The view from one of the last abortion clinics in Louisiana

He’s provided abortions for nearly 40 years. Now, the man known in court documents as “Dr. John Doe 1” – or “Doe” for short – is ready to retire and wondering whether anyone will be around to take his place. There are one or two local physicians who might be willing to hack it – to risk judgment from their peers and neighbors, face hostility from antiabortion extremists, and conceal their identities from the public, as Doe has done for most of his career.

But at some point, likely late this year, he plans to hang up his scrubs for good.

“We’re going to kind of face the point where [I have to] say, ‘Look, if none of the other OB-GYNs in this state are willing to come up and step up to the plate, then too bad,’” he says one April afternoon after his shift at Hope Medical Group for Women in Shreveport, Louisiana, where he’s performed abortions since 1981. “I’ve done as much as I can do, you know?”

Providers have for decades been a key target of anti-abortion activists; an entire category of abortion regulations is aimed at chipping away at their ability, and by extension their desire, to offer abortion care.

Now, as activists on both sides prepare for the possible overturning of Roe v. Wade, that long-term strategy is paying off. When not facing the threat of public animosity, doctors in anti-abortion strongholds like Louisiana are often shamed for their decision to provide abortions. A barrage of laws restrict how, where, and when they can perform the procedure. Clinics that manage to stay open are tied up in compliance and litigation, a drain on time and resources. The pressure has seeped into medical schools, especially in conservative areas where providers are most scarce: Students aren’t getting exposed to even basic abortion care unless they seek it outside their regular coursework.

Abortion rights opponents say you can’t force doctors to do, or teach, something to which they’re morally opposed. Abortion is often a medically unnecessary procedure, and it would be unethical to compel anyone to perform it, they say. Medical schools and residencies need only train students to attend to emergency abortions or miscarriages – which schools and hospitals do – and not actively prevent students who want to from learning about abortion.

Abortion rights activists, however, say that the current environment is one in which doctors who choose to provide abortions feel scorned and even threatened. It discourages physicians who would otherwise perform abortions from doing so and chokes the provider pipeline, particularly in restrictive states. Women then have to deal with longer wait times at clinics and doctors who are tired or overextended. Some women aren’t able to access abortions at all.

What good is a woman’s right to choose whether or not to have an abortion, they ask, if no one is able or willing to perform them?

‘How terribly naive I was’

Doe is still in scrubs when he walks into the clinic administrator’s office at Hope Medical. It’s only about 4 p.m. but he’s had a long day; he was late for his shift at the clinic, he says, because he had to deliver a baby that morning for a patient at his private practice.

Providing abortions had never been Doe’s first choice. The clinic had first approached him in the early 1980s, less than a decade after the Supreme Court legalized abortion in the United States via Roe v. Wade. He’d only lived in Louisiana a few years, having moved here from Texas for his residency. He says he believed abortions should be legal and safe, and that women should have access to them. But it seemed every doctor he knew who volunteered to perform abortions soon found themselves overwhelmed by the demand.

What changed his mind was a young man’s sense of bright-eyed duty, helping women in need. “I kind of viewed myself as this knight in shining armor,” he says with an ironic smile. “How terribly naive I was.”

He soon discovered that a wall stood between him and his colleagues. He had been in partnership with two other physicians, both of whom wound up leaving the practice because he was doing abortions and “they couldn’t stand the pressure.” These days, only two local OBs in his hospital network will take calls for him, forcing him to work six, seven, eight days without reprieve.

Meanwhile, the landscape for providers was changing. Abortion clinics like Hope Medical began cropping up, moving abortion care away from hospitals and the schools with which they were affiliated. The shift broadened access to the procedure, but it also created a gap between abortion and academic medical care.

Clinics were also becoming easy targets for harassment and violence. The National Abortion Federation, the professional association of providers, counted 40 clinic bombings and seven murders of doctors and staff between 1977 and 1999. The first murder was that of Florida physician David Gunn, who was shot and killed outside a clinic in Pensacola in 1993. A rash of others followed: In 1994, receptionists Shannon Lowry and Leanne Nichols were gunned down at the clinic where they worked in Brookline, Massachusetts. Later that year, provider John Bayard Britton and volunteer James Barrett were shot and killed outside another abortion clinic in Pensacola. In 1998, security guard Robert Sanderson died in a bombing at an Alabama clinic, while provider Barnett Slepian was murdered in his home in Amherst, New York.

All this began to weigh on Doe, who struggled with depression. He started hiding his identity, although that didn’t stop protesters from accosting him when he went to and from Hope Medical, or sending nasty mailers about him to his neighbors. “I was receiving so much grief over providing abortion services, I wanted to quit working here,” he says.

He kept going because he felt – still feels – an obligation to the women and girls who came to the clinic for help: Like the intellectually disabled young woman who’d been raped by her brother, and who’d hummed church hymns in the operating room. Or the woman whose pregnancy was at risk because she’d needed a heart transplant. Or hundreds of others, he says, their stories both tragic and everyday.

“I’m not pro-abortion. I’m just pro-choice,” Doe says firmly. “If you believe that abortion should be available, you at some point decide: Where does the buck stop?”

Demand outweighing supply

A similar question drew Rachael Phelps into the reproductive health field more than a quarter-century ago. In the spring of 1992, just before she started medical school, Ms. Phelps heard a speaker at a women’s rights march in Washington, D.C., talk about the lack of physicians willing and able to perform abortions. She decided that day to become a provider herself. After getting her degree at Johns Hopkins University in Baltimore, she worked at Planned Parenthood, spending 13 years as the organization’s medical director. Dr. Phelps still provides abortions about one day a week, driving hundreds of miles from her home in upstate New York to support clinics throughout the state.

But she and Doe are in the minority. A recent survey in the journal Obstetrics & Gynecology found that in 2016-17, 72% of OBs reported having had a patient in the past year who needed or wanted an abortion, but only 23% said they had performed one. Most of those who said they did not provide abortion care came from the South and the Midwest. The most common reasons given were personal beliefs, restrictions placed on their practice, and attitudes among office staff. A previous study by the Guttmacher Institute also found that more than a third of OBs in private practice who declined to provide abortions also said they wouldn’t provide a referral to patients seeking one.

“There’s a lot of people who go into private practice who want to provide the service for their own patients and are kept from doing it because of ... partners who won’t do it, staff who object, hospitals who won’t let you do the case in the hospital,” says Dr. Phelps, who now works at Medical Students For Choice (MSFC), a Philadelphia-based nonprofit that funds and advocates for abortion care training in medical schools.

Since starting at MSFC earlier this year, Dr. Phelps has focused on connecting medical students in campuses nationwide with professionals willing to train them in abortion care. She also leads training sessions herself.  

“Most medical schools in the U.S. never mention the word ‘abortion’ in their curriculum,” Dr. Phelps says in a phone interview. “There is a huge shortage of providers, and there’s nobody getting trained to replace [them].” 

“It’s really dependent on your experience,” adds Alana, a former president of the Tulane Medical School chapter of MSFC, in New Orleans, who asks that her last name not be used. “If a resident or attending [physician] is not comfortable discussing any of these topics, and you don’t have a lecture about it, how are you going to learn about it?”

A spokesman for Tulane – which is a private university and not subject to state restrictions on abortion in public institutions – told the Monitor in an email that abortion education at the school “is restricted to lecture instruction as part of our third year clinical rotation.” He did not respond to a request for details on what the instruction looks like.

Anthony Levatino, a retired OB-GYN who performed more than 1,200 abortions early in his career but has since become a vocal opponent of abortion rights, says he doesn’t remember much specific training on abortion provision from his years in med school. Most of what he learned came from his residency, and he says students today who want that kind of training should choose hospitals and clinics where they can get that exposure.

“I would tell them, ‘If this is important to you, look critically at the training in residency,’” says Dr. Levatino, who stopped doing abortions after his daughter was killed in a car accident in 1984. “‘Don’t put yourself in a position where you’re going to face some kind of barrier – for instance, a Catholic hospital.’ [Students] are not helpless.”

In Dr. Levatino’s view, one reason fewer physicians are performing abortions is that the procedure takes a toll on them. They start to see, he says, that abortion is taking a life. Doctors who feel that way have the right to choose not to provide abortions, he adds.

“What Roe v. Wade says is that patients can legally obtain this procedure. It is not granted as a positive right,” Daniel Sulmasy, who teaches biomedical ethics at Georgetown University. “[The law] respects the conscientious choices of physicians who, even if they don’t want to interfere in that opportunity for women, do not feel comfortable providing it themselves.”

Physicians who do choose to perform abortions shouldn’t have to face violence or harassment, he adds.

It’s also unrealistic to expect uniformly broad access to any medical procedure in a country like the U.S. says Jeffery Bishop, a professor of philosophy and health care ethics at St. Louis University. “You’re going to get a different kind of medicine in New York City than you will in some rural town in Wyoming,” he says. “That’s just the nature of it.”

For providers like Doe who live that reality, however, it’s a lot to shoulder. Hope Medical is one of only three remaining clinics in Louisiana – and that number could go down under a state law, currently being litigated (Doe is a plaintiff), that would require abortion providers to have admitting privileges at a nearby hospital. “I don’t know where to go from here,” Doe says.

Learning on a papaya

On a Monday night this spring, Alana sits in a conference room with 20 or so other medical students. On the table before her is a papaya – a proxy for a uterus – and a pump. The students are here for an MSFC-hosted training session on manual vacuum aspiration, the most common form of abortion. For about half an hour, Alana and her peers practice the technique on the fruit as two physicians, both volunteers, roam the room, commenting on and correcting their work.

It’s the kind of event that Alana had hosted when she was MSFC president her freshman year. Under her leadership, the chapter had forged relationships with local women’s rights groups and MSFC affiliates at other universities. Alana herself had testified against antiabortion bills in Baton Rouge and, in the summer of 2017, spent two weeks shadowing doctors at an abortion clinic in Mexico City. All done in addition to her required coursework.

Now a year away from graduation, Alana remains an active MSFC member. At a café in New Orleans the morning after the training session, she talks about seeing her work as a kind of advocacy. “If you’re really trying to provide a full spectrum of care,” particularly to underserved or underprivileged communities, she says, then that must include “trying to change the system in some way.” 

She knows that she’s unusual in her cohort, that she’s choosing a difficult path. She’s not even sure she’ll want to live in a state like Louisiana if she becomes an abortion provider. But she sees medicine through a humanitarian lens – she worked in international development before switching gears and going to med school – and hopes to use her skills to improve women’s lives.

“Unfortunately, or fortunately, there’s a lot of prestige that comes with wearing a white coat,” Alana says. “I’m going to wear it and use it as a tool to advocate.”

In Shreveport, Doe mulls the idea of a new generation of activist abortion providers, and the thought brings a smile to his face. “I’d love to talk to them,” he says. He’d have advice; stuff he learned the hard way over four decades. 

“Most of the time it’s really not horrible,” he says. “But I am reminded almost every day of ... how difficult my life has been because I work with this clinic.”

“You’ve got to do it just because you believe women deserve the opportunity.”

Editor's note: This story has been updated to correct the nature of Dr. Doe's private practice. It is an OB-GYN practice.