Women’s Reproductive Health Education in Catholic Academic Healthcare Institutions: Time for Transparency, Authenticity, and Reflection

Abstract

This article illustrates the tensions between the precepts of the Ethical and Religious Directives for Catholic Healthcare Services and the Accreditation Council for Graduate Medical Education as they apply to education in obstetrics and gynecology, and argues that moving forward, Catholic sponsorship of obstetric and gynecologic residencies now requires transparency, authenticity, and reflection in order to mitigate these inherent tensions.

Introduction

The contemporary practice of women’s reproductive health involves medical, surgical, and psychosocial dimensions that are assimilated by the practitioner through a lengthy and challenging process of education. For the traditional medical practitioner, this journey begins in medical school and typically extends through four additional years in postgraduate specialty training in obstetrics and gynecology. Other routes toward the practice of women’s reproductive health exist, and include specialty training in family medicine and internal medicine, as well as that course of study leading to advanced-practice nursing care.

Postgraduate training programs in obstetrics and gynecology are accredited by the Accreditation Council for Graduate Medical Education (ACGME) and a specialty-specific Review Committee (RC). These entities publish requirements for education in obstetrics and gynecology, most recently in 2019, and include a requirement for training and practice in contraception and sterilization (ACGME 2019). At odds with these requirements is the Ethical and Religious Directives for Catholic Health Care Services (ERD), currently in its Sixth edition and most recently published in 2018 by the United States Conference of Catholic Bishops (USCCB). These directives indicate that contraceptive practices and sterilization cannot be promoted, condoned, or permitted within a Catholic healthcare institution (directives 52 and 53). The bishops indicate that by disallowing contraceptive practices within Catholic healthcare organizations, they are not imposing on the freedoms and rights of the American patient: “Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teach authority of the Church” ( ERD 2018, 8). As such, the ERD fundamentally preclude residency programs in obstetrics and gynecology sponsored by Catholic healthcare institutions from attaining compliance with ACGME related to contraception education. Alternatively, the ACGME Program Requirements preclude full expression of Catholic identity in Catholic academic health centers that sponsor training in obstetrics and gynecology.

An ethical framework that resolves these tensions, if it can be successfully constructed, must acknowledge the moral foundations of the prohibition of contraceptive practice in Catholic healthcare institutions and establish at the same time the imperative of contraceptive learning, teaching, and practice in the education of the contemporary obstetrician/gynecologist. However, until the underlying tensions are fully and explicitly elucidated, any such framework will be subject to misinterpretation and misapplication. This article describes the underlying and often unrecognized tensions between the precepts of the ERD and the ACGME and presents transparency, authenticity, and reflection as necessary attributes of any further dialogue related to mutual cooperation as outlined in Section VI of the ERD.

Background: Training in Obstetrics and Gynecology

The educational architecture of training programs is generally influenced by requirements of the ACGME, and its subsidiary arm charged with specialty-specific oversight, the RC for Obstetrics and Gynecology. The RC monitors and determines compliance with its requirements for appropriate education in obstetrics and gynecology. Requirements include assuring appropriate educational resources (library availability, an academically oriented faculty, etc.) and appropriate clinical resources (such as an appropriate patient base, resources for clinical care, sufficient clinical volumes for education, etc.).

The requirements also include compliance with an educational curriculum that is centered on women’s reproductive health. This necessarily includes an educational experience leading to expertise sufficient for independent practice in all aspects of reproductive health including the control and regulation of female fertility. This particular aspect of reproductive health encompasses practices related to the enhancement of fertility including in vitro fertilization as well as practices related to the limitation of fertility in the female patient. Contraceptive practice relates to the reduction of fertility and focuses on modifiable sexual behaviors, medical interventions, and surgical sterilization. “Contraceptive health” is a term of art. Together with contraceptive practice, contraceptive health promotes reproductive risk reduction and overall general and reproductive well-being enhancement. The goal of reproductive well-being is usually defined by medically and socially determined outcomes. Thus, contraceptive health in its secular sense is not typically defined by moral or religious underpinnings. Appeals to moral or religious underpinnings in defining contraceptive health, which pragmatically result in the limitation or elimination of contraceptive practice, are prone to fail. When viewed with the belief that contraception and contraceptive practice are morally disordered and intrinsically wrong, the use of medical or social endpoints of efficacy becomes frustrating.

Nevertheless, contraceptive health and practice have moved to the forefront of contemporary obstetrics and gynecology. As stated in the ACGME Program Requirements for Obstetrics and Gynecology:

Residents must have experience in managing complications of abortions and training in all forms of contraception, including reversible methods and sterilization. (ACGME Program Requirements IV.C.7.c)

Contraception is central in the education of the practitioners in this specialty. From educational and moral points of view, the distinction between “training” and “practice” deserves some clarification at this point. A structured course of education in obstetrics and gynecology will include “training” that leads to competency for the independent “practice” of elements of the specialty. “Training” in clinical medicine takes on many attributes and may include didactic lectures, case studies, and simulation. Ultimately, it must include the supervised delivery of care to patients in order to assure clinically competent providers capable of independent and unsupervised practice. The progression from novice to expert demonstrates the overlap of “training” and “practice” from an educational point of view. From a moral point of view, there is also overlap.

“Practice” in a moral sense implies not just the independent delivery of high-quality and lawful health care. “Practice” implies the acknowledgement of the intentions of care rendered, shared with the patient, and as clearly defined as possible. This promotes respect for the person by disclosing the range of outcomes expected for a medical intervention, such as contraception or sterilization, as well as risks and alternatives. “Training” by its very nature in health care includes learners who are guided by mentors. Both are moral agents. But there is a natural hierarchy and differential in clinical knowledge, experience, and mastery within a given specialty that exists between learner and mentor. In large measure, the learner is influenced by the moral and ethical foundations presented and applied by mentors, similar to the clinical foundations the mentors present and apply in their educational roles. Voluntary matriculation of a learner in an obstetrics and gynecology residency implies a willingness of the learner to participate in an educational curriculum that may include aspects of care that the learner finds morally objectionable, whether the learner actively and specifically participates in that care or not. In this sense, the learner is exposed to different levels of cooperation with morally objectionable care as the mentor is the primary agent for clinically and morally appropriate care in the academic environment. The extent to which distinction between the moral dimensions of “practice” and “training” can be used to resolve moral conflicts in obstetrics and gynecology residencies under Catholic sponsorship remains to be explored. It is anticipated that the nature of the moral conflicts requires comprehensive elucidation before any reasonable steps can be taken in attempts to reduce such conflicts.

Background: Catholic Sponsorship of Residencies in Obstetrics and Gynecology and the ERD

In 2016, 246 obstetrics and gynecology residency programs in the United States were recognized by the ACGME (Rayburn 2017). Approximately 18 of these programs are sponsored by Catholic institutions (Guiahi et al. 2017), but determining on an annual basis, the exact number is difficult due to hospital and healthcare system mergers in the shifting healthcare landscape. Of all hospitals in the United States in 2016, the Catholic Church owned 14.2 percent (Thorne et al. 2019). In 2016, 1,287 first-year residents entered training in obstetrics and gynecology (Rayburn 2017). Approximately the same number of graduates complete the four-year training in obstetrics and gynecology annually, with an attrition rate of 4.2 percent (Rayburn 2017). Thus, about one in fourteen obstetrician/gynecologists in the United States is trained in a Catholic institution (Steinauer and Freedman 2017). Given these numbers and the proportion of training programs under Catholic sponsorship, the nature of the requirements of the ACGME has significance in scope and impact.

Catholic Sexual Ethics and the ERD

A long and rich history chronicles and illuminates Catholic teachings in sex, marriage, and procreation. Only the germane points are presented here as they pertain to education in obstetrics and gynecology. Theological perspectives highlight current controversies (since Vatican II) and varying opinions about sexual morality among Catholic theologians (Meilander 2001; Cahill 2014; Salzman and Lawler 2016). While these opinions stimulate curiosity, discourse, and reflection, they remain subordinate to magisterial teachings on sexual ethics as interpreted by the USCCB and described in the ERD.

Contemporary Catholic sexual ethics is influenced and reinforced by Pope Paul VI’s encyclical Humanae Vitae issued in ¹⁹⁶⁸. The encyclical extols the spiritual splendor that is manifested in the loving relationship between spouses. By continued resolve in promoting the teachings in Humanae Vitae, the magisterium and the USCCB present the universal character of the Catholic Church to increase the understanding of faith. This resolve serves as a foundation for which universal truths, in the eyes of the Church, remain foremost in all discourse related to our human relationship with God. For Catholics, this foundation is central to the unifying identity of the Church and, thus, is immutable. Dissenting views of the holdings of Humanae Vitae are particularly threatening to the core tenets of Catholic faith related to human sexuality. From Humanae Vitae flows the interpretation that each and every act of conjugal love manifests both unitive and procreative dimensions and must be open to life. This interpretation remains the foundation of the contemporary prohibition of contraception in Catholic sexual ethics.

However, as noted by Kelly (2004): “…the beauty of what Pope Paul says about marriage and sexuality has been largely overshadowed because of the importance given to his conclusion that each and every marriage act must remain open to procreation…” (p. 104). Despite popular disapproval of the prohibition of contraception and sterilization, Humanae Vitae offers direction for pastoral care and takes practical form in the ERD. The ERD (2018) “are concerned primarily with institutionally based Catholic health care services. They address the sponsors, trustees, administrators, chaplains, physicians, health care personnel, and patients or residents of these institutions and services” (p. 4). The main emphasis on medical education in the ERD is focused on research (directive 4) and not necessarily the passage of medical knowledge to a new generation of learners. Additionally, an evangelical arm of stewardship (directive 9) invokes cooperation with the ERD for all employees of Catholic institutions. The ERD in sum focus on the delivery of health care in Catholic institutions and not specifically the administration of education within these institutions. Although the ERD have been intended to standardize a morally based approach to health care within Catholic institutions, variation continues in their clinical application (Guiahi 2018).

The Strained Coexistence of Obstetrics and Gynecology Education in Catholic Healthcare Institutions

While the education of a contemporary obstetrician/gynecologist is multi-dimensional, this education necessitates skill acquisition through active learning. Through this process, residents develop lasting practice patterns based on exposure to and experience in the breadth and depth of the specialty of obstetrics and gynecology. As stated in the ACGME Program Requirements for obstetrics and gynecology,

Graduate medical education transforms medical students into physician scholars who care for the patient, family and a diverse community; create and integrate new knowledge into practice; and educate future generations of physicians to serve the public. Practice patterns established during graduate medical education persist many years later. (ACGME Program Requirements, Int.A)

Learning must be “hands-on.” In addition to direct patient interaction and care, learning may include the use of simulation models for such procedures as abortion, intrauterine device placement, and implantable contraceptive device placement. Furthermore, while resident education may occur at multiple clinical sites, the sponsoring institution “…assumes the ultimate financial and academic responsibility for a program of graduate medical education, consistent with the ACGME Institutional Requirements” (ACGME Program Requirements, I.A). Finally, the focus on increasing authority and responsibility for patient care is “a core tenet” of graduate medical education (ACGME Program Requirements, Int. A). For appropriate education of obstetrician/gynecologists, a single sponsoring institution must have oversight of the educational environment and assure graded and progressive skill acquisition, responsibility, and independence in the field. Skill acquisition must include those procedures representing the breadth and depth of the specialty.

In obstetrics, such skills include those related to management of the antenatal period and the birth process including vaginal delivery and cesarean delivery. In gynecology, such skills include those related to disease of the female pelvic organs and medical and surgical management of early pregnancy complications such as ectopic pregnancy, spontaneous abortion, and management of fertility. Skill acquisition in induced abortions is a requirement of the ACGME as part of the scope of practice of gynecology, unless a resident declines this training (ACGME Program Requirements IV.C.7.a-b).

Perhaps acknowledging that contraception and sterilization do not hold the same moral position in American culture as abortion, the ACGME requires programs and sponsoring institutions to provide education in contraception and sterilization through a separate requirement (ACGME Program Requirements IV.C.7.c). The requirement for education in contraception and sterilization is explicit. While several noncontraceptive indications exist for reversible methods of contraception and sterilization (with an expanding list of these indications), the most common indication is for prevention of pregnancy. To meet the contraception and sterilization education requirements of ACGME, the training may occur outside of the physical boundaries of the sponsoring Catholic institution. But the training must be provided and coordinated by that sponsoring institution to be in compliance with the ACGME.

Issues arise at the interface of Catholic moral theology and its sexual ethics, and contemporary education and practice of obstetrics and gynecology. The first and potentially most fractious is abortion. The Catholic Church has clear teachings prohibiting direct abortion, and these are described in the ERD (directive 45). In the context of education in obstetrics and gynecology, all abortions requested by women for purposes of family planning are considered illicit and are prohibited in Catholic healthcare environments, “even based upon the principle of material cooperation” (directive 45). In recognition of moral objections to abortion, the ACGME states that no resident is required to provide or learn abortion services against their religious or moral convictions (ACGME Program Requirements IV.C.7.b). Institutions may not obstruct or impede this education for residents who desire it and in fact must provide access to training in the provision of abortions as part of the planned educational curriculum (ACGME Program Requirement IV.C.7.a). The current practice of obstetrics and gynecology following graduation from residency may, for some providers, exclude abortion services. However, education during residency related to pre- and postabortion counseling is required, as well as management of complications of abortion.

The ACGME recognizes an “opt-out” option for training in abortion that is extended to residents. The ACGME does not recognize a similar “opt-out” option for training in abortion that is extended to sponsoring institutions. “Formal cooperation” (or at least “immediate material cooperation”) by employment and overall accountability for the education of the trainee by a sponsoring Catholic institution is apparent, even if such procedures are performed in a separate, non-Catholic facility. Catholic institutions should maintain moral opposition to such material cooperation with education in abortion services and “need to be concerned about scandal in any association with abortion providers” to be fully cooperative with the ERD (directive 45).

The sponsoring institution must be responsible for assuring education in the use of contraceptive medications, devices, and sterilization to be in compliance with ACGME requirements. This education may include the use of “models” such as those used in training related to implantable contraceptives and intrauterine devices but ultimately should include direct, supervised treatment of patients. This remains a particularly important educational point as a majority of obstetrician/gynecologists trained in Catholic institutions cite dissatisfaction with their contraceptive health education and ability offer reproductive health options when in practice (Guiahi et al. 2017).

Why Transparency, Authenticity, and Reflection Are Necessary

The moral tensions present have historically led to creative clinical and academic relationships and solutions to attempt to meet the apparently competing requirements of the ERD and the ACGME. Appealing to the “principle of cooperation” is attractive but problematic. For example, the principle of cooperation has been considered unsuccessful in resolving issues related to tubal ligation at the time of cesarean delivery in Catholic institutions (O’Rourke 2002, 47).

Approximately 650,000 postpartum sterilizations are done in the United States annually, the majority at the time of cesarean delivery (Garcia et al. 2018). Residents in obstetrics and gynecology training are required to learn and perform this procedure. Cesarean delivery is considered a major abdominal surgery, and attendant risks are associated with the anesthesia as well as the surgery itself. Tubal ligation or salpingectomy at the time of cesarean is effective, convenient, and safe (Garcia et al. 2018). From an educational viewpoint, to disallow a requested tubal ligation at the time of cesarean removes educational opportunity for residents. From a medical viewpoint, to disallow tubal ligations at the time of cesarean increases the chances and potential medical risks of unintended future pregnancy. Disallowed tubal ligations also expose the patient to the anesthetic and surgical risks of tubal ligation at a later date as a second procedure needs to be performed. While the ERD prohibits direct sterilization such as tubal ligation under any circumstance, the strict application of the directive prohibiting sterilization effectively means that residents will not have the opportunity to learn and perform tubal ligation. Patients expecting tubal ligation at the time of cesarean delivery must anticipate that the procedure will not be done and must accept the risk of a second surgical procedure if permanent sterilization remains desired after they have recovered from the cesarean delivery. Thus, cooperation with the ERD in Catholic healthcare institutions related to tubal ligation at the time of cesarean delivery results in lost opportunity for resident education, the imposition of the risks of a second surgical procedure on the patient, and the risks of unintended interval pregnancy. Educational requirements of the ACGME related to tubal ligation for purposes of elective sterilization remain unmet in those Catholic healthcare institutions that offer postgraduate education in obstetrics and gynecology.

Previous challenges of the application of the principle of cooperation have resided in the complexities of the “gradation” of cooperation (Squires 2013). The qualifying terms of “formal,” “immediate material,” and “mediate material” cooperation hint at the potential for confusion and misapplication of this principle. In the area of reproductive health, the Catholic Church has had an unwavering position on the impermissibility of contraception and sterilization. It follows that further attempts to apply the principle of cooperation are no less likely to fail in either partial or total resolution of moral conflict between the ERD and the ACGME requirements.

Thus, issues surrounding contraception and sterilization education and practice are increasingly challenging. The ACGME, by requiring education and skill development for reversible and permanent contraception, tacitly acknowledges the limits of an “opt-out” option for this aspect of gynecologic care. This is inherently problematic for Catholic institutions, which “may not promote or condone contraceptive practices…” (directive 52). Broadly and specifically interpreted, the education of trainees in contraceptive practices, as described and required by the ACGME, both “promotes and condones” contraceptive practice and requires the learning and performance of sterilization under the auspices of the sponsoring institution.

The USCCB has further clarified their position on material cooperation within Catholic healthcare institutions by the addition of directives in the newest edition of the ERD published in June 2018. Directive 73 states “…a Catholic institution must ensure that neither its administrators nor its employees will manage, carry out, assist in carrying out, make its facilities available for, make referrals for, or benefit from the revenue generated by immoral procedures.” As a sponsoring institution of resident education in obstetrics and gynecology, an academic Catholic healthcare institution must forego cooperation with the ERD to meet the requirements of the ACGME and the general expectations of trainees entering into obstetrics and gynecology residencies. For instance, institutions sponsoring postgraduate medical education appoint a designated institutional official (DIO) to oversee the academic activities of each residency program in the institution. Each residency program must have a program director (PD) to oversee and specifically manage the academic activities of specialty-specific training programs. The DIO and the PD of residency programs in obstetrics and gynecology must assure compliance with ACGME training requirements. Residents are typically employed by the sponsoring institution. Thus, in meeting the ACGME requirements for training in obstetrics and gynecology, both administrators (such as the DIO and PD) and employees (residents) will be involved in creating, coordinating, implementing, and managing clinical education in contraception and sterilization, which is specifically prohibited by the ERD.

In searching for mitigation or resolution of conflicts some specific examples, in addition to those already presented, may serve as talking points in transparent and authentic discourse. Each example is followed by supporting Directives and Requirements:

1. Those employees of Catholic healthcare services that sponsor residency training in obstetrics and gynecology, including the DIO, PD, and residents, must adhere to the ERD as a condition for employment. This precludes abortion, sterilization, and contraceptive practice (directives 5 and 9).

2. Programs must provide training or access to training in abortions, sterilization, and all forms of contraception as part of the planned curriculum. Failure to meet all or part of this requirement is considered noncompliance and presumably leads to adverse accreditation action if uncorrected (ACGME Program Requirements IV.C.7.a-c).

3. Abortion, sterilization, and contraception are not permitted in Catholic health institutions nor are Catholic health institutions permitted to engage in immediate material cooperation in these acts. This precludes collaboration and cooperative agreements between sponsoring Catholic institutions and participating, non-Catholic facilities to meet these educational requirements for this training (directives 45, 52, 53 and 70).

4. In cooperative agreements related to abortion, sterilization, and contraception, formal cooperation may take on various forms such as approving, authorizing, defending, or directing morally illicit acts and is always morally wrong. Again, coordination of rotations to family planning clinics in participating, non-Catholic facilities is precluded (Introduction, Part 6, ERD).

5. Administrators and employees such as DIOs, PDs, and residents must not “manage, carry out, assist in carrying out, make facilities available for, make referrals for, or benefit from the revenue generated by immoral procedures.” To the extent that coordination of family planning education as required by the ACGME involves managing and oversight of morally objectionable activity, noncompliance with the ERD is apparent (directive 73).

6. The diocesan bishop should be consulted in a timely manner whenever there is the possibility of “serious adverse consequences for the identity or reputation of Catholic health care services” or “a risk of scandal.” In dioceses in which training in obstetrics and gynecology occurs at a local Catholic health care facility, the diocesan bishop should be consulted (directive 68).

7. For those programs that utilize off-site rotations at participating sites to meet ACGME requirements for family planning, the required program letter of agreements specifying the duration and content of the educational experience should be shared with hospital leadership and local diocesan bishops (ACGME Program Requirements I.B.2 and directive 68).

8. As specialty education in obstetrics and gynecology necessarily occurs within “…clinical settings that establish the foundation for practice-based and lifelong learning,” the restrictions listed in the ERD and their overall impact on education in abortion, sterilization, and contraceptive practice and education should be explicit, public, and available to applicants for residency, residents in training, and faculty in Catholic-sponsored programs (ACGME Program Requirements, I.A).

9. If a collaboration is deemed to involve wrongful cooperation in obstetrics and gynecology training, the local diocesan bishop should be informed immediately, and the leaders of the institution should resolve the situation as soon as reasonably possible. Whether resolution is possible, or even plausible, is untested (directive 77).

These conflicts lead to morally tenuous positions. For those Catholic healthcare institutions directly sponsoring comprehensive and compliant training in obstetrics and gynecology, including required contraceptive and sterilization practice, noncompliance with the ERD, is manifest. Acknowledging the conflicts between the ERD and the contemporary practice of gynecology, Catholic institutions can discontinue educational sponsorship of these training programs (Smith 2019). Discontinued sponsorship does not necessarily mean closure of a program. Transfer of sponsorship to a non-Catholic sponsoring institution offers advantages of reducing moral tensions while preserving the educational opportunities at the Catholic institution not related to morally objectionable activities. Or, Catholic institutions may advance the position that “teaching” contraceptive health and practice is not actually “promoting or condoning” it but a necessary and morally appropriate step to maintain their training programs. If there were no educational sponsorship, or if there was a successful argument that teaching contraception and sterilization was morally different than practicing, promoting, or condoning them, moral tensions might be reduced. Both approaches could resolve the conflict related to education of physicians in obstetrics and gynecology specific to contraceptive health and practice.

Furthermore, the ACGME and professional societies might emphasize that the practice of gynecology requires the acquisition of expertise in contraceptive health and practice through residency education. Those residents with personal or moral objection to contraceptive practice might find enhanced professional satisfaction in a different specialty field, one without the expectation of female contraceptive expertise. Or, the ACGME could modify its standards and remove specific requirements for education in abortion, sterilization, and contraception, leaving the scope and implementation of this education to be determined by the sponsoring institution. If there were no specific ACGME requirements related to these areas of gynecologic practice, or if a successful argument could be made that abortion, sterilization, and contraception are aspects of women’s reproductive health care that do not require ACGME oversight, moral tensions might be similarly reduced.

Finally, these moral dilemmas expand their dimensions with the acknowledgement that funding for postgraduate education is largely borne by taxpayers through government-sponsored funding for educational “slots” for training in specialties including obstetrics and gynecology (Schuster 2017). A reasonable conclusion is that some taxpayer-sponsored trainees in obstetrics and gynecology are unable to effectively serve the morally pluralistic society that in large measure sponsors their education through taxpayer support of their postgraduate programs.

Currently, sponsorship of training programs in obstetrics and gynecology by Catholic institutions allows moral conflicts to persist, hidden within the religious, administrative, clinical, and academic foundation of such institutions. A “don’t ask, don’t tell” approach in which sponsoring Catholic institutions do not internally and publicly embrace the ACGME requirements, and the ACGME does not acknowledge the restrictions imposed on postgraduate education in obstetrics and gynecology within Catholic-sponsored residencies in its accreditation processes, potentially leads to a quiet, morally erosive, and damaging “stalemate.” Certainly, the effects of concealment or deceit are at the foundation of directive 71 of the ERD, which warns of the potential harms of scandal. Directive 71 also indicates that in certain circumstances, scandal may be mitigated by an explanation of what is being done in a Catholic healthcare environment. This presupposes authentic disclosure of all relevant issues related to the scandal-sensitive issue.

Scandal itself is a complicated, nuanced topic (Nairn 2012). Scandal may be described as active, in that an activity or relationship invokes morally suspect dimensions in the situation at hand. Scandal may also be passive, in that the mere situation at hand has attributes of morally suspect dimensions, without direct or intentional activity of the parties involved (Nairn 2012). Both may apply to the issue of contraception and sterilization training in Catholic-sponsored obstetrics and gynecology residency. The implication of scandal in the Catholic sense exists when the DIO and PD in a Catholic-sponsored residency plan and coordinate rotations for employed residents to gain skills in contraception and family planning, as required by the ACGME, even if off-site. This leads to ambiguity in the resolve of Catholic-sponsored residencies in obstetrics and gynecology to promote their Catholic identity. This is especially so when concerned with the morally contentious area of contraceptive practice.

Scandal may be construed in a secular sense as well. The ACGME publishes requirements of contraception and sterilization education. But if it does not take steps to ensure compliance with those requirements within all residencies in its purview, including Catholic-sponsored residencies, the requirements lose meaning. This leads to potential ambiguity in the resolve of ACGME to maintain accrediting standards for robust postgraduate education in contraceptive health and practice. Persistent, hidden moral tensions may increase perceptions of scandal in both a Catholic and secular sense, especially if they are allowed to persist without resolution or management.

As with other areas of moral tension, the issues must be fully illuminated and acknowledged. What may be the most important aspect of such dialogue is the ability to engage parties in participatory, constructive discourse. Taken literally and transparently, the educational standards of the ACGME and the directives of the ERD are incompatible. However, taken authentically, both the standards of the ACGME and the directives in the ERD represent deeply held beliefs related to the importance of formalized education and the proper scope of reproductive health in Catholic environments. Obligations to both learners and patients can be morally uncomfortable and pragmatically challenging. Dialogue must be carefully considered and approached with sensitivities to all interests. However, if left unaddressed, hidden moral tensions may lead to further polarization or marginalization of the issues. As with the moral imperatives of the ERD, the educational imperatives of the ACGME should be viewed in their totality. While requiring education and the development of competence in contraceptive health and practice, the ACGME has provided flexibility in the approach to this education and has offered opportunity for those institutions morally opposed to contraception, yet which offer training in obstetrics and gynecology, to provide education outside of the institution itself. The ACGME views education in specialties in the multiple dimensions in which patients are cared for and in which learning occurs. Where obvious moral tensions in issues related to reproductive health exist, there remain large areas of confluence of goals and objectives of education of learners in obstetrics and gynecology, including the care of marginalized and underrepresented populations. To the extent the Catholic healthcare institutions actively seek out opportunities to care for these populations, education in obstetrics and gynecology can effectively assist in this mission and enhance learning and education in this context.

The Catholic faith has the tremendous evangelical opportunity to demonstrate its healing mission through sponsorship of training programs. Likewise, the unique educational opportunities in obstetrics and gynecology that exist in Catholic healthcare environments can be enhanced through observation of the requirements, and flexibility, of the ACGME. Education in obstetrics and gynecology within Catholic healthcare institutions where such education is congruent with the ERD can, and should, continue. This education should include rational discussions of advantages and disadvantages of natural fertility regulation. To distinguish its Catholic roots, this education should also include formal training in ethics that distinguishes different bioethical frameworks. These include principlism, in which human dignity has become grounded in autonomy as the ascendant, and sometimes sole, value, and personalist bioethics in which human dignity, for Catholics, is grounded in the belief that all are made in the “image of God.” When moral conflicts can be resolved, trainees in obstetrics and gynecology in Catholic healthcare institutions have the tremendous opportunity to learn the healing ministry through strong Catholic influences. The Church can advance the centering and nurturing promise of its healing ministry to a new generation of obstetrician/gynecologists. Additionally, many Catholic-sponsored residency programs are recognized for their high obstetric volumes and gynecologic surgical cases, which are an important attribute of robust training environments, and noted positively by graduates from these programs (Guiahi et al. 2017).

In summary, this article has attempted to describe the moral tensions that exist within academic Catholic health centers sponsoring residencies in obstetrics and gynecology. These tensions arise in attempts at simultaneous compliance with ACGME Program Requirements and the ERD. For the ACGME abortion, sterilization and contraceptive training is no longer optional for programs and must be part of the planned curriculum. For the USCCB, the sponsorship of residencies in obstetrics and gynecology poses obvious material cooperation with illicit practices. In their most recent iterations, both the ACGME Program Requirements and the ERD move further away from acceptable resolutions as each outline the necessary attributes of fundamental compliance and cooperation. While resolution of these conflicts may not be possible, management of conflicts and tensions through transparency and authenticity in approach to the issues will mitigate ambiguity and the potential for scandal in both Catholic and secular meaning. Most importantly, full and explicit elucidation of these tensions with open dialogue as a first step will likely contribute to and enhance the moral environment that patients should expect when receiving care in Catholic healthcare institutions, whether that care is rendered by trainees, staff physicians, or other healthcare providers.

Biographical Note

James F. Smith, Jr., MD, DBioethics, FACOG, is currently an adjunct professor in the Department of Medical Education at Creighton University School of Medicine in Omaha, Nebraska. He is a maternal fetal medicine physician by training and has interests in humanities in medical education, the history of medicine, and the moral tensions that exist at the interface of Catholic health care in a pluralistic society.