Medical ethics has become an integral part of doctors’ training, and medical students are schooled on the arguments underpinning a range of ethical issues. Sometimes, whatever views a doctor has about the ethics of a particular practice, the scope for discretion may be limited by the doctor’s legal obligations. Although the Abortion Act 1967 sets out what constitutes a legal abortion, it also establishes a right to conscientious objection (section 1(1)). This means that, emergency treatment to save a woman’s life aside, doctors are free to decide whether or not to participate in abortions, according to their personal moral beliefs. Although there are many areas in medical ethics where doctors are called upon to exercise moral judgement—for instance, in deciding whether or not to disclose confidential information in the public interest—treatment decisions are generally made on medical grounds and not on the basis of a doctor’s personal ethical beliefs. For this reason, we argue that it is important to understand the views medical professionals hold on abortion.

People’s views on abortion reflect their beliefs on fundamentally important issues such as when life begins, when the rights of the fetus become equal to the rights of the mother and whether or not we have complete sovereignty over our own bodies. Abortion is a relatively common procedure in the UK: in 2006 193 700 were performed.1 Consequently, at some point in their training, most doctors will have to address the question of whether to offer unbiased counselling and sign the necessary paperwork for a termination. We cannot assume that opinions on matters of ethical concern remain static: practices that seemed outrageous in the past can become commonplace and practices that were once commonplace can seem outrageous now. Given that doctors are under no legal obligation to participate in abortion provision, an increasing trend among medical students to be unwilling to participate would suggest that abortion provision in the future might be affected. Surveying medical students may therefore be an early indication to planners of changes ahead. Yet there is little data on medical students’ views on abortion2 and we found no studies of the views of UK medical students.

BACKGROUND

Studies of medical students in the USA indicate that most students hold views on abortion, the majority of them broadly pro-choice.2^–5 Most suggested that women are more pro-choice than men.5^–8 However, one study on students reported that females were less likely to endorse abortion than males.9 Two studies of US students suggested that older students were more pro-choice than younger students,4 6 but one reported the opposite.7 This is interesting, because in the USA, medical students are generally older than in the UK, where medical studies are undertaken when the student is an undergraduate. Although some medical schools in the UK now offer accelerated programmes for graduate students, the vast majority of students start studying at the age of 18 to 20 years. Several surveys of US doctors have shown that religion is one of the most significant demographic factors affecting doctors’ attitudes towards abortion,10 and a study of British general practitioners found that Christians were more pro-life than non-religious ones.11 Another study of British general practitioners found 82% to be “broadly pro-choice” and 18% “broadly antiabortion”.12 Forty-six per cent were in favour of liberalising UK law so that women could request an abortion without the need for doctors’ signatures in the first trimester, but when asked if “the 1967 Abortion Act, requiring the written agreement of two doctors before any legal abortion can proceed, is appropriate and should remain unchanged”, only 37% thought it should be changed. This lack of consistency could have arisen for two reasons. The questions might have been poorly phrased, so subjects were unsure what they were being asked, hence giving apparently inconsistent answers. Alternatively, it may reflect people’s internal inconsistencies on a difficult ethical issue. One US study found that although 30% of medical students were strongly pro-life, only 3% would never perform an abortion or refer a patient for one.2 In contrast, doctors in Northern Ireland were generally pro-choice in their beliefs but were reluctant to be personally involved in abortion provision.13 The Abortion Act 1967 is not applicable in Northern Ireland and doctors performing terminations may be prosecuted. An Irish study found most family planning and obstetrics or gynaecology doctors thought that abortion should be legalised in Northern Ireland, but “no group believed they should be the ones responsible for performing the terminations if it were legalised”.13

In this study we assessed the extent to which medical students were willing to be involved in abortion provision and whether this was consistent with their views of abortion. We asked students if, in their future career as a doctor, they would be willing to (1) provide unbiased counselling, (2) sign the paperwork necessary for a woman to have an abortion or (3) actually perform an abortion. We assessed if students’ willingness to be involved in abortion provision was influenced by the circumstances of the pregnancy, as suggested by previous research.4

Our aims were to establish whether UK medical students held strong views on abortion and, if so, whether the views they held were pro-choice or pro-life; and to establish whether UK medical students’ views on abortion were significantly influenced by the students’ gender, year of study and practising a religion. A secondary aim was to explore the reasons why students held pro-choice or pro-life views and to assess the internal consistency of their views on abortion and whether their private morality was consistent with their views on the current UK law.

METHODS

Data collection

Five hundred questionnaires were distributed to first- and second-year pre-clinical University of Birmingham medical students. Questionnaires were distributed before the students’ formal teaching on abortion law and ethics in year 2.

Our questionnaire was designed using principles of questionnaire methodology.14^–18 It contained three sections: (A) attitudes to UK abortion law and ethics, (B) willingness to participate in abortion as a doctor and (C) demographic data.

We piloted the questionnaire on first-year graduate-entry students before their ethics training on abortion. The South Birmingham Research Ethics Committee granted ethics approval.

Data analysis

The data were analysed using a statistical package for social sciences (SPSS, version 10.0).

In section A we required students to categorise themselves as “strongly pro-life”, “moderately pro-life”, “undecided”, “moderately pro-choice” or “strongly pro-choice”. We then listed the main ethical arguments for the pro-life and pro-choice positions (table 1) and asked students to state whether they thought that their views on abortion were influenced by each of these factors, using a scale of 1 to 5 (strongly agree, agree, undecided, disagree, strongly disagree). The answers were then scored from 1 to 5, with 1 a view considered to be strongly pro-life and 5 strongly pro-choice. For those questions where an answer of 5 would equate with a pro-life view, the scores were inverted.

To determine how much each of these ethical arguments influenced students’ views on abortion, we performed Kruskall–Wallis analyses to compare students’ self-categorisation (pro-life, undecided, etc) with their score for each argument. We also compared their self-categorisation with whether they agreed that life begins at birth or at conception. Students were also asked to score whether they felt strongly about abortion.

To assess whether students’ beliefs concerning ethical issues such as the status of the fetus, when life begins and the rights of the mother correlated with their self-rated categorisation, we created a “belief index” by combining students’ data on eight questions from section A (see appendix 1—Questions used to create indices). Answers were scored from 1 to 5. The total score ranged from 8–40, with 8 reflecting a strongly pro-life view.

To assess the extent to which students’ private beliefs affected their view of current UK law, a similar “law index” was created by scoring the extent to which students agreed with the following statements: (1) I believe the law offers adequate protection for unborn children. (2) I believe the law offers enough choice for women. (3) Fathers of unborn children should be able to prevent abortion.

Section B of the questionnaire asked students whether they would offer unbiased counselling for a woman wanting an abortion, would sign the necessary paperwork, or would perform an abortion in six different circumstances: when a woman’s health or life is at risk, if she has been raped, if there is risk or certainty the child will be disabled/diseased, or if the pregnancy is unwanted. A “behaviour index” was created: students scored 1 if they would never offer abortion services, 2 if undecided, and 3 if they would offer services. The total score ranged from 18 to 54. The lower the score, the more pro-life the behaviour index was considered to be. For example, a score of 18 would correspond to a student who would never offer abortion services in the form of counselling (in any of the 6 situations), sign paperwork (in any of the 6 situations) or perform an abortion (in any of the 6 situations).

The three indices were then used to compare the students in different categories (eg, pro-life compared with pro-choice).

RESULTS

Of 500 questionnaires, 470 were returned (response rate 94%) but only 300 had complete data for sections A and C (60% sample). These 300 questionnaires were included in our analyses. Table 2 shows the demographic data for our sample.

Of the 300 pre-clinical medical students, 29% rated themselves as moderately or strongly pro-life and 64% moderately or strongly pro-choice, and 7% were undecided.

How students rated themselves (ie, strongly pro-life, moderately pro-life, etc) was significantly influenced by year of study (χ² for trend (4) = 10.4, p = 0.04). Seventy per cent of second-year students were pro-choice, versus 54% of first-years. Self-categorisation was also influenced by gender (χ² (4) = 14.4, p = 0.006). Fifty-eight per cent of females and 64% of males considered themselves to be pro-choice. Students who practised their faith were more pro-life than non-religious students (χ² (4) = 34.5, p<0.001). We asked students to state their religion, but there were too many different religions to allow significant comparisons between views of different religious groups and therefore we only compared practising with not practising a religion.

Are students’ beliefs consistent with how they categorise their stance on abortion?

Each of the questions in section A showed a highly significant difference between groups (p<0.05), all in the directions one would expect (eg, more students who rated themselves as pro-life thought life begins at conception). As these questions showed a significant difference between student categories, we considered them valid arguments for use in creating the belief index.

There was a highly significant difference (χ² (4) = 99.4, p<0.001) between the belief index scores in the five groups of students. Students’ belief-index scores increased as they became more pro-choice, demonstrating that how students categorise their views on abortion is consistent with their beliefs about the status and rights of the fetus and the rights of the mother.

Do students’ private beliefs correlate with what they think the law should allow for other people?

Law-index scores increased as students became more pro-choice, and a significant difference was found between the law-index score in different categories (χ² (4) = 48.0, p<0.01), demonstrating that students’ self-categorisation correlates with what they think the law should allow for others.

Consistency between students’ beliefs about abortion and their opinion on the law were also demonstrated by a significant correlation between individuals’ belief indices and law indices (r = 0.424, n = 281, p<0.01).

Significantly more men (45%) than women (25%) believed that fathers should be able to prevent abortion (χ² (4) = 21.2, p<0.001).

Does willingness to participate in abortion provision correlate with students’ beliefs about abortion and the law?

Behaviour-index scores increased as students became more pro-choice, and there was a significant difference in scores between student categories (χ² (4) = 74.1, p<0.001). There were significant correlations between individuals’ scores for the behaviour and belief indices (r = 0.52, n = 281, p<0.01) and between the behaviour and law indices (r = 0.34, n = 281, p<0.01), indicating consistency between how students predict they would behave when offering abortion services and their private views on abortion and abortion law.

Is students’ willingness to be involved in abortion provision influenced by level of participation and circumstances of the pregnancy?

Of the 300 questionnaires, 280 had complete responses to section B. Table 3 shows the percentage of students willing to offer counselling, sign paperwork or perform an abortion in six different situations. We could not apply statistical analyses to these data and acknowledge that differences we discuss may not be statistically significant.

Students’ willingness to be involved in abortion provision appears to be influenced by the level of participation and the circumstances of the pregnancy. Most students would provide unbiased discussion (83–97% across six circumstances). However, when the level of participation increased to signing paperwork, their willingness declined (50–84% across six circumstances). This fell further for performing an abortion (37–67% across six circumstances). The circumstances surrounding pregnancy are an important factor. Students were most willing to provide services where the mother’s life was at risk (eg, 84% were willing to sign the paperwork necessary to obtain an abortion). Where the pregnancy was unwanted or the fetus might have a disability, students were least willing to participate (50% and 51% willing to sign paperwork, respectively).

Is students’ willingness to be involved in abortion provision influenced by their views on abortion?

Overall, there was a decline in willingness to be involved in abortion provision from pro-choice to undecided to pro-life students (table 4).

Is student’s willingness to be involved in abortion provision influenced by the stage of pregnancy?

We compared students’ willingness to sign the paperwork at early and late stages of pregnancy. Across four levels of participation, students were more willing to sign paperwork early in pregnancy than late, but when the mother’s life or health was at risk, most students would be willing to sign the paperwork late in pregnancy.

DISCUSSION

UK medical students’ views on abortion

Our study provides the first detailed investigation of the views of UK medical students on abortion. The majority of medical students rated themselves as pro-choice (62%), versus pro-life (33%) (in both these groups, 27% reported holding their views strongly) or undecided (7%). We found that second-year students were more pro-choice than first-years, but although previous research suggests that age affects views on abortion,2 4 there was no significant difference in the average ages of students of the two year groups, and so it appears to be year of study rather than age accounting for the difference. As the questionnaire was administered before formal study of the ethics and law related to abortion, this was not a factor. The apparent change of attitudes over time could be investigated by surveying the same students to see whether the difference between the two cohorts persists and whether students continue to get more pro-choice as their studies progress. It might also be explained by life changes during this time, such as leaving home, being exposed to a broader range of ideas and becoming more sexually active.

It is perhaps surprising that a higher percentage of men considered themselves pro-choice than women, since pregnancy directly affects women’s bodily integrity. Previous research on this issue is inconclusive; some studies have found that women are more pro-choice6 and others that men are more pro-choice,9 and others found no gender difference.4

Consistent with previous research,10 students who practise a faith rated themselves as more pro-life than those who did not. This may be because the belief that life is sacred is central to many religions.

Consistency in beliefs underpinning views on abortion, the law and professional behaviour

A number of arguments for and against abortion have been identified (table 1). We found that all of these arguments significantly influenced students’ views on abortion, and thus no arguments were redundant. People were consistent in how they rated themselves and in the beliefs they held concerning the status of the fetus and the rights of the mother. There was a significant difference between pro-life, undecided and pro-choice students and their mean scores on our belief index.

We found that students’ private beliefs correlated with what they thought should be permissible in law and with what they would be willing to do as doctors. This result did not replicate research in the USA or Northern Ireland. In the USA, many strongly pro-life students were willing to be practically involved in abortion provision4 (ie, their private morality did not prevent them from being practically involved). In Northern Ireland, doctors who wanted the law liberalised did not want to be personally involved in abortion provision.13

Abortion provision

Our results show that students’ willingness to be involved in abortion provision was related to their views on abortion, the level of participation, the circumstances of the pregnancy and the stage of the pregnancy. These data were all in the directions one would expect. For instance, pro-life students were less willing to be involved in abortion provision than pro-choice students. People were more willing to be involved in serious situations (eg, when the mother’s life was at risk) than in less serious situations (unwanted pregnancy).

One of the most striking results was that only half of all students thought they would sign paperwork and only 36% would perform an abortion in cases where the child was unwanted. Of the 193 700 abortions carried out in 2006, 97% were performed under section 1(1)(a) of the Abortion Act,1 which in practice is the section most commonly used in the case of an “unwanted” pregnancy. If there were a risk to the mother’s health or life, 80% and 84% of students, respectively, would sign paperwork, and even most pro-life students would sign in these circumstances. Therefore, even though the students in our study would be willing to provide abortion services in these more extreme situations, their views might well prevent them from providing services in the vast majority of cases where abortion is requested.

CONCLUSIONS

The vast majority of medical students held a views on abortion. Most students (62%) described themselves as pro-choice, and, importantly, we found that students’ beliefs conformed to what they might be willing to do in practice. Given that a study in 2000 found that 82% of general practitioners were pro-abortion, compared with 18% anti-abortion, it is possible that a shift in attitudes towards abortion is occurring that may affect future abortion provision. We suggest that further research following the same cohort of students into their medical careers would help elucidate whether attitudes to abortion are genuinely changing, or whether doctors become more pro-choice throughout their careers. If doctors do tend to become more pro-choice, it would be interesting to know whether this is specifically related to the ethical teaching they receive as part of their training or a more general trend as people grow older.

In general, we argue that it is important to have objective data quantifying and understanding what medical professionals think about important ethical issues such as abortion. We propose that this is an under-researched area, and further nationwide studies with doctors at different levels of their training would be timely.