, before I developed safer techniques for later abortion, there were many patients I turned away. I do cases now that I wouldn't have considered doing twenty or thirty years ago.

On the other hand, there are limits. But it really doesn't happen. I mean, if you come in and start arguing with me or threatening me, I'm not going to take care of you. One thirteen-year-old kid told me that she wanted me to be shot. Her mother was distraught—she wanted the kid to have an abortion. I said, "Well, do you want me to be shot and killed before or after I do your abortion?" She said, "Before." I said, "So you don't want to have an abortion." She said, "No, I don't want to have an abortion." I said, "Well, why are you here?" She said, "Because I'm too young to have a baby." The kid was like a mirror—she was reflecting everything she had heard. I told her, "I tell you what, I appreciate your coming in, but I don't do abortions on people who don't want to have an abortion, and I don't do abortions on people who want to kill me." There's no way I'm going to do an abortion on someone that's going to say, "You killed my baby and I told you not to."

People come in and they say, "I think I should have an abortion but I'm not sure." They spend hours trying to figure it out. I say, "Look, you go think about it, and after you've decided what you want to do, then let us know." I've got thirteen patients in the waiting room who are here and they know what they want to do and I have to help them.

The doctrine of fetal personhood—which says that a full human life begins at the fertilization of an egg—has obvious legal inanities built in regarding taxes, insurance, litigation, etc. It can make I.V.F. or certain forms of birth control illegal. What are the issues that you see with it from a medical standpoint?

Who knows when the fertilization occurs? Is it when the sperm enters the ovum? Is it when it forms a blastocyst? When it attaches to the wall of the uterus? What if it's in the fallopian tube—an ectopic pregnancy, which can be a fatal problem [and cannot result in a child]? There's a thing called a hydatidiform mole—it results from a fertilized egg, but it's a tumor that looks like a bunch of white grapes. Is it a person? These politicians are in a realm they should get the hell out of, because it does not make any sense. This idea of fetal personhood means that birth is no longer a legal event, that birth doesn't have any meaning. But it's not about logic or reason, it's about politics. Women have a new role in society and they're able to compete with men for jobs and money and power, and a lot of the men don't like that.

Today, as opposed to before Roe, safe self-managed abortion is possible through telemedicine or getting pills in the mail. In your book, you seem wary about the idea that abortion could be safe without a physician involved.

This is an interesting, complicated subject. First of all, I'm in favor of anything that helps people have more access to fertility control that's safe and that is easy for them and within their means. For most people, remote treatment with telemedicine and mifepristone works. For most people, it's safe. I have some issues with it, but that's partly because I've done tens of thousands of surgical first-trimester abortions without a single major complication. I know when the patient is safe, and I know when her abortion is over and her uterus is empty.

You've never had a major complication in a patient?

For an early abortion, no. For later abortions, my complication rate is between 0.2 per cent and 0.5 per cent. My issue with medication abortion is—is there a follow-up exam? Do you know if the uterus is empty or not? Who's going to take care of them if there's a complication? Because of political oppression, people are afraid to take care of the patient. There was a young woman in Las Vegas who had a medication abortion. She started bleeding, she went to the emergency room, she did the right thing. They told her she was going to be O.K. and sent her away. She went back to a different emergency room, and they said, "O.K., we're going to transfer you to another facility," and she died before she got there.

I think that the medications themselves are quite safe. My issues have a lot to do with the way they're used, and a lot of that is because of the repression from the political system.

This book is full of gratitude for people who've supported you and helped you throughout the decades—doctors who vouched for you to get admitting privileges, who covered emergency calls. Many of these people are gone now; many of your colleagues, like George Tiller, whose patients you took on after his death, have been injured or murdered by extremists.

My best friends. My best friends in my whole life.

And now there's a new generation of physicians defending and practicing abortion; there are more clinics performing abortion in all trimesters. But policy has regressed to a place that's worse than it was when you began your career. Did you think that this was the world you'd be living in, that this was what your life would look like at age eighty-six?

Well, I didn't really think about that, but I knew that Roe would be overturned. I know what these people are like. They'll stop at nothing. This has been on its way for a long time, and things are worse than they were before Roe, and I am appalled at the severe consequences for women.

We tend to focus, for good reasons, on those consequences, talking about what happens when people can't get abortions. Can you talk about the impact that abortion itself has had in your patients' lives?

Almost every week, we receive loving messages from former patients that include photographs of the family they were able to have after safely terminating a pregnancy. One woman, for whom I performed a selective termination for the first time in my career, almost twenty years ago, in a twin pregnancy in which one of the twins was healthy and the other was catastrophically abnormal and threatening the development of the healthy twin, sent me warm, handwritten notes thanking me for helping me save her pregnancy and have one healthy child.

Another example is a young woman who discovered she was pregnant as she was about to start college at a prestigious liberal-arts school. She wrote a note telling me that she was able to start and complete college and medical school, and now specializes in pediatrics at a major university teaching hospital on the East Coast. These are only two examples of thousands, and I receive messages from patients not just years but decades after I've helped them.

I'll tell you about something that just happened in my office. My head counsellor was counselling a young woman from Texas, age twenty-one, from a minority group, well educated and thoughtful. The pregnancy would make it impossible for her to set out on her chosen course in life. My counsellor remarked to me that this young woman was "at the precipice of adulthood." This is a succinct and perceptive metaphor for the condition of many of our patients. It's exactly what I've seen since beginning this work fifty-three years ago, and it continues to be true today.

Why do you continue to do this work at your age? Do you feel that you can't retire?

Well, I love my work. I love taking care of patients. It's very clear to me that I need to turn this over to other people, and I've been trying to do that for a long time. I'm always trying to make things better in my practice. I'm training young physicians, and I now have three of them who are working for me, who are quite good—highly conscientious and well trained, very careful, and the patients are safe. I have front-desk staff who give the patient support and therapy the minute they answer the phone, the best head counsellor I could possibly have, nurses who are just the best in the universe. I have to see that all of that continues.

But I do have other things to do, things I've put off for decades. I've done research in the Peruvian Amazon going back to 1964. I have stacks of material that I need to read and process. I have to write a second edition of my textbook [" Abortion Practice "]. And I like to have fun. I like to go skiing and play the piano. I like to read books and write stuff. My body's not quite as good as it was fifty years ago, but I'm not dead yet, to the chagrin of my enemies.