Controversies in medical ethics: training in abortion.

St. Mary's Hospital is a Roman Catholic owned and operated teaching hospital located down town. The hospital has several internship and residency programs and medical student rotations, including one in obstetrics/gynecology. The administrator of the hospital learns that part of the requirements for an accredited residency program in obstetrics and gynecology is that all residents learn the indications, processes, and procedures for performing therapeutic abortions. The administrator issues a ruling saying that this is completely unacceptable and that no abortions will be done in St. Mary's Hospital.

Furthermore, the administrator states that it is completely unacceptable to have medical students or residents rotate across the street at Municipal Hospital to perform abortions. He simply does not want his obstetrics/gynecology learners participating in abortions at any location if they are to have an affiliation with his hospital. The American College of Obstetrics and Gynecology (ACOG), on the other hand, insists that to maintain an accredited residency program, the residents must learn this procedure.

What is to be done? Is it appropriate for St. Mary's Hospital to maintain an obstetrics/gynecology residency program or should they close it? One of the residents in the program, Dr. Mary Smith, insists that she is being denied complete training in her specialty by virtue of St. Mary's policy. She is threatening legal action. What is to be done? Should you continue the medical student rotation at St. Mary's?

Commentary

The US Supreme Court legalized abortion across the United States with the Roe versus Wade decision in 1973. For nearly 25 years, the issue of abortion has being hotly debated within the medical community, with both sides feeling passionate about the issue. Primary care physicians and obstetrician/gynecologists will commonly encounter ethical debates in their hospitals and communities on this topic, particularly if their hospitals are connected to medical training programs. In 2002 (the latest year on which national figures are available), for every 100 live births in the United States, 246 abortions were performed. (1) This topic cannot be avoided.

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The Catholic Church has a longstanding position on abortion that was reinforced in 1995 by Pope John Paul II: "[Church's teaching on abortion] ... is unchanged and unchangeable. Therefore, by the authority which Christ conferred upon Peter and his successors ... I declare that direct abortion, that is, abortion willed as an end or as a means, always constitutes a grave moral disorder, since it is the deliberate killing of an innocent human being. This doctrine is based upon the natural law and upon the written word of God, is transmitted by the Church's tradition and taught by the ordinary and universal magisterium. No circumstance, no purpose, no law whatsoever can ever make licit an act which is intrinsically illicit, since it is contrary to the law of God which is written in every human heart, knowable by reason itself, and proclaimed by the Church" (Evangelium Vitae 62). Thus, not only is abortion a sin for Catholics, it is heresy that is punishable by excommunication from the Catholic Church.

The administrator of St. Mary's (a Catholic owned and operated hospital) has every right to decide not to allow doctors to do abortions in his hospital on religious grounds. However, he does not have a right to say what doctors should do across the street. If the administrator feels strongly enough about the issue, then he should shut down the obstetrics/gynecology rotation at his hospital since it won't allow doctors to do what the ACOG says they need to learn. With regard to the medical school rotation, there is no requirement by the Association of American Medical Colleges (AAMC) that training on abortion be part of the medical curriculum; in fact, the word "abortion" does not appear in either the AAMC Policy Guidance on Graduate Medical Education (2) or the Learning Objectives for Medical Student Education. (3) Thus, it is possible for medical student rotations to continue at St. Mary's, even in obstetrics and gynecology, without abortion training and rotations provided at other hospitals to meet this need.

We would hope that some compromise could be reached if everyone could sit down and discuss this with some level of calm. For example, the administrator might be convinced to forgo his requirement that students not be allowed to participate in abortion training at any location if they take rotations at his hospital. In fact, if he ensures that the obstetrics/gynecology medical student rotation (or residency rotation) at St. Mary's is a great learning experience without providing abortion training, this may go a lot further than putting restrictions on students' training opportunities elsewhere.

Acknowledgments

Thanks to Edward C. Halperin, MD, FACR, Vice Dean at Duke University School of Medicine, who came up with these cases for the 13 Medical School Consortium that took place on May 1, 2005 at Duke University Medical Center in Durham, NC.

References

1. Stobbe M. Abortions trend up in 2002. Associated Press (Atlanta), November 23, 2005. Available at: http://www.llalive.com/news/news_article.aspx?storyid=72365. Accessed May 4, 2006.

2. Association of American Medical Colleges. AAMC Policy Guidance on Graduate Medical Education: Assuring Quality Patient Care and Quality Education. October 2001. Available at: http://www.aamc.org/patientcare/gmepolicy/gmepolicy.pdf. Accessed May 4, 2006.

3. Association of American Medical Colleges. Report I: Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Medical School Objectives Project, January 1998. Available at: http://www.aamc.org/meded/msop/msopl.pdf. Accessed May 4, 2006.

Only those who attempt the absurd will achieve the impossible.
--Escher

Harold G. Koenig, MD

From the Department of Psychiatry and Behavioral Sciences and the Department of Medicine, Duke University Medical Center, Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC.

Reprint requests to Harold G. Koenig, MD, Professor of Psychiatry and Behavioral Sciences, Associate Professor of Medicine, Box 3400 Duke University Medical Center, Durham, NC 27710. Email: [e-mail]