Opt In, Opt Out and Generation Next
Some might argue that any obstetrician/gynecologist should be willing to terminate a pregnancy to protect a woman’s health or save her life, and thus it should be part of training. Medical schools have confronted this question for years. Abortion became a mandated aspect of clinical training for obstetricians and gynecologists in the United States in 1995. Just a year later, Congress intervened to create the Coats Amendment, an opt-out provision allowing residents who objected to abortion for religious or other moral reasons to refuse to participate in abortion provision, training or referrals. This is not necessarily a bad thing, however.
The opt-out provision has given rise to a deeper level of reflection on the part of the physician trainee, weighing personal, moral or religious perspectives against professional obligation and responsibility towards the woman patient. Through our work with the Ryan Residency Training Program, a national initiative to integrate abortion training in teaching hospitals, we have found that all residents need to learn about the circumstances under which a woman decides to terminate her pregnancy. Their training should include other medical procedures that are part of an abortion, such as pelvic sonography, pain control and cervical dilation.
The decision to participate in the abortion itself should be based on residents’ social and religious background and how this informs their practice of medicine. Even more important is discerning what the personal conscience dictates. Some will not enter the clinic or the treatment room, whereas others will dilate the cervix but not evacuate the uterus. Others will terminate pregnancies only under certain health conditions of either the woman or the fetus.
Before the residents’ rotation they undergo an orientation that may include values clarification workshops, as well as discussion with peers and faculty mentors. One resident discussed his dialogue, as someone who did not provide abortions, with residents in the opt-out study at Brown University: “These difficult conversations make me believe that, regardless of our ultimate decision and stance, the dialogue about abortion can be mutually constructive.”
The experience prompted her to reconsider the tenets of her religion and apply the principles of empathy and compassion. Under direction of her conscience, she decided to learn to provide abortions.
The women themselves are an important influence, as stated by another resident from the study: “In the morning we brought relief to one woman by ending her pregnancy; in the afternoon I witnessed the sadness and devastation another woman experienced while miscarrying in our emergency department…. I discovered that, for each of these women, my role was to provide compassionate, competent care, tailored to her unique set of circumstances.”
Results of these encounters vary. For example, in our national study on opting out of abortion training, we heard from a male resident whose religious belief was that life starts at the moment of conception. This informed his decision to neither perform nor participate in abortion. In fact, he was reluctant to enter the abortion clinic. He decided to help with postabortion contraception counseling as a way to prevent the future need for an abortion. Learning more about a woman’s particular circumstances, he was forced to reflect on his premise of conscience, his judgment of the woman, of other physicians doing abortions and the physician’s role in meeting a patient’s needs and requests. His religious perspective took on a new dimension: his gender, when he considered that, as a man, he would never have to make a decision about terminating a pregnancy growing in his own body. Over time, the direction of this resident’s conscience changed. He would offer abortion as an option and refer the women to a colleague.
In another scenario, a resident did not want to participate in an abortion but was expected to go to a clinic and learn about the process. Again, her religious beliefs prevented her from providing abortions. She was pregnant, and when she arrived at the clinic, the resident was forced to walk through a picket line of demonstrators urging her not to “kill her baby.” She had no intention of having an abortion, but when she put herself in the shoes of the women coming to the clinic, she was so moved and angered by the threatening picket line that she changed her mind about doing abortions. The experience prompted her to reconsider the tenets of her religion and apply the principles of empathy and compassion. Under direction of her conscience, she decided to learn to provide abortions.
Conscience, defined by a complex mixture of religious interpretation and socialization, remains abstract until applied in the context of medical practice. Through the Ryan training program, we support physicians-in-training in becoming conscious of their private morality and distinguishing between their private morality and their professional responsibilities. This experience will also help future practitioners to find ways to grapple with their own conscience and to fulfill their promise of serving their patients.