By Tia Will
Let me start by explaining why I felt the need to write anything beyond my Vanguard posts about this topic. Over the past few days, it has been clear to me that many readers appeared to be getting their information solely from the abbreviated version of that tape that can be found online and the interpretations of it promoted by the group that produced the tapes. I also was basing my responses on the same limited information. So I decided to look further into the issue and to share first some facts about the tapes and then my interpretations of those facts with you when relevant. My impressions and experiences are clearly labeled as such.
First, there are two tapes that are currently getting a lot of online and media attention. Chronologically, The first tape was made apparently over a year ago with Planned Parenthood (PP) executive director, Dr. Nucatola. This tape documents a slightly longer than two hour conversation between Dr. Nucatola and two actors from Mr. Daleiden’s group, who falsely claimed to be members of a private, for-profit biomedical tissue procurement group providing tissue to researchers.
The second tape purportedly made in February, 2015, features another Planned Parenthood executive Dr. Gatter and actors from the same group using the same false premise as in the first meeting.
I will address these interviews separately starting with the interview of Dr. Nucatola purportedly conducted in 2014. Unfortunately it did not occur to me to record the approximate times for verification until about 22 minutes into the tape, so if you do not trust my accuracy, you can watch the entire first 22 minutes. After that point I recorded the approximate time on the interview so that I could be checked for accuracy if desired. The link to this tape is in the Vanguard article of this date.
Very early in the conversation, Dr. Nucatola makes the point that Planned Parenthood affiliates are non-profits. As a non-profit, “they just want to break even”.
“Every penny they save is a penny they can give to [or spend on] another patient.”
Much has been made online about the doctor’s comments about “fetal parts”. However, it is the male “representative” who brings up the subject of specific fetal parts and the gestation ages at which they can be obtained. He states that his company preference is for tissue at least in the 12-18 week range and preferably as far advanced as 24 weeks. It is not the PP executive who brings up or prolongs this portion of the conversation except to point out that the majority of procedures are done at a lower gestational age and the late term procedures are performed by a limited number of practices. Also not stressed are her comments about the need for additional patient safety precautions with procedures occurring after approximately 16 weeks of gestation.
The “representative”, again specifying the value of “fetal parts”, is met by the following points from the PP executive. She explains that the cost is based on the amount of time spent caring for the patient. Implied is that the cost is not determined by the “cost of the body part” but as she states “in all cases, the cost is going to be about staff time since that is the only cost to the affiliate.” Here she is discussing only the time commitment from the clinic staff.
In this portion of the conversation she makes no mention of the need to rent or maintain the actual clinic space if owned, nor the cost of equipment and equipment processing necessary to perform any medical procedure. She then states: “at the end of the day [the affiliates] want to offer the [tissue donation] service because that is what the patient’s are asking for.” This last statement I can personally vouch for. I have been asked by a number of patients if they are able to donate tissue from their pregnancy terminations. Since I do not know the answer to their question, I always direct them to the group that performs the procedure.
The subject of appropriate counseling then arises. The PP executive states that it is important that the patient make the decision to have the procedure prior to any discussion of tissue donation. The male “representative” then misstates her position as her having said that the tissue donor consent should be done “as early in the process as possible.” She corrects him. She further notes that: “Planned Parenthood has very strict protocols for consent for use of research materials and that Planned Parenthood does not engage directly in any tissue related research.” To the best of my knowledge, this is a true statement.
There have also been expressed concerns that patients who were planning to donate their tissue would somehow be treated differently from those who were not donors.
22 minutes: There is an inaudible comment from the female “representative” followed by a clear comment from Dr. Nucatola to the effect that this is part of the ethical concerns about donation and that the procedure would be done in the same way and that these patients would not be cared for any differently from any other patient.
24 minutes: Dr. Nucatola states that additional procedures, medical devices, and repetitive visits would not be ordered to provide intact tissue for studies. In other words, the woman would not be further inconvenienced or put at increased risk or discomfort for this procedure.
25 minutes: She states: “Ethically they do not want to treat the patient any different than they would any other.”
28 minutes: The male interviewer steers the conversation to specific techniques. Dr. Nucatola then comments that ultrasound can be used to determine where best to place instruments so as to avoid tissue damage.
What she does not mention is that this is common obstetric practice. Ultrasound is frequently used to determine fetal position to prevent unnecessary risk to the patient caused by performing the procedure blind without knowing the exact position of the fetus. In my opinion, performing ultrasound is standard practice prior to this type of procedure and thus does not represent a significant departure from standard practice as it would be performed for any other patient at the same gestational age as well.
48 minutes: Dr. Nucatola reiterates that “the affiliates are non profit and working on a razor thin budget.”
57 minutes: She states “…partnering with tissue procurement companies is not something that affiliates know how to do and that this is being driven by patients asking to be able to donate the tissue.” Although not explicitly stated she makes several comments thanking them for their persistence in setting up the meeting thus implying that this is why she has chosen to meet with these reps and why she wants to come up with ways that PP can help in providing donated material to researchers.
59 minutes: Nucatola states: “The affiliates are not looking to make money. They are looking to better serve their patients. That is their bottom line.”
63 minutes: She states “[The affiliates] don’t have a lot of money and I think that they would rather just spend it taking care of patients.” PP does 40 % of the abortion procedures in the country. “Our goal is to keep access available.” “With regard to cost per specimen.…At the end of the day, we just want to be able to keep the doors open.”
68 minutes: Dr. Nucatola makes the point that what will be seen with more restrictive policies is that more and more later pregnancy terminations will be seen since women will have less access to obtain the procedure earlier in the pregnancy. She emphasizes the importance of maintaining access to avoid these later gestational age terminations.
In my opinion, if she were out for profit, surely she would want more, not less of the late term procedures.
87 minutes: The male interviewer asks if his company were to take on essentially all the responsibility for consenting the patients, processing the specimens, and if they required minimal space, would the affiliates be willing to offer the specimens for free. Dr. Nucatola’s response is “I don’t really know. I think so. Probably. The bottom line is that this should not be seen as a revenue stream since that is not what it is.”
To me, these do not sound like the words of a woman trying to drive a deal for a for-profit venture.
Two minutes later she states: “Nobody should be selling tissue. That is not the goal here.”
96 minutes: After the male interviewer has again questioned her about how to get the most intact specific body parts she responds: “If you have something very specific in mind, the best way to approach this would not be through a clinic ( such as PP) but rather with a private provider who would be better equipped to alter their procedures.”
It is clear to me that she is being consistent in her statements that PP would have no interest in altering their basic procedures to accommodate this for-profit private company nor in maximizing any funds that might be provided by this company to cover processing costs.
99 minutes: Dr. Nucatola accurately indicates that this is an area of medicine in which there has not been extensive data to determine best practices and that there is significant individual provider variation in technique.
It would appear that this statement of fact has been misconstrued to mean that people would alter their practices to the harm of patients to obtain tissue. Four minutes later he again tries to get her to imply that practice would be changed to be able to salvage more fetal tissue. She gives a specific example (that of the use or lack of use of digoxin) and again reiterates that people are not going to deviate from their usual practice for this purpose.
120 minutes: The participants take breaks to go to the bathroom. Around this time, Dr. Nucatola at the urging of the female “representative” explains why she chose family planning as her sub-specialization and provides the story of woman who was referred to her on her last day of residency having experienced a complication of a late term abortion done by a private provider. The patient’s last words to her were “Don’t let me die”. The patient did die during an emergency hysterectomy aimed at saving her life. It was after this that Dr. Nucatola, who had done a number of late term abortions without complication, recognized that she had a skill set that could prevent these kinds of tragedies from occurring, and this episode informed her decision to continue with the provision of this service.
My feeling is that she would have had no reason to fabricate such a story for a couple of private company representatives who were already courting her. To me, this rationale for choice of career rings with complete sincerity and is not compatible with a woman solely in it for the profit.
142 minutes: After bathroom breaks, the interviewers again steer conversation back to money. The doctor states that at the end of the day: “If we could take money out of the equation….which is what most affiliates want to do….” Male interviewer states: “ We are talking about people in the non-profit sector so their motivations are a little different.”
He clearly knows this to be true or he would not feel the need to edit and lie. The doctor responds that this is a matter of who is benefitting and that benevolence is a major motivating factor for the affiliates: “Affiliates are looking to benefit in different ways from just dollars and cents. They want to break even. They want to be compensated for the time and space.”
To me, Dr. Nucatola repeatedly despite numerous attempts to get her to state otherwise maintained the following points, which based on my experience I believe to be both valid and true:
1) PP is willing to facilitate the acquisition of fetal tissue for research purposes per patient request.
2) They are attempting to facilitate these transfers at cost or less than cost.
3) There is no evidence that any profit motive is involved.
4) There is no evidence that the decision to have a pregnancy termination is in any way contingent upon knowing that the tissue will go to research, as the procedure consent always precedes a conversation about donation.
5) There is no evidence that any PP affiliate or their individual providers will alter any practice to the detriment of any patient in order to obtain intact tissue.
Interview with Dr. Gatter
In what is obviously not the beginning of the conversation, the interviewer starts by asking Dr. Gatter how much she wants to charge. Dr. Gatter responds by saying: “Why don’t we start by you telling me how much you are used to paying.” No one says what is being purchased. At this point it could be a service, it could be expertise, it could be tissue. We simply don’t know because no one has said yet. But it is important to note that we have no idea who initiated a conversation about money since we do not see the beginning of the interview.
Ominous sounding music is played and a text is inserted accurately stating that it is illegal to sell human tissue. What is not said is that Dr. Gatter is not selling tissue.
She makes this clear in a statement to another individual who has obviously just arrived. About the interviewers, she makes the following comment.
“They are a for-profit company that is connecting researchers with people who are willing to donate tissue. Please note the use of the word donate, not sell.
Volume of procedures was noted as 800 per year with 60 in the second trimester.
In explaining the procedure as done by one affiliate, Dr. Gatter states that the consent for tissue donation and all of the tissue processing was done by the private tissue procurement company’s representative. She states: “So this was compensation….We didn’t do anything for this.”
For a doctor who does procedures it is clear that she doesn’t mean that PP is not “doing anything”. They are obviously the ones to whom the patient presents; whose staff has to consent the patient for the actual procedure; who purchase all products and equipment to perform the procedure; who owns or rents the space in which the procedure is done; and who actually performs the procedure. All of this has costs to PP. And yet, the video has been edited to make it appear to the viewer as though none of these costs exist and that PP is “selling the tissue” to someone who is “doing all the work”.
2:30 minutes: Dr. Gatter then makes the statement that the patients do not get anything as part of the donation of tissue. This is factual since it is illegal for the patients to sell tissue, just as it is illegal for PP. However, the way the Daleiden group has interpreted this statement is to mean that the patients do not get anything, but PP profits from the tissue sale, which is not true. They are being compensated for services and space as both interviews revealed.
2:40 minutes: Interviewer asks how much Dr. Gatter would want. Dr. Gatter responds: “Why don’t we start with you telling me how much you usually pay?”
The interviewer says that is not the way to handle the issue. She states that she wants to find an amount that would “make Dr. Gatter” happy.
Dr. Gatter makes the comment that she doesn’t want to “low ball.” Why she wouldn’t want to low ball is a matter of conjecture. Does she mean because she might mislead the company representative if she names too low a number? Or does she mean that she doesn’t want to regret stating too low a number and then realize that the affiliates wouldn’t be covering their actual cost with this number? We don’t know what she means because it is not followed up on factually.
When she does eventually make a guess (after being badgered by the interviewers), she chooses $75.00 only to have the company representative tell her that is “way too low.” Dr. Gatter then says: “Well initially I started to say $50.00. I worked for a place where we charged $50.00…” but the “company representative” cuts her off to tell her that is too low.
Anyone who knows anything about the cost of medical equipment and or services knows that neither $50 nor $75 for a single specimen comes even close to covering for the equipment cost, let alone personnel or medications, or space or any of the other myriad costs of this procedure. This is not a negotiation. It is an estimate of the amount of compensation that they would accept to offset a small portion of the costs of the procedure, not a negotiation or “haggling” to increase profit.
So Dr. Gatter, obviously taken aback states: “We do not want to be in the position of being accused of selling tissue,” because that is obviously not what they are doing, and then asks the company representative: “So what were you thinking about?”
The representative responds: “Way higher than that – $100 per specimen.” This is not Dr. Gatter bidding up the cost, but rather the representative telling her that she is not asking for enough.
4:20 minutes: Dr. Gatter mentions the change to the “IPAS” (a hand-held suction device) to preserve tissue intact. What is not mentioned by anyone in the conversation is that at less than 12 weeks use of the IPAS is rapidly becoming the preferred technique. It is less traumatic not only to the tissue, but also for the patient. I anticipate that within 5-10 years almost all of the procedures in this gestational age range will be done with this device. However, Dr. Gatter correctly states that it would need to be presented to the patients as a departure from their current procedure.
As a practicing clinician, I obtain consent this way on a regular basis. If I plan to deviate from the standard procedure, I explain to the patient the reason why I feel that my deviation is optimal, what the difference is between procedures, what she can expect, and I obtain her consent. This is the heart of informed consent and ethical medical behavior, not a sleazy attempt to con a patient, or a potentially risky deviation from the norm.
Dr. Gatter then makes a statement with which I disagree. She opines that there is no difference in patient comfort between the two procedures. From what I have heard from colleagues, the IPAS is significantly more comfortable for patients although I would not expect Dr. Gatter to know that, since that is apparently not their standard procedure.
The representatives again bring up the subject of cost and Dr. Gatter states that she will have to check with other affiliates to see what they are charging and clearly states that the money is not the main consideration. This concern is brushed aside by the representative who again states: “What amount will make you happy,” clearly disregarding that Dr. Gatter had estimated $50 to $75, which the representative told her earlier was: “Way too low.”
7:52 minutes: Dr. Gatter states: “It has been years since I have talked about compensation.” Clearly she is not a skilled negotiator haggling for the best price.
Shortly after this, the female representative makes an unintelligible comment to which Dr. Gatter responds, obviously joking: “I want a Lamborghini.” Whether or not this comment could be interpreted as offensive we simply cannot tell because we do not know what the representative said. By no stretch of any of the preceding conversation could she be seen as linking profits from this enterprise to the ability to acquire an expensive luxury car. But that is what is being insinuated.
So my conclusions about these tapes are:
1) They were obtained under clearly false premises.
2) The doctors had no idea that they were not speaking with representatives of a for-profit tissue procurement firm specializing in fetal tissue acquisition for researchers attempting to find cures for serious medical illnesses.
3) They had no idea that they were being recorded.
4) These tapes do not substantiate any claims other than that one of these doctors likes to drink wine in the afternoon after she has completed patient care for the day (as she clearly states early in the tape), and that the other may (or may not depending on the preceding comment) engage in inappropriate or black humor.
5) There is nothing on these tapes that would suggest a profit motive, any illegal activity, or any suggestion that PP is acting in any other than what they perceive to be the patient’s best interests even if the interviewers do not agree.
6) I would think that Planned Parenthood would be completely open to a close look at these particular allegations, which if based on these interviews are clearly baseless.