During the first 13 weeks of pregnancy, when about 90 percent of abortions in America are carried out, the fetusâs 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 protestersâ signs and the billboards along Midwest highways, images that can be difficult to look at for long.
Many of the women who visit Hernâs clinic do so because their health is at riskâor 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 Hernâs 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 limitsâconsiderations about time and pain and fingernail development. Hern is reluctant to acknowledge any limit, any red line. He takes the womanâs-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.
âThe fee will be about $6,000,â 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 organizationâs number. âYou can do partial cash and credit card, yes,â 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 couldnât 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 patientâs abdomen to stop the fetusâs heart. This is called âinducing fetal demise.â Then Hern will insert one or more laminariasâa sterile, brownish rod of seaweedâinto the patientâs cervix to start the dilation process.
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 Hernâs former patients. Most of the women who agreed to talk had wanted a child. But theyâd 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.
âI put my baby down,â Kate Carson, whoâd gotten an abortion at Hernâs clinic in 2012, told me. Sheâd been 35 weeks into a much-wanted pregnancy when her doctor diagnosed multiple brain anomalies. Carsonâs daughter, the doctor said, would have trouble walking, talking, holding her head up, and swallowing. âItâs euthanasia. Thatâs the kind of killing this is,â she said. âBut I would do it again a million times if I had to.â
Amber Jones, who terminated her pregnancy at about 24 weeks in 2016, told me that her babyâs diagnosis meant he would not survive. Hern reassured her, she said, that she âshouldnât be made to carry the pregnancy. That itâs bullshit, and we have the right to access health care.â
Carson and other patients described Hern as brusque. But they seemed to take comfort in that brusqueness, as though Hernâs fierce assurance helped them feel more sure themselves. âI wouldnât say he has a great bedside manner,â Carson told me. But âthe degree of respect that I felt from him was enormous.â
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 clinicâs 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. âThere isnât a single woman who has ever written on her bucket list that she wants to have a late abortion,â Catherine said. âThere is always a reason.â
The reason doesnât really matter to Hern. Medical viability for a fetusâor its ability to survive outside the uterusâis 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 womanâs willingness to carry it. He applies the same principle to all of his prospective patients: If he thinks itâs safer for them to have an abortion than to carry and deliver the baby, heâll take the caseâusually 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.
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. Hernâs 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 terrifiedâand so was she. He recalls that after he finished and told her she wasnât pregnant anymore, she wept with relief. He did too. âI was overwhelmed by the significance of this operation for this young womanâs life,â he told me. âThis was a new definition, for me, for practicing medicine.â
Regardless of the circumstances of pregnancy, in Hernâs view, a womanâs lifeâher humanity, her wishesâisnât just more important than her fetusâs. 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.
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, itâs the opposite, Hern replied. Being so vocal âincreases the political cost of assassinating me.â
âThatâs dark,â I said.
He simply shrugged. âThis is what I have to think about.â
