Why LeRoy Carhart Won't Stop Doing Abortions

Leroy Carhart was at his abortion clinic near Omaha when he got the phone call. It was Sunday morning, a little after 10, and the doctor was in surgery. He felt his cell phone vibrate. Carhart ignored it, finishing the abortion before checking his phone. The number for George Tiller's head nurse in Wichita, Kans., flashed on the screen. The timing was unusual; Carhart didn't often hear from Tiller on Sunday mornings. He thought it might have to do with a patient, maybe an emergency. But when Carhart called back, Tiller's nurse was crying. "George is dead," she told him through sobs, relaying the news that Tiller, the late-term-abortion provider, had been fatally shot at his Lutheran church. (Article continued below...)

Carhart was scheduled to work in Tiller's clinic the next day; he was one of three abortion doctors who took turns assisting there. His car was already packed for the five-hour drive from Omaha to Wichita he'd made every third Sunday for the past five years. Carhart decided he would still go, to see Tiller's family and help figure out what would happen to the clinic. But first he would see the patients at hand. His waiting room, after all, was full of women who'd crossed state lines and waited hours to see him. "I didn't have any time to sit here and feel sorry for myself," says Carhart. He hung up the phone, went back into the operating room, performed another abortion. By day's end, he had seen a dozen women.

Carhart knows there are people who want him dead, too. A few days after Tiller's murder, Carhart's daughter received a late-night phone call saying her parents too had been killed. His clinic got suspicious letters, one with white powder. It's been like this since Carhart started performing abortions in the late 1980s. On the same day Nebraska passed a parental-notification law in 1991, his farm burned down, killing 17 horses, a cat, and a dog (the local fire department was unable to determine the fire's cause). The next day his clinic received a letter justifying the murder of abortion providers. His -clinic's sidewalks have been smeared with manure. Protesters sometimes stalk him in airports. The threats, the violence, now the assassination of his close friend—all of it has left Carhart undaunted, and the billboard-size sign over his parking garage still reads, in foot-high block letters, ABORTION & CONTRACEPTION CLINIC OF NEBRASKA. "They're at war with us," says Carhart of the anti--abortion activist who killed Tiller. "We have to realize this isn't a difference of opinions. We need to fight back."

What makes Carhart such a target isn't just that he performs abortions—about 1,800 doctors do so today—but that he is among the very few still willing to do so late into pregnancy. Only 1.3 percent of abortions happen after the 21st week of pregnancy, according to the Centers for Disease Control. But those procedures have become the focus of intense debate. To pro-choicers they are tragic stories of late-discovered anomalies, with heroic doctors terminating a fetus that wouldn't survive long after birth. To pro-lifers they are morality tales that best prove the point about all abortion. "I don't support any abortions, but I think third-trimester abortions are particularly abhorrent," says Nebraska's attorney general, Jon Bruning, who has publicly called Carhart "one sick individual" and vowed to act on any evidence that would warrant an investigation. In the third trimester, Bruning says, abortion is "not only morally abhorrent but visually and physically abhorrent. You have a child with arms and legs."

A public-opinion poll in May found 68 percent of Americans support Roe v. Wade's comprehensive protection of elective, first-trimester abortion. But the farther along a pregnancy gets and with each biological milestone a fetus passes, the numbers drop and Americans become more cautious and conflicted. Around 24 weeks, when the fetus is likely viable outside the womb, the right to terminate becomes most controversial and abortion least accessible. Roe recognized the unique status of late-term abortions and gave states the power to restrict or disallow abortion when the fetus is viable (with an exception for "the preservation of the life or health of the mother").

Past viability, no doctor will terminate a pregnancy without a compelling reason. But what is a compelling reason, and who decides? Some would count a serious fetal abnormality, mental or physical; others would not. What if the baby has a 50 percent chance of surviving outside the womb? A 30 percent chance? While most of us navigate these questions in theory, Carhart deals with them in practice. At Tiller's clinic, he saw a rape victim in the third trimester of pregnancy. Every time she felt the baby move, she said, it brought back the rape all over again. She'd made three suicide attempts. Carhart performed her abortion. "If a woman is going to kill herself, then I think you have to look at it for her health," he says. The day before Tiller's death, a woman came into Carhart's Nebraska clinic 28 weeks along. Carhart asked her what she would do if she had to carry the baby to term. "She didn't say she was going to kill herself," he says. "She said she would put it up [for adoption]." He turned her away.

Carhart has a few firm lines; he won't, for example, do elective abortions past 24 weeks, because the fetus is likely viable. "It just makes sense to me," says Carhart. "After a certain point in time, the fetus is viable and we have to look at it differently than if it were not viable." And at 24 weeks, many studies show a fetus's chance of survival to be above 50 percent. Any earlier and the survival rate is lower; at 22 weeks it's less than 10 percent. But Carhart admits that such clear guidelines rarely present themselves. "There are times when abortion is the right answer," he says. "There are times when abortion is not the right answer. I hope I get it right."

There are many circumstances that can bring a woman to seek a late-term abortion. But whether she is that suicidal rape victim or a well-heeled New Yorker who just discovered a fatal fetal defect, her options for ending the pregnancy are limited. Since Tiller's death, there are fewer than 10 doctors across the country willing to help. LeRoy Carhart is one of them.

In the wake of Tiller's assassination, Carhart began offering late-term abortions in his own practice—before, he'd done so only at Tiller's Wichita clinic—and started planning a new late-term clinic to replace Tiller's, where he could see women in the late second and early third trimesters. He's fielded calls from three physicians who want to learn how to do abortions. Two have already begun training. "I think the only thing I can do…is just train as many doctors as I can to go out on their own and provide abortions and get enough people providing them," says Carhart. "That makes [the anti-abortion activist's] job 10 times harder because there are now 10 times more of us."

Carhart is 67, heavy-set and deliberate in his movements and speech, a man who looks as if he could use a good rest more than a five-hour drive to Wichita. If his life had taken a different course, he would be thinking about wrapping up an uneventful career as a general surgeon in Omaha. That's where he founded an emergency walk-in clinic in 1985, after a 21-year career as an Air Force surgeon. Carhart had trained as a fighter pilot in Texas and England—although he never flew in combat—and got his medical degree, from Hahnemann Medical College in Philadelphia, while still in uniform. He was a surgeon at Ouffett Air Force Base near Omaha before retiring as a lieutenant colonel. His life seemed set in a comfortable mold—married to his -elementary-school sweetheart with two teenage children and a 62-acre farm outside town. It all changed in 1987, when a nurse prevailed on him to spend a day at the abortion clinic where she worked. Talking to the women reminded him of the patients he had seen as a medical student, in the days before Roe: women whose botched abortions, anywhere from the first to the third trimester, left them with perforated uteruses, intestines protruding from the vagina, or untreatable pelvic infections. The way Carhart remembers it, it was a good week for the emergency room if only five women died. Soon after the visit he trained at an abortion clinic in Philadelphia, performing more than 500 abortions in four months. When he returned to Omaha, Carhart began splitting his time between his friend's abortion clinic and his own emergency facility. Some specialists, who objected to his abortion work, refused to see patients Carhart referred to them, even if the patients came from his emergency practice. When his farm burned down in 1991, Carhart got defiant: he added an abortion practice to his walk-in clinic. His two physician assistants quit in protest.

It was at Tiller's clinic that Carhart first performed late-term abortions. The two met in 1988 at a National Abortion Federation meeting and quickly became friends and confidants: two unassuming Midwestern doctors who were both risking community pressure—if not yet their lives—doing abortions in conservative states. "He would always be there," says Carhart. "He would call me if he had a hard patient; I would call him when I needed someone to talk to. We became each other's therapists." When Kansas passed a law in the mid-1990s requiring second consultations for abortion, Carhart would do Tiller's over the phone. In 1998 he began assisting with surgeries in Tiller's clinic, and starting in 2004 he spent every third week there.

At the same time, Carhart began challenging partial-birth-abortion bans, first the one in Nebraska and then the federal law. The bans, which state legislatures began to pass in the mid-1990s, generally targeted a procedure called intact dilation and extraction, in which the dead fetus is removed intact after the skull is crushed. It is a rare procedure, used in 2,200 of the 1.3 million abortions performed in 2000, and only in cases where doctors believed it was the best option for minimizing risks to a woman's health, according to the Guttmacher Institute. Carhart worried that the Nebraska law, passed in 1997, wouldn't just ban intact D&E but was vague enough to criminalize other types of abortion. Backed by the Center for Reproductive Rights, Carhart filed a suit against Nebraska's attorney general. The case made it to the Supreme Court in 2000 and was decided in his favor, overturning the Nebraska ban for both its vagueness and its lack of an exception for women's health. When Congress passed a national ban in 2003, Carhart challenged again and returned to the Supreme Court. The court then ruled against him, leaving a national ban intact today. Carhart became a pro-choice hero, receiving awards from NARAL and Planned Parenthood for his activism.

Carhart can't pinpoint how exactly he went from reluctant visitor to controversial abortion provider, why he chose a job that attracts death threats and protesters. Part of it is stubbornness; he won't be bullied out of what he sees as a legitimate medical specialty. "Abortion is not a four-letter word," he says. "I'm proud of what I do."

But if Carhart is proud of his practice, he seems equally burdened by it. He talks about being an abortion doctor not necessarily as a career choice, but as a job he had to take since few others would. "It's like that quotation: 'If not you, who? If not now, when?' That whole thing," he says, giving a modified version of a Hillel quotation ("If I am not for myself, who will be for me? And if I am always for myself, what am I?"). He won't take long vacations because "you can't leave the women waiting, or at least don't want to." He maintains medical licenses in seven states so that if another provider is "hurt, retired, or killed," he can step in. If women need this service, Carhart reasons, who is he to say no? If he won't provide these complex and challenging abortions, who will?

The Abortion and Contraception Clinic of Nebraska is an unimpressive two-story building that shares a gravel parking lot with a shut-down gas station. On a Sunday in June, patients start arriving at 8 a.m. The clinic attracts a regular group of four or five protesters, who carry posters of fetuses and newborns, but they generally take the weekend off. Patients open an outside door and slip their driver's license through a small glass window, where an assistant verifies their ID before buzzing open the clinic's inside door. Carhart's staff has taken more precautions since Tiller's death. They now arrive at the clinic in street clothes, changing into their scrubs inside, and turn over any suspicious mail to the federal government. A short hallway leads to a bare-bones waiting room, four lines of eight or so seats. It feels like any medical waiting room, where you'd be called into a dentist's chair or an appointment for a physical. But there are some differences, like the vending machine that sells both Doritos and condoms. Thank-you notes and photographs, mostly of Carhart and his staff, line the windowsill and reception desk. One is a photo of George Tiller and Bill Clinton shaking hands. THIS HANDSHAKE WAS FOR ALL OF US, the inscription reads.

By 10 a.m., every seat in the waiting room is full. There are 14 patients on the schedule. Some bring a boyfriend, girlfriend, or parent, but many come alone. Patients spend about five hours in Carhart's clinic, most of it sitting here, waiting. They wait for an assistant to call their name, walk them to one of the small counseling rooms, verify the pregnancy, and take an ultrasound to identify the date of conception. They wait for blood testing and pre-op medications. They wait for a patient-advocacy session, in which assistants read off a script: Did anyone force you to be here today? Are you sure you want to terminate your pregnancy? And finally, they wait to be called into one of Carhart's two operating rooms.

A surgical first-trimester abortion takes approximately 10 to 15 minutes. There are a few different procedures to terminate early pregnancies; Carhart uses one called suction dilation and curettage, or suction D&C. (His clinic also offers medical abortions, which can be used through the eighth week of pregnancy.) In a suction D&C procedure, the cervix is dilated with rod-shaped instruments and the contents of the uterus removed with a tube connected to a suction device. Sometimes a thin metal instrument (a curette) is used to scrape out the uterus. Carhart enters the operating room, introduces himself as Lee, and begins operating. Patients mostly make nervous small talk during their abortions. One cries. Another tells Carhart that she saw him on TV. "I think it's so great what you're doing," she says as he performs her abortion. "We need someone to stand up for us."

About a month after Tiller's -murder, Carhart started offering abortions beyond 22 weeks in his Nebraska clinic. He bases his practice on a conservative interpretation of Nebraska law and will operate only when another physician has declared the fetus unable to live more than momentarily outside the womb. It's just a temporary way to address the dearth of late-term providers. In the coming months, Carhart plans to open a new late-term clinic in the Midwest, where he can see the women Tiller saw: in the late second and early third trimesters, their life or health at risk, and carrying either a viable or nonviable fetus. He doesn't know where exactly he'll be located—perhaps still in Nebraska, if his legal team gives the OK; perhaps Wichita—but he has investors and lawyers working on it. Even in the early planning stages, he's been remarkably forthright about his goal. Ten days after Tiller's death, on prime-time television, Carhart promised Anderson Cooper that "we are going to do everything in our power to ensure that women still have an option for late-second- and the early-third-trimester abortions that are medically indicated."

Friends have advised Carhart to stop appearing on television, that he's only making himself more of a target. But he doesn't believe in keeping quiet, especially when it comes to abortion. "That's the last thing Tiller would want," he says. "If we give in, they win, and that's unacceptable." A wave of anti-abortion violence in the 1990s—three doctors killed in five years—coincided with a dramatic drop in providers, from 2,680 in 1985 to 1,787 in 2005. Carhart worries that if he and other doctors retreat, Tiller will have the same legacy. Besides, he says, he's already done thousands of abortions—stopping now wouldn't do much to temper the anger of those who oppose him. "Everybody says I should do less," says Carhart. "But I think I'm already at risk. Whether you have an 89 percent chance of being shot or a 91 percent chance, I don't think it's that different." The threat of violence is always in the back of his mind, and lately in the forefront. He was unnerved when he delivered a eulogy at Tiller's memorial service at the National City Christian Church in Washington, D.C., standing at a pulpit in front of an unfamiliar, open-invitation crowd. He began by asking for a moment to compose himself. Carhart doesn't go out in public, just shuttling between his house and the clinic. Is it a permanent change? "I don't think so," he says. "[But] when I feel safe enough I'll probably get shot."

Carhart makes a few remarks like this, about getting shot, during the days I spend in his clinic. They drop casually into conversation, without a moment's pause or hesitation, and with jarring complacency. I can't tell whether he's serious, if he believes he'll be shot, or is just using this as a defense mechanism, a way to stay sane by making light of looming threats. I think about how his comments might look in a magazine that falls into the wrong hands. And I wonder whether he might do best to heed his friends' advice, send me packing, and continue quietly with his work.

In our last interview, I ask Carhart whether it's true, if he really thinks he will be killed by anti-abortion violence. We're sitting in his operating room; he's just finished a day of surgery and is still wearing his white lab coat. Carhart shrugs, takes off his glasses, rubs his eyes. "I think George and I always assumed we were a target," he says quietly. And then he shakes my hand, walks me to the door. In a few hours he'll fly to another state to work at another clinic for two days, in the "whirlwind" of work that began after Tiller's death. The last thing I see as I drive away is the sign over his building, proclaiming his defiance to the heavens above and the protesters below.