of the Kermit Gosnell case:
Section I: Overview
This case is about a doctor who killed babies and endangered women. What we mean is that he regularly and illegally delivered live, viable, babies in the third trimester of pregnancy – and then murdered these newborns by severing their spinal cords with scissors. The medical practice by which he carried out this business was a filthy fraud in which he overdosed his patients with dangerous drugs, spread venereal disease among them with infected instruments, perforated their wombs and bowels – and, on at least two occasions, caused their deaths. Over the years, many people came to know that something was going on here. But no one put a stop to it.
Let us say right up front that we realize this case will be used by those on both sides of the abortion debate. We ourselves cover a spectrum of personal beliefs about the morality of abortion. For us as a criminal grand jury, however, the case is not about that controversy; it is about disregard of the law and disdain for the lives and health of mothers and infants. We find common ground in exposing what happened here, and in recommending measures to prevent anything like this from ever happening again.
The “Women’s Medical Society”
That was the impressive-sounding name of the clinic operated in West Philadelphia, at 38th and Lancaster, by Kermit B. Gosnell, M.D. Gosnell seemed impressive as well. A child of the neighborhood, Gosnell spent almost four decades running this clinic, giving back – so it appeared – to the community in which he continued to live and work.
But the truth was something very different, and evident to anyone who stepped inside. The clinic reeked of animal urine, courtesy of the cats that were allowed to roam (and defecate) freely. Furniture and blankets were stained with blood. Instruments were not properly sterilized. Disposable medical supplies were not disposed of; they were reused, over and over again. Medical equipment – such as the defibrillator, the EKG, the pulse oximeter, the blood pressure cuff – was generally broken; even when it worked, it wasn’t used. The emergency exit was padlocked shut. And scattered throughout, in cabinets, in the basement, in a freezer, in jars and bags and plastic jugs, were fetal remains. It was a baby charnel house.
The people who ran this sham medical practice included no doctors other than Gosnell himself, and not even a single nurse. Two of his employees had been to medical school, but neither of them were licensed physicians. They just pretended to be. Everyone called them “Doctor,” even though they, and Gosnell, knew they weren’t.
Among the rest of the staff, there was no one with any medical licensing or relevant certification at all. But that didn’t stop them from making diagnoses, performing procedures, administering drugs. Because the real business of the “Women’s Medical Society” was not health; it was profit. There were two primary parts to the operation. By day it was a prescription mill; by night an abortion mill. A constant stream of “patients” came through during business hours and, for the proper payment, left with scripts for Oxycontin and other controlled substances, for themselves and their friends. Gosnell didn’t see these “patients”; he didn’t even show up at the office during the day. He just left behind blank, pre-signed prescription pads, and had his unskilled, unauthorized workers take care of the rest. The fake prescriptions brought in hundreds of thousands of dollars a year. But this drug-selling operation is the subject of separate investigation by federal authorities. Our focus was on the other side of the business.
Murder in plain sight
With abortion, as with prescriptions, Gosnell’s approach was simple: keep volume high, expenses low – and break the law. That was his competitive edge. Pennsylvania, like other states, permits legal abortion within a regulatory framework. Physicians must, for example, provide counseling about the nature of the procedure. Minors must have parental or judicial consent. All women must wait 24 hours after first visiting the facility, in order to fully consider their decision. But Gosnell’s compliance with such requirements was casual at best. At the Women’s Medical Society, the only question that really mattered was whether you had the cash.
Too young? No problem. Didn’t want to wait? Gosnell provided same-day service. The real key to the business model, though, was this: Gosnell catered to the women who couldn’t get abortions elsewhere – because they were too pregnant. Most doctors won’t perform late second-trimester abortions, from approximately the 20th week of pregnancy, because of the risks involved. And late-term abortions after the 24th week of pregnancy are flatly illegal. But for Dr. Gosnell, they were an opportunity. The bigger the baby, the more he charged. There was one small problem. The law requires a measurement of gestational age, usually done by an ultrasound. The ultrasound film would leave documentary proof that the abortion was illegal. Gosnell’s solution was simply to fudge the measurement process. Instead of hiring proper ultrasound technicians, he “trained” the staff himself, showing them how to aim the ultrasound probe at an angle to make the fetus look smaller. If one of his workers nonetheless recorded an ultrasound measurement that was too big, it would just be redone. Invariably these second ultrasounds would come in lower. In fact, almost every time a second ultrasound was taken, the gestational age would be recorded as precisely 24.5 weeks – slightly past the statutory cutoff. Apparently Gosnell thought he would get away with abortions that were just a little illegal. In reality, of course, most of these pregnancies were considerably more advanced.
But the illegal abortion business also posed an additional dilemma. Babies that big are hard to get out. Gosnell’s approach, whenever possible, was to force full labor and delivery of premature infants on ill-informed women. The women would check in during the day, make payment, and take labor-inducing drugs. The doctor wouldn’t appear until evening, often 8:00, 9:00, or 10:00 p.m., and only then deal with any of the women who were ready to deliver. Many of them gave birth before he even got there.
By maximizing the pain and danger for his patients, he minimized the work, and cost, for himself and his staff. The policy, in effect, was labor without labor.
There remained, however, a final difficulty. When you perform late-term “abortions” by inducing labor, you get babies. Live, breathing, squirming babies. By 24 weeks, most babies born prematurely will survive if they receive appropriate medical care. But that was not what the Women’s Medical Society was about. Gosnell had a simple solution for the unwanted babies he delivered: he killed them. He didn’t call it that. He called it “ensuring fetal demise.” The way he ensured fetal demise was by sticking scissors into the back of the baby’s neck and cutting the spinal cord. He called that “snipping.”
Over the years, there were hundreds of “snippings.” Sometimes, if Gosnell was unavailable, the “snipping” was done by one of his fake doctors, or even by one of the administrative staff. But all the employees of the Women’s Medical Society knew. Everyone there acted as if it wasn’t murder at all. Most of these acts cannot be prosecuted, because Gosnell destroyed the files.
Among the relatively few cases that could be specifically documented, one was Baby Boy A. His 17-year-old mother was almost 30 weeks pregnant – seven and a half months – when labor was induced. An employee estimated his birth weight as approaching six pounds. He was breathing and moving when Dr. Gosnell severed his spine and put the body in a plastic shoebox for disposal. The doctor joked that this baby was so big he could “walk me to the bus stop.” Another, Baby Boy B, whose body was found at the clinic frozen in a one-gallon spring-water bottle, was at least 28 weeks of gestational age when he was killed. Baby C was moving and breathing for 20 minutes before an assistant came in and cut the spinal cord, just the way she had seen Gosnell do it so many times.
And these were not even the worst cases. Gosnell made little effort to hide his illegal abortion practice. But there were some, “the really big ones,” that even he was afraid to perform in front of others. These abortions were scheduled for Sundays, a day when the clinic was closed and none of the regular employees were present. Only one person was allowed to assist with these special cases – Gosnell’s wife. The files for these patients were not kept at the office; Gosnell took them home with him and disposed of them. We may never know the details of these cases. We do know, however, that, during the rest of the week, Gosnell routinely aborted and killed babies in the sixth and seventh month of pregnancy. The Sunday babies must have been bigger still.
Butcher of women
Dr. Gosnell didn’t just kill babies. He was also a deadly threat to mothers. Not every abortion could be completed by inducing labor and delivery. On these occasions, Gosnell would attempt to remove the fetus himself. The consequences were often calamitous – though that didn’t stop the doctor from trying to cover them up.
One woman, for example, was left lying in place for hours after Gosnell tore her cervix and colon while trying, unsuccessfully, to extract the fetus. Relatives who came to pick her up were refused entry into the building; they had to threaten to call the police.
They eventually found her inside, bleeding and incoherent, and transported her to the hospital, where doctors had to remove almost half a foot of her intestines.
On another occasion, Gosnell simply sent a patient home, after keeping her mother waiting for hours, without telling either of them that she still had fetal parts inside her. Gosnell insisted she was fine, even after signs of serious infection set in over the next several days. By the time her mother got her to the emergency room, she was unconscious and near death.
A nineteen-year-old girl was held for several hours after Gosnell punctured her uterus. As a result of the delay, she fell into shock from blood loss, and had to undergo a hysterectomy.
One patient went into convulsions during an abortion, fell off the procedure table, and hit her head on the floor. Gosnell wouldn’t call an ambulance, and wouldn’t let the woman’s companion leave the building so that he could call an ambulance.
Undoubtedly there were many similar incidents, but even they do not demonstrate Gosnell at his most dangerous. Day in and day out, the greatest risks came when the doctor wasn’t even there. Gosnell set up his practice to rely entirely on the untrained actions of his unqualified employees. They administered drugs to induce labor, often causing rapid and painful dilation and contractions. But Gosnell did not like it when women screamed or moaned in his clinic, so the staff was under instruction to sedate them into stupor. Of course his assistants had no idea how to manage the powerful narcotics they were using. Gosnell prepared a list of preset dosage levels to be administered in his absence. But no allowances were made for individual patient variations, or for any monitoring of vital signs. All that mattered was the money. The more you paid, the more pain relief you received. It was all completely illegal, and completely unsafe.
Only in one class of cases did Gosnell exercise any real care with these dangerous sedatives. On those rare occasions when the patient was a white woman from the suburbs, Gosnell insisted that he be consulted at every step. When an employee asked him why, he said it was “the way of the world.” Karnamaya Mongar was not one of the privileged patients. She was a 41-year-old, refugee who had recently come to the United States from a resettlement camp in Nepal. When she arrived at the clinic, Gosnell, as usual, was not there. Office workers had her sign various forms that she could not read, and then began doping her up. She received repeated unmonitored, unrecorded intravenous injections of Demerol, a sedative seldom used in recent years because of its dangers. Gosnell liked it because it was cheap.
After several hours, Mrs. Mongar simply stopped breathing. When employees finally noticed, Gosnell was called in and briefly attempted to give CPR. He couldn’t use the defibrillator (it was broken); nor did he administer emergency medications that might have restarted her heart. After further crucial delay, paramedics finally arrived, but Mrs. Mongar was probably brain dead before they were even called. In the meantime, the clinic staff hooked up machinery and rearranged her body to make it look like they had been in the midst of a routine, safe abortion procedure. Even then, there might have been some slim hope of reviving Mrs. Mongar. The paramedics were able to generate a weak pulse. But, because of the cluttered hallways and the padlocked emergency door, it took them over twenty minutes just to find a way to get her out of the building. Doctors at the hospital managed to keep her heart beating, but they never knew what they were trying to treat, because Gosnell and his staff lied about how much anesthesia they had given, and who had given it. By that point, there was no way to restore any neurological activity. Life support was removed the next day.
Karnamaya Mongar was pronounced dead.
See no evil
Pennsylvania is not a third-world country. There were several oversight agencies that stumbled upon and should have shut down Kermit Gosnell long ago. But none of them did, not even after Karnamaya Mongar’s death. In the end, Gosnell was only caught by accident, when police raided his offices to seize evidence of his illegal prescription selling. Once law enforcement agents went in, they couldn’t help noticing the disgusting conditions, the dazed patients, the discarded fetuses. That is why the complete regulatory collapse that occurred here is so inexcusable. It should have taken only one look.
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Section IV:
The Intentional Killing of Viable Babies
Gosnell left dozens of damaged women in his wake. His reckless treatment left them infected, sterilized, permanently maimed, close to death, and, in at least two cases, dead. Their injuries and deaths resulted directly from Gosnell’s utter disregard for their health and safety. However, if their fate was entirely foreseeable, it was not necessarily the product of specific intent to kill. The same cannot be said of untold numbers of babies – not fetuses in the womb, but live babies, born outside their mothers – whose brief lives ended in Gosnell’s filthy facility. The doctor, or his employees acting at his direction, deliberately killed them as part of the normal course of business.
Gosnell and his staff severed the spinal cords of viable, moving, breathing babies who were born alive.
Surgical abortions in Pennsylvania, performed up to 24 weeks of gestational age, are legal. Killing living babies outside the womb is not. The neonatologist who testified before the Grand Jury defined “born alive.” According to this expert witness, the federal Born-Alive Infants Protection Act defines a human as “somebody who’s been completely expelled from the mother and has either a heartbeat, pulsating cord, or is moving.”
Pennsylvania’s Abortion Control Act defines “born alive” similarly, but adds breathing and brain wave activity as indicators of life. 18 Pa.C.S. §3203.
Gosnell’s staff testified about scores of gruesome killings of such born-alive infants carried out mainly by Gosnell, but also by employees Steve Massof, Lynda Williams, and Adrienne Moton. These killings became so routine that no one could put an exact number on them. They were considered “standard procedure.” Yet some of the slaughtered were so fully formed, so much like babies that should be dressed and taken home, that even clinic employees who were accustomed to the practice were shocked.
Baby Boy A
One such baby was a boy born in July 2008 to 17-year-old we will call “Sue.” Sue first met Gosnell at the Atlantic Women’s Medical Services, an abortion clinic in Wilmington, Delaware, where Gosnell worked one day a week. The girl was accompanied by her great aunt, who had agreed to pay for the procedure, and who testified before the Grand Jury.
After an ultrasound was performed on Sue, Gosnell told the aunt that the girl’s pregnancy was further along than she had originally told him, and that, therefore, the procedure would cost more than the $1,500 that had been agreed upon; it would now cost $2,500. (Gosnell normally charged $1,625 for 23-24 week abortions.) The aunt paid Gosnell in cash at the Delaware clinic. He inserted laminaria, gave Sue pills to begin labor, and instructed her to be at the Women’s Medical Center in Philadelphia at 9:00 the next morning.
Sue arrived with her aunt at 9:00 a.m. and did not leave the clinic until almost 11:00 that night. An ultrasound conducted by Kareema Cross recorded a gestational age of 29.4 weeks. Cross testified that the girl appeared to be seven or eight months pregnant.
Cross said that, during 13-plus hours, the girl was given a large amount of Cytotec to induce labor and delivery. Sue complained of pain and was heavily sedated. According to Cross, the girl was left to labor for hours and hours. Eventually, she gave birth to a large baby boy. Cross estimated that the baby was 18 to 19 inches long. She said he was nearly the size of her own six pound, six ounce, newborn daughter.
After the baby was expelled, Cross noticed that he was breathing, though not for long. After about 10 to 20 seconds, while the mother was asleep, “the doctor just slit the neck,” said Cross. Gosnell put the boy’s body in a shoebox. Cross described the baby as so big that his feet and arms hung out over the sides of the container. Cross said that she saw the baby move after his neck was cut, and after the doctor placed it in the shoebox.
Gosnell told her, “it’s the baby’s reflexes. It’s not really moving.”
The neonatologist testified that what Gosnell told his people was absolutely false.
If a baby moves, it is alive. Equally troubling, it feels a “tremendous amount of pain” when its spinal cord is severed. So, the fact that Baby Boy A. continued to move after his spinal cord was cut with scissors means that he did not die instantly. Maybe the cord was not completely severed. In any case, his few moments of life were spent in excruciating pain.
Cross was not the only one startled by the size and maturity of Baby Boy A.
Adrienne Moton and Ashley Baldwin, along with Cross, took photographs because they knew this was a baby that could and should have lived. Cross explained:
Q. Why did you all take a photograph of this baby?
A. Because it was big and it was wrong and we knew it. We knew something was wrong.
* * *
I’m not sure who took the picture first, but when we seen this baby, it was – it was a shock to us because I never seen a baby that big that he had done. So it was – I knew something was wrong because everything, like you can see everything, the hair, eyes, everything. And I never seen for any other procedure that he did, I never seen any like that.
The neonatologist viewed a photograph of Baby Boy A. Based on the baby’s size, hairline, muscle mass, subcutaneous tissue, well-developed scrotum, and other characteristics, the doctor opined that the boy was at least 32 weeks, if not more, in gestational age.
Baby Boy A Gosnell simply noted the baby boy’s size by joking, as he often did after delivering a large baby. According to Cross, the doctor said: “This baby is big enough to walk around with me or walk me to the bus stop.” The doctor released Sue to go home 13 or14 hours after she arrived. Her aunt described her condition: “She was moaning. She was standing up. She was like holding her stomach, doubled over.” She remained in pain for days and could barely eat. When she developed a fever, her aunt called Gosnell. He instructed the aunt to take her temperature and asked if she was taking pain medicine he had given her – which she was.
But he did not have her come in to be checked out. And he did not suggest that she go to a hospital. When Sue started throwing up a few days later, her grandmother contacted a different doctor, who told her to get to a hospital right away.
Sue was admitted to Crozier-Chester Hospital. Doctors there found that she had a severe infection and blood clots that had travelled to her lungs. According to Kareema Cross, who spoke to the aunt, Sue almost died. The teen stayed at the hospital for a week and a half. She became extremely thin and took months to recover, according to her aunt.
Other babies killed by Gosnell and his staffBaby Boy A was among the more memorable large babies that Gosnell killed, perhaps because of the photographs, or because his teenage mother almost died too. He was not, however, the only one. Ashley Baldwin remembered Gosnell severing the neck of a baby that cried after being born. The baby had “precipitated” when the doctor was not in the clinic. Lynda Williams placed the baby in a basin on the counter where the instruments were washed and called the doctor to come. Ashley heard the infant cry. She saw the baby move while it was on the counter.
She estimated the infant was at least 12 inches long. When Gosnell arrived at the clinic, she recalled, “he snipped the neck, and said there is nothing to worry about, and he suctioned it.”
If Gosnell was absent, his employees would kill viable babies. Ashley Baldwin saw Steve Massof slit the necks of babies that moved or breathed “five or ten” times.
Massof, repeating what he had been taught by Gosnell, told her that that it was standard procedure to cut the spine in all cases. Ashley testified:
Q. These larger babies, when Dr. Steve was there, did he ever – was he ever there when any of the larger babies precipitated?
A. Yes
Q. Babies that would move?
A. Yes.
Q. So, Dr. Steve – what would Dr. Steve do with babies that moved?
A. The same thing.
Q. The same thing. And how many time did you see Dr. Steve?
A. A lot. He told me that – don’t worry about it. They are not living. It is just a reaction.
Kareema Cross testified that, between 2005 and 2008, she saw Steve Massof sever the spinal cords of at least ten babies who were breathing and about five that were moving.
When Massof left the clinic in 2008, Lynda Williams took over the job of cutting baby’s necks when Gosnell was not there. Cross saw Williams slit the neck of a baby (“Baby C”) who had been moving and breathing for approximately twenty minutes.
Gosnell had delivered the baby and put it on a counter while he suctioned the placenta from the mother. Williams called Cross over to look at the baby because it was breathing and moving its arms when Williams pulled on them. After playing with the baby, Williams slit its neck.
When asked why Williams had killed the baby, Cross answered: Because the baby, I guess, because the baby was moving and breathing. And she see Dr. Gosnell do it so many times, I guess she felt, you know, she can do it. It’s okay.
Adrienne Moton also killed at least one baby by cutting its spinal cord. Cross testified that a woman had delivered a large baby into the toilet before Gosnell arrived at work for the night. Cross said that the baby was moving and looked like it was swimming. Moton reached into the toilet, got the baby out and cut its neck. Cross said the baby was between 10 and 15 inches long and had a head the size of a “big pancake.”
Gosnell later measured one of the baby’s feet and said that it was 24.5 weeks. Gosnell’s illegal and unorthodox practices resulted in the birth and then killing of many viable, live babies.
Killing really had to be part of Gosnell’s plan. His method for performing lateterm abortions was to induce labor and delivery of intact fetuses, and he specialized in patients who were well beyond 24 weeks. Thus, the birth of live, viable babies was a natural and predictable consequence. The subsequent slitting of spinal cords, without any consideration for the babies’ viability, was an integral part of what Gosnell’s employees called his “standard procedure.”
Steve Massof described this “standard procedure.” It required the clinic’s unequipped staff to manage a clinic full of sedated patients who were thrown into full labor, and then to “deal” with whatever precipitated, including live babies – all while the doctor was at home, or jogging, or working at a clinic in Wilmington. In particular, Massof described what Gosnell expected him to do when babies precipitated in the afternoon and evening before the doctor arrived:
A: As I mentioned earlier, Dr. Gosnell would dilate the cervix to make room for passage of the products. And with the Cytotec, softening the cervix, the outlet of the uterus, well, mother nature would take its course. Every woman is different.
Q: What would happen?
A: Well, the fetus would precipitate.
Q: What do you mean?
A: Oh, come right out, right out. Just you know, I would be called, somebody would call me and at that point what I would have to do is, I’d have to go and tend to that patient.
Q: How would you do that? What would you do?
A: As – well, my first – my first reaction would be is at that point it depended sometimes it happened in the waiting room, sometimes it happened in the bathroom because, you know, a woman would be pushing in the bathroom. Sometimes, you know, it happened everywhere in the clinic.
So what I would do is, I’d make sure that when – if the fetus precipitated, the cord was cut. Also, a standard procedure, the cervical spine was cut, as well as make sure that there wasn’t bleeding or, in other words, the placenta came down and that’s the way – we insured less blood would be lost.
Q: How often did this happen?
A: More times than I really care to remember. I would have to say every week it would happen to at least 50 percent of the patients.
Q: Fifty percent of the time?
A: Yeah, easy, easy. That – you know, and that is how, you know, and that’s what would happen.
Q: You said it was standard procedure to cut the – first to cut the umbilical cord?
A: Yes.
Q: That’s from the mother or how is that attached?
A: Well that is from the mother to the fetus.
Q: And where would it be? Would it still be – the placenta would still be in the mother’s uterus?
A: Yes.
Q: Okay.
A: Yes. And so I would cut the attachment and you know, then the cervical portion of the spine at that point. Those were the larger patients.
Q: So you said that was standard procedure. What do you mean when you say standard procedure?
A: Well, that’s – that was his standard procedure.
Q: When you say his, do you mean Gosnell?
A: Yes.
Q: Did he show you how to do that?
A: Yes, he did.
Q: When did he show you how to do that?
A: He showed me how to do that maybe 2004, sometime within a year I started working there, that is what he did during his [second-trimester] procedures.
Tina Baldwin corroborated that this was Gosnell’s standard procedure. She explained that after a fetus was expelled, Gosnell “used to go ahead and do the suction in the back of the neck.” She saw this “hundreds” of times. Gosnell told her that this was “part of the demise.”
Gosnell’s technique of aborting pregnancies by inducing labor and delivery, while unnecessarily painful for the women, did not itself constitute a crime. What made his procedure criminal was that he routinely performed these abortions past the 24-week limit prescribed by law. Not only was this a crime in itself, it also meant that he was regularly delivering babies who had a reasonable chance of survival.
Except Gosnell would not give them that chance. Pennsylvania law requires physicians to provide customary care for living babies outside the womb. Gosnell chose instead to slit their necks and store their bodies in various household containers, as if they were trash.
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