‘But,’ Dr Garber turns to her, ‘don’t forget what we were talking about as well. About the suitability of—’
‘Don’t worry, Tim. I’m coming to that. You’ll have your say. I’m just making sure it’s clear that I … that we recognise there are particular pressures in a surgical job. Challenges which Nancy here has obviously coped with admirably with the exception of this one occasion.’
‘Oh, I see. Here we go. Time for a little GP-bashing, is it?’ Dr Garber places his hands palm-down on the table. ‘No. You know what. I’m going to say my piece now, as we agreed I would. Nothing much. I don’t have a whole spiel. I just want Nancy to hear that I think it is possible to agree with abortion in principle and yet not find it possible to be involved oneself. I know this. I mentioned … in one of our sessions, I said that I have referred women for abortions. I used to, that is. But I don’t do it any more. And not because … I don’t judge these patients, you understand. It is not my position to. But what I have found is that, since my own circumstances have changed, since I became a father, I have not been able to make these abortion referrals.’
‘But, Tim, for the here and now, what is the …?’
‘My point is …’ he replies, putting the tips of all his fingers together carefully. Here’s a church and here’s a steeple, open it up and there are the people. ‘That it is possible that some of the duties of being a doctor may be just too much for us. Or we may be up to the task one day, but not the next. So, all I’m saying is, it’s clear that Nancy felt she was doing the right thing. Maybe we all see that she had the right intentions. But perhaps it takes a certain kind of person to do her job, whether we like it or not, and it may be that she is just not that kind of person. I want her to think about it, Miriam, that’s all.’
Miss Mansfield looks at me as if she is expecting, even inviting me to join in, to contribute, to take somebody’s part. But there isn’t anything for me to say, nothing to add that will make a difference to the verdict they have already determined. For once, I am simply curious. Interested to see how they have wrapped my experience up in a bundle and put a bow on it, how each of them has found a version of the truth that might give coherence to this pathology, to what I have done and what has happened to me. This is exactly what Miss Mansfield is doing as I start to listen to them again.
‘… would have been so easy for her to conscientiously object to learning this aspect of gynaecological care. Just think of it. I mean, imagine if a whole group of my trainees said, you know, we have a religious objection to doing any operations that might result in the need for a blood transfusion. It would not be called “conscientious refusal of care” which, Nancy, is what everyone has renamed conscientious objection now, it would be called completely unacceptable doctoring, for God’s sake. I mean, who are these doctors to say they will do this part of the job but not that? Leaving the others to do all of it, to feel isolated because of it, to end up in a mess as Nancy has done. The department has something to answer for, in my opinion, and so does the Royal College!’
There is a pause in which Dr Garber and Miss Mansfield shuffle their papers, realign themselves, find a way to sit next to each other peaceably. Only Vivien, sphinx-like, remains composed. Light from the window behind the panel table frames the three of them, arranged in a stiff, official row. I look at the soft hair on Tim Garber’s head. I have merely been unsuited to my work. That’s what he thinks. It exempts him from having to ponder the philosophical nature of the work itself, doesn’t it, or the question of what it might mean if a person did feel comfortable in such a job. He only has to consider this case, this example of a supposedly oversensitive doctor, unequal to a difficult task.
And proud Miss Mansfield, the cat who walks by herself, is just championing the cause of all lonely cats, is she not? It is as if she has expurgated the whole abortion issue from her tale. For her, perhaps, this whole situation boils down to the simple question of whether a doctor has balls or not, whether or not enough support has been forthcoming from above. And though she may have started out thinking of me as weak, this is probably not her final opinion. I imagine she sees her own bravery in my decision to do not just a part but all of the job I have been given.
So, while I still await my verdict with anticipation, with a respect for the fact that what is said in this room will determine my future as a gynaecologist, as a doctor, while I see Vivien straightening herself up in her seat, bringing a great sense of excitement and dread into me, while my adrenal glands do what they do, releasing catecholamines into my body, telling me the time has come, the moment has arrived, I also know that whatever has been determined will not be enough to condemn or acquit me in my own eyes. There has been too much left undiscussed. My own account has been parlous.
But the time has come and I am very still. Everything is in slow motion now. I see Vivien’s profile, her high brow and straight nose. I see Miss Mansfield and Dr Garber nod to her. I see her young hands frame a single sheet of paper. I see her turn towards me, oh so calmly, her violet eyes directed at me. And the surprise of her deep, steady voice, heard for the first time, comes to me with the shock of her words.
‘We, the members of this panel approve Dr Nancy Mullion’s fitness to practise. We are satisfied that – with the application of temporary conditions and restrictions – Dr Mullion is safe to continue in her work as a gynaecologist at this hospital. We do not feel this case merits referral back to the GMC. It is our unanimous decision that Dr Nancy Mullion be free to decide whether or not she continues in her current line of work. Our decision has been ratified by the Chief Executive of this hospital trust.’
I take the news deep into myself. It is like a parcel that is not yet unwrapped. I cannot unwrap it. I remember as a child holding a present unopened in the palms of my hands. It upset my aunt that I did this. She called me ungrateful. I am on my feet because Miss Mansfield and Dr Garber are advancing towards me. They are smiling and I cannot just sit here and let them approach while I sit like a stone. Miss Mansfield has a sheet of paper, which she gives to me. These are the conditions and the restrictions and a copy of the verdict, she says. I should take my time thinking of what I want to do; until the end of the week should be enough. And if I want to reconsider a career in surgery, I should come and see her. Her door is open to me. Her skin is soft and powdered, the wrinkles in it fine. She is tiny, suddenly, standing up. Dr Garber too takes my hand in two of his and offers me congratulations. Vivien stays sitting.
I thank them all. I don’t know quite when to turn and leave the room. I feel the hospital paper beginning to curl between my thumb and index finger from the sweat in my hands. I walk through the door. I straighten my neck and hold my head high. This is my hospital again, if that’s what I want it to be. I wait for the feeling of jubilation that is surely due. But it doesn’t come. My feet take me past the morgue and all the way to the end of the corridor. There is a small courtyard at the back of the building, near Estates, and I head towards it. There won’t be anyone I know there. As I pass through the clinical departments of the hospital to its nether regions, where they keep dead bodies, where fork-lift trucks are parked in dusty subterranean corridors, where towers of supplies, pads and mattresses and tubing rest naked, not yet important in the job they are to be used for, I see the personnel change too. Fewer and fewer white coats people these corridors. I notice no nurses here. No blue uniforms for the proud dietician, the doctor-hungry physiotherapist, the pretty speech-and-language girl. Men with big stomachs, and stooped men, and men with folded cheeks and rheumy eyes clank beds and machinery. A young lad swears as he bends to pick up a stack of hand towels which he has piled too high against a wall. A Filipino man stops his partial mopping to let me pass. I meet his eye by way of thanks.
I go out of one of the outsize metal doors. The smoking area is empty. I rest my feet among the butts and look at the page in front of me. Headed notepaper with a list of my judges’ names at the top. Underneath, there is an exact copy of the
words Vivien spoke, letting me off the hook. Beneath this are two paragraphs. The first one bears the heading Restrictions. I read, ‘For six months, Dr Mullion should not do any emergency surgery during on-call hours. She should only perform elective surgery under consultant supervision. For review by the Occupational Health Department in six months.’
The final paragraph on the page is entitled Conditions and reads ‘Dr Mullion may continue to practise as long as she follows the restrictions and recommendations as given here. Dr Gilchrist advises a course of cognitive behavioural therapy, to be arranged by the Occupational Health Department. He does not see the need for psychodynamic therapy. All panel members agree that a mentor be nominated within the Obstetrics and Gynaecology Department with whom Dr Mullion be free to air any concerns on a weekly basis. This consultant has not yet been found.’
I fold the paper in half, then into quarters. I look at the litter at my feet and up at the unwashed back façade of the hospital in which I have been trained and in which I have fallen. I feel utterly deflated. I think about the oddity of how, at no point in this process, have I talked about how it actually feels to do an abortion. It seems a big gap suddenly, a hell of an omission. Perhaps this is why I feel so little sense of triumph. And if I have not been able to say these things to a panel, over four weeks of questioning, have been mute even with my own sister, then to whom am I meant to speak? Is there anyone in the world I might recount my experience to, any setting on earth in which these facts might, finally, be let out? Might there be a metaphorical way of gesturing at the essentials of my work? Could I perhaps paint a picture just in colours? Imagine the blue of a day before it starts. That has been the sad hue of my work.
I get up and go back into the hospital. Could I have told those doctors one kind of story that would have suggested another? Might I have described the time when my dad ran over a fox? He stopped the car and found the fox half dead and twitching. And cried by himself as he searched with numb hands for a heavy stone to finish the job. And how he still dreams about this fox that he killed, its eyes like foil in the night.
I leave the unseemly part of the hospital behind and re-enter the clinical zone, the part fit for public viewing. Or could I go a tiny bit further and describe to someone just one detail? Imagine the posture of a foetus when it is no longer warmly forming but out in the breathless air of our adult world. There was a man once, a young man whom I certified dead when I was a junior doctor. He lived a life of only about twenty years. He had been born with cerebral palsy, and at a time and in a place where he was not given any physiotherapy. And so, as an adult, his body was contorted with strictures and contractures. He had what used to be described in the medical literature as a windswept appearance, like trees in stormy places whose branches stay hectic and extreme even on still days, unable to relax from all the gales they have wintered. He died in this position. And, like those trees, even in death he held his pose of absolute suffering, frozen in this mould of terrible life. Could I say that I am reminded of this man when I see my work before me? Can I say that no one expects becoming a doctor to be easy, but that I did not expect it to be this hard?
I pick up pace now. I walk down one corridor, turn into another, head for the Gynaecology Department, my academic home. I am right on time for the lunchtime meeting. I am searching for a way to speak. How many years has it taken me to get to this point? There are things I must say head-on. But it is a problem. We don’t see Oedipus put out his eyes. He comes back on stage and they are gone and there is blood on his face. We wouldn’t want to actually see him put out his eyes, would we?
At the door of the seminar room I stop. I see them all in there, going through the weekly accumulation of morbidity and mortality. And I think to myself that there are a hundred ways for me to say anything but what is on my mind. Look at how many times I have tried even in the past four weeks. How I have hedged and skirted around the truth of what I have seen and what I have done. Look at how many versions a doctor can manufacture and still miss right out on the truth: the truth of how we can grow and fall apart, of how a person can be dismantled.
Looking through the panes of glass in the window I see Frederick. He smiles at me and raises his eyebrows. I give him a thumbs-up. He beckons me in. Is this my chance to speak out? It seems as if the great gap between what I have been asked and what I have given of my own accord should not be allowed. I should not allow it. Suddenly it strikes me that this is a crisis of silence. My own small crisis. The huge abortion crisis. And every crisis in between. Each story of each unwanted pregnancy which itself came from someone not saying what had to be said or not being listened to. Don’t touch me. I don’t want more children. I am not happy with this. I want you but I’m not on the pill because I’m not a slut, you know. Can we use a condom? I wish you would love me. Will doing this make you want to stay? And no one is talking about what happens later, either. Not the women patients, not the doctors, not the brothers and husbands and fathers, not the sisters and mothers and friends. This is what happened in my abortion. Here is the abortion story of the person I love. This is the abortion that I did yesterday. This is what it means to me, and this, and this and this.
I stand at the door but I don’t go in. I am not ready. But I know that if I don’t find a way to say these things, I will never go back into the seminar room again. I have been quiet for much too long.
Would it be better to express myself in writing, to put my thoughts on paper? Might the printed word be the way to get my story across? It would be a way to give my panel of judges, these colleagues, at least the option of knowing the truth. I could make some sort of symbolic gesture. I could change the font, use italics perhaps. And it would be a way of saying do not read these next words if you don’t want to understand my reality. Bow out now if you feel faint-hearted. It would be my sign, my way of warning them that they were on dangerous ground. That I was about to start saying all the things that remain so hidden. And my gesture would bear testimony to the self-censorship that even the abortion provider cannot rid themselves of. My very script would bear the stigma of stigma. If you want to expurgate what you read or limit what you see, just scan ahead a few pages and carry on from there. This is what I might say.
And then, having given this warning, perhaps I might at last go freely? Might I start trying to express the particularities of my experience, to say what I need to, to put myself back together, because I have been broken by my own silence. Might I now bring forth, from the darkness of my mind, the things that I have seen and done and felt?
I have done early abortions. And I have not found it all that difficult. It is clearly much harder to have it done than it is to do it. People talk about women having abortions for social reasons. But there is nothing casual about it. Any provider can tell you this. It’s perfectly clear, if you do a list under local anaesthetic, that there is nothing easy about the tears that sneak out horizontally from a woman’s eyes, the tears that course not down her cheeks, but towards the ears, because she is lying down. There is nothing cavalier about the way a girl’s thighs tremble. Nothing slapdash about the chattering of her teeth, or of the sound of a nice lady muttering, ‘Oh fuck, oh fuck’ under her breath. Or about the pain that even the local anaesthetic won’t take away. Or the vomiting.
But an early termination is technically straightforward, once you’ve done your first one. Once you’ve crossed the line from being someone who has never done an abortion, to someone who has. The cervix doesn’t need much dilating. The contents of the womb are light. You can offer tablets to a woman with a very early unwanted pregnancy, or use a small manual vacuum aspirator, made in light and pretty white plastic as if it were trying to fit in with other women’s domestic paraphernalia. Or you can opt for an electrical suction technique. The only challenge is to ensure the job is complete.
The task doesn’t end with the surgery, though. When you finish doing the abortion, you take the products of conception into another room called the sluice. This is t
he room in which you have to make sure that things are as they should be. It is a job the doctor should do. A person should be responsible for their own dirty work, not give it to another member of staff to do for them. If you are going to do this job, you should have to face the whole thing, I think. You should be the one to talk to the patient, if you are going to terminate her pregnancy. You should be the one to do the check on that pregnancy after it has been removed.
For this job, you need a fine-meshed sieve. It’s not a medical instrument, it’s a sieve, like the ones we all have in our kitchens. You put the contents of your clinical bowl or jar into that sieve and gently run a tap over it, to filter out the important bits. With a gloved hand and a gentle touch, you look for the gestational sac. At five or six weeks’ gestation, this is the size of a woman’s little fingernail. The sac and the desidua look quite similar at this stage. The way to tell them apart is to transilluminate the tissue. This involves floating it in a tiny glass dish, over a light. By doing this, you will recognise the gestational sac because it looks like a tiny piece of coral. It is fronded. It is not upsetting to look at. It is pretty, and looks like a plant. There is nothing humanoid about it. This is reassuring. Perhaps this should make no difference, but it does.
I have done mid-term abortions. And I can tell you that by the end of the first trimester, things are harder. I don’t care what the philosophers say. Maybe life is life, and it’s all the same whether a conceptus is one day or six months old, but it feels different. My experience tells me another truth. It is still possible to perform at least most of the abortion using a suction cannula attached to an electrical pump. But even before you switch that pump on, it is a hard situation to be in. We use ultrasounds all the time now. And before you even start, the ultrasound shows you a human image on its screen. After a while of course, this image and the subsequent disintegration of this image does not affect you as profoundly as it may do on the first occasion. Everything gets easier with time. This is not a mark of the abortion provider’s moral decrepitude, surely? It is a fact of life, that some things get easier and easier.
Dirty Work Page 14
