Abortions after 20 weeks are about ending suffering. To deny someone that care is barbaric

They travel dozens, hundreds, sometimes thousands of miles seeking health care. They come with fetal conditions so severe, their babies will not survive. Or they are far too young to consent to sex, let alone become a parent. Other times, it's the first chance they've had to escape domestic violence, or because they live in states with so many restrictions, they couldn't access abortion care sooner.

By most estimates, a small number -- 1 percent -- of abortions happen after 20 weeks, and not in the monstrous way people would have you believe.

As I fill a syringe with a chemical that will stop a fetus's heart, what I am doing is fulfilling my patients' request to end suffering, whether that of the baby with brittle bone disease who will not survive labor and delivery or the parents who could not bear to witness it. The polarizing political rhetoric of "ripping babies out of wombs right before birth" or "no one is having an abortion near their due date" is simplistic and wrong. Abortion later in pregnancy is critically important for the people who need it. To them, politics are irrelevant. They need the care that they need.

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In contrast to what people think of doctors who provide abortion care later in pregnancy, all of us doing this work have thought deeply about the moral and ethical implications of doing so. We've concluded that not only is it in line with our personal values, but that to refuse would be a violation of our own conscience and our professional ethics. Conscientious refusal of care, in which physicians cannot be forced to provide care to which they morally object, is talked about frequently -- but conscientious provision of care gets less attention. I provide third-trimester abortions because it would be against my own moral code to endanger the life and welfare of someone by forcing them to carry a pregnancy to term against their own wishes and best judgment.

Within the idea of a moral code is a distinction between moral simplicity and moral clarity. Ending a third-trimester pregnancy is not morally simple. Even people who support abortion care sometimes view these abortions differently than those earlier in pregnancy. Moral clarity, however, comes with remembering that few events affect the trajectory of a person's life more than the decision whether or not to give birth and the conditions under which they do so. People seeking abortion care have already done their moral calculations and concluded that ending the pregnancy is the right decision.

People are certainly best suited to judge their own life circumstances, yet it is curious that many politicians seem comfortable leaving this moral choice to individual state legislatures to impose. When a person's instinct is to take on suffering so their child does not have to, or to prevent suffering in the first place, I have a moral obligation to assist them in this grim choice, because to not do so would be unconscionable.

This Atul Gawande quote hangs in my office: "Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person's life. When we forget that, the suffering we inflict can be barbaric. When we remember it, the good we do can be breathtaking."

When my patient is ready, I inject the substance slowly and observe the fetus's heartbeat slow ... become slower ... and stop. I remove the needle. I hold her hand. I tell her the injection has worked. I tell her how sorry I am that she's in this situation. Yet they thank me. They always thank me. This gratitude used to baffle me until one of my patients explained that this compassionate care "makes an unbearable situation slightly more bearable."

Later I induce labor and end her pregnancy. Along with the profound sadness that hangs in the room, I often see love and comfort -- unbearable grieving but also relief. I hope having some agency and choice in how their devastating situation ends provides at least a tiny salve of solace to this person and their family. What I know is that denying them agency during this time would be barbaric.