Physicians are just as divided as the rest of the nation on this controversial issue.
Physicians are just as divided as the rest of the nation on this controversial issue.
How would you advise a patient who wants to terminate her pregnancy? Do your own views about abortion influence the care you render? If you find those questions hard to answer, you're not alone. According to our survey results, remaining objective on this subject is a big ethical dilemma for physicians. And doctors, it seems, are just as passionate about the subject as the rest of the country, with strong opinions on both sides influenced by factors like religion, politics, and medical training.
Donald A. Rose, a retired family practitioner living in Hood River, OR, was opposed to performing abortions when he first entered family practice. But as more women came forward with convincing reasons for wanting the procedure, his thinking turned around. Then he had an experience that changed his mind.
"Once I tore perfectly formed upper and lower extremities from the fetus's torso in the uterus," he says. "The terrible, irrefutable reality struck me that, in performing abortions, I'd been killing babies for the convenience of the parents. I made a 180 degree turn and have discontinued doing abortions."
Neal A. Pock, a retired ob/gyn living in Tyler, TX, is on the other side of the argument. He began performing abortions once they became legal. "I was practicing in the Bible Belt, an area where people hold predominantly pro-life views, and a lot of people were less than happy with what I was doing," says Pock. "Once abortion became widely available, though, lots of lives were saved.
"We don't require people to die from cervical cancer because they acquired sexually transmitted HPV infections. We don't require people to die from lung cancer because they chose to smoke. Medicine is predicated on helping people overcome mistakes they make, not on making value judgments."
Pock has at least one bioethicist on his side. "Abortion should be legal but rare," says Paul Root Wolpe, a bioethicist at the University of Pennsylvania School of Medicine. "Surely, the procedure as a method of birth control is morally repugnant, but legalized abortion has a legitimate place in this society as the only humane alternative to back-alley abortions."
Many survey respondents told us they found certain circumstances especially troubling. Several cite cases in which the fetus has congenital abnormalities. Another says, "Second trimester terminations and selective abortions for multiple gestations are the most troubling."
Those are samples of the sentiment, what are the numbers?
We asked "Should abortion remain legal?" Seven doctors out of 10 say Yes. Surprisingly, it's cardiologists, not ob/gyns, who are the strongest proponents (82 percent vs 65 percent).
"Perhaps that's because cardiologists are less likely to be directly involved in either the abortion or the abortion decision, says Rosamond Rhodes, Director of Bioethics Education at the Mount Sinai School of Medicine in New York. "Or cardiologists may be more likely to see the medical need for the procedure. When the life or well-being of a cardiac patient is threatened by a pregnancy, the need for an abortion becomes a dramatic medical issue."
Physicians in the Midwest and the South are the least likely to be pro-choice. One doctor in four in those areas of the country would outlaw the procedure. That's not surprising, says bioethicist Wolpe: "It's well known that people from the Midwest and Southeast are less accepting of abortion than residents of either coast."
Perhaps the most dramatic battles on the national abortion agenda recently have involved what's termed "partial-birth abortion." So we asked doctors whether it should remain legal. (In this procedure, intact dilatation and extraction, the physician partially delivers a living fetus vaginally before terminating its life and completing the delivery.) Only 27 percent favor keeping the procedure legal. But a nearly equal percentage aren't sure. Again, cardiologists are the least likely to be opposed, with nearly two-fifths believing the procedure should remain legal. Ob/gyns are least likely to be on the fenceonly 10 percent say they're not sure; they're also most likely (57 percent) to believe the procedure should be outlawed. Their No votes find little support in the courts. A US Supreme Court decision two years ago declared Nebraska's ban on "partial-birth abortion" unconstitutional, calling into question antiabortion laws in 29 other states.
Another hot-button issue is parental notification when minors seek abortions. In 1992, the US Supreme Court decision Planned Parenthood of Southeastern Pennsylvania v. Casey gave states the right to impose restrictions on abortion, such as parental involvement requirements, mandatory counseling, and waiting periods. Thirty-two states enforce parental consent or notification laws. And almost three-quarters of our responders said they favor these laws.
Finally, we asked doctors what they'd do if a patient asked their advice about whether to get an abortion. One respondent in five would counsel the patient against it, with FPs being the most likely (27 percent) to do so, and cardiologists the least (9 percent). The vast majority, 75 percent, would refer the patient to another doctor or clinic.
How do doctors' views compare with those of the general public? It seems that it depends on how the question is asked. The most recent Gallup Poll shows that only 25 percent of the population at large say abortion should be legal under any circumstances; 51 percent say it should be legal only under certain circumstances. That 25 percent is a far cry from the 69 percent of physicians who voted for unequivocal legality. When asked if they'd like to see Roe v. Wade overturned, however, 60 percent of the general public said No. That puts them much closer to our doctor respondents' views.
"Most medical organizations avoid political or philosophical questions, and instead speak about safeguards and standards," says Richard G. Roberts, board chair of the American Academy of Family Physicians. "The academy wants to make sure patients aren't hurt. The physician has a duty to discuss all options with the patient; the doctor's personal views should not interfere with the patient's decision."
The American College of Physicians-American Society of Internal Medicine and the American Medical Association go a step further. According to the ACP-ASIM, "if a doctor doesn't want to be involved in abortion in any way, he or she still has an obligation to refer patients," says Lois Snyder, director of the organization's Center for Ethics and Professionalism.
The AMA's Principles of Medical Ethics sanctions abortion as long as the procedure is done "in accordance with good medical practice and under circumstances that do not violate the law." The association's stance on third trimester abortion is that the procedure be used only if alternative procedures pose materially greater risk to the woman and if fetal anomalies are incompatible with life.
In principle, most physicians come down on the pro-choice side of the abortion question, but in practice, they don't want to do abortions. Only 4 percent of respondents say they'd offer to do a patient's abortion if they were qualified.
"Could it be because there isn't enough abortion training offered?" asks Daniel Callahan, co-founder of The Hastings Center in Garrison, NY. "Less than half of ob/gyn residency programs routinely offer abortion training, and that's a problem," says Vicki Saporta, president and CEO of the National Abortion Federation. The NAF, a professional association of abortion providers, offers ongoing CME specifically on abortion and teams up with residency programs to provide training where it's lacking. California has become the first state to address that issue. In August the legislature passed a bill requiring that abortion be part of residency training. Even residency programs that offer abortion training may not do it effectively, though, says Lois Backus, executive director of Medical Students for Choice in Oakland, CA. "Some ob/gyn faculties are entirely antichoice, making for a hostile environment," she says. "Medical residents are sometimes graded poorly on presentations on emergency contraception, for example, because 'their choice of topic is offensive to certain students.'" If the faculty has a mixed opinion on abortion, the administration often prefers to avoid the issue because it's too political and controversial for an educational setting, she adds.
Dorothy Pennachio. Abortion: A right or an outrage?. Medical Economics 2002;19:77.