For Doctors-to-Be, an Agonizing Question Looms: to Perform Abortions or Not?

·Contributing Writer

For many medical residents, the decision whether to train to perform abortions is not an easy one — it’s a deeply personal question that can prompt major soul searching. With the debate over abortion raging stronger than ever, due in part to an anti-abortion group’s undercover videos claiming to expose Planned Parenthood for illegally selling fetal tissue procured from the procedures, and in a day and age where everyone jumps to quick conclusions, we wanted to bring you these thoughtful, brutally honest essays from residents struggling with their decisions to perform abortions. (Illustration: Getty Images)

“I was and remain uncertain about when life begins.”

That’s a statement that can resonate with many of us when it comes to the controversial topic of abortion — no matter how positive we are about our stance on a women’s right to have one.

Questions of this sort can be especially burdensome to a first-year obstetrics and gynecology resident, a doctor-in-training embarking on rotations to learn how to perform the essential skills of the trade.

On one hand, your mission is to help people — all people — who need it, but on the other, if you are at all conflicted on the above statement, you may wonder if it’s your job to help a fetus, too.

Medical personnel in the field of obstetrics encounter abortions in a very different manner than the average person.

“When you work in OB, especially in the emergency room, you see people coming in bleeding, people losing pregnancies, people experiencing pre-term labor very early,” Janet Singer, MSN, CNM, and a faculty member in the obstetrics and gynecology residency program at the Warren Alpert Medical School of Brown University in Providence, R.I., tells Yahoo Health.

The end of pregnancy is unavoidably as much a part of obstetrics care as birth itself.

“Rhetoric prevents us from having real conversations about the truth of abortion,” says Singer. But the instructor found herself acting as “a little bit of an ‘abortion liaison’ for the residents” in her program. She found herself regularly having conversations with residents on their ob-gyn rotations about their work — and their feelings about performing abortions, in particular. Singer then began a discussion group for residents receiving abortion training, creating a safe space to talk about their feelings, and later “made it my mission” to sit down with each resident while doing abortion training and check in with them and see how they were doing.”

Related: Why Women Do (and Don’t) Choose Fetal Tissue Donation After Abortion

She began gathering and publishing narratives from residents about their abortion training. Her academic paper “Four Residents’ Narratives on Abortion Training: A Residency Climate of Reflection, Support, and Mutual Respect” was published in the July 2015 issue of Obstetrics and Gynecology, the preeminent journal of the field.

The four featured first-person narratives, which have been excerpted here, come from residents who entered the program with various stances on receiving abortion training: two of the residents ultimately opted to receive abortion training, while two decided not to receive this training. You can read the full text of each narrative here.

Narrative 1: “If I lose the convenient excuse that my patients can just as easily see a dozen other providers in my city, could I really turn these women down?”

When I started residency, I was open to the possibility of providing terminations. I was and remain uncertain about when life begins, and I used to hope that a deeper understanding of fetal development might help me make such a decision empirically.

Over the course of internship, I came to understand embryonal development as a fluid yet constant march toward being human in which an embryo at six weeks is an entirely distinct entity from an anatomically formed fetus two months later. Unfortunately, this acquired knowledge has failed to help me fully define my position.

Increasingly, I have found myself caught up in an endless array of rhetorical questions. Is there not a more profound difference between 10 and 20 weeks than between 20 and 30? If my first task as a physician is to do no harm, how can I justify harming a fetus? I do not pretend to know the answers to these questions, but given what I perceived to be an abyss of ambiguity, I chose not to provide elective terminations. …

Since opting out, I have realized that my line of thinking has been feto-centric at best and overintellectualized at worst. Nonetheless, in the absence of a clear moral understanding of abortion, I can only do no harm. Before my own observational experience at Planned Parenthood, my classmates had told me that patients there were appreciative in a way that was entirely unique among the services we provide. At Planned Parenthood and in our own resident clinic, I have participated in terminations with varying levels of involvement. Based on these experiences, I know for certain that a pregnancy termination is one of the most life-changing interventions we can offer. …

As someone who entered obstetrics and gynecology because of the opportunities to empower women, I find myself feeling guilty that I cannot get over what increasingly seems to be a theoretical suspicion that life as seen on a two-dimensional ultrasound scan represents actual life. I wonder if I will change my mind after residency, if and when I encounter women who have less (or no) access to abortion services.

If I lose the convenient excuse that my patients can just as easily see a dozen other providers in my city, could I really turn these women down? I went into medicine because I believe doctors should provide services for underserved patients, and frankly my decision not to provide terminations challenges my identity as a physician and as someone who cares about women’s health.

The experience of talking and writing about receiving abortion training has proved to be as surprising for Singer as for the residents themselves.

“I think that for me, someone who is so strongly pro-choice, I personally have to reconcile the amount of respect I have for these pro-life residents. I know they want to be the best doctors they can be. They have these personal beliefs that completely conflict with my personal beliefs, but they are respectful and compassionate. I used to believe that no one should be an ob-gyn and not perform abortions,” says Singer. This is no longer the case: Reflecting on one resident who opted out of abortion training, Singer says, “She is an amazing doctor. I would absolutely refer someone to her.”

Related: Who Is the 26-Year-Old Man Behind the Planned Parenthood ‘Sting’ Videos?

The same goes for all the residents of all opinions regarding abortion training with whom Singer has worked.

“They support each other 100 percent. They are respectful of each other’s views. They debate them around — but they are respectful.”

Narrative 2: “Seeing the fetus on an ultrasound scan and then watching it as we did the procedure really shook me to the core.”

I grew up in a Catholic family where the pro-life position was dogma. As I grew older and developed my personal beliefs and ideals regarding women’s reproductive choices, I began to question this position. Still, at the start of residency, I was not sure if I was ready to perform elective terminations.

I realized that the lion’s share of my reluctance was driven by “what would my mom think of me?” I struggled with my own faith, and with what God would think. … I was nervous about my first day at Planned Parenthood. I envisioned protesters chanting and throwing objects at me. After my first morning of early abortions, we performed an 18-week termination.

Seeing the fetus on an ultrasound scan and then watching it as we did the procedure really shook me to the core. I thought maybe I had made the wrong choice, and I could not stop thinking about what my family would think if they knew what I had done.

Later that week we had an informal gathering of residents who had struggled with abortion training. It became apparent that others shared similar feelings. Many of us felt more comfortable with early abortions and struggled with second-trimester cases. Regardless of whether we performed abortions or not, it had to do with patient care and, in this case, our patients are the mothers.

After listening to the struggles of fellow residents, I convinced myself to return to the clinic. There, I soon realized how powerful it was to be able to comfort and assure such vulnerable patients. I began to frame my interventions at the clinic as life-changing for women. … Looking back, I am very happy with my decision to participate in abortion training, despite how emotionally challenging it was for me. The residents with whom I work provided tremendous support for me as I struggled with the choice of providing terminations. I feel that my clinical skill set was broadened dramatically, and, subsequently, I have been able to perform other gynecologic procedures with a level of confidence and skill that I did not have before.

Although I firmly believe in a woman’s reproductive rights and would feel comfortable doing a termination in certain dire circumstances — such as a fetus with a condition incompatible with life or to preserve a woman’s life or health — I do not expect to perform terminations in my future practice.

Singer emphasizes that one often-overlooked aspect of receiving abortion training and becoming an abortion provider is how hugely satisfying the work is.

Related: Coincidence … or Is It? Planned Parenthood ‘Sting’ Video Isn’t First to Derail Legislation

Pointing to the public perception that most abortion providers are “doctors who do it because they are committed to reproductive rights but hate doing it – that’s not true. It’s hugely fulfilling work and [abortion providers] are proud to do it.” She adds, “It’s not often in medicine where someone comes in with a major life crisis and you can help them in a matter of hours.”

Narrative 3: “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.”

Our residency abortion training is usually done during the second year; however, I was asked to cover the service one day as an intern. I had a clear stance about the right to choose, but being present during the physical procedure gave me pause.

Although I did not perform any procedures that morning at Planned Parenthood, I was unsettled by the juxtaposition of two different patient experiences. 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. When my second-year rotation came along, I was nervous about what it would feel like to perform an abortion myself. As with all surgical procedures, the invasive nature of the act becomes less apparent with increasing experience and the woman’s well-being appropriately takes center stage.

I was able to see the big picture: the women were incredibly appreciative, the clinicians were caring and sensitive, and we were providing a needed service.

I would love to live in a world where no abortions are needed. Countless parents are stretched too thin socially, financially, or personally to take care of another child. Although I might not always understand an individual woman’s choices, if she feels that she cannot be a parent for whatever reason, I will support her in that decision. I see little role for my personal values in the shared decision-making process.

The truth is that being involved in this work scares me. I am fearful of the violence and taunting that protesters have inflicted against providers. Assaulting providers in the name of “protecting life” disgusts me, especially because abortion is legal. … I have worked through my own internal struggles, but these broader societal issues will shape how I practice in the future. Participating in abortion services has left me fulfilled and honored, and I consider the provision of this care a privilege.

Singer hopes the residents’ narratives and the discussion group they have formed for ob-gyn residents at their school can be “a model for how to have a more civilized conversation that recognizes the complexity of abortion. Both sides get trapped in the rhetoric of what’s going on. From the pro-choice side, we argue that this is nothing — but the fetus is something. It may not be a life or an autonomous life, but it is something. So when does it become more than something? These are the questions faced by all of us every day who work in ob-gyn.”

Narrative 4: “I knew the information I had given her had guided her toward this decision, and I was uneasy with the fact that, because of my personal beliefs, I could not start her induction.”

I am a born-again Christian, and I believe that life begins at conception. I believe that, since I do not have the power to create life, I do not have the power to take it.

I am proud of my choice and do not apologize for it, but that was not always the case. … Would my patients feel judged and unsupported if I told them that I could not provide a service that they needed? Could I be truly impartial in my counseling? …

Recently we had a patient with previable premature rupture of membranes. Knowing the facts and figures, I was able to counsel her extensively about her options. While she cried and wrestled with her decision, I held her hand and told her I knew she faced a difficult decision, one that would be difficult for anyone. She ultimately chose to proceed with a termination.

I knew the information I had given her had guided her toward this decision, and I was uneasy with the fact that, because of my personal beliefs, I could not start her induction. Thankfully I was able to ask for help from supportive co-residents. …

I realize that not providing terminations does not make me a “bad” ob-gyn. It makes me, well, me: a unique human who has her own passions, beliefs, struggles, and decisions. I also feel that being true to myself and unwavering in my beliefs makes me a better, more honest, and relatable physician.

“I think that people think of abortion as a gruesome thing,” concludes Singer. “So people try not to think about it, so they don’t realize the really positive side of it. If one in three women have had an abortion, than one in three women have the experience of what an abortion provider is — someone who is caring and kind. But no one talks about that.”

Singer’s work, however, certainly is making strides in changing common perceptions.

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