COMMENTARY

Abortion and Medical Students: Education at a Crossroads

Emily Kahoud

Disclosures

July 30, 2019

In Context of the Woman

Ob/gyns and others in academia emphasize the importance of integrating family planning into preclinical and clinical curricula. "My ideal world," Tocce says, "would be for every student to come out with accurate information about counseling, about the procedures, about safety of these procedures, et cetera." However, she acknowledges that "everyone has their own belief system.... I don't ever want to be construed as trying to change anyone's beliefs, but I want everyone to get accurate medical information." Tocce and others that believe that accurate information should be integrated preclinically.

Current Rutgers NJMS medical student Ritika Tamirisa wants to further our perspective by adding more pregnancy education or teaching about the stages of the fetus in the context of the woman in whom these changes are taking place. Tamirisa points out that pregnancy "can end up giving you a blood disorder, a vascular disorder.... It can trigger immune reactions, such as postpregnancy celiac disease. It can lead to nerve damage. It's not healthy even when you do everything by the book. And for a lot of women seeking abortion, they can't do it by the book—there's access issues."

Beyond understanding the basic mechanics of abortion at every stage to counsel patients in making informed decisions, as with other procedures and conditions, medical students should also be exposed to challenging cases. As Jennifer Gunter, MD, asserted in a recent New York Times op-ed piece, medical schools typically do not teach abortion in the context of the mother's life being in danger or in the context of a baby who is not likely to survive long owing to severe prematurity or unsurvivable birth defects. Medical students, much like the public at large, rarely learn the intricacies of abortion for a fetus whose short life is likely to include pain and invasive life-preserving interventions that may achieve little.

Importantly, laws constructed by politicians to respond to issues in medicine can never account for the infinite permutations inherent to our evolving understanding of the human body. Thus, asserts Michael E. Shapiro, MD, chair of the Bioethics Consultation Committee and associate professor of surgery at Rutgers NJMS, decisions regarding "what to do with a severely damaged infant who has either a limited life expectancy or the likelihood that their life is to be of little meaning to them is a decision that should be made between the physician and the patients' parents."

The debate on the issue of abortion legality, Shapiro believes, stems from the notion that "either women seeking abortions or the physicians who were helping them are either cruel or insensitive or unthinking and don't wrestle with this question."

Considering Fetal Pain

This dearth of education provided to medical students also includes issues concerning the fetus. Although steeped in controversy, any soon-to-be medical professional who aims to "cause no harm" must consider fetal pain. This is especially true because fetal surgery is increasingly used to correct complex birth defects, including spina bifida, mediastinal and sacrococcygeal teratomas, amniotic band syndrome, and pulmonary agenesis.

Currently, research mostly agrees on the notion that fetal pain does not exist before 20 weeks. According to Carlo Bellieni, MD, member of the Directive Board of the Study Group on Pain and Sedation of the Italian Society of Neonatology, pain requires the presence of nociceptors, a connection between the nociceptors and the spinal cord, and a connection between the spinal cord and the thalamus at the bottom of the brain. "This is set at about 20 weeks of gestational age," he explains. When asked whether medical students should learn about these findings, Bellieni suggests that, from the perspective of a neonatologist, the importance of learning about fetal pain lies in the fact that "we're now in a new frontier: that of prenatal surgery and of watching the fetus as a patient."

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