Accreditation Council for Graduate Medical Education (ACGME) Abortion Training Requirements Are Inconsistent with Federal Law

A Texas Attorney General opinion released last week concluded that Texas must not refuse ACGME accreditation because a program does not provide training in aborting.

Dear Senator Campbell:

With the federal Coats-Snowe Amendment in mind, several questions are asked about the Accreditation council for Graduate Medical Education (“ACGME”) and medical schools. The Coats-Snowe Amendment, {42 U.S.C. § 238n(a),} enacted in 1996, generally prohibits discrimination against a health care entity for refusing to engage in certain abortion- related training activities. It provides, specifically:

[t]he Federal Government, and any State or local government that receives Federal financial assistance, may not subject any health care entity {Federal government and State and local governments receiving Federal financial aid may not be subject to any other health care entity.[ing] an individual physician, a postgraduate physician training program, and a participant in a program of training in the health professions} to discrimination on the basis that—

(1) An entity declines training for induced abortions.

(2) If the entity is unable to arrange for the specified activities, or

(3) the entity attends (or attended) a post-graduate physician training program, or any other program of training in the health professions, that does not (or did not) perform induced abortions or require, provide or refer for training in the performance of induced abortions, or make arrangements for the provision of such training….

ACGME is described as “an independent physician-led, non-for-profit organization that establishes and monitors professional education standards necessary in preparing doctors to provide safe, high-quality, medical care for all Americans.” {As of July 2020, ACGME is the sole accreditor for graduate medical education.} ACGME requires that graduate medical education programs be compliant with its requirements in order to receive and maintain accreditation. ACGME will not accept programs that violate its requirements. [it]You may be sent a warning letter or placed on probation. If violations continue, the ACGME could withdraw the accreditation. {Accreditation means federal funding that a program in graduate medical education may receive..} …

ACGME says that the following is what it means by “[a]The residency education must include the ability to have an induced abortion experience. Additionally, programs should be structured so residents can “opt out” of this program, education, or training. The ACGME also states that a program without a “specific family planning curriculum that includes direct procedural training in abortions … unless it is requested by and developed for a resident desiring training” is an opt-in curriculum. ACGME also considers opt-in programs to be non-compliant. This background and context will help us to answer your query.

[I.]Texas may offer training in induced abortions under the Coats-Snowe Amendment. This is contrary to ACGME standards..

The Coats-Snowe Amendment, which prohibits local or state governments from receiving federal financial aid, forbids discrimination against students or doctors refusing to receive induced abortion training. It also bans graduate medical education programs that do not provide training or demand induced abortive procedures. Federal law is incompatible with and conflicts with the ACGME guidelines, which mandate induced abortion training. This amendment instructs local and state governments about how to deal with conflicting accreditation standards. It says that

[i]When determining whether to give a legal status (including a certificate or license) to a health-care entity, the Federal Government, State, and local governments that receive Federal financial assistance shall consider accredited any postgraduate doctor training program that is required to perform an ininduced abortion, require, provide or refer for training in the performing of such abortions or make arrangements to do so, regardless of the exceptions or exclusions.

To put it another way, the Coats-Snowe Amendment demands that Texas: (1) make any accredited graduate medical education programs that do not provide or require induced abortive training; and (2) license all doctors or students who have completed training at such programs or are not involved in induced pregnancy training. The Coats-Snowe Amendment does not require graduate medical education programs that offer induced abortion training to be provided on an elective basis. However, the amendment ignores ACGME’s opt-out accreditation standards and permits such programs to give abortion training without any accreditation consequences.

[II.]Doctors and students may be able to exercise their conscience rights by opting out of inducing abortion training.

Coats-Snowe Amendment language does not require that all graduate medical education programs offer opt-in induced abortion training. However, a program which forces someone to opt out of this training could potentially violate other students’ and doctors’ conscience rights. The federal Religious Freedom Restoration Act and Texas Religious Freedom Restoration Act protect a person’s freedom to exercise their religion. The TRFRA as well as the RFRA both prohibit government officials from significantly restricting a person’s freedom to exercise religion unless that is required in order to advance a compelling public interest or is the most restrictive way of doing so.

If there is no compelling government reason to require doctors or students from religiously diverse backgrounds to complete such training, then the TRFRA/RFRA could be violated by the State’s compliance with opt-out regulations. A court can also decide that the State or medical school following an opt-out training requirement for abortion could be in violation of the First Amendment if it compels a person not to exercise their First Amendment rights. These constitutional and legislative concerns are why a graduate medical school program must offer opt-in induced abortive training.


The Coats-Snowe Amendment … prohibits the State of Texas from discriminating against physicians, medical students, or graduate medical education training programs for their refusal to participate in abortion related training. The State of Texas is required to ignore Accreditation Council of Graduate Medical Education accreditation standards, which require the provision of induced abortive training on an opt out basis. This allows graduate medical education programs the freedom to offer induced abortion instruction on an elective basis.

Additionally, any graduate medical education program that makes it mandatory for a person not to participate in such training poses constitutional and religious freedom risks and can be interpreted as violating the rights of students and doctors. A graduate medical education program must implement opt-in abortion training due to these legal and constitutional concerns.