“It’s important to foster open discussion about the topic”: Development, Implementation, and Evaluation of an Ethics of Abortion Independent Learning Module for Second Year Medical Students

doi:10.21203/rs.3.rs-2837364/v1

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“It’s important to foster open discussion about the topic”: Development, Implementation, and Evaluation of an Ethics of Abortion Independent Learning Module for Second Year Medical Students

https://doi.org/10.21203/rs.3.rs-2837364/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 25 Sep, 2023

Read the published version in Reproductive Health →

You are reading this latest preprint version

Purpose

Despite the frequency of abortions, one-third of medical schools in the US and Canada did not include coverage of that topic, according to a survey conducted in 2002–2005. The purpose of this project was to develop, implement, and evaluate a module for second year medical students related to the ethics of abortion.

Methods

The module was designed as Independent Learning Time (ILT). The stated purpose was for students to consider some of the recent debate in the ethics literature related to conscientious objection and abortion and how personal views may influence future practice. The ILT included readings and Power Points to view. Students were asked to write a one-page refection on one of three writing prompts.

Results

The most commonly selected writing prompt was on personal values in relation to abortion (56.5%), followed by information about nearest provider of reproductive services to their rural preceptor site (34.7%), followed by conscientious objection (23.3%). We received many positive comments about the ILT, such as: “First, I would like to acknowledge my gratitude for this assignment and its subject. I believe it is very important that future physicians learn the entirety of women’s reproductive health care, including abortion and contraception, but unfortunately this is not always the case in medical training”.

Conclusions

There has been an extremely positive response to the ILT. With the exception of the prompt specific to our regional campus mission that includes rural preceptorships during the preclinical years, this module could be implementable at other medical schools.

Elective abortion is a common medical procedure, with a rate of 14.6 per 1000 women aged 15-45 years in the US in 2014 [1]. Despite the frequency of abortions, one-third of medical schools in the US and Canada did not include coverage, according to a survey conducted in 2002-2005 [2].

The organization Medical Students for Choice (MSFC) “believes that abortion and family planning training should be a standard part of all medical school curricula” [3]. Specific to ethics of abortion and physician responsibility, MSFC includes the following learning objective: Understanding of the ethical and legal issues surrounding abortion and physician responsibility. In group interviews of MSFC members in affiliated with 7 MSFC chapters in 4 Midwestern states, students related avoidance of abortion in the medical school curriculum and suggested that abortion education be provided in both the preclinical curriculum and in the obstetrics and gynecology (OB-GYN) clerkship [4]. A survey of OB-GYN clerkship directors published in 2005 found that 25% included no formal education about abortion, and 23% reported that they did not know if formal education about abortion was included in the preclinical years [5].

Best practices for delivery of abortion content have not been developed, but King and Penzias advocate for the following when teaching about abortion and other morally and spiritually charged topics: listen, commit to an open discussion and create a supportive environment [6]. Burns and Shaw noted that abortion education is lacking for medical students and proposed Observed Structured Clinical Examination (OSCE) to assess sensitive and nuance discussion with patients about pregnancy options [7].

The University of Minnesota Medical School, Duluth campus, was founded in 1972 with a mission to be a leader in educating physicians dedicated to family medicine, to serve the needs of rural Minnesota and Native American communities. Courses during the first two, pre-clinical years are systems-based and taught in blocks. Hormonal and Reproductive Medicine is a six-week course taught toward the end of the second year. Student evaluations at the end of the course in 2019 included a request for additional information related to ethics of elective abortions be added to the curriculum. An independent learning module on the ethics of abortion was developed and implemented the following year, and then revised based on student feedback for the next year. Separately in the curriculum, students are introduced to medical and surgical aspects of abortion care. This manuscript summarizes course development and implementation of this independent learning module in the first three years of content delivery. The project was reviewed by the University of Minnesota Institutional Review Board with a determination of not human subjects research.

Curriculum Development and Implementation

The Ethics of Abortion module was designed as an Independent Learning Time (ILT) assignment, with 110 minutes blocked in the schedule for completion, with a due date 3 ½ weeks after the assignment and materials were released in the student calendar. The curriculum design team included an OB-GYN clerkship director (SLH), the course director for Hormonal and Reproductive Medicine (AKS), and a certified healthcare ethicist (CAM). The stated purpose of the assignment was: for students to consider some of the recent debate in the ethics literature related to conscientious objection and abortion and how personal views may influence future practice. Legal standing about abortion was not included, with students advised during a live session to stay tuned to Federal, state and county legislation regarding abortion. Learning objectives included the following:

Learners will compare stances from professional organizations related to abortion care.
Learners will understand the arguments for and against conscientious objection for abortion care/referral
Learners will explain how their personal views toward abortion will intersect with their future patient care as a physician

Learning activities included:

Read Chapter 1 in: Life’s Work. A Moral Argument for Choice by Dr. Willie Parker. Published by Simon and Schuster, 2017.
Read professional organization stances on abortion care:
- AMA stance: “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care” (AMA Code of Medical Ethics, 2001). “AMA Code of Medical Ethics Available Online.” AMA Journal of Ethics, vol. 3, no. 4, 2001, doi:10.1001/virtualmentor.2001.3.4.code1-0104.
- Code of Medical Ethics Opinion 4.2.7: The Principles of Medical Ethics of the AMA do not prohibit a physician from performing an abortion in accordance with good medical practice and under circumstances that do not violate the law.
- ACOG Abortion Policy: “While ACOG recognizes and respects that individuals may be personally opposed to abortion, health care providers should not seek to impose their personal beliefs upon their patients nor allow personal beliefs to compromise patient health, access to care, or informed consent.”
- The Catholic Ethical and Religious Directives for Healthcare Services, Sixth Edition. Directive 45: Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. (https://www.usccb.org/resources/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06_0.pdf)
View the following Power Points:
- Abortion in the US after legalization by Carolyn Joffe, PhD, UCSF, 27 minutes
  - https://www.innovating-education.org/2016/02/abortion-in-the-us-after-legalization/
- Abortion and Its Multiple Contexts by Carolyn Sufrin, MD, PhD, UCSF, 24 minutes
  - https://www.innovating-education.org/2016/02/abortion-in-multiple-contexts/
Read the following two articles that provide a point/counter point to a duty to refer and conscientious objection:
- Cowley C. Conscientious objection in healthcare and the duty to refer. J Med Ethics 2017;43:207-212. PMID: 28255026. https://jme-bmj-com.ezp1.lib.umn.edu/content/43/4/207
- Finegan T. Conscientious objection to referrals. PMID: 30242077. J Med Ethics 2019;45:277-279. https://jme-bmj-com.ezp1.lib.umn.edu/content/45/4/277

Assessment was done via reflection. Students were asked to choose one of three prompts and to write a one-page refection. The three writing prompts were:

Where is the nearest provider of abortion services to your RMSP site? Does the local hospital at your RMSP site provide tubal ligations and vasectomies? How would this availability of reproductive services and your own personal beliefs influence your practice? (RMSP refers to Rural Medical Scholars Program, a required course for medical students on the Duluth campus in support of the rural mission. Students have 5-weeks of clinical placements at rural sites in Minnesota and western Wisconsin during their first two years of medical school).
Dr. Parker is a Christian and frames his argument to support reproductive choice as a moral one. Explore your own values in the context of your upbringing and how they influence your opinion of abortion services.
What is your opinion of conscientious objection and referral for abortion services?

The grading rubric for the reflection can be found in the Table.

The following supplementary, non-required, resources were provided for additional reading in relation to the reflection:

Blackshaw BP, Rodger D. Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion. J Med Ethics 2019;0:1-5. PMID: 31473656
Bonow A, Nokes E, eds. Shout Your Abortion. PM Press, 2018. Interview with four providers start on page 173.
Fiala C, Arthur JH. There is no defense for “conscientious objection” in reproductive health care. Eur J Obstet Gynecol Reprod Biol 2017;216:254-258. PMID: 28757115
Gerrard JW. Is it ethical for a general practitioner to claim conscientious objection when asked to refer for abortion? J Med Ethics 2009;35:599-602. PMID: 19793938
McLeod C. Conscience in Reproductive Health Care. Prioritizing Patient Interests. Oxford University Press, 2020.
Morrell KM, Chavkin W. Conscientious objection to abortion and reproductive healthcare: a review of recent literature and implications for adolescents. Curr Opin Obstet Gynecol 2015;27:333-338. PMID: 26241174
Weiner R. Conscientious objection: a Talmudic paradigm shift. J Relig Health 2020; 10 Jan. PMID: 31925633.

The Ethics of Abortion ILT has been completed by three cohorts of year two medical students: 63 in the first year that it was implemented, 66 in the second year, and 64 in the third year. The distribution of students who responded to the three reflection prompts can be found in the figure. Note that the numbers sum to greater than the total number of students because some students responded to more than one of the prompts.

A number of students included positive comments about the ILT along with their reflections. Some illustrative comments included the following:

I really appreciate the time in our medical school curriculum that is dedicated to continued reflection on this topic, I think it is really important prior to going into clerkship years.

I’m glad we have had the time to reflect on a hotly debated ethical issue within the bound of this class while also not directly meeting with our peers. I am not sure how this has been conducted in the past, but as this is an emotional ethical issue, I think it’s been good to have had the space to reflect while not openly confronting it without peers around us. I am sure this will be a challenging topic for all of us in many ways as we develop throughout our time as physicians, and even into our retirement. The fact that this is a difficult discussion demonstrates that it matters, and that it matters a lot.

I found this assignment to be one of great insightfulness and reflection.

I would like to start by mentioning that I’m grateful that the topics of reproductive health and reproductive justice have been incorporated into our medical school curriculum, and I appreciate the safe space that our school allows to discuss these emotionally and politically charged topics. These topics have historically been highly controversial–perhaps now, more than ever, with our current political climate–and they’re somewhat taboo to talk about. In order to achieve more favorable health outcomes for everyone involved, it’s important to foster open discussion about the topic and practice active listening when hearing from both sides of the debate.

First, I would like to acknowledge my gratitude for this assignment and its subject. I believe it is very important that future physicians learn the entirety of women’s reproductive health care, including abortion and contraception, but unfortunately this is not always the case in medical training.

The only critical feedback that was received came from written student evaluations about the module from the anonymous final course evaluation. The following comments were received in the final evaluation of the Hormonal and Reproductive Medicine course, in which this module was incorporated:

Although I am sure this was not the intention, in my perspective, it felt that assigning this article to read was using Dr. Parker’s “Christian background” as leverage to specifically target students who identify as Christian, singling them out, and using this chapter as an attempt to undermine the very basic teachings of the Christian faith as a way to proclaim that abortion can be justified and is in fact a “Christian act.” Additionally there was zero content to ask students to ethically consider the negative impacts of abortion in our culture.
I am SO glad this was included in the curriculum, but I think it would be really beneficial to have more of a required small group discussion about abortion in addition to the reflection- much like we did for physician aid in dying in the End of Life course. I appreciate the reflection, but I think it would be really helpful for the class to hear other perspectives in real time instead of reading a paper and reflecting… All in all, I'm glad abortion is at least somewhere in the curriculum, a topic that I recognize is controversial and not included in all medical school curricula, but I would have loved to see it less as a self-directed learning opportunity.
If you're going to do this assignment please put it out in a way that actually represents both sides equally and fairly. The way most of these articles read they seemed to be presenting one side as clearly immoral and wrong and not representing what they actually believe.

This Ethics of Abortion ILT was developed in response to medical student request for abortion education in the Hormonal and Reproductive medicine block in year 2. There has been an extremely positive response to the ILT, with several students indicating that, not only were they grateful to have the opportunity to reflect on the topic, but also that they were able to do that in private due to the controversial nature of the topic. The fact that the majority of students chose the reflection prompt related to personal values associated with abortion further supports this positive student response to the module and interest in considering their views about abortion.

Having this curriculum in the preclinical years helps provide a space for students to consider this topic prior to starting on clinical rotations like OBGYN where they will treat patients going through an abortion and to have already had exposure to this topic in the preclinical years, and to consider this very polarizing health concern and possibly increase mindfulness in the care of patients going through this issue. It also helps to prepare them for the ethics discussion that occurs in the OBGYN clerkship that encompasses a case on abortion and consideration of the ethical principles in relation to abortion from the physician and patient standpoint.

We are not aware of any other published curriculum on this topic for preclinical medical students. With the use of interviews with fourth year medical students who had applied to OB-GYN residency programs, researchers discovered that the term “elective” in relation to abortion education reflects personal, judgmental bias⁸, and that many students were committed to providing or referring for abortion because they felt that it was the ethically correct thing to do [9].

For faculty wanting to incorporate this module into their curriculum, a possible change would be to delete the first prompt about availability of reproductive services at their local rural preceptor site if that is not relevant. Given the smaller percentage of students choosing the prompt about conscientious objection, that prompt could also potentially be deleted, with just the single prompt about attitudes toward abortion offered as a reflection. Small group discussion or case simulation could also be considered, with assurance of psychological safety and experienced small group facilitators, and balance with expressed desire by some students to initially process this material in private.

In conclusion, we have demonstrated a highly successful ethics of abortion independent learning module that was developed in response to student request. With the exception of the prompt specific to our regional campus mission of rural health that includes rural preceptorships during the preclinical years, this module should be implementable at other medical/health professional schools.

Ethical Approval

The University of Minnesota IRB reviewed the project and determined that it was not human subjects.

Competing interests

All authors declare that they have no known competing interests in relation to this manuscript.

Authors' contributions

All authors developed the ILT. CAM summarized the data and drafted the manuscript. All authors contributed to writing the manuscript and reviewed and approved the final draft.

Funding

No funding

Availability of data and materials

Not applicable

Jones RK, Jerman J. Population group abortion rates and lifetime incidence of abortion: United States, 2008–2014. Am J Publ Health. 2017;107:1904–9. 10.2105/AJPH.2017.304042.
Steinauer J, LaRochelle F, Rowh M, Backus L, Sandahl Y, Foster A. First impressions: what are preclinical medical students in the US and Canada learning about sexual and reproductive health? Contraception. 2009;80:74–80. 10.1016/j.contraception.2008.12.015.
Medical Students for Choice. Curriculum Reform. https://msfc.org/wp-content/uploads/2017/01/BaselineCurriculumLearningObjectives.pdf, accessed April 17, 2021.
Wear D, Keck-McNulty. Medical Students for Choice: origins, current orientations, and potential impact. Teach Learn Med. 2003;15:52–8. 10.1207/S15328015TLM1501_10.
Espey E, Ogburn T, Chavez A, Qualls C, Layba M. Abortion education in medical schools: a national survey. Am J Obstet Gynecol. 2005;192:640–3. 10.1016/j.ajog.2004.09.013.
King LP, Penzias A. Fostering discussion when teaching abortion and other morally and spiritually charged topics. AMA J Ethics. 2018;20:E637–642. 10.1001/amajethics.2018.637.
Burns RM, Shaw KA. Standardizing abortion education: what medical schools can learn from residency programs. Curr Opin Obstet Gynecol. 2020;32:387–92. 10.1097/GCO.0000000000000663.
Smith BEY, Bartz D, Goldberg AB, Janiak E. Without any indication”: stigma and a hidden curriculum within medical students’ discussion of elective abortion. Soc Sci Med. 2018;214:26–34. 10.1016/j.socscimed.2018.07.014.
Merz AA, Janiak E, Mokashi M, Allen RH, Jackson C, Berkowitz L, Steinauer J, Bartz D. We’re not called upon to be nonjudgmental”: A qualitative exploration of United States medical students’ discussions of abortion as a reflection of their professionalism. Contraception. 2022;106:557–63. 10.1016/j.contraception.2021.09.004.

Table. Grading rubric for one-page writing reflection

0 points

2 points

4 points

6 points

8 points

Assignment not turned in (or turned in late)

Shows minimal engagement

with the topic, failing to

recognize multiple

dimensions/ perspectives;

lacking even basic

observations

Shows some engagement with

the topic without elaboration;

offers basic observations but

rarely original insight

Demonstrates engagement

with the topic, recognizing

multiple dimensions and/or

perspectives; offers some

insight

Demonstrates engagement

with the topic, recognizing

multiple dimensions and/or

perspectives with elaboration

and depth; offers considerable

insight

No competing interests reported.

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Journal Publication

published 25 Sep, 2023

Read the published version in Reproductive Health →

Editorial decision: Major revision
04 Jul, 2023
Reviewers agreed at journal
23 Jun, 2023
Reviews received at journal
20 Jun, 2023
Reviewers agreed at journal
16 May, 2023
Reviewers agreed at journal
03 May, 2023
Reviewers invited by journal
01 May, 2023
Editor assigned by journal
21 Apr, 2023
Submission checks completed at journal
21 Apr, 2023
First submitted to journal
19 Apr, 2023

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“It’s important to foster open discussion about the topic”: Development, Implementation, and Evaluation of an Ethics of Abortion Independent Learning Module for Second Year Medical Students

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