Dr. Susan Bane was in her OB-GYN residency in North Carolina when she got the order to meet the attending physician in the operating room for a D&C, or dilation and curettage, a procedure that removes tissue from a woman’s uterus.
Once there, she assumed the D&C was necessary because the woman had suffered a miscarriage, but as she performed the ultrasound, she was surprised to learn that the problem was fibroids and to discover “there’s a live baby in there.”
Bane, who opposes abortion, told the attending physician that she wasn’t comfortable being involved in the procedure, and she was permitted to leave. But, she says, “It was still hard for me to do” in a hierarchical and competitive environment where residents are evaluated by more senior physicians and there’s often the expectation that physicians know how to perform abortions.
Bane’s experience is one that is far removed from that of the average American who may be passionately opinionated about abortion and yet never be asked to take part in one.
But medical students preparing for a career in obstetrics and gynecology must decide whether they want to be trained in these procedures. And a seemingly minor question — whether they have to opt-in or opt-out of abortion training — is at the heart of legislation proposed last month by a pair of Republican legislators.
The Conscience Protections for Medical Residents Act, proposed by Oklahoma Sen. James Lankford and North Carolina Rep. Greg Murphy, would require that OB-GYN training programs that currently require residents to opt out of training change to opt in.
The change might seem small, but for those in medicine, it has big implications, potentially affecting the number of physicians who provide abortions. Opponents say that such a change puts women’s health at increased risk. But Bane and other advocates of the measure believe that requiring residents to opt-out is a coercive standard that essentially takes a side in a contentious debate.
Who supports opt-out abortion training?
Since 1996, the Accreditation Council for Graduate Medical Education has required residency programs in obstetrics and gynecology to offer abortion training, but residents are allowed to opt-out for moral or religious reasons.
The American College of Obstetricians and Gynecologists says that opting-out should continue to be the standard, saying in a position paper reaffirmed in 2025, “The nature of opt-in training places the burden to create a clinical experience on the residents and establishes a culture of marginalization for abortion provision and those who wish to obtain training.”
A spokesperson for the group declined to comment, but previously, Rachel Gandell Tetlow, vice president of government and political affairs for the group, told NOTUS in a statement, “Emptying a uterus is a foundational skill to the practice of obstetrics and gynecology. This is something OB-GYNs must be able to do in order to be able to provide evidence-based medical care.”
“These life-saving skills are essential to the safe care of women experiencing pregnancy loss of many kinds, including miscarriages and stillbirths. Training in dilation and evacuation procedures affords ob/gyns critical and lifesaving skills, preparing us to enter an exam room with confidence and offer our patients evidence-based, comprehensive care.”
Writing for MedPage Today in opposition to the change, Dr. Anna Whelan, Dr. Erinma Ukoha and Dr. Hayley Miller argued that an opt-in system “creates significant barriers, burdens junior doctors, and stigmatizes an essential component of comprehensive reproductive care.”
“Changing this training requirement is dangerous for patient care and will seriously reduce access to quality healthcare for pregnant people, worsening the existing maternal health crisis in the U.S. Further, limiting this core training will worsen the health of all pregnant individuals, including those experiencing miscarriage or stillbirth,” they wrote.
The authors and other proponents of abortion rights say that there are already not enough physicians trained in what they call “abortion care,” and that an opt-in system will result in even fewer physicians with these skills.
Whelan recounted an experience she had as a third-year resident when a woman who was 20 weeks pregnant began hemorrhaging. “I had been trained to perform a dilation and evacuation ... a minimally invasive second trimester abortion procedure; however, the supervising attending that night had not. Even at a busy, well-resourced hospital, there was no supervising obstetrician available in the middle of the night to perform this life-saving procedure, and as a resident, I was not able to perform this without a trained supervisor.”
The woman wound up having abdominal surgery that affected her future pregnancies, surgery that would not have been necessary if she could have had a D&E, Whelan said. (A D&E, dilation and evacuation, typically done in the second trimester, while D&Cs are typically done in the first trimester.)
Whelan and her co-authors consider instruction and practice in such procedures “core training” and say OB-GYNs should learn the “full scope of OB-GYN procedures, including abortion care.”
The American Association of Pro-Life Obstetricians and Gynecologists responded to the op-ed in a thread on X that said, in part, that an opt-out system causes people who oppose abortion to avoid the specialty, and that “residency training should again focus on essential skills and increasing the number of OBGYNs, not abortion training mandates.”
An ‘ethical obligation’?
It’s not just OB-GYNs who are being trained in abortion, however. There has been a push in recent years for more family doctors and primary-care physicians to offer abortion services.
Writing for STAT, Dr. Christine Dehlendorf and Dr. Jody Steinauer said, “Family physicians are already the second-most common providers of abortion care in the U.S., providing 17% of medication abortions and 7% of procedural abortions.”
Steinauer is director of The Ryan Residency Program, which works with OB-GYN residency programs to integrate abortion training, which may be offered at hospitals or at off-site clinics. (The University of Utah, for example, offers its OB-GYN residents training in abortion — up to 18 weeks, per Utah’s abortion law — at a Planned Parenthood clinic, the local Ryan Residency site.)
In an interview, Steinauer said that “obstetrics and gynecology is the one specialty of medicine where it is our ethical obligation to do an abortion to save someone’s life or prevent significant harm even if we are personally opposed to abortion.”
In 1995, before the Accreditation Council for Graduate Medical Education required OB-GYN residency programs to offer abortion training, 12% of programs did so; now, the number is 72%.
Steinhauer said that while the moral and religious objections of residents opposed to abortion are respected, the opt-out system improves women’s health care because residents who have abortion training have more training in skills that aren’t specific to abortion, such as ultrasounds.
She also said that some residents, while personally opposing abortion, choose to participate in all aspects of the abortion training but the actual abortion, gaining greater competency in counseling, for example, or providing post-abortion care.
Switching to opt-in makes famously difficult residencies even more challenging for young physicians, she said. If it’s not a routine part of their training, those who opt-in have to do training on their own limited free time, and possibly have to find others to cover their shifts. “If you’re in an opt-in program, it’s really hard to go out of your way to get trained,” Steinhauer said.
That said, many programs have retained opt-in throughout the years. When Bane was in her residency at East Carolina, the program was opt-in, and a University of Utah Health spokesperson said in a statement, “The University of Utah Spencer Fox Eccles School of Medicine’s approach to abortion training has always been voluntary and opt-in.”
Is abortion health care?
In their op-ed for STAT, Steinauer and Dehlendorf describe abortion as “basic, essential health care.”
To Bane and her colleagues in the American Association of Pro-Life Obstetricians and Gynecologists, however, abortion is the antithesis of health care.
“The purpose of medicine is health and healing, and as OB-GYNs, we’re taking care of two patients: a mom and a baby. There’s no place for induced abortion in health care,” Bane said, adding that she believes the motivation for people wanting opt-out programs is to increase the number of abortion providers.
And abortion rights supporters, indeed, do say more providers are needed, and that those being trained in abortion need more opportunity to gain experience in post-Dobbs America. The Guardian recently interviewed an American family practice physician who traveled to Mexico for additional training in abortion and said he only got three days of hands-on abortion training during his residency.
“That’s just not enough if you want to practice abortion care,” he said.
But Bane says that most OB-GYNs don’t incorporate abortion into their practice. “I have been practicing for 28 years, and I’ve never had to do an induced abortion to save a patient’s life,” she said. (She notes, however, that she uses the term “abortion” to describe a procedure with the intention of terminating a pregnancy inside the uterus, with the goal of not having a live birth — which is different from medical intervention in a miscarriage, an ectopic pregnancy, or a medically necessary maternal-fetal separation that ultimately results in the death of the fetus.)
“When you think about the purpose of medicine, which is health and healing, the direct and intentional killing of one of our patients is not health care,” Bane said, and she says the hierarchical nature of residency training makes it difficult for young physicians who share her beliefs to opt out. “It’s not as simple as stating your opinion. There are repercussions for your opinion.”
A similar debate has been taking place with regard to the training of physicians for medical assistance in dying. A 2021 paper published in the Journal of Medical Ethics argued that in one state in Australia, where assisted dying is legal, declining to participate is “ethically complex” for junior doctors.
“For junior doctors wishing to exercise a conscientious objection to (voluntary assisted dying — VAD) their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting,” the authors wrote.
Lankford, the Oklahoma senator who is a co-sponsor of the legislation that seeks to change the opt-out system, declined an interview, but has said in a statement: “Medical residents should never be pressured to violate their beliefs in order to finish their training or advance in their careers. Many went into medicine to protect life, not take it. No one should have to choose between their conscience and their future in medicine. Our bill makes that clear and ensures medical students and residents can follow their convictions as they care for their patients.”
To Steinhauer, everyone is able to follow their convictions now. “We really do honor the individual’s right to opt out,” she said, adding, “There’s a myth that these people’s rights are not being upheld. They absolutely are, with deep empathy.”