After Tiller

PBS Premiere: Sept. 1, 2014Check the broadcast schedule »

Filmmaker Interview

Filmmakers Lana Wilson and Martha Shane discuss the making of their film, After Tiller.

POV: For those who haven't seen the film, can you give us a quick thumbnail description of what After Tiller is about?

Lana Wilson: Well, After Tiller goes inside the lives of the last four doctors in the country who are openly providing third-trimester abortions, and they're doing this work in the wake of the assassination of their friend and colleague Dr. George Tiller in 2009.

POV: And who was Dr. Tiller for those who don't know?

Martha Shane: Dr. George Tiller was one of the few doctors in the country who for years was providing the later abortions. He worked in Wichita, Kansas and in a lot of ways, he was a bundle of contradictions. On the surface he was a Christian and very dedicated church-goer and he was actually murdered in church and he had been an active member of the military before he started his practice. So in a lot of ways, that's what originally drew us into the story — how is this man who is one of the most vilified abortion doctors in the country, also this very passionate, practicing Christian? That was just sort of the tip of the iceberg and then from there we began to explore the stories of these four other doctors.

Lana Wilson: I remember just watching the news coverage of Dr. Tiller's death. It was all over the cable news networks and it was covered in the same way that the abortion debate is usually covered in this country, which is as a war, basically. America is at war, there are these two sides, it's a very black-and-white issue, the news would get a talking point from each side of the issue and they would say Dr. Tiller is this controversial doctor who has been killed at church, America is at war over this issue. And that was it. And it was really frustrating to watch because, as Martha says, this was a complicated human being but the news was just treating him as this symbol of controversy.

And it was also frustrating because it seems sometimes like in the abortion debate, people are driven to extremes because we're talking about a lot of abstract ideas. There isn't a lot of talking about the gray area in the middle, the real lives and the very practical, challenging situations that the women and the doctors who are caught in the center of this are facing. So it was frustrating to see this coverage and it just made me think, I wish we could look at the abortion issue in a different way and put the doctors and the patients in the center. Because regardless of whether or not you agree with the work that Dr. Tiller is doing, the four doctors in our film, they're at the center of a firestorm and wouldn't anyone be curious just to be them for a day? What is it like to be them? How does this work affect their personal lives? Their families? How do they get through the day? Are they worried about their safety all the time, why are they doing this work in the first place? What would motivate someone to risk their life every day for a job that most people in the country don't really appreciate and many people don't support, or are actively fighting against. What is it like to be them?

POV: The four doctors in the film, tell us about them and how you first made contact with them?

Lana Wilson: The two male doctors were the ones who came on board with the film first, Dr. Warren Hern and Dr. LeRoy Carhart. We sent them information about our idea and then we called them to follow up. Dr. Carhart, he's very easygoing, mild mannered, as you can see in the film. He immediately said come visit, he's always been trying to get people, particularly Nebraska legislators and journalists, to come to his clinic and see the ways in which he's really helping his patients. So he was eager to have us and pretty quickly, much to our surprise, signed on with the film.

It took him [Dr. Hern] a little bit more time. I think at first he said, "I'm not sure anyone really wants to hear this story, I don't think people will be interested in this," but as soon as he allowed us to come out and talk to him, he very quickly also warmed up to us and sort of paraded us around saying we're going to help these young women make this film no matter what. And then the two female doctors took about a year to get on board.

Martha Shane: At first when we asked them, the two female doctors told Martha and I no, absolutely not, they didn't want to do it and they were very clear about that. But we stayed in touch with them over the course of a year and kept them posted on the progress of our filming. We eventually convinced them to let us meet them and we had dinner in Albuquerque and I think just to meet them in person was good because they can see we're just nice people, we're not scary. I think they saw that we were young women and they thought we wouldn't be a difficult presence to have in the clinic. They thought most patients would be comfortable around us.

They didn't get into this work to be political figures at all. They got into this because they're doctors, they want to help patients and they're upset that they're at the forefront of this national controversy just for being doctors, as they see it. The other side of that is that there are these people who are targeting them and focused on vilifying them. What we told them was, the fact of the matter is these people are putting huge amounts of effort behind vilifying you every single day. The only chance you have and the only chance anyone in America has of understanding where you're coming from at all is if you tell your stories.

I think they thought about that and they thought, the real way to get to this is to tell the patients' stories too. We said we wanted a film with the patients and they felt like, if you can just meet these women and hear some of their stories you'll at least see this issue very differently and you'll realize that it's more complicated than you thought it was.

POV: Can you help set their work in kind of the larger context because in this country there's a large debate on abortion. And they focus on a very specialized section in their medical practice. So give us some context of where it sits.

Martha Shane: Overall, the abortions that take place in the third trimester are less than 1 percent of all the abortions that are done in this country. So it's a very, very tiny percentage and we don't know exactly, but it's even probably less than half a percent. And it's impossible to know exactly how many are being done because it's possible that some people may be able to obtain a later abortion in a hospital or if they know an OBGYN who will do it, so it may be that there's some of these abortions happening sort of under the radar, but these are the only four doctors who are open about doing this.

And the reason why they're open about doing it is because it makes them accessible to a much wider range of patients, so low income women who don't necessarily have a doctor who can refer them to someone are able to just Google it and find them on the internet. So in that way they have a much, they have a really wide range of patients from all different backgrounds.

They're also really experts in this film in the sense that patients will come from all over the world to see them because they're doing more of these later abortions than anyone else and as a result they have become experts. They're specialists and there aren't a lot of people who do very many of these.

And it is of course because by the nature of it. The most controversial and the most targeted and the lowest sort of percentage of Americans support the right to have these later abortions. But as we've learned through the process of making this film, so little is known about the reasons why a woman would seek a third trimester abortion, what's actually involved in the procedure. And so I think a lot of people don't know for example that one of the major reasons why women seek these is because they have a fetal anomaly that's diagnosed late in the pregnancy. So it's actually a wanted pregnancy.

Martha Shane: The counselors at the clinic were really our best allies. They were the ones who would present initially the fact that we were there to the patients. And then they would say, if you want to learn more you can go talk to Lana and Martha.

And maybe 10 percent of the patients would agree to do that. And then a small percentage agreed to actually be part of the film. And we gave them the choice about whether to show their faces on camera or not. And I think it points to the fact that abortion is so stigmatized in this country that almost all of the patients chose not to show their faces. But the people who agreed, it felt like they were in a lot of cases, people who had never expected to find themselves in this situation.

They may have even been anti-abortion up to this point. And they felt like there were so many misconceptions out there about the reasons why a woman would seek a third trimester abortion. So they wanted to be part of sort of telling this story as it was happening to them.

POV: Talk about that a little bit more in terms of the reasons why, at this particular stage of a pregnancy, someone might be seeking an abortion.

Lana Wilson: There's a whole range of reasons why a woman might seek a third trimester abortion. One of the challenges in making the film was figuring out how to reveal those reasons gradually and how to make it really work and how to take the audience on a. on a process that kept pushing them further and further as you watch the film. And we worked with an extraordinary editor, Greg O'Toole to help us do that.

And what we decided to do at the end was start with the most clear-cut cases. The cases where it's a planned pregnancy, it's very much wanted. These people are looking forward to having their baby and then they get a diagnosis that there's something wrong with the pregnancy, late in the pregnancy. Or maybe they've gotten a diagnosis that's something's wrong earlier, but they thought, you know what, we can manage that, we can afford the extra costs, we can take care of this baby.

But then they get more diagnoses of more and more problems later. That kind of thing just tends to happen as a pregnancy develops. There's nothing that you can do about it. And so in those cases, parents are making very difficult decisions about parenting really and about the kind of suffering that if they had this baby, what kind of life would it have? It would have a very short life of a lot of pain and suffering. And so they're making incredibly challenging decisions like that. And that's what you see in the beginning of the film.

But then there are other cases that are more complicated. Cases where a woman wanted an abortion much earlier in the pregnancy but couldn't afford it. A woman who might be working four different jobs. She could have five kids already, and is just barely making it financially. It can take that kind of woman a long time to raise the money to pay for an abortion. And if she raises enough money and then goes to a clinic, she'll often find out that now she is further on in the pregnancy and needs to raise even more money.

So it becomes this long process of trying to keep up with the mounting costs of the abortion as you go later and later in pregnancy. So there's that, which I think people aren't aware of because you don't realize until you meet some of these people just how difficult the lives are of some women in this country. The people who are just barely making it, living lives of total chaos.

There are also younger women, women who are young teenage girls who didn't realize they were pregnant. They haven't had a comprehensive sex education, so they might not even recognize the most basic signs of pregnancy. They could not be aware of birth control or not have access to it often. The really young teenage girls are absolutely terrified to tell anyone about this because their parents will be angry at them or will kick them out. In some cases their parents have told them, if you ever screw up, you're going to be kicked out. So they could be afraid of that.

So that's another possibility. There's rape victims who are in denial, again, especially younger women could be in denial for a long period of time about what happened to them and the fact that they could be pregnant. And so there's a whole range of reasons. In the film we tried to use patients that have more and more complicated and ethically challenging cases, because we wanted to push people more and more, as you watch the film, to think about it in ways that you haven't thought about this before.

POV: The film does a pretty incredible job of giving us a picture of the kind of moral and ethical debates that the doctors have within their offices as to whether or not they proceed with a particular procedure. Can you talk a little about that process you saw unfold? Was that something that you were aware of going in? I'm curious to hear more about that. I thought that was a really fascinating behind-the-scene.

Martha Shane: When we first visited the Albuquerque clinic to, just to meet the doctors, I remember the two female doctors there said that they were meeting with an ethicist that day or that weekend. And we were sort of like, "Wow, an ethicist." We thought that was so fascinating. But then we realized that the reason why was that they had come from Kansas where there was always another doctor who had to sign off on doing the abortion.

So for the first time, they were faced with this whole new situation of having to make these decisions entirely on their own. And so they were really in that moment wrestling with the ethics and the sort of moral calculus that goes into making every decision about whether to provide a woman with an abortion. And I think that in a lot of ways, we definitely did not know that that was going to be such a big part of the film at the beginning, we were glad that it happened because I think you know you see a lot of the, the two female doctors, because they're thinking about the ethics of this, they bring actually in a lot of the anti-abortion arguments.

So, for example in the film when Dr. Sella says, "I think of the fetus as a baby," that's something that's very off-message for the pro-choice movement and that you might expect to hear more from an anti-abortion protester or something. But at the same time, she's saying but I always come back to the woman and what she's going through. So I think to hear them sort of voice, to really like make the whole way that they think about this transparent was, was really great for the film and did allow us to sort of just focus on these doctors who are thinking about the anti-abortion arguments as much as the pro-choice in a lot of ways.

POV: The way you were able to transcend that black and white and capture that, some of that ambivalence, that struggle, is really skillful. There's one point in the film, I think it's Dr. Robinson, who talks about some women just aren't good storytellers.

Lana Wilson: Well, that was something that appealed to us a lot as filmmakers too in that we thought that using these stories in the film, we could show the idea that well some women just aren't good storytellers. Why would that be? It's touching on these larger issues. Like they don't have as much education, or they've lived in poverty their whole lives and they're always used to arguing to get different government benefits and getting refused over and over.

So why would they ever feel confident enough that anyone would believe their stories in the first place? There's just so many factors that go into that and realizing that yeah, you really are judging. These doctors are judging women's stories and we as an audience are also listening to these stories and evaluating, "Do I think that's right or not?" "Would I do that? Or would I not do that? Would I carry on the pregnancy?"

I think that's what's going through your mind when you're watching any film, but especially this one. I think you're also sympathizing with the doctors. What a tough position they're in to have to make this call, what would I do? The more you do that and the more you try to make these different judgments, the more you realize how impossible it is, without being that person. And I think that one of our goals by drawing people's attention with Dr. Robinson to the, the ideas about that some women just are better storytellers than others and what advantages does that give them in a medical context, but also in their entire lives.

Looking at that makes you realize that this could all use more compassion and less judgment actually. And I think that that's something we learned from the doctors too, just how they listen to women. They don't feel that they're there to judge anyone, they're just there to listen, to be compassionate towards these women who are coming to them in the most desperate, challenging circumstances of their lives and to then think, can I safely help this person or not?

They're not there to make moral judgments about if what they're doing is right or wrong, and if they made mistakes that led them here. They don't see that as their role. And it was incredible to learn from them in that way.

POV: Any time you do a film on this subject — abortion is such a hot button issue at the best of times. And third trimester abortion especially so. Like I said earlier, this film is obviously from the point of view of those doctors providing that service. But how do you include those other voices in a way that breaks through that noise of the two opposing sides?

Martha Shane: We thought a lot while we were making the film about how to include the anti-abortion voice because we wanted this to be completely focused on these four doctors. And we felt like there was enough out there where it's going back and forth, talking point, talking point. Through Dr. Carhart's story, you do encounter a lot of the protesters. And what we sort of worked on that and developed a style that was just very straightforward and observational.

We were able to do that to a certain extent. But again, it's not really their story. And what was interesting actually was when we were filming the exteriors of the clinic and we'd say, you know, we're just going to film what you're doing, just keep praying. Those people always wanted to share their feelings. Like they always wanted to be interviewed.

And it was never a problem. Whether they're OK with being on camera, it was more like they wanted to be on camera so much cause they really passionately believe in their point of view.

Lana Wilson: Yeah, I think it's also just that we have heard the stories of the protesters, outside the clinics and of the pro-choice leaders on the news, endlessly our whole lives. And the people who have been in the shadows the whole time are the doctors. For us this movie was about wanting to pull back and curtain on something that's so stigmatized and so little talked about, that we really have no idea what their point of view is.

And we hope that that's what the film would reveal, that, that they have very complicated feelings on this. That the doctors themselves would be the first to acknowledge that this is an issue that, that people can disagree about and they're very candid about their ethical struggles with this work as you say and then the ambiguity that's inherent in the work. But we were just so interested in that because we felt like it was a perspective that hadn't been heard before. And also that the patients come from a variety of perspectives too.

There's one patient in the film who is anti-abortion. And she grew up that way and she's always been anti-abortion. Yet she's in this situation.

POV: Over the past couple of years there's been more legislation passed in the states which are addressing abortion issues or restricting access. What are some of the trends that you've seen over the past couple of years around the country or in these states in particular where you focused on it?

Martha Shane: Well the trend that sort of had the most impact on the doctors in our film is the passage of these week abortion bans. Those are definitely in conflict with Roe vs. Wade, but the courts have not yet really heard that case. So Nebraska as the first one where Dr. Carhart was practicing and that's what sent him away. And then at least nine other states have since then passed similar legislation.

Then in tandem with some of the other laws that we've seen that are restricting access to abortion such as waiting periods or requiring that doctors have admitting privileges in hospitals nearby, have really cut down the number of abortion clinics. I think Texas is down to like six... Don't quote me on that, but it's down to a very small number of abortion clinics because of these, these laws that maybe on the surface sounds like they make sense and are designed to protect patients but in fact really just force these clinics to shut down.

So I think what that does is it forces, it makes it much difficult for patients to obtain an abortion in the earlier trimesters and it means that more and more of them are pushed to later trimesters. And then if they hit that week wall, they have to either travel out of state, or they have to just move forward with the pregnancy.

It just seems incredibly like these restrictions have made it so much more difficult for a lot of women who are already in a very difficult, who are already struggling just to sort of get by.

POV: I want you to clarify something just to make sure I fully understand it. We're focused on four doctors here who you term as the only four who are openly providing this service. That does not mean this service is not being provided elsewhere?

Lana Wilson: It is the case that there are definitely people in this country who are secretly providing third trimester abortions. But it's so interesting because you would think, oh well, someone in New York who knows a doctor who knows someone could probably get one. But any stereotypes you'd have are not true, because it's true we have met people who said that their doctor knew someone who did a third trimester abortion in a hospital for instance. And we've heard a lot of stories like that. But we've also met wealthy women from New York who had to go to Albuquerque for a later abortion who were the most well connected people in the world, yet couldn't find one of these under-the-radar providers to help them.

It's women from all different economic classes that we've seen at these clinics. So in some ways, we hear these stories about connections and doctors, but it doesn't seem to have really any direct link to how well connected you are. It seems to be more a matter of luck and happenstance and if you know the right doctor. But the reason these four doctors are so dedicated to being open is because it is equalizing. Any woman in the country, no matter how much money she has can definitely find them on the internet. That's the bottom line for them. So it's, it's, it's that. It's being there for the patients, but I think the other reason that these four doctors are set apart, why they're open is because they're very proud of what they do, of the work they do. They love their jobs. They find it rewarding. They, they feel like they're helping every patient who comes to them.

And they're proud of it. And they don't want to be hiding in the shadows. They don't want to be closeted. And they all have a real kind of stubbornness to them. I think that's this one thing that all four of them have in common. They have different personalities but they're all very stubborn. And part of that is, is why they're out and why they want to say, we're proud to be doing this work, we're going to be totally open about it. So it's a, it's also a personality distinction I think that sets them apart from the under-the-radar people.

POV: What have been some of the the audience reactions that you've encountered as you've been out on the road and in theaters and in festivals?

Martha Shane: I think one of the most interesting reactions has been from anti-abortion people in the audience. And I think what we've heard from them the most is just this thing of, this is so much more complicated than I realized. And that's what we also hear from the, from the pro-choice side as well. So in a way I feel like whether you're pro-choice or anti-abortion, the film pushes you to think about your perspective in a deeper way than you necessarily have. And pro-choice people have to think, well how far am I willing to go with this? Am I willing to support a woman's right, even if I don't agree with her decision in this instance?

And then anti-abortion people have to think, well is it really true that across the board in all these situations I feel like a woman shouldn't have the right to an abortion? And I think the fetal anomaly cases, for a lot of them push them the hardest to consider whether maybe that should be a right in some cases.

POV: This is a film, which we talked a little bit about, deals a lot with ethics. I'm curious also about the ethics of being a documentary filmmaker in taking people's stories and shaping them and taking them out into the world, particularly when you're dealing with an issue like this. So how do you go about working with your subjects to make sure they are prepared? I know they're public figures to a certain extent, but this takes it to a whole other level. And what you feel your obligation to them as filmmakers is in this process?

Martha Shane: That's a really interesting question. I mean I think you know at the beginning the real concerns were security and so we collaborated with the national abortion federation to make sure that we weren't sort of inadvertently exposing any part of their lives that people don't already know about. So for many of the doctors the antiabortion movement already knows what their car looks like or their house looks like. For others, they don't. And so we were careful to protect their privacy as much as we could.

And then I think for us, just the most important thing ethically I think was that we went and we showed the film to them before we had picture. I mean we were very happy with where the film was but we also wanted to make sure that they said to us, yes, you got this story right. And we wanted to make sure that was a conversation because it was so sensitive and we realized it could have a big impact on their lives and we were lucky that they did and I think just going forward, it's really about involving them in the outreach process as much as they want. And they've been so excited, especially the two.

Because the two male doctors were more public figures before it's more of a new thing for the two female doctors and they've been so excited to represent the film and to talk to medical students and they feel I think that the film is a tool that they can use to get their stories out there and to move forward an understanding of this issue that they couldn't just communicate all by themselves.

So we just try to work with them as much as possible to get them in front of audiences and they're really good at that and enjoy it.

Lana Wilson: Yeah, the other thing I'll add to is, because this is such a hot-button issue in America, it was just interesting to us how much pressure we got from different groups who have political stakes in this issue before the film was done. People were so scared about it. About effects it could have on the whole abortion debate in this country, about parts being taken out of context about this and that and it was very stressful to be told by leaders of some major groups you can't include this because then people will take it the wrong way and they'll think blah, blah, blah and in the end our editor Greg just kept saying just be honest, the simplest thing to do is just be honest so that's ethically you know what we just asked ourselves the entire time.

We don't want to be trying to create a character out of this person or fake some kind of dramatic arc, the stakes are so high here because these peoples lives are literally on the line. We just have to be able to look back at this and say regardless of whatever the fallout is from this movie, we were being honest and with the facts and we're not misleading anyone. We kind of just asked ourselves over and over again the entire way because it's very easy, especially when you're editing and you're in to veer off into trying to create these arcs and these ideas and characters and things that are more like you would write into a script in a fiction film because of course the process is so similar, you're just doing the writing afterwards with the documentary.

But there is still a basic reality that you're trying to be honest to so that tension is always really interesting when you're when you're shaping the final scenes.