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

“The ACGME ... states that a [training] 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] non-compliant with its accreditation requirements.”

From a Texas Attorney General Opinion released last week, which concludes that Texas must ignore any ACGME accreditation refusals stemming from a program's not providing training in abortions.

Dear Senator Campbell:

You ask several questions related to medical schools and accreditation standards of the Accreditation Council for Graduate Medical Education ("ACGME") in conjunction with the federal Coats-Snowe Amendment. 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 specifically provides that

[t]he Federal Government, and any State or local government that receives Federal financial assistance, may not subject any health care entity {includ[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) the entity refuses to undergo training in the performance of induced abortions, to require or provide such training, to perform such abortions, or to provide referrals for such training or such abortions;

(2) the entity refuses to make arrangements for any of the activities specified in paragraph (1); 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….

The ACGME describes itself as "an independent, not-for-profit, physician-led organization that sets and monitors the professional educational standards essential in preparing physicians to deliver safe, high-quality medical care to all Americans." {As of July 2020, ACGME is the sole accreditor for graduate medical education.} The ACGME imposes requirements on graduate medical education programs to obtain and retain accreditation if the programs substantially comply with the requirements. "If a program violates the ACGME's requirements, [it] may receive a warning or be placed on probation. If the violations are not cured, then the ACGME may withdraw its accreditation of the program." {Accreditation implicates federal funding a graduate medical education programs may receive.} …

The ACGME states that "[a]ccess to experience with induced abortion must be part of residency education" and that programs must be structured such that residents may "'opt out' rather than 'opt in' to this curriculum, education, and 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. The ACGME then characterizes an opt-in program as being non-compliant with its accreditation requirements. With this background and context, we consider your inquiry.

[I.] Pursuant to the Coats-Snowe Amendment, and contrary to ACGME standards, Texas medical schools may provide training on induced abortions on an opt-in basis.

As discussed above, the Coats-Snowe Amendment prohibits state or local governments receiving federal financial assistance from discriminating against a doctor or student who refuses to undergo induced abortion training, or against a graduate medical education program that refuses to provide or require training in the performance of induced abortions. Reliance on the ACGME standards, which require induced abortion training, is inconsistent with, and thus conflicts with, federal law. The Coats-Snowe Amendment instructs state and local governments how to respond to such conflicting accreditation standards. It states that

[i]n determining whether to grant a legal status to a health care entity (including a license or certificate), or to provide such entity with financial assistance, services or other benefits, the Federal Government or any State or local government that receives Federal financial assistance, shall deem accredited any postgraduate physician training program that would be accredited but for the accrediting agency's reliance upon accreditation standards that requires an entity to perform an induced abortion or require, provide, or refer for training in the performance of induced abortions, or make arrangements for such training, regardless of whether such standard provides exceptions or exemptions.

In other words, the Coats-Snowe Amendment requires the State of Texas to: (1) recognize as accredited any graduate medical education program that does not offer or require induced abortion training if it otherwise meets the licensing or accreditation criteria; and (2) license any doctor or student who completes their training at such a program or who does not otherwise participate in induced abortion training. Thus, while the Coats-Snowe Amendment contains no language directly requiring graduate medical education programs to provide induced abortion training on only an elective, opt-in basis, it effectively disregards ACGME's opt-out accreditation standard and allows those programs to provide abortion training on an opt-in basis without an accreditation consequence.

[II.] Opt-out induced abortion training may implicate conscience rights of doctors and students.

The language of the Coats-Snowe Amendment does not specify that individual graduate medical education programs must offer opt-in induced abortion training. But a program that forces a person to affirmatively opt-out of such training potentially implicates other conscience rights of doctors and students. For example, the Texas Religious Freedom Restoration Act (TRFRA) and the federal Religious Freedom Restoration Act (RFRA) protect a person's free exercise of religion. Both the TRFRA and the RFRA prohibit the government from substantially burdening a person's free exercise of religion unless it is necessary to further a compelling government interest and is the least restrictive means of furthering that interest.

To the extent no compelling government interest exists for requiring doctors and students with conflicting religious beliefs to undergo such training, the State's or medical school's adherence to opt-out requirements could violate the TRFRA and the RFRA. Similarly, a court could determine the State's or a medical school's adherence to an opt-out abortion training requirement violates the First Amendment to the extent it coerces a person to forgo his or her First Amendment rights. Given these constitutional and statutory concerns, a graduate medical education program should implement opt-in induced abortion training.

Summary

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. It requires the State of Texas to disregard Accreditation Council for Graduate Medical Education accreditation standards that compel the provision of induced abortion training on an opt-out basis, thereby allowing graduate medical education programs to provide induced abortion training on an elective, opt-in basis.

Furthermore, a graduate medical education training program that forces a person to affirmatively opt-out of such training raises constitutional and religious freedom concerns and implicates conscience rights of doctors and students. Given these constitutional and statutory concerns, a graduate medical education program should implement opt-in induced abortion training.

Comments

[John F. Carr]

What is the legal consequence of not being ACGME-accredited? It is easy to think of cases where it is not indisputable on the available record that a school would be accredited except for violating ACGME doctrine on abortion.

[DaivdBehar]

Zero tolerance for woke. Cancel the ACGME.

[Gasman]

The consequence of not being ACGME accredited?

For the program, they loose federal dollars that support the training program, over $100,000 per physician trainee per year. Physicians in training do no directly generate revenue, that is, have bills submitted under their name to medicare or medicaid, for work they do during training.

Consequence for the residents in training:
A physician completing residency training at a non-approved program will not have ACGME certificate of training. When it comes time to obtain state licensure for independent practice, malpractice insurance, and hospital admitting or operating privileges, they might find that they are functionally unemployable.
Thus, it is the trainees who ultimately determine the death of a training program. Residents will sensibly flee a program on the ropes of probation for brighter programs that can guarantee ACGME certificates of completion of training.
A few physicians with weaker resumes who could not otherwise obtain acceptance into a competitive residency training program or field might gamble on training at a probationary or non-accredited program on the chance that accreditation might be obtained in time for their training to count; it is an expensive and risky gamble.

[fabvom]

So if I understand this correctly the potential end result would be the ACGME withdrawing accreditation from Texas residencies. Currently in order to get board certified a physician must graduate from an ACGME accredited residency. So this could create a scenario where doctors who graduate from Texas residency programs would effectively be locked into practicing in Texas only.
I'm not sure if this would mean that Texas hospitals would then be forbidden from requiring board certification for their physicians? This seems crazy, but unless I am misreading something it would be the end result unless either Texas or the ACGME changes their rules.

[John F. Carr]

It's a federal law so the results ought to be the same nationwide.

[Frank Drackman]

docs can always start their own Board, like Rand Paul did.

[Rossami]

No, you have it backwards. The ACGME is (or is threatening to) withdrawing accreditation to training programs across the US if they either don't offer abortion training or offer that training only on an opt-in basis. If Texas is right, that withdrawal of accreditation is a violation of federal law. Withdrawals solely on that basis will be deemed to be reinstated (or accreditation granted) for the program.

In theory, there will be state-specific implications. In practice, this is the first step toward litigation based on the federal law. The result of that litigation will be a nationwide ACGME policy one way or the other.

[NumaNumaPompilius]

The law only prohibits the government from discriminating in that fashion. So arguably it would be a violation of federal law for any state to treat training programs that refuse to teach abortion procedures (and the doctors who graduate from them) differently from those that do. But ACGME itself is not in violation of any law (unless they're acting in some sort of quasi-state capacity that makes the law apply to them in a way I'm not seeing)

[ravenshrike]

What would happen in the long term after some court cases filed against a state demanding ACGME accreditation in order to practice as a physician in that state is that effectively it would force states to drop accreditation requirements entirely until an alternative accreditation source that did not require abortion training was accepted. And there would be plenty of people willing to fund such lawsuits.

[Rossami]

Given the government-mandated connection between accreditation and licensure, ACGME is an agent of the state and therefore inherits the government's non-discrimination obligations.

ACGME could get out from under these obligations if the government broke the connections between accreditation and licensure. But it's worth noting that they lobbied for those requirements in the first place.

[Darth Chocolate]

This is the problem with having "independent" cartels deeming who is and is not worthy of credentialing.

The same can be said of ABET accreditation in Engineering, as a requirement for a PE license is generally graduation from an ABET accredited school (although some jurisdictions allow for alternative paths).

[Stephen Lathrop]

Yeah, what a horror it is to have private civil institutions with actual influence over what happens in society. The flip side, of course, is that every standard-setting function defaults to government.

Conservatism, if that is what this is, has traveled a long way from Burke.

[Darth Chocolate]

Sorry, professional licensure is a state level function. Why they abdicate their responsibility to an unaccountable cartel is madness.

It like allowing the ABA to have a say in legal education without any governmental oversight. Oh, wait, I guess that's the way it works.

It is one thing to have an independent body to make recommendations regarding the educational requirements in a non-partisan manner. It is entirely wrong to have political agendas dictating what is and is not considered education.

For example, if the ABET requires courses in mechanics, that's fine. For the ABET to dictate that mechanics must be taught in an LGBT+ non-patriarchal paradigm that celebrates diversity is a perversion of mechanics. I am unaware that ABET even has this on their radar screen, but I use it as an example.

Once you bring politics into it, it becomes indoctrination - not education.

[ReaderY]

So the only people who can be trusted not to have a political agenda are the politicians?

[Charles Epperson]

No, since it is political it should be addressable in the political arena. There is at least accountability for the most part with the actual Government.

These "independent" boards are unaccountable and cannot be regulated at all.

[Darth Chocolate]

Thank you.

[bernard11]

Why they abdicate their responsibility to an unaccountable cartel is madness.

Maybe it's because the cartel has a good idea of what constitutes adequate training, while the yahoos of the Texas legislature don't have a clue.

It is entirely wrong to have political agendas dictating what is and is not considered education.

Yet that is what Texas is doing. And not just in medical education.

[Darth Chocolate]

And it is precisely what ACGME is doing by requiring the abortion component.

Because you obviously cannot be a competent brain surgeon if you don't have a few D&C's under your belt. Let's just hope the abortion training doesn't kick in at the wrong time.

It is wrong to make this a blanket requirement. Make it an elective.

[David Nieporent]

I don't think you bothered to read the story before commenting. ACGME doesn't make the training a blanket requirement; it is an elective.

For the doctors. What ACGME is doing, which is purportedly inconsistent with federal law, is making it mandatory for training programs to offer the training, not for any doctor to undergo it.

[Rossami]

It's a little more complicated than that. ACGME is making the training a requirement that programs may (or may not) allow individual doctors to opt-out of. That's not the same as making it an elective - something you would typically opt-in to.

[Gasman]

ACGME does tailor resident training to the specialty.
So no, neurosurgeons would not be asked to train in abortions; likely if they requested to do so their program would decline, as this would take time from brain surgery training, and be outside the scope of practice of the brain surgeons who train resident brain surgeons.

OB/GYN residents are the obvious training target for reproductive interventions, including abortion. Family practice docs will spend a few months of their 3 years residency birthing babies. They might have the option to learn abortion in their residency if the OB/GYN department had teaching bandwidth to spare.

[Rossami]

re: "Maybe it's because the cartel has a good idea of what constitutes adequate training"

Maybe in theory but the evidence is very clear that they are not acting on those ideas. Read any of the articles here about licensure abuse. Hair-braiders, masseusses, dentists, etc. These cartels are abusing the "public safety" and "education" claims to create artificial barriers to entry and/or to impose their own political agendas.

[bernard11]

Sure there is licensure abuse, but that doesn't mean it's universal. There are pretty big differences between hairdressers and doctors.

A lousy haircut is one thing, a botched operation something else.

[ReaderY]

I see this particular issue - whether a hospital that doesn’t believe in/do abortions can operate a residency program - as a separate issue from the general question of accreditation. Society is sufficiently split on the issue that it seems to me not unreasonable for government to step in and override the accreditation association to permit people to be doctors without requiring them to be trained in abortions, and perhaps on a few other very socially controversial issues where the accreditation association takes a strong position in one direction that is widely disagreed with. And I see that as a separate issue from how to do accreditation generally.

[David Nieporent]

Sorry, professional licensure is a state level function. Why they abdicate their responsibility to an unaccountable cartel is madness.

The appropriate focus of your ire should be licensing, not accreditation.

[Michael P]

Doctors mostly can't get a license unless they have credentials from an accredited institution. That's one angle where this becomes a problem. The other problem, as pointed out above, is if an institution loses government funding as a result of discrimination that is illegal under this federal law.

[ducksalad]

Mr. Chocolate, if it makes you feel any better ABET hasn't gone that way, at least not yet. They have been putting more emphasis on "soft skills" but it's fairly generic stuff about communicating well and being able to work on a team. One opening for the woke is a requirement to be aware of the societal impact of engineering decisions, but most programs satisfy one by covering environmental and safety regulations, and one can't really object to that.

ABET *is* more than a little cartel-ish. As others have noted, it's main use is as a way to judge whether an out-of-state program is real. There's a problem with ABET but handing that job to federal agency would make it even worse.

[rsteinmetz]

I'm an Architect licensed in 11 states. Most Architects are required to have a degree from a National Architectural Accrediting Board (NAAB) accredited program as a condition of licensure. This allows the 55 licensing boards to judge the adequacy of the education of any graduate from a US and some foreign schools. The individual state boards can't be expected to be familiar with the quality of all 172 programs at 136 different schools including 4 overseas. Some states have provided exceptions for some local schools that were not accredited and some states provide alternate means qualifying for licensure. In addition every jurisdiction generally requires passage of the National Council of Architectural Registration Boards (NCARB) examination and most accept licenses from other states as a basis for granting candidates a license without substantial additional requirements.

States generally require a license before providing services within that state, mostly to make sure the Architect is familiar with the local requirements and that board has jurisdiction over the Architect should something go wrong.

The system is somewhat cumbersome but does provide uniformity of qualifications.

Engineering generally operates in a similar way.

[grb]

(I just want to applaud another architect commenting here. Can't leave it all to lawyers - they'll muck-up everything)

[Brett Bellmore]

Depends on the field of engineering. Usually customer facing engineering works that way.

I'm a tooling engineer, approaching retirement. I'm not in any way licensed. Though I have substantial relevant college education, I arrived at being an "engineer" by apprenticeship, starting as a detailer, and am one because my employer deems me one.

[ReaderY]

I imagine this issue would need to get resolved, and the Texas Ag’s opinion tested, through a lawsuit. But perhaps a lawsuit might need to await actual enforcement of the ACGME’s position against a dissenting hospital.

[John F. Carr]

And like performing an abortion in violation of SB8, refusing to teach about abortion is a risk where the cost of winning may be too great to bear.

Below this article I saw an ad, presumably selected based on the contents of this web site: "Board Cert: Diversity Medicine". I like to imagine that's about race confirmation surgery, but it's probably nothing so exciting.

[Kenneth Almquist]

I don't expect this to end up in court. The State of Texas, as far as we know, is going to follow the legal advice of its Attorney General, in which case there's no reason to sue Texas. The Texas Attorney General's opinion doesn't identify any limitations on what ACGME can do, so it doesn't provide a basis for suing ACGME.

[bernard11]

a program that forces a person to affirmatively opt-out of such training potentially implicates other conscience rights of doctors and students. For example, the Texas Religious Freedom Restoration Act (TRFRA) and the federal Religious Freedom Restoration Act (RFRA) protect a person's free exercise of religion. Both the TRFRA and the RFRA prohibit the government from substantially burdening a person's free exercise of religion

So apparently students can opt out of the abortion training, but the AG says doing so would somehow "substantially burden" free exercise.

And I say bullshit. I'm really tired of this crap. Filing out a form or something is not in any way shape or form a "substantial burden."

I mean, really. There are way too many people in this country using religious belief as an excuse for all kinds of nonsense.

[Darth Chocolate]

Just like the Branch Covidians and their patron St. Fauxi.

Now there's a religious cult if there ever was one.

[Rev. Arthur L. Kirkland]

Medicine is a reality- and science-based endeavor.

Competent adults neither advance nor accept superstition-based arguments or positions in reasoned debate among adults, particularly with respect to public affairs.

The mainstream should not permit supernatural nonsense to interfere with accreditation and licensing of medical professionals -- and will not, over the long term, in my judgment. Especially not in advanced, educated, successful, modern states, and not with respect to national standards. There may be a few backwater jurisdictions that try to flatter superstition at the expense of medicine, but I doubt they will act as separatist misfits forever.

[David Nieporent]

It's hard to see how requiring an opt-out could burden a student's free exercise rights — but as I mentioned above in response to Darth Chocolate, this rule does require that the training be offered, so if a student wanted to be trained, the training program would be required to provide it. Which could implicate the training entity's religious freedom.

[Stephen Lathrop]

The nation's vital interest in adequately trained physicians—including adequately trained anti-abortion physicians—vastly outweighs any religious burden which adheres to putting aside a see-no-evil, pro-ignorance approach to medical practice.

[Brett Bellmore]

The issue here is that abortion is a niche specialty in medicine, and a controversial one that most people pursuing a medical career want nothing at all do do with.

Imagine for a second that the ABPN mandated instruction in conversion therapy, with an opt out for individual students, but not educational institutions. That's a pretty good analogy to how controversial mandating abortion training is.

[grb]

Brett Bellmore: "That's a pretty good analogy ..."

Who are trying to kid? I expect the percent of Doctors-in-training who support a woman's right to chose is equal to the substantial majority support of Americans overall - probably significantly higher. The only polls I found were excessively tiny or old, but they both showed 60-70% for woman's choice vs 20-30% against.

What does that do to your analogy? There will never be more than a minority faction supporting state womb control, and you can expect that number to shrivel even further once our Taliban finally seizes power. Parading faux-piety has come pretty easy for them up to now, with Roe existing as a safety backstop. Things will get harder once they finally (finally!) get their dreamed-of opportunity to blight the lives of tens of thousands of women yearly.

[Rev. Arthur L. Kirkland]

Meetings of Libertarians For Statist Womb Management and Libertarians For Big-Government Micromanagement Of Ladyparts Clinics are convened regularly at this site -- which is odd, because the Volokh Conspiracy advertises that it is "often libertarian."

Can anyone explain this?

[Stephen Lathrop]

It is an incompetent analogy.

Abortion is bedrock, bog standard medical practice. It has to be understood by medical practitioners for all sorts of reasons, and not purely involving pregnancy termination. A physician who has no intention to practice abortions may nevertheless need to understand abortion methods and their medical implications to consult adequately about a host of medical conditions and procedures.

Even abortion opponent physicians need to know abortion procedures in detail to advise responsibly patients who have abortions scruples, but also medical conditions which threaten them medically, or which threaten a fetus they carry. It is a reasonable medical training standard to require that a physician not practice blanket anti-abortion counseling without understanding thoroughly the medical implications of that advice.

[Krayt]

Exactly. The occasional botched legal abortion, one would hope the ER doc in the most anti-abortion hospital in the country was aware of the kinds of things that might have gone wrong.

[Rev. Arthur L. Kirkland]

Some hospitals might wish to rely on divine intervention and divine inspiration rather than science, education, experience, credentials, and expertise . . . or perhaps figure the woman invited demons into the situation and deserves what she gets.

Carry on, clingers.

[Rossami]

You are ignoring the point of the analogy. Yes, we know precisely how the mechanics of abortion work. It is, as you say, bog standard. We also know precisely how the mechanics of conversion therapy works. Brainwashing is also bog standard.

What makes conversion therapy wrong is not the mechanics or medicine of the procedure but the ethics of whether it should be done at all. What you are ignoring is that for a significant portion of the population (including some doctors), abortion is just as ethically problematic.

[Stephen Lathrop]

What you are ignoring is that for a significant portion of the population (including some doctors), abortion is just as ethically problematic.

So what? It remains an inapt analogy. Put the analogy aside, and you cannot reach the same conclusion without it. Which means you are just trying to use the analogy to change the subject and confuse the reasoning.

There is nothing ethically problematic about requiring a doctor to know in detail about a procedure, even if it is a procedure the doctor will not for ethical reasons plan to perform. Insistence to the contrary smacks of an attempt to use religious legal leverage to deprive medical students of needed training which religionists prefer would be withheld.

[Brett Bellmore]

How precisely would any doctor need training in a procedure they will never use?

[Brett Bellmore]

Precisely my point. And I question if you can even call it "brain washing" if the patient volunteers for it.

[bernard11]

Imagine for a second that the ABPN mandated instruction in conversion therapy,

No. I won't imagine that. It's a stupid analogy.

Conversion therapy is RW bullshit. Abortions are actual procedures that doctors perform. Objections to conversion therapy are based on the fact that it is destructive nonsense, not on religious belief.

[Rossami]

I'd be a lot more sympathetic if you weren't using the same specious "undue burden" argument every time someone brings up voter identification. You're coming off as just pissed-off that conservatives have the gall to use progressive tactics.

[rsteinmetz]

Requiring a student to make a statement of their beliefs to opt out could have a negative impact on a students relationship with other students and faculty, while not taking an elective would not have the same effect.

[Krayt]

Is that a religious burden? Then the sisters of whatever didn't even want to be forced to fill out a form to decline something or other, that suggested a religious burden, but even that seemed strained.

For that matter, most religions expect you to proudly support Jesus, and not deny him three times before sunrise.

[rsteinmetz]

I don't think the burden needs to be religious, but comes from publicly stating unpopular religious beliefs.

Not all people who object to abortions are Christians, that just happens to be most of them here.

[Rev. Arthur L. Kirkland]

Not all religious kooks are Christians, although many Christians strive to make it seem that they are.

[bernard11]

Am I? Every time? I think it depends on what the requirement is, and how hard it is to meet. Here we are talking about filling in a simple form or something like that.

I do bring up the idea that the GOP is engaged in voter suppression. Because they are.

[Rev. Arthur L. Kirkland]

Not merely voter suppression, but indeed race-targeting voter suppression.

Which is why they are the losers of America’s culture war. America is great because our bigots don’t win.

Carry on, though, clingers . . .

[ReaderY]

I think the best argument here was that the law applies not just to individuals but to institutions, so the hospital itself can opt out.

But I think this particular argument is a weak one. I am very skeptical that requiring opt-out, by itself, violates anything.

[Dan Lo Pan 2]

There are plenty of reasons for a woman to need a D&C that don't involve pregnancy termination.

[Rev. Arthur L. Kirkland]

Trying to reason with superstitious hayseeds, half-educated bigots, and disaffected hayseeds is pointless and likely counterproductive.

[Alpheus W Drinkwater]

That's true, but perhaps a D&C for those other reasons wouldn't be covered by Coats/Snowe, since the text of the statute specifically says "abortion." Just a guess.

[Dan Schiavetta]

Texas is dumbing down and turning into an evangelical theocracy.

"They had won the championship of the East-middle Kansas Conference, which consisted of ten denominational colleges, all of them with buildings and presidents and chapel services and yells and colors and a standard of scholarship equal to the best high-schools." -- Elmer Gantry

[ReaderY]

I may be misunderstanding the opinion. If the opinion says a hospital can opt out, it may well be correct. If it says that the law prohibits the accrediation agency from having this as a requirement for anyone because requiring someone to opt out might violate someones rights, that’s totally bogus.

Federal law does not prohibit hospitals from serving pork, operating on Saturdays, etc. least someone might object but feel unconfortable opting out.

And if it is simply daying hospitals are entitled to opt out, I expect we will have to see if the accrediting agency honors the opt-out before there can be standing for a lawsuit. The requirements themselves wouldn’t violate the law, just refusing to honor an opt-out.

[Rev. Arthur L. Kirkland]

Hospitals are not obligated to participate in mainstream programs, including residency, accreditation, teaching, etc. But if they wish to participate in the mainstream rather operate on Misfit Island, they should not be entitled to defy national standards, not even if they claim 'the fairy tale made me do it.'

[Rossami]

Yes, you are misunderstanding the opinion. Let's see if we can stick with your "serving pork" analogy to sort it out.

The accreditation agency is requiring the hospital to serve pork. The hospital is not allowed to opt out of a pork-based menu.
The accreditation agency is further imposing requirements that make it more difficult for patients to not get served pork. That is, the patients must individually opt-out of the pork menu. The hospital is not even allowed to offer a beef-based standard menu with a pork opt-in.
Flouting the accreditation agency's requirement triggers legal consequences for the hospital and therefore for their patients.

The opinion effectively says that making it harder to not get served pork has the effect of violating the patients' civil rights. Implied but utterly uncontroversial is that the triggering of legal consequences makes the accreditation agency an agent of the state and thus subject to federal non-discrimination law. They cannot do by proxy what they cannot do directly. The fact that it's two proxies (government to agency to hospital) does not change the analysis.
Therefore, any negative decision by the accreditation agency on the sole basis of that rule must be void.

[Alpheus W Drinkwater]

Okay, so why would making it harder to not get served pork (or not get abortion training) violate the patient's civil rights? That's the part I don't understand. I thought the issue was forcing the teaching institution to offer abortion training.

[Brett Bellmore]

Imagine for a moment that the patient is Jewish or a Muslim.

[Alpheus W Drinkwater]

And religiously observant, I'll imagine that too. They may need to check a box or take some other step to opt out of meals that contain pork. Still don't see the civil rights violation.

[Rossami]

Well, the court precedents disagree. They see it as a first step toward having to ask permission to practice (that aspect of) their religion. Another way to think of it is as chilling their right to express their religion.

Yes, being asked to check a box is a very small infringement. But given the very extensive historical evidence of governments oppressing and/or suppressing religious minorities, it is not a path that we want to let the government even start down. Especially when they were unable to present a compelling government interest for the check-box in the first place.

[hobie]

These are the pressing issues that keep us Texans up at night. You couple this with the vote count in Pennsylvania and you can see why our AG is so busy

[Alpheus W Drinkwater]

You'd think he would just wait until Dobbs is decided. If abortion is illegal in Texas, surely Texas medical graduate programs can't be expected to train students in an illegal procedure.

[Rev. Arthur L. Kirkland]

Expectations aside, why would a Texas statutory choice or a Texas medical program’s choice require a national accreditation authority to revise its standard to accommodate the superstition-driven preferences?

[Stephen Lathrop]

Are criminologists untrained in illegal procedures? I prefer my medical experts conversant with medical procedures, legal and illegal alike. Do you suppose no graduate of a Texas medical program will ever encounter a patient with symptoms consequent to illegal abortion?

[John F. Carr]

If I had to estimate, I would say the average graduate would never have to diagnose and treat consequences of an illegal abortion, but somebody in this year's class will. So the mode of the distribution is 0 per career, but the mean is not 0.

And now I have Kaposi's sarcoma on my mind. It was a rare disease a doctor might see a few times in a career. Then about 40 years ago it started showing up every week in some cities.

[Alpheus W Drinkwater]

I would prefer my medical experts that way also, but if Texas outlaws abortions, it's a little hard to picture how a graduate medical program there would train their students without breaking the law. And I don't know for sure, but I would guess the complications that arise from a botched backroom abortion are significantly different than performing a medical abortion.

[David Nieporent]

Do you suppose no graduate of a Texas medical program will ever encounter a patient with symptoms consequent to illegal abortion?

I assume the vast majority of such graduates will not. But so what? You don't need to know how to perform an abortion to know what to do if you see a patient bleeding, any more than you need to know how to do a heart transplant if you encounter a patient whose heart is faulty.