An analysis of those "medically necessary" Tiller abortions

The assertions that the abortions Tiller was infamous for were performed on women whose lives were in danger have begun to fade. As they should, as people ponder the utterly nonsensical idea that any woman could face a life-threatening or health-threatening pregnancy complication for which the safest course of action is to strenuously avoid all inpatient care at fully-equipped hospitals and to instead spend three days at the La Qunita attended by your mom or boyfriend.

That said, let's look at exactly what justification there was for these abortions.

Kansas law only allows third-trimester abortions (post-viability abortions done on fetuses who could have been delivered alive) for two reason:

“(1) The abortion is necessary to preserve the life of the pregnant woman; or (2) a continuation of the pregnancy will cause a substantial and irreversible impairment of a major bodily function of the pregnant woman.”

Now, these reasons are clearly bogus in the first place, since a pregnant woman whose life or health is in danger in the third trimester would need care in a fully-equipped hospital, not in the La Quinta. There's no medical reason not to do an emergency c-section or delivery in a hospital, where the mother will be attended by medical professionals. There can be no medical reason to have her spend three days in a motel attended by her husband, partner, sister, parents, or friends. But the Supreme Court, in Doe v. Bolton created a "health" need for post-viability abortions. The "need" is a judicial one, not a medical one, invented by men in black robes, not doctors in white coats. Up until Roe and Doe, there was no such thing as a post-viability abortion. I can't stress that enough: Up until Roe and Doe, an abortion by definition was the termination of a pregnancy prior to fetal viability.

That said, Dr. Paul R. McHugh, who reviewed the redacted medical records on George Tiller's post-viability abortions, explores the reasons given as justification:



Highlights: Interviewer reviews Dr. McHugh's impressive qualifications. Dr. McHugh explains that Attorney General Kline asked him to review the records to "confirm or reject the idea" that the women were "in danger of suffering a substantial and irreversible impairment if the pregnancies continued -- impairment of a psychiatric kind." He did not think those records supported the claim that the women would suffer any substantial and irreversible impairment, as spelled out in Kansas law. The question he was asked was did he, an independent psychiatrist, concur with the idea that an abortion was necessary to prevent substantial and irreversible psychiatric damage.

Dr. McHugh indicated that he looked for evidence of the following: Where the records adequate to develop a diagnosis? Did the diagnoses represent a substantial and irreversible impairment? Would an abortion resolve the problem? Were these adequate psychiatric justifications?

He pointed out that the records were redacted, since names and identifying information were removed. He was to look at the quality and adequacy of the examinations done to determine a psychiatric justification for abortion. The interview establishes that Dr. McHugh was the state's expert witness, and that he wrote an affidavit of his findings.

As a side note, I'd like to point out that Paul Morrison, who replaced Phil Kline, never contacted Dr. McHugh to follow through on the case. Dr. McHugh was not called on to testify when Tiller finally went to trial. And, what's more, Paul Morrison never addressed the issue of whether or not the abortions in question were medically justified according to Kansas law. He stuck to one narrow point: Was Dr. Neuhaus, who signed off on all of the abortions, sufficiently "independent" under the law? Whether or not the records substantiated the claim that the abortions were medically justified was never addressed in court.

What were some of the reasons given by the mothers for these late-term abortions? These abortions were done at 26 to 30 weeks. I address the issue of accuracy in estimating gestational age, and the potential these babies had for survival, here. In a nutshell, assuming that Tiller's estimates of these babies' ages were 100% accurate (odds are against that but we'll assume), they had at least an 80% chance of survival if delivered live via emergency c-section or labor induction, as is the standard of care for treating women with third-trimester pregnancy complications.

So what did Dr. McHugh find were the reasons for these supposedly compelling, health-preserving late term abortions?

"The mothers were expressing ... great senses of distress and worry about their future. They were tearful, and preoccupied that only an abortion would help them. They said that they were sad and frightened, and they spoke about fears that their future life would be changed. They expressed ideas that they were not being given adequate support, and that they felt that the abortion would help them."

The interviewer asks him to summarize his findings. Dr. McHugh says these records were "very inadequate psychiatric records." He described them as being very brief, lacking a patient history, lacking detail. "There was no clear work of -- in those records that would be construed of capable of giving you a full picture of the mental condition of these women. They highlighted certain kinds of things that .... were sometimes of a most trivial sort, from saying that 'I won't be able to go to concerts' or 'I won't be able to take part in sports'" to a reluctance to surrender the child for adoption or concern about the child's future. "At no time could you see and understand the future of these individuals and in what way they could be seen as full people, people capable of being helped in this situation. Rather, they were highlighted for certain kinds of -- well, preoccupations and concerns." Dr. McHugh pointed out, "I could pick out only bits and pieces of this. This is not a -- None of them represented a full psychiatric history."



Highlights: Interviewer asks for Tiller's justifications. "He had mostly social reasons for thinking that the late term abortions were suitable. That the children ... would not thrive. That the woman would have her future re-directed. That they wouldn't get a good education after they had a child. That they would be always guilty in some way about having that child. That they had been abused already and that this -- to have the baby would be another form of abuse. These ... are not psychiatric ideas... These were social ideas. .... There was nothing to back these things up in a substantial way."

Dr. McHugh also stressed the lack of follow-up planning, no follow-up care of any sort, including a lack of a psychiatric aftercare plan. There were also no explorations of alternative treatments other than abortion. "You couldn't even begin to try to get a true picture of the person." He noted again that some of the justifications included concerns about attending the prom, or concerts, or sporting events. Dr. McHugh also noted that attending concerts and sporting events, or pursuing an education, are things many people pursue after having a baby.

"Occasionally you would hear someone say their suicidal ideation would increase." Dr. McHugh noted that "being pregnant and being the mother of a child up to age one actually reduces the suicide risk to women from three to eight-fold." He also noted that abortion and miscarriage are known to increase suicide risk. There was nothing in the records to indicate why Tiller felt that these women's situations ran so far contrary to the established patterns of suicide risk.

Dr. McHugh again noted the paucity of information on these cases, and the lack of proper psychiatric work-ups. "These cases have not been studied thoroughly. And the diagnoses that have been made, such as depression, adjustment disorder and the like -- those are not substantial and permanently impairing conditions. Those are conditions we psychiatrists deal with all the time." He points out that most psychiatric practice involves helping patients to overcome these diagnoses "and restoring people to their mental health. We do that all the time."

Dr. McHugh says, "I think that these young women were all in a demoralized state of mind. You -- These diagnoses become almost interchangeable, at least on the evidence that's produced here. They're all fundamentally demoralized young women and what they needed was support, help, care, and long-term treatment for the situation that they had, in which they felt abandoned, so that they could once again feel, as they should feel, that their future is rich."

The interviewer asked if it wasn't a breach of medical care to lack follow-up plans. Dr. McHugh says, "It relates to my concern about these records as not being adequate, either in what they brought to the case, or what they propose for the case other than the abortion. And I had to ask myself, looking at these records, is any person who comes to this clinic ever found not to be appropriate on psychological or psychiatric grounds for abortion?"

The interviewer asked if Tiller ever rejected a patient. Dr. McHugh said he'd seen no such records. "I'm saying that looking at these records, and what they were employed to do, I can't imagine that anyone wouldn't satisfy those criteria." He added, "From these records -- anybody could have gotten an abortion if they wanted one."

"When I look at the records, as far as I can tell, all these young women were very similar in the sense that they were all demoralized. And what other diagnostic term you wanted to give it was almost interchangeable on the basis of these records. They were discouraged -- fearful, worried young women who needed support, and would express a variety of ideas in that context to win what they were looking for. And that's -- that's the way to understand these people in my opinion. And a thorough psychiatric examination, and a thorough and adequate psychiatric plan was needed by them, and was not received -- here, anyway."



Highlights: She asked about Tiller's training in psychiatry and psychology. Dr. McHugh says he doesn't know, though he does understand Tiller worked in pathology for a while and was not a psychiatrist. And he stresses that he wasn't called upon to judge Tiller's qualifications, just to review the records and their adequacy as far as psychiatric evaluations and psychiatric treatment planning.

The psychiatric assessments justifying the abortions evidently were being done by Tiller, and each file included a letter from a second doctor who expressed "her" opinion -- indicating that it was always the same doctor (Likely Dr. Kristen Nuehaus) -- seconding Tiller's opinion that the woman would indeed suffer a substantial and irreversible impairment of a bodily function, psychiatrically, should they not have abortions. Dr. McHugh noted, "that letter did not come with the kind of pages of psychiatric study, evaluation, biographical details, understanding of the person on which -- from that record you could confirm that opinion." He noted, "At least from the record,that second opinion ... rested upon an encounter with the young woman and a statement of her present state of mind. So it was an opinion derived in much the same way, from the statements of the patients themselves of how distressed they were." He noted that the letters were not highly detailed, but a letter was "brief, symptom-only based, and unsubstantiated in its prognosis on the basis of a rich detailed study of the young woman and her potentials."

He looks at the lack of any review of the woman's situation, or her resources. "One wonders looking at this why some consideration isn't being made to employ them for the benefit of these patients." He notes that the impression one gets from reviewing the cases is, "These young women came here for an abortion, and the effort on the part of the psychiatric assessment was to support that -- that idea that an abortion is appropriate rather considering the alternatives, the risks and benefits of this to this person in a life."

The interviewer asked if any of the files showed sufficient psychiatric evidence to justify an abortion. Dr. McHugh saw none. They were all based on the "present state of mind of being distressed" and the social idea that the patient's opportunities might be lessened if they bore their children.

Dr. McHugh felt that the records were inadequate to perform a diagnosis, and very inadequate to understand the women in question. He picked up that they were "discouraged" and "demoralized" and "disheartened" and a psychiatric diagnosis of depression seemed very inadequate to him. The records were so inadequate that they did not, in his opinion, support the diagnoses given, nor of any other diagnosis. He felt that no psychiatrist would consider them adequate records to make a diagnoses or make a psychiatric plan. And, he noted, despite the paucity of information on which to base a psychiatric plan, these files were in fact being used to make a psychiatric plan -- to perform an abortion as a treatment for the diagnoses in question.

The interviewer went through the diagnoses given and asked did they constitute permanent and irreversible impairments, and Dr. McHugh indicated no, and that furthermore these conditions, if the diagnoses were correct, are treatable in pregnancy.




Highlights: "How would you summarize ... Tiller's findings that justify these late term abortions?" McHugh noted, "All I can carry away from this is that by these criteria, is that no person that would want an abortion -- a late-term abortion --would be turned away from that. So I presume that the idea here is to justify that surgical procedure. That -- And these records on a psychiatric basis do not justify that."

The interviewer asked about the social reasons Tiller used. Dr. McHugh referred to his notes. Tiller claimed that a patient would end up uneducated -- which is a social prediction, not a medical prognosis. That the patient feared occupational setbacks or family disapproval.

Dr. McHugh said, "I don't mean to say that if you do lose out in your education that that's not harm, but it's a social harm, and those kinds of things should be treated in a social fashion. And by supporting the individual, re-moralizing her, giving her her strengths ... she then, as we know, independently can demand the kinds of support ... that she would be entitled to!"

Dr. MrHugh quoted one of Tiller's notes justifying one of these third-trimester abortions: "If she was forced to carry to term, she would end up as an uneducated person without occupational skills and have multiple other pregnancies. ... All of those things are social predictions! .... I'm saying, and we psychiatrists would say, will be avoided if you can get this person once again to feel what she's entitled to feel, that she is an independent individual with rights.... If you teach her that the only thing that can be done here is that this viable human being has to be killed in order for her to have anything in her future, that's a lesson, that's a social lesson, that may well... take from her the sort of sense that she can overcome hurdles that life brings her."

He points out that this sort of defeatist attitude toward women in any other context would be treated with the appropriate scorn.

Dr. McHugh expressed a sense that Tiller was reinforcing the patients' views of themselves as powerless and incapable, with no promise and no strengths, that Tiller was underscoring and reinforcing a sense of hopelessness.

Dr. McHugh says, "Doctors are supposed to give hope to people, and give support to people, and they have to believe that there is such hope to be found in them. And usually ... that kind of hopeful attitude comes out of taking the full history of the person, noticing not simply what life has imposed upon her, but what she has brought to life, what her strengths are. If we approach a psychiatric problem as though there are only deficits rather assets for a person, we will never have an optimistic and future-oriented therapy for people. We've got to see their assets as well as their vulnerabilities.... And those don't come across in these records."

He adds, "By the records, anyway, what is being looked at is the state of mind of the woman right at the time, in which the issues of the stressing aspects of her present context are emphasized, and her strengths, her assets, the things that she brought, and, by the way, our capacity to open up for her and broader her horizons as to what can happen in the future for her is neglected. It's as though, from the records .... one has the idea that the purpose of this visit is to justify an abortion, rather than the purpose of this visit is to have a full psychiatric understanding of this person and see all of the alternative ways that she could approach her life."



The interviewer then reinforced that these are viable fetuses, late in pregnancy. "These are the very kinds of little babies that are being taken care of in ICUs all around our country. .... To eliminate them is a serious business. .... There's no psychiatric reasons for that."

Dr. McHugh notes that "There is no psychological condition for which abortion is the cure."

The interviewer asked why Dr. McHugh chose to speak out. He noted that he was invited to this situation by an Attorney General, and that psychiatry was being called in to justify these abortions. "This is not a full psychiatric practice that we are seeing here. Rather, psychiatric terms are being employed to justify doing a procedure." He sees speaking out as "speaking out for my discipline."

Dr. McHugh said, "These records are not adequate records for the support of a serious decision for abortion, and that they do not represent psychiatry at its best, and psychiatry at its best should be employed when serious decisions are being made."

"The people of Kansas have written these laws," Dr. McHugh stressed. "'Viable fetuses should not be aborted unless there is a substantial and irreversible condition that the pregnancy will produce.' Well, when a psychiatric diagnosis is brought forth, I think that the people should understand that that requires a heck of a lot more than I found in these records. That's what I' here and that's what I'm trying to report."

And the narrator recaps.

The things Dr. McHugh brought forth are in keeping with what investigators found when they researched abortion lobby claims that late abortions are done only in desperate situations where either mother or baby had a terrible diagnosis. In fact, what Dr. McHugh describes being done in Kansas to get around laws against post-viability abortions is highly reminiscent of the rubber-stamping psychiatrists used to do to enable women to get around laws banning elective abortions prior to legalization.

As this woman's testimony bears out that these abortions are not being done to address women's critical health issues, and also, Tiller is not reporting statutory rape. She was only 14 years old.



She describes pushing her baby out into a toilet, which was the standard way the abortions were done at Tiller's facility.

You can hear Michelle Arnesto's unedited testimony about her illegal late-term abortion at Tiller's mill here. And there are summaries of other cases here. The cases, in a nutshell, are 26 weeks for Anxiety Disorder Not Otherwise Specified or Adjustment Disorder with mixed anxiety and depressed mood; 29 weeks with no reason given for declaring the fetus "non-viable"; 28 weeks for Major Depressive Disorder Single Episode, 28 weeks with no note on the mother's medical condition, 28 weeks for Major Depressive Disorder Single Episode, etc. And -- often -- no medical justification given at all.

Even one of Tiller's friends pointed out, in a marvel of understatement, "Some of his practices are hard to defend."

Amen to that.