Today’s hearings include medical advice from psychiatrists, obstetricians and the masters of maternity hospitals.
THE OIREACHTAS COMMITTEE on Health and Children today began three days of public hearings on the government’s proposed new legislation on abortion, following its decision to legislate to allow abortion within the terms of the X Case ruling.
The first day of hearings – split into four two-hour sessions – included submissions and a Q&A with the Department of Health and Irish Medical Council (9:30am), the masters of three maternity hospitals (11:45am); psychiatrists (2:45pm) and obstetricians (5pm).
Good morning, and thanks for joining us. It’s shaping up to be a pretty intense few days in the Seanad chamber, as medical, legal, professional and faith groups all offer their thoughts on proposals to offer limited legal abortion in Ireland.
We’ll be carrying live video of proceedings all week, with liveblogs throughout.
Just to familiarise you with what’s going on: these are meetings of the Joint Oireachtas Committee on Health and Children (whose members you can see here). It’s holding three days of hearings, with the first day (today) devoted to medical advice, the second to legal advice, and the third to moral advice.
As you can see in the text above, today’s hearings are broken into four sessions, with the Department of Health and the IMO; the masters of maternity hospitals; obstetricians and psychologists offering their thoughts in that order.
The first hearings, brought to order at 9:30am, will include Geraldine Luddy, a principal officer at the Department of Health, and the Irish Medical Council’s president Kieran Murphy and chief executive Caroline Spillane.
By the way, in a break from tradition, all of this week’s hearings will be held in the Seanad chamber – taking advantage of the fact that the Oireachtas is still technically in recess. The chamber is much larger than the traditional committee rooms and will allow for greater numbers of politicians and interested parties to be present.
It’s Gavan Reilly here, by the way. Hello. I’ll be taking the first two-hour stint – today’s hearings will go on until 7pm, so we’ll have our team of writers taking shifts throughout the morning and afternoon.
So – we’re in business. Chairman Jerry Buttimer TD (Fine Gael) is calling the house to order, going through the usual business of asking people to turn off their phones, and the committee – marking the first Oireachtas business since the death of junior minister Shane McEntee – begins with a minute’s silence in memory of the late Meath East TD.
Buttimer: In December the government decided to address the A, B and C ruling by introducing legislation in line with the Constitution (which gives equal regard to the lives and mother and child), as has been interpreted by the Supreme Court (which says the mother has a right to an abortion where their life is put at risk by continuing the pregnancy).
Buttimer says the committee will compile a report for the government, based on the reports made to it this week. “It is vital that these meetings are held in a manner that is respectful and tolerant.” He adds that the list of people due to attend this week was compiled based on invitations suggested by members of the committee and other members of the Oireachtas.
Buttimer says the insights of medical professionals today will help to frame the committee’s hearings for the rest of the week.
“I am conscious that we are meeting in the eye of the nation… we will have a constructive, positive and comprehensive debate.”
A hint as to the mechanics of the rest of the week’s meetings: members of the committee will get 60 minutes for Q&A to the witnesses; non-members (the other TDs and Senators who are not among the committee’s own members) will get another 20 minutes. This is after opening statements, and there’ll be another 10 minutes at the very end for summaries.
A quick reminder, before we begin, on privilege: Witnesses to committees have absolute privilege (anything they say cannot be considered libellous, for example) but if someone is asked to stop speaking and they continue nonetheless, they only have qualified privilege.
And away we go.
Geraldine Luddy from the Department of Health will give a background briefing to kick us off. She says she is “confident” that the hearings will help the Department of Health strike the right balance in the legislation. (By the way, it’s actually the Department of Justice that will produce the final legislation here.)
She recalls that the matter of abortion has been discussed at public and Oireachtas level has been discussed regularly in recent years, with a conclusion each time that full legislation was the most appropriate way to bring legal clarity and definition to the area.
Luddy summarises the state of play to date: abortion is currently a felony under laws from 1861, and can lead to life imprisonment. In 1983 we held a referendum introducing a new clause where the state acknowledged the “right to life of the unborn” and guaranteed to seek to uphold this right, with equal regard to the life of the mother.
In 1992, the X Case resulted in the Supreme Court interpreting this clause to the effect that an abortion could be carried out if there was a risk to the life of the mother, and if this risk could only be addressed by terminating her pregnancy.
Luddy continues: We had another set of referendums in 1992; the Twelfth Amendment, which would have removed the threat of suicide as grounds for an abortion, was defeated. However, other referendums allowing people to distribute information on abortion, and guaranteeing the right to travel to seek an abortion, were both approved.
Another referendum was held in 2002 which again proposed to remove the threat of suicide as grounds for abortion. Again, this was rejected.
Luddy moves on to the A, B and C case. In the case of Miss C – an applicant who had become pregnant and feared that her cancer could return as a result – it was found that no criteria or procedures had been named in Irish law, by which the probability of a threat to Miss C’s life could be determined. This was a breach of her rights under the European Convention on Human Rights.
This ruling prompted the creation of an Expert Group which submitted its report two months ago.
Luddy: The government agreed to introduce legislation to address this ruling, and to act further once the Department of Health outlined its policy requirements. The committee’s deliberations will help the Department to decide upon these requirements.
We now move onto Kieran Murphy, the president of the Irish Medical Council.
Kieran Murphy, IMC: From a doctor’s first day in college until their retirement, the IMC’s role is to ensure the highest quality of tuition, care and competence. In the interest of patient and public safety, the Council has been given sole responsibility to ensure only doctors with the necessary education, training and skills are registered to practice medicine in Ireland.
Murphy: The IMC also offers guidelines to its members on registered medical ethics. This is compiled by an ethics working group including members and non-members, including experts from medicine and other fields. It is a principle-based document that must apply to all registered doctors irrespective of their specific field. These are the cornerstone of each doctor’s practice.
Murphy again recaps that it is not lawful to encourage an abortion in individual cases, and that doctors have a duty to provide care, support and follow-up services to a woman who undergoes an abortion abroad.
There are some circumstances where, due to the extreme immaturity of the baby, an intervention to save the life of the mother can result in the death of a child.
Murphy adds, specifically, that the IMC guidelines are not a legal code.
Murphy refers to the Expert Group report and a commentary it has compiled on this (which will be released to the public later). He summarises the IMC’s input as follows:
- The treating doctor’s opinions and rationale for decision-making must be documented;
- The diagnosis must be evidence-based and expeditious;
- The decision should be formally notified to the woman.
The doctors must be registered in the specific division, and have completed training to the highest international standards. This is so the patient can be assured that the doctor possesses the necessary knowledge and skills to be able to make the appropriate skills.
The view of the IMC is that special procedures do not need to be developed to deal with the case of emergencies. The location of medical facilities, where such procedures could be carried out, is a matter for the Minister for Health.
A review panel should have access to legal expertise on a formal basis, the IMC believes.
On conscientious objection: legislation and registration should include the ability for an individual to exercise the right of conscientious objection, but that any such objection does not absolve a doctor of performing the best possible treatment.
The right to conscientious objection must be balanced against the right of the patient, particularly in an emergency case.
Murphy concludes by saying the IMC believes it is in “the public interest that doctors have legal clarity when making clinical decisions”, and that the appropriate part of the 1861 Act – which criminalises any woman who undergoes an abortion, and a doctor who performs one – should be repealed.
Questions will be delivered by three members at a time, and answered in bulk.
The questions begin with Billy Kelleher TD (Fianna Fail). Has there ever been a termination carried out in this country under these guidlines, and has a complaint ever been made to the IMC over a doctor’s refusal to do so? Also, does the IMC have any concerns that legislation could be too prescriptive – where legislation could make it to difficult to discern a doctor’s duties without a lawyer being present? Finally, Had the IMC and its members come across difficulties at how clinical decisions were made in the past and at present?
Caoimhghín Ó Caoláin TD (Sinn Féin) again asserts the current legal state of play, and refers to the IMC’s belief that clinical decision makers must be registered in a specialist division (presumably obstetrics and gynaecology). Does this include psychiatrists? What are the specialised divisions? And are there enough of them to deal with the country’s maternity wards on a 24/7 basis? He says we must first be sure there are enough staff to make the appropriate decisions.
Mattie McGrath TD (Independent) wants to make a question to the Department of Health, and is interrupted by Buttimer who says questions for the Department itself will not be put today (as was agreed at a procedural meeting last night). He can put the questions later in the week if he wishes, Buttimer says.
So, onto Ciara Conway TD (Labour), the committee vice-chair. She only has one extra question, on conscientious objection. Can the IMC give examples of how this would manifest itself in everyday practice, and to offer a real-life example of how this could present itself.
Murphy’s responses: Firstly, to Kelleher’s question on whether any complaints have ever been made about termination of pregnancies. “To the best of my knowledge, The Council has not received any complaints about terminations of pregnancy”. The guide is a high-level principled documents covering a range of scenarios, including consent, and complaints are categorised under a variety of sections (as can be seen on the IMC’s website).
Whether the IMC has concerns about the legislation being unduly prescriptive… that’s up to the Oireachtas. It’s up to the Oireachtas to inform itself about the concerns about the range of stakeholders, including the IMC and professional groups. It’s only by formulating and helping to involve themselves that one can arrive at that conclusion. The IMC’s only main concern is the protection of the public.
Also on Kelleher’s question about differences between clinical situations… this is perhaps a better question for obstetricians appearing later, he says.
On Ó Caoláin’s questions and the IMC guidelines on abortion, “it’s important to understand that the guidelines that the council has published are not a legal code. They are guidelines to assist doctors in their practice.” All doctors work in environments with many different practice guidelines. It’s important that members understand that IMC guidelines are a further set of guidelines “in a framework which is compromised of many different guidelines – which are all underpinned by, and must be consistent with, the law.”
On Ciara Conway’s question about conscientious objection: Again, this is probably a better question for the obstetricians and psychiatrists later on, Murphy says – suggesting they are the ones who are at the front line and are more likely to see such circumstances.
Caroline Spillane, the IMC chief executive, chips in: on Kelleher’s question about complaints. In 2012 the IMC received about 420 complaints, categorised into very broad areas, such as ‘treatment’ and ‘professional standards’. She agrees that she is unaware of any complaint under the abortion-related section of its ethics guide. If one was submitted, the IMC has a legal framework to investigate and an inquiry may be held if there was evidence of a shortcoming.
With regard to registration and categories: There are 18,000 registered medical professionals, in five specific divisions including the ‘Specialist’ division, with between 3,000 and 4,000 members. There’s a sub-categorisation within that, which is detailed in the IMC’s annual report.
Here’s Senator Colm Burke (Fine Gael), who asks about which options the IMC sees as the ‘most workable’, and also discusses the fact that of 19 maternity hospitals in Ireland, only three have perinatal psychiatrists – all of which are in Dublin. Does the IMC believe the patient should come under their remit when deciding on a course of action?
Regina Doherty TD (FG) asks how many terminations under the threat of suicide have been carried out since the X Case ruling in 1992, and asks for a description of the procedures that lead up to a decision that an abortion should be performed.
Denis Naughten TD (Ind, formerly FG) has two questions: How has the abortion section of the guidelines changed from before and after the X Case, and also asks if the IMC is confident that in an emergency situation, there would be enough specialist expertise in each of the current 19 maternity hospitals to diagnose the risks to an expectant mother.
Kieran Murphy deals with Burke’s questions first: He refers to the IMC’s submission (which will be made public later) that the legislation should set out a criteria for the number of professionals involved, in collaboration with the stakeholders involved. The council’s primary role is to protect the public, by ensuring doctors have the skills and knowledge to practice safely. A doctor registered in the specialist division has a standard of training equivalent to the best in the world, which is why it believes doctors should be registered in its Specialist unit before making decisions on a subject like this.
It’s up to the HSE to determine if there’s sufficient capacity in the health service to meet the public’s needs, Murphy says, saying this should be referred to the psychiatrists speaking later.
On Doherty’s question: How many terminations have been carried out since X? “The Council does not have this information.” It only becomes aware of such procedures when a complaint is made. Because it’s not aware of any complaints having been made, it can’t discern whether such procedures have ever been carried out.
On Naughten’s question about the advice before and after X: The Council sees each edition of its guide as a “further refining” of its advice. The guide notes that medicine is continuously evolving – this is the reason why new guides are issued. There were ethical guidelines that pre-existed X, but the current ones reflect the current legal framework.
Spillane comments on the number of specialists available, and again underlines that the IMC’s role – which is merely to ensure that doctors have the best possible training and skills. It’s up to the HSE to ensure matters like the allocation of staff.
Denis Naughten has two follow-up questions: Why does the IMC not think there’s any need for provisions in the case of emergencies, and he asks again for some updates on how the ethical guidelines have shifted before and after X.
Kieran Murphy, on the first question, says the council’s position is simply that it doesn’t think it’s necessary to expand on why. The principles underlying a decision are similar, whether or not the decision is an emergency or not. The same procedures should apply in all situations.
On the second, Murphy again says the ethical guide is a “dynamic document” which is “continually being refined”. He paints an example by saying the most recent guide is from 2009 and has even since been supplanted by updates on the interactions between doctors and industry.
All doctors work within the law of the land. The Supreme Court ruling changed the law of the land, so the guidance that the council offers to doctors changed. The guidance always reflects the current legal position.
A bumper slew of questions…
Robert Dowds TD (Labour) asks about situations where doctors have to deal with pregnant women whose lives can only be saved by a termination. “To what extent are they in a legal quandary at the moment?” he asks, also seeking clarity on whether an abortion can be carried out if the mother’s health is at risk.
Seamus Healy TD (ULA) again wants to revisit the questions about conscientious objection, and the locations at which specialists work.
Catherine Byrne TD (FG) asks for clarification on the impact of an ‘extreme immaturity’ of the baby on the issue.
Peter Fitzpatrick TD (FG) wants elaboration on the IMC’s belief that doctors’ decisions should be documented and expeditious. How defines documentation, and what defines speed?
Senator John Crown (Ind), himself a consultant oncologist, asks if the IMC thinks the current setup – where practices are defined by referenda and courts, as opposed to by formal black-and-white legislation – is adequate.
He also discusses the possibility of ‘entryism’ on the Medical Council, where people may be admitted based on belief, and asks whether the opinions outlined by the IMC in this circumstance on these issues were unanimous or whether there was internal dissent about it.
Finally, a technical question: if someone asks if their health will be improved by a termination, and a doctor says ‘Yes’, are they in breach of medical guidelines?
Kieran Murphy reads Robert Dowds the current legislation on abortion – the Offences Against The Person Act 1861 – which makes it a criminal offence to undergo an abortion or to perform one.
Murphy dodges the questions on the health of the woman (as opposed to her life) because it was outside the scope on which it was asked to make a submission. “The Council has not taken a view on the health of the woman,” he says neatly.
Addressing Healy’s question on emergencies and staffing levels: the basis for decision-making shouldn’t be any different in an emergency or non-emergency situation, and it’s up to the Minister for Health to ensure the appropriate distribution of health professionals as they are needed.
Onto Catherine Byrne’s question about ‘extreme immaturity’ and what that means: “If a baby is delivered over 28 weeks, the likelihood of the child surviving is very high. If it’s less than 20 weeks then clearly that is inconsistent with survival. I suggest this is an issue that should be teased out with the obstetricians.”
On Peter Fitzpatrick’s request for clarification about ‘evidence-based’ decision-making… politicians will be aware that all doctors are legally required to keep professional confidence, and do so by remaining up-to-date in their practice. This to ensure the public is protected by having an up-to-date doctor who stays informed of new research.
Finally, asking “Deputy Crown” (sic) and clarity for doctors – again, ask the obstetricians. “The Council’s view is clearly that it is in the public interest that doctors have legal clarity.” Its guidelines are not a legal code, though they follow on from legislation, and they reflect the current legal framework.
Caroline Spillane (the Medical Council CEO) follows up on Crown’s question as to whether the IMC’s current position was unanimously agreed. by saying the ethics guide was made up by council members and non-council members, and chaired by a non-member. It took an evidence-based approach, she says.
Crown says his questions haven’t been addressed, and asks if the current situation (where no legislation has been issued) provides clarity and needs addressed, and asks again if the Council delivered any “watered-down recommendations” about emergencies as a result of an internal impasse.
Billy Kelleher (FF) also has a follow-up on conscientious objection: Does the IMC believe this should be made public? When should a clinician be required to tell their peers or administrators that they have a conscientious objection to carrying out an abortion procedure?
Murphy appears reluctant to answer Crown’s question on whether legislation is preferred to none, though he says the government’s decision to bring in legislation is “welcome”.
On the second question, Murphy says the Council – which has 12 medical members and 13 lay members – speaks with one voice. Each group attracts a variety of opinion, but it has agreed on a consensus view which is reflected in the submission today.
Regarding conscientious objection, the IMC believes an objection does not absolve responsibility to a patient in an emergency situation, and that a patient should be informed as quickly as possible of the possibility of a doctor’s conscientious objection becoming an issue.
Mary Mitchell-O’Connor TD (Fine Gael) asks about how a diagnosis of a risk to the life to the mother is made, and specifically what “evidence” is used in arriving at an “evidence-based conclusion”.
Caoimhghín Ó Caoláin TD (SF) is back in, and wants an indication of what sort of timeframes the IMC says in mind when defining ‘emergencies’ and so on.
On Mitchell O’Connor’s question, Murphy says the practice of medicine is increasingly evidence-based. This means making a decision involves weighing up the available evidence, and ensure the treatment option being provided is based on the best available evidence. All medical decisions should be evidence-based – including being familiar with the most recent literature, best practice and research.
To Ó Caoláin’s question on timeframes: more work needs to be done to tease out individual details within the final regulations. Again, Murphy says, this is probably a question better put to the people on the ground: the psychologists and obstetricians appearing later today. “This clearly will evolve with the development of regulations,” he says.
Back to Senator Colm Burke (FG): “Do you believe all three options [outlined in the Expert Group report] are workable?”
Murphy: The Council’s primary concern is for protecting the public. This is by ensuring the education and training of doctors is “at an appropriate standard, that is benchmarked favourably internationally”.
A member whose name I missed (apologies!) asks if the current situation and lack of legal clarity has cost any female lives, and asks whether, if the 1861 law is removed, should there be a duty of care towards the unborn child in legislation?
Billy Timmins TD (FG) asks about the impact of the Savita case – and for how long there has been any clamour to have the existing guidelines legislated for.
Senator Jim Walsh (FF) returns to the theme of diagnosis being ‘evidence-based’ – what is the evidence base of suicide as a ground for termination, in the IMC’s view? And does the IMC believe that there are two patients in a pregnancy and that this approach has served Ireland well?
Murphy responds to the question on how a risk of suicide is assessed. He says medicine is always evolving and doctors need to ensure that they remain up to date. Within each field it is important that knowledge and skills remain current – which is precisely why mandatory professional competence requirements were brought in. Doctors should be guided by their primary responsibility to act in the best interests of their patient, he says.
The current ethics guide, released in 2009, was developed after extensive consultation with the public, professionals, government and others. He adds that the IMC went out of its way to obtain a ‘Plain English’ mark from the National Adult Literacy Agency, so that the general public would be able to understand it.
That unnamed member was Terence Flanagan TD (FG), to whom Caroline Spillane says the council can only act based on complaints it has received. Having earlier said she’s not aware of any complaints having been made in the field of abortion.
(Interestingly, by the way, this indicates that the Medical Council has not received any complaints about the treatment of Savita Halappanavar, from either Savita’s family or from the other medical professionals who acted in her case.)
Sen Jim Walsh (FF) says his questions haven’t been answered, and with the clock running down, puts them again.
Sen Labhrás Ó Murchú (FF) says the IMC didn’t address earlier questions about whether its members had reservations about the previous lack of legislation (or otherwise). He also puts the question once more about how many people may have died because of the lack of clarity.
Sen Paul Bradford (FG) says a problem cannot be addressed without knowing its scale. How many complaints have been made to the Medical Council because of the current constitutional/legal position?
Terence Flanagan TD (FG) is back again and asks what clinical research exists to indicate a link between suicide and abortion.
Eamonn Maloney TD (Labour) raises concerns about the direction this morning’s hearing is taking – with the Medical Council, a professional registration body, being pressed for its opinion on matters when the IMC is not itself a legislative body.
Murphy addresses a comment made by Ó Murchú discussing how the current ethical guide was given its ‘plain English’ award, and outlines that process. He adds that a new Council is to be elected next year and that the guide will be revised by new Council after its election.
To Paul Bradford‘s question about complaints on the current legal situation: the council receives complaints if a doctor is deemed to be in breach of its guide. He isn’t aware of any complaints about doctors acting outside the guidelines on the field of abortion. He again reiterates that doctors are required to uphold modern best practice.
“Any clinical decision that is taken needs to be guided by the best available evidence,” he repeats, again adding: “Doctors have guidance from lots of different sources.” The Medical Council ones aren’t the only ones – individual disciplines like psychiatry have their own guidelines too.
Kieran Murphy makes a final submission, saying the Medical Council was grateful for the opportunity to contribute. He acknowledges that the current questions before the country are “challenging” but that the Council is committed to ensuring the public is protected to the best possible extent at all times.
And with that, the committee is adjourned for a few minutes. Phew! That was quite a bit of typing there…
OK – so, what have we learned there? Well, if we weren’t clear now, we can be pretty assured that the Medical Council’s role is only to regulate the profession and to ensure that doctors are trained to the highest possible standards.
It also isn’t aware of any maternal deaths as a result of the current legal position, though this is qualified by the fact that the Council would only become aware of one if a complaint connected to a death was submitted to it. It is not aware of any such complaints have been filed.
Finally, a main take-away point: the Medical Council believes the proposed new laws should provide for doctors to have conscientious objection in the field of abortion, but that a patient should then be put into the care of an alternative practitioner who does not have such objections.
In an emergency situation, however, the doctor is not absolved from their requirement to deliver the necessary and appropriate care to a patient who needs it. This suggests that a doctor should be permitted only to cite a conscientious objection if an alternative practitioner is available and can act with the appropriate speed.
And that’s that for now. The masters of the Rotunda, Holles Street and Kerry hospitals will be along at 11:45am to take questions, for whom Gavan Reilly signs off to leave you in the hands of Christine Bohan…
Hello all, Christine Bohan here taking over from my colleague Gavan Reilly. The 11.45am session has just begun and over the two hours, we’ll be hearing from doctors from three hospitals: Dr Rhona Mahony, Master of the National Maternity Hospital in Dublin, Dr Sam Coulter Smyth, Master of the Rotunda Maternity Hospital also in Dublin, and Dr Mary McCaffrey of Kerry Hospital in Tralee.
Here we go…
Dr Rhona Mahony of the National Maternity Hospital is first up to speak:
Dr Rhona Mahony of the National Maternity Hospital in Holles Street begins by saying: We are all here today with the primary objective of preserving life.
She sets out her credentials and background and says that one of the main issues involved is why doctors need enhanced legal protection where a woman may die and where treatment to save her life may involve termination of pregnancy. She says it must be made very clear that if there is any chance at all that a baby will survive at the threshold of viability, every effort will be made to save that baby – this seems to be directed at some of the questions which were made to the IMO in the earlier session.
Dr Mahony says she wants to reassure women in Ireland that doctors will always work to save the life of the woman if she is at risk of dying. “We will not hesitate to do so,” she tells the Committee. However, she says, the difficulty arises where the risk to life is not immediate.
Dr Mahony says many women with underlying diseases often continue with their pregnancy. “Women will risk their own lives to reproduce,” she says. She says the substantial issue is defining what the risk of dying is: “The interpretation of risk is not the same for all people,” she says.
Dr Mahony brings up the risk of death by suicide, which she says is “the most controversial issue” being discussed. She says: I’m not a psychiatrist, but as a woman, I am offended by some of the pejorative and judgmental views that women will manipulate doctors in order to obtain a termination on the basis of fabricated suicidal ideation. This also assumes that psychologists can’t tell the difference when someone is really suicidal or not.
Dr Mahony has finished up now and hands over to Dr Sam Coulter Smyth, the Master of the Rotunda Hospital in Dublin.
He begins by giving some facts and figures about treating women in the Rotunda. He says the hospital sees about 40 women with life-threatening illnesses every year. Of these, there are 5 or 6 cases a year where interruption of pregnancy is needed to save the mother’s life – he gives the example of maternal collapse, where immediate intervention is required, or an underlying illness such as cancer.
He says it is very rare for a woman to say that she is suicidal at the hospital.
Dr Coulter Smyth suggests some guidelines for how to decide whether a woman’s life is at risk. He recommends 2 senior obstetricians should be involved in making the decision, along with whatever specialist is involved (e.g. a cardiologist if it’s a cardiac issue, a psychologist if it’s a mental health issue).
Dr Coulter Smyth finishes up and hands over to Dr Mary McCaffrey of Kerry Hospital in Tralee.
Here’s a screengrab of the Seanad listening to Dr Rhona Mahony’s statement a few moments ago. Very unusual to see so many non-members of a Committee attending a meeting like this:
Dr McCaffrey is describing what it’s like for smaller and rural hospitals providing maternity care for pregnant women. She says it’s incredibly rare to see a woman in a life-threatening situation during pregnancy, re-iterating what Dr Mahony and Dr Coulter Smyth said.
She says in smaller maternity hospitals, gynaecological services for women are becoming the Cinderella of the health services, and that hospitals do not have specialised gynaecological wards top put women in.
Dr McCaffrey speaks strongly in favour of doctors being allowed to make a conscientious objection to carrying out a termination. She says: There was concern about one sentence in the expert report which says that in most jurisdictions, the individual’s right to a conscientious objection is not absolute. Everyone has the right to a conscientious objection and that has to be respected. I have worked in the UK, everyone I’ve spoken to has worked in other jurisdictions, and people’s right to a conscientious objection has been respected elsewhere so it’s important for us that that would happen in legislation here in Ireland. People should not be discriminated against for their beliefs.
There is now going to be sixty minutes of questioning from the Committee members.
Billy Kelleher (FG) kicks things off by asking for clarity on conscientious objections and where the doctors stand on it.
Caoimhghín Ó Caoláin (SF) asks three questions in one. He asks about how the doctors would envision an independent review system functioning if a woman’s life is in risk, which, he says, currently has a lack of clarity.
He also asks about the 1861 Act, which made abortion illegal, and asked if that law has at any time impaired or impacted decisions made by doctors.
Mattie McGrath (Ind) asks if the doctors believe that there will be an increase in the number of abortions if terminations are made available to women whose life is at risk through suicide.
Ciara Conway (Labour) asks whether the ethos of hospitals could impact on the treatment of women who need life-saving procedures. She also asks for clarity on the position of whether women suffering illnesses such as cancer can receive medical terminations if necessary.
The doctors are answering now. Dr Rhona Mahony speaks first.
She addresses Billy Kelleher first using what I believe is technically known as a smackdown. “Nobody is talking about opening floodgates,” she says. The risk of death in pregnancy is extraordinarily rare but it does exist – and this is what the doctors are focusing on. This does not mean there’s going to be a huge number of cases where women will be undergoing abortions.
When it comes to conscientious objections she says that her role as a doctor is to save the life of her patient. She says: We are talking about those cases where we feel that a woman is going to die during pregnancy and the risk of death can be ameliorated by ending the pregnancy.
She emphasises again that the role of doctors is to preserve life.
Dr Mahony brings up the 1861 Act: I need to know that I will not go to jail if, in good faith I believe a termination is the right thing to do to save a woman’s life – and I need to know that the woman will not go to jail either, she says.
It doesn’t matter that no-one has been sent to jail before, she says. The issue is that there is a significant risk – or at least, that doctors perceive that there is a risk that they could be sent to jail for what they do. She says doctors need further guidance and clarity on this.
Dr Mahony echoes comments made by Dr Coulter Smyth earlier and says that two obstretricians should be able to make the decision on whether a woman needs a termination. She emphasises that doctors need flexibility to make the decision: this is a medical decision based on medical facts, she says. Doctors must be able to make these decisions if they are to do their jobs properly and preserve life.
Dr Coulter Smyth addresses the issue of conscientious objections. He says he cannot think of “any circumstances” where any health professional, where a mother’s life was at risk, would say that they would not be involved in her care, “so I cannot see that that would be an issue”.
Dr Mary McCaffrey addresses Billy Kelleher’s question about whether lists should be published of doctors that will carry out medical terminations. No, she says. If you publish a list of doctors that will carry out certain practices, you discriminate against people who won’t do them. No practitioner will ever allow a woman to die because they won’t carry out certain practices, she says.
More questions for the doctors now. I’ll list the questions as they’re asked.
Denis Naughton (FG): He begins by asking about the number of abortions carried out in the Rotunda, going back to something Dr Coulter Smyth said earlier where he indicated that six terminations had been carried out to save the life of the mother. He also asks about the fear among smaller maternity hospitals that this could lead to some amalgamation of smaller hospitals or reduce the capacity of existing hospitals.
Robert Dowds (Lab): He says there’s a clear lack of certainty over whether a woman’s life is absolutely at risk. He asks if it’s possible to legislate adequately without removing the Eighty Amendment from the constitution which, he says, puts restrictions on abortion in this country.
Seamus Healy: He asks Dr McCaffrey if local units could deal with emergency cases or if women would have to go to larger centres around the country.
Regina Doherty (FG) She asks Dr Mahony about something she said about how she is being stopped from making certain actions about treating women. She also asks how many terminations or early deliveries have been carried out in each hospital for women presenting as suicidal since the X Case.
Senator John Crown (NUI): “You’ve all made me a little prouder to be a doctor today,” says Senator Crown. He asks if they believe any women have died because women did not receive a termination because doctors felt they could not act under current guidelines.
Dr Coulter Smyth says he believes six terminations were carried out in the Rotunda last year to save the life of the mother. He says the number has remained roughly the same but the incidence has risen in recent years, which he says is due to the increasing age of women getting pregnant, the increasing complexity of illnesses while pregnant, and rising obesity levels.
He says he’s not aware of any women who have died because they did not receive a termination. Dr McCaffrey, who is next up to speak, says she is not aware of any such maternal deaths either.
Here’s what Dr Coulter Smyth said earlier about terminations in the Rotunda last year:
Is termination of pregnancy ever necessary? I would say yes. In our hospital last year we had six situations where I can absolutely tell you for sure, that if intervention had not been made, if that mother had not died soon after the event, she would have died subsequently [...] In our hospital they happened six times in the last year.
Dr Mahony says extrapolating how many extra cases are anticipated is difficult because the numbers involved are tiny.
She says there were 3 cases in the National Maternity Hospital last year where doctors had to intervene prior to foetal viability because of medical concern that the woman would die. She says she believes the national figures are between 10 and 20 each year – again, she emphasises that these are tiny numbers as a proportion of the women who get pregnant every year. She says:
We never kill a foetus. That is not what we are about
She says occasionally doctors have to deliver a pregnancy before a baby is capable of surviving. Where there is any chance at all that doctors can preserve the life of a baby, doctors will do so, she says. She says it is always the role of doctors “to preserve life, and society should be very reassured of that”.
Some more questions:
Mary Mitchell O’Connor (FG): What deficiencies are in the medical guidelines at the moment, she asks. Also, does the ethos of the hospital impact on how women are treated.
Peter Fitzpatrick (FG): Are pregnant women getting the treatment they’re entitled to when there’s a risk to the life, as opposed to the health of the woman, he asks.
Aside: Slightly surprising how few questions there are from Labour TDs. Ciara Conway, Robert Dowds and Eamonn Maloney have all spoken but the questions have been very much dominated by Fine Gael TDs.
We are asking for legislation broad enough to allow us to do our job, but we also want regulation, says Dr Mahony. She says this would allow for monitoring so that it can be very clear that all decisions are appropriate and in accordance with the wishes of society.
Again, she emphasises that this is about preserving life and saving women’s lives
On the issue of the ethos of hospitals, she is very clear: she says doctors don’t practice according to any ideology or ethos, “we practice according to clinical demand,” she says. “It is a science”.
Dr Coulter Smyth reiterates what the three doctors have said about there being an issue with emergency situations. He says medical council guidelines are there for emergency situations, but the law says differently.
Final round of questioning before this session ends. Seven minutes to go:
Denis Naughton (FG/Ind) : Asks for further comment on medical emergencies, as opposed to long-standing illnesses, which could threaten the life of a pregnant woman.
Robert Dowds (Lab): Asks for an answer to his earlier question but says he accepts that it may not be possible for legal reasons.
Dr McCaffrey says there is a real need for obstetric physicians, a type of specialist doctor who specifically looks after the illnesses women have during pregnancy. She says it would minimise the number of women getting to the point where their life is in danger if such a role existed in Ireland.
Dr Mahony addresses Denis Naughton’s point about what happens if there’s an emergency at a small rural hospital and a second signature were required to authorise a termination. Dr Mahony is very clear:
If there is an emergency, I will save the life of the mother, she says. I will not wait for a second signature. That is my job.
Dr Mahony again says the risk of suicide cannot be simply dismissed. “To do so is judgmental,” she says. It’s offensive to suggest that women may fabricate suicidal feelings, she says. She emphasises that suicidal ideation is extraordinarily rare and should not be confused with general issues surrounding mental health.
So members of the Committee have now finished their questioning so the floor has been thrown open to TDs and Senators who are attending the meeting:
Senator Fidelma Healy-Eames (FG): She asks for clarification on a question asked earlier about how many women, if any, have died because they weren’t able to get a termination.
Terence Flanagan (FG): A lot of questions from Terence Flanagan. He asks if the doctors have ever withheld a treatment to save a mother’s life and if there were any incidents in which women do not receive appropriate medical care due to the current state of the law.
Then he asks what exact procedure is carry out when a pregnancy is terminated if, for example, the woman is 24 weeks pregnant.
He ends by asking Dr McCaffrey why she constantly refers to “a patient” and if she does not believe that there are two patients – the woman and the foetus.
Billy Timmins (FG): Asks for figures about how many women in Britain commit suicide while pregnant.
Understandably, Dr Mahony begins by being very firm about the questions asked by Terence Flanagan.
She says that a baby would not be terminated at 24 weeks. “When there is an opportunity to save a baby’s life, we will save it,” she says. She points out that viability is around the 23 week mark, and doctors will offer a baby every opportunity to survive. She says: please, let us not ever talk about the ridiculous concept of termination at 24 weeks or 30 weeks. Let us not confuse this issue.
All three doctors say they have never withheld treatment for a woman whose life was threatened while pregnant.
In the home stretch of questioning now…
Senator Ivana Bacik asks about the drafting of legislation. She says in a non-emergency situation, the doctors have indicated that one signature should be enough to authorise a termination. But in non-emergencies, who should the two signatures (as recommended by the expert group report) come from? Two obstetricians? An obstetrician plus one other medical professional?
Peadar Tobin of Sinn Féin asks if the views of the doctors would be representative of professional colleagues or if there would be a more diverse range of views.
Two women in Ireland took their own lives while pregnant between 2009, and 2011, according to Dr Mahony. She says she doesn’t know if termination of the pregnancies would have saved them “but I’m saying as a doctor we cannot dismiss it [risk of suicide”.
On the issue of regulation, she says where possible, two obstetricians should be involved in any discussion to terminate a pregnancy. She says where additional expertise is required, at least one other doctor who is an expert in that field should be involved in the process. She says doctors are used to working in teams and this would not be unusual.
And on that, it’s over. Jerry Buttimer, the chair of the Committee, thanks the doctors for speaking and reminds members to return promptly at 2.45pm when they will be hearing from five psychiatrists on the issue.
Ok, so that was interesting for two reasons: partly because of the facts provided by the doctors which shed a lot of light on exactly what we’re talking about here – particularly the actual number of terminations carried out in Irish maternity hospitals to save the life of the mother, which have not been made public before, as far as I know? – but also for the clear and level-headed language used by the doctors, which has been absent from some parts of the debate on abortion.
The three doctors repeatedly emphasised that the number of cases where a woman is at risk of dying during a pregnancy is tiny, but all said that they would – and indeed, have – treated women who presented as such. The issue of treatment in rural versus urban hospitals was raised and the difficulties in treating emergency cases which could arise in a small hospital which is already seeing services curtailed. Dr Mahony also spoke out strongly about how the risk of suicide must be included as a life-threatening condition, saying it was offensive to women to imply that they would lie to obtain a termination.
Dr Mahony told the Committee several times that doctors are operating in a legal vacuum where they fear jail because of the lack of clarity in the law.
My colleague Hugh O’Connell will be continuing our coverage of the Committee from 2.45pm, when it will be hearing from psychiatrists. Thanks for reading so far – hope you’ll stick with us.
Good afternoon. Still with us? We’re about to head into the third session of hearings on the planned abortion law with psychiatrists set to answer questions from TDs and Senators. Hugh O’Connell with you here for the next two hours.
This afternoon we will be hearing from
- Dr Anthony McCarthy, College of Psychiatry Ireland
- Dr Joanne Fention, College of Psychiatry Ireland
- Dr John Sheehan, College of Psychiatry Ireland
- Professor Patricia Casey, Dept. of Adult Psychiatry, UCD & Mater Misercordiae University Hospital
- Professor Veronica O’Kane, Dept. of Psychiatry, Tallaght Hospital
The committee is returning now and members and witnesses are taking their seats in the Seanad chamber.
Dr Anthony McCarthy from the College of Psychiatry up first saying that unwanted pregnancies are particularly likely to be associated with distress and difficulties for the individual. Aware that it is a highly divisive issue. We don’t wish to add to the conflict and distress be commenting on the wider issues want to to keep it in the scope of what is being examined by the committee.
One pregnant woman referred to clinic may say that they experienced pregnancies and not babies – a difference that must be understood. The fact that no maternity unit outside of Dublin has dedicated perinatal psychiatric specialists is a point of concern, he says. An issue raised in an interview on Morning Ireland earlier today.
Dr McCarthy says that suicide is rare in pregnancy but it does happen and has to be considered. In the UK between 2006 and 2008 there were four suicides in pregnancy and over 2 million live births. Suicide rates are lower in pregnant women than non-pregnant women. Pregnancy can confer a protective effect, he says, but we need to be aware of risks. We see real women, each of them as an individual and not as statistics.
Sympathy shown to victims of cyber bullying who took their own life and pejorative references to women in the cases of pregnancy and suicide come in for criticism from McCarthy.
Dr McCarthy continues, saying that women need to be heard, believed and helped. Some women have a passive death wish. He says it is a complex issue and not just ticking a box, saying they are suicidal. Suicidal ideation may or may not be associated with mental illness.
Dr McCarthy says that absolute predictive power of suicide is not always possible. Psychiatrists are still best placed to make decisions on whether or not people are suicidal.
Some well publicised comments that psychiatrists will be manipulated but he says that all psychiatrists are aware of intentions of some small number of people to threaten suicide. But the vast majority of people are very genuinely depressed or stressed and are seeking help. Women in pregnancy are no different in this regard to any other people who say they are suicidal.
However, the issue that psychiatrists will be asked to assess is if there is a real and substantial risk of life to the mother through suicide and whether this risk can be removed by termination.
There was no psychiatric input into the Supreme Court X Case, McCarthy notes and he goes on to say that his body are not expecting a huge number of women to come to them in the event of legislating for the X Case and believes the majority will continue travel to the UK.
McCarthy says finally that any psychiatrist has a right to conscientious objection.
Professor Patricia Casey, Dept. of Adult Psychiatry, UCD & Mater Misercordiae University Hospital up now.
Professor Casey says she has two major points. The first is that suicide in pregnancy is very rare and when it does occur it is associated with mental illness and she says it should be treated in the same way as any other person.
She says there is no evidence that abortion reduces suicide risk in pregnant women and some evidence that it may have a negative effect in some instances.
Professor Casey says there is an impression out there that many women in Ireland are dying by suicide as there is not legislation for X but she says that is not the case.
The national suicide rate in women has been static for decades, she says. One hundred women died by suicide in 2011. For women dying in pregnancy, there were no deaths during pregnancy in the delivery of 680,000 live births over 21 years in three Dublin maternity hospitals.
Professor Casey says that a British report found that four women died during pregnancy over a three year period because of inadequate medical treatment. She says that we are not very good at predicting suicide because of the inherent problems in identifying suicidal behaviour.
Numerous studies suggest “we are wrong more often than we are right” she says. A woman who is pregnant and suicidal needs proper treatment and in her clinical practice if somebody is suicidal and at immediate risk they are hospitalised where they are fully assessed.
Professor Casey says she has never seen a pregnant women who is suicidal and for whom abortion is the only answer. In two cases she says that her patients were being coerced into having an abortion and were suicidal because they were being coerced.
Professor Casey says that there is no evidence that abortion is a treatment which averts suicide in women, citing evidence from a British study. She said the same study found that abortions led to mental health problems in people who had prior mental health problems.
Suicide in pregnancy is rare, she summarises. No evidence that abortion helps mental health. Legislation for X that includes suicide is not supported by any scientific evidence, she says. Suicide risk should be excluded, Professor Casey concludes.
Professor Veronica O’Kane, Dept. of Psychiatry, Tallaght Hospital is up now.
Professor O’Kane says that the expert group report refers to mental health grounds, not just suicide. Slightly wider then discussion taking place so far.
She says that not every single women wants to continue with her pregnancy when they are suffering with mental illness. In the UK, she witnessed a case where a woman had four previous pregnancies where the baby was taken into care and she was pregnant with her fifth child.
Some women do become suicidal because they can’t cope with prospect of unwanted pregnancy and unwanted parenthood. Sometimes this happens in cases where they have been abused when they are younger and do not want to abandon a baby, by giving it up for adoption, in the same way that they feel they were abandoned.
Professor O’Kane says that the experts in this area only see very rare cases of suicidal ideation when women are pregnant. Women who are pregnant will not go to a obstetrician, they will go to their GP, she says.
Professor O’Kane says that “risk management” is the “bread and butter” of what psychiatrists do in terms of what risk a patient poses to themselves and to others. Most people in Ireland who die by suicide do not see psychiatrists and the people who do are usually “managed well”.
Matter for legal profession and legislators here but from her position the recommendations given to them by expert group report are “excellent”. Psychiatrists can act in an advisory capacity in a way similar to advising on the Mental Health Act in 2002.
On the debate, 130,000 Irish women have had abortions since 1983, 5,000 per year, 14 per day. She said that if UK abortion services were not available death and injury would ensue, injury and death to women and injury and death to babies. In countries where these services are not available this happens, she concludes.
Billy Kelleher, FF, asks that of 130,000 women who have gone to the UK, is there a chance or a probability that a higher percentage of those women would have suicidal tendencies and potentially carry out the act of suicide itself?
Caoimhghin O’Caolain, SF, asks is the rareness of the situation a reason not to regulate or legislate? Are we short of cover for supporting women in relation to mental health given there are just three perinatal psychiatrists in the jurisdiction? Will the inclusion of suicide be open to abuse?
A quick side note, Professor Veronica O’Kane is actually Veronica O’Keane.
Seamus Healy, WUAG, asks if witnesses could address issue of legislation and whether or not it would open the floodgates for abortion in Ireland and could they address issue of whether or not women may manipulate their doctors if legislation is brought in.
Ciara Conway, Labour, says that suggestion that women will be able to dupe doctors is greatly offensive. She says this needs to be at the fore of their minds. Raises Professor O’Keane’s point about women who feel suicidal often not presenting to obstetricians but will actually go to their GP, notes that GPs have not been invited to give evidence. She says that even if the cases are rare “one is one too many” and that this should not be seen as a reason not to legislate.
Not sure if Conway is asking questions here or just making points….
Dr Anthony McCarthy, College of Psychiatry Ireland, going through answers now says that without having seen 130,000 going abroad it is hard to assess the risk to their life by suicide.
He says that between 1900 to 1950, 10 per cent of women of child bearing age who committed suicide were pregnant at the time they committed suicide, now that number is at two per cent. The rates have gone down but he has no doubt that many women are going to England for terminations.
He says that “of course sometimes we will get it wrong” but like all people working in medicine there is some subjective decision making, based on objective facts.
He says that his obstetric colleagues will feel “very exposed” if the 1861 Act is not repealed.
Dr McCarthy says that a very small group are going to be so distressed and depressed that they will access an abortion in Ireland if legislation is brought in. ”They are not going to come near us,” he says because of the narrowness of the legislation.
“I can’t see the floodgates opening,” he adds because the number of women coming forward will be so small due to the nature of the legislation and the safeguards that will be in place.
“The appalling abuse of women in this case is just dreadful,” he says when dealing with the suggestion that women will dupe doctors if suicide is included.
Professor Patricia Casey says that “we just don’t have the statistics” in relation to how many women who go abroad to access an abortion do so because they are feeling suicidal.
She says that legislation has always got to be based on good medicine and fact. There are a lot of assumptions in these questions that if a woman is suicidal in pregnancy abortion is the only thing that will help. That is a chain that doesn’t flow, she says. The balance of evidence is that abortion has a neutral effect or a negative effect. Too many unknowns there she says to suggest that legislation will be evidence or science based.
Professor Casey says there is a definite shortage of perinatal psychiatrists. In relation to the abuse of the legislation she says it is a valid question. She points to evidence in Britain that indicates this is a valid issue to raise.
Will legislation open the floodgates? “There will certainly be widespread abortion within a short period of time,” she says because GPs in good faith will send pregnant women for assessment. The system will be described as “cumbersome” and “in due course will be opened up”.
But she does not think women will manipulate the system.
Professor O’Keane (and not O’Kane, as she was wrongly identified earlier) says that it is her view that a percentage of the women who travel to UK for abortions do so because they are “very mentally distressed and suicidal”.
She says that legislation should not be stopped from being introduced because of the prospect of it being abused. She points out that checks can be carried out to ensure systems are working properly.
O’Keane’s evidence is being cut off at certain points because of microphone problems. Now being addressed by the committee which has paused for some mic adjustment. We discover that O’Keane’s knee is turning the switch on and off again. Should be sorted now hopefully.
In any case, O’Keane concludes her answer.
Senator Colm Burke, FG, asks what does the panel feel is the most workable solution in relation to psychiatric assessment of patients and how that might be carried out. Asks if the panel feels there is enough being done in relation to medical services about referring people to specialists at an earlier stage than is happening now.
Senator Marc MacSharry, FF, asks if his sister or wife or neighbour presented to a GP expressing suicidal intentions, how long would it take for them to be seen by a perinatal psychiatrist and how long would it take to give a diagnosis.
Denis Naughten, FG, raises the issue of four women in Britain dying by suicide before birth of baby, would that rate have been higher is abortion was not available in the UK? Ask do witnesses anticipate far more cases being presented to them as perinatal psychiatrists if legislation is brought in.
Senator John Crown, Ind, raises issue of Professor Casey’s prepared statement which alludes to argument that there may be floodgate phenomenon but she says that this is “not something you should be discussing”. Not something that should be testified about. Notes that she is an affiliate of an organisation that has a “non-professional” argument to evidence.
Crown is referring to the Iona Institute of which Professor Casey is a member.
Dr McCarthy says that there should be two psychiatrists who make the assessment because he believes that cases of people presenting with suicidal intentions while pregnant will be so rare.
Professor Casey says that any legislation is going to be “bad law” because it won’t relate to any evidence.Anything that promotes earlier referral is absolutely essential as a way of combating maternal suicide, she says.
Professor Casey says that suicide does occur even with best treatment in the world because it is unpredictable.
Referring to Crown’s comments, Casey says that a study in Finland found that suicide was three times the national average among women who had an abortion. There is no evidence that abortion helps women’s mental health, she says.
On the ‘floodgates phenomenon’ she says: “I think there will be widespread abortion in a short period.”
Professor O’Keane says that the woman decides after the advice she receives, so it is not psychiatrists who are determining whether or not an abortion is necessary. The ultimate decision is with the woman after she receives whatever advice or guidance is provided for under the legislation.
Peter FitzPatrick, FG, asks do women who have abortions increase the risk of mental health problems? And also asks does motherhood protect against suicide?
Regina Doherty, FG, points out that the scenario of the X Case has not been raised with the psychiatrists this afternoon. She asks what option in the expert case is the best to deal with people who do not have advice from perinatal psychiatrists or obstetricians.
Questions also from Jillian Van Turnhout and Mary Mitchell O’Connor too but we didn’t quite catch them.
Professor O’Keane says that there is a need for this legislation as the majority of people are going to the UK are having those terminations for mental health reasons. Again mic trouble with Professor O’Keane means we can’t get all of her answer…
Professor Casey says not everybody who is suicidal has a mental illness, they are suicidal because they are pregnant in some cases. She wonders what role psychiatrists have if someone doesn’t have a mental illness, that’s a very important issue, she says. Are psychiatrists being used in this “simply to get government off the hook”, she asks.
Does abortion increase the risk of mental illness? Casey says there is no increase generally according to a study but for a sub-group of women there was an increased risk because of mental health problems or coercion. Abortion does increase overall the risk of mental illness by 30 per cent, according to another study. So there is a disagreement among psychiatrists, Casey says.
Professor Casey says that because there will be a lot of people coming forward for the service, there will be an attempt to dismantle the current restrictions and extent the availability of abortion if legislation is brought in.
Dr McCarthy says that children are a key issue in all of this and points out that a child who is 17 would have to have their parents present if they are being assessed in relation to the possibility of suicide because of pregnancy.
He says that it is important not to generalise and that each case has to be assessed individually. He says on the issue of whether abortion increases the risk of suicide overall the effect is neutral.
Dr McCarthy says that psychiatrists’ role will be advisory. We are now going to hear from non-members of the committee.
Terence Flanagan, FG, among a number of questions asks how often have panel had to treat a woman who is pregnant and suicidal. Does the panel think there should be any time-limits. Would they agree with abortion after 30 weeks where abortion is threatened. Do they believe there are two patients in pregnancy, including unborn child.
Aodhán Ó Ríordáin, Labour, says that discussion of whether or not suicide should be included is “futile” because of Supreme Court judgement and address this point particularly to Professor Casey.
Bernard Durkan, Fine Gael, asks about statistics in Northern Ireland, what stats are available and Senator Terry Brennan says he met a young man 10 or 11 years ago who he had been told was going to commit suicide but did not have a clue as to how to assess whether this was true or not that this man was suicidal. In the end he did not take his own life. But he asks what are the main issues the panel considers when women present with suicidal intentions.
Professor Casey says that she believes there are “absolutely” two patients in pregnancy – the woman and the child. She says that she came to give her expert opinion and has done so in good faith. “If that isn’t what you had in mind, I apologise to you,” she says but Aodhán Ó Ríordáin, to whom she was referring, insists that his point was that “we have to legislate” because of the X Case judgement.
Women will get necessary treatment when they are depressed and suicidal, she says and on the issue of Northern Ireland and statistics on abortion there Casey says “let’s see what happens in the coming weeks now that Marie Stopes has moved in there” referring to the recent opening of the Marie Stopes clinic in the North.
Professor O’Keane says that death during pregnancy is rare and points to a study in Britain which found that maternal suicide was more common than previously thought and was actually leading cause of maternal mortality. She says she fully agrees with Aodhán Ó Ríordáin on the need to legislate.
Nearly coming to an end now and Dr John Sheehan, College of Psychiatry Ireland is speaking for the first time and says that the rate is so rare for maternal mortality in Ireland. Pregnancy at 30 weeks is certainly a very viable foetus he says in relation to Terence Flanagan’s question and in the Rotunda they try to save foetuses from 24 weeks, he says.
He says that the notion of suicidality is a highly changeable issue. Someone who may express suicidal intentions one day may not do so the next. He says the job legislators have is “extremely difficult” and that is borne out in the complexity of the evidence heard today. Your liveblogger would not disagree with that!
Dr Sheehan says that in his profession they will see people who are profoundly depressed and clearly the intervention in that case is to admit them to hospital and support them and help them and not go in and make a decision that is permanent or irrevocable.
Dr Sheehan continues saying that psychiatrists strive to provide the best care for women. On the ‘floodgate phenomenon’ he says that “none of us” can pick out someone who will go on to take their own life. From a mental health perspective they are good at assessment of risk but impossible in terms of making a prediction.
Fine Gael TD Billy Timmins asks is there a study overall that says that pregnancy has a protective effect against suicide. While Michael Creed, Fine Gael, asks what the alternative option would be if a pregnant women presents with mental health issues.
Creed raises issue of Savita Halappanavar and asks of Professor O’Keane, who raised the issue initially, what “substantiated knowledge” does she have regarding to the Indian woman’s death in Galway but Buttimer says it would not be appropriate in today’s meeting. Creed appears to be annoyed by the fact it was raised given an investigation is ongoing and the circumstances of the case are not clear.
Coming towards the end now and Professor O’Keane says that regarding children, it’s true for children that UK and US that overall a pregnant teenager is more likely to commit suicide than a non pregnant teenager while a pregnant adult is less likely to commit suicide than a non-pregnant adult.
She says that adolescents are at a hugely increased risk of committing suicide if they are pregnant. She says there is confusion about suicide being a leading cause of death in pregnancy. It is but it is also rare and the reason it is rare is because all death in pregnancy is rare.
And that concludes this session. We’ll be continuing at 5pm.
Okay so briefly before the next session starts the main points from that are the belief College of Psychiatry Ireland that instances of women presenting with suicidal ideation will be rare in the case of legislation. This view was repeatedly emphasised by Dr Anthony McCarthy.
However, Professor Patricia Casey was very much in disagreement with this saying that very clearly that she thinks it will lead to “widespread abortion” in Ireland within a short period and said that any legislation will be “bad law” because it will not be based on fact and science.
As is often the case in the abortion debate particularly when the two sides come together as they did today in the case of Casey – who is against legislation – and the rest of those giving evidence – who appeared to be for it – there was lots of studies and facts being bandied about.
In contrast to the fairly sedate affairs this morning this afternoon’s session was a bit more contentious given the presence of Professor Casey and her expression of her very firm belief that legislation was not necessary despite these hearings being set-up for the sole purpose of hearing evidence that will feed into the process of drafting legislation, a decision the government has already made.
Perhaps an indication of what is to come when the advocacy groups give evidence on Thursday. I’m signing off now and Sinead O’Carroll will take you through the last session of the day.
Good evening. It’s Sinéad O’Carroll here, taking over from Hugh O’Connell. We’re into the last session of the day, during which we’ll hear from the Irish Family Planning Association, the Institute of Obstetricians & Gynaecologists and Maternal Death Enquiry Ireland.
CEO of the IFPA Niall Behan is up first. He gives an overview of what services his association offer, including crisis pregnancy counselling. He says women who choose abortion are from “all walks of live”. He says the decision to have an abortion is not taken lightly by women.
As a service provider, the IFPA has welcomed the government’s decision to implement the ABC versus Ireland judgement.
Behan says that very few women who access IFPA services do so because of a risk to their lives. However, there are some who come to their offices because of serious underlying health problems. Some, he says, are pregnant after being advised not to have a child (or another child). Others have been told that pregnancy can worsen a pre-existing condition.
Behan questions the distinction in current Irish law which distinguishes between the woman’s life and her health. He says Ireland is the only country in Europe to make such a distinction.
Behan tells the Oireachtas that many women have travelled outside the State for services that are criminalised in Ireland. Many do not have medical records or referrals, he added.
Women should have confidence that their decisions will be accepted without stigma, Behan continues. Any legislation should not be theoretical…it should be effective and make services accessible.
Behan: The IFPA has had clients who have had suicidal thoughts – a small number have followed through on these threats and taken overdoses.
Focusing on the criminalisation of abortion, Behan says it is the IFPA’s view that legislation to implement the ABC judgement must remove the laws in the 1861 Offences Against the Person Act which criminalise any woman – or anyone helping that woman – who “procured a miscarriage”.
Professor Richard Greene of Maternal Death Enquiry says the important background to this issue is that maternal fatality in Ireland is continuously touted as being low. He says data from 2009 to2011, using scientific approach, identified 25 mortalities. Six were associated directly with the pregnancy, 13 were indirectly linked to the pregnancy and six were noted as having coincidental causes.
The indirect causes in the Irish cases included heart disease, epilepsy and influenza. There were also two suicides – one of which occurred during the pregnancy and one occurred after the baby was born.
Greene says that Irish women who are pregnant receive excellent health care. He says it is important for women to understand that there is very good results in this county. “We need to take away some of the scare and concerns that are out there in the public,” he added.
Professor Robert Harrison, chairman of the Institute of Obstetricians & Gynaecologists, says it is more appropriate for his colleague Fionnuala McAuliffe to give the body’s presentation as he is no longer practicing medicine. However, he said he will speak up if his 47 years of experience is required.
Professor Fionnuala McAuliffe says her group applaud the Expert Group’s report and said it is very important for doctors to have legal clarity when a termination or very premature delivery of a baby is required.
The test to be applied in such cases can only be a medical one, to which precision cannot be offered, continues McAuliffe (echoing Dr Mahoney’s comments from this morning’s session).
McAuliffe says that in emergency situations, current practice is the preferred option.
But statutory, legal protection is required for doctors and their patients. Legislation and regulation will provide this, according to the Institute.
The Institute has asked to be consulted on the final wording of legislation and regulation so medical practitioners can continue to provide life-saving treatments to patients.
And we’re into question time.
First up, Fianna Fáil’s Billy Kelleher asks the Institute if anyone has come across a legal difficulty in deciding to terminate a pregnancy – that they could not intervene because of lack of legal clarity or the threat of 1861 Act?
Caoimhghín Ó Caoláin, SF, echoes earlier statements that GPs were left out of these hearings, despite them being the first port of call for many pregnant women. He asks Behan for an indication of the number of people in contact with the IFPA who attempted suicide when pregnant? He also asks whether he thinks women will continue to travel for abortion services rather than access Ireland’s mental health services?
Ó Caoláin asks the Institute to clarify its point that general hospitals can make decisions about pregnancies in emergency situations.
Labour TD Ciara Conway brings up the point of pregnancy in underage girls. She wants to get real-life experiences from the IFPA about young girls who are pregnant and may be at risk of suicide.
She also asks the Institute what will the review practice will look like. She says it has to be practical and not cumbersome.
And lastly is Senator John Crown. He says maternal mortality is such a rare event that it is hard to enunciate causal factors, and so asks Professor Greene to explain more about the data he spoke about earlier. “Are we aware of any case in this State that a woman died needlessly because of the legal vacuum around the issue of abortion?”
McAuliffe to answer the questions first.
She says that she is aware of cases that have been referred to the UK for treatment because of legal uncertainties. They pertain to pregnant women who are in danger (but not necessarily immediate).
McAuliffe said that general hospitals should be able to make decisions about pregnant women because there is often not time for transportation to another hospital.
Answering Ciara Conway’s question, McAuliffe said that rates of teenage pregnancy is low in Ireland. Those under the age of consent will need a next-of-kin present, she added.
McAuliffe said that a review panel should have up to 30 doctors on it so a timely decision could be made. She said she agreed with Conway on that point and that Ireland’s psychiatrists have a system in place that could be looked at as a model.
Answering Senator Crown, McAuliffe said she does not know of any woman in Ireland who has died because of the legal vacuum. She said if the woman’s life is in imminent danger, then they will “press on” with treatment.
Greene says that Ireland is the “top few” in terms of maternal mortality – he says he does not have evidence to support the theory that this is the case because we don’t have termination of pregnancy. Those type of conclusions can’t be made, he adds.
Responding to Deputy Conway, he said that there was no deaths of girls under the age of 18 included in his statistics.
Dr Caitriona Henchion says that the IFPA tries to encourage anyone who presents with suicide ideation to engage with psychiatric services through their GPs.
She says that some women would still choose to travel for abortion services as they wouldn’t want the delay or the problem of the psychiatric assessment. But she adds that there would be women who would not be able to afford to travel would benefit from such a system.
Behan says that two failed suicide attempts by two of its clients happened in the past three years. In one case, the barrier to abortion services was cited as a factor.
Behan says his organisation has been dealing in ‘contested areas’ of policy for the past 40 years and has always worked within tight guidelines.
Senator Imelda Henry says we have to trust our doctors and medical professions. Says she doesn’t have a question but again raises the point that there is no GP representative at the three-day hearing in the Oireachtas. Henry adds that she is aware of doctors in the West of the country making referrals to the Marie Stopes Clinic.
Buttimer responds to say GPs were invited but declined.
Peter Fitzpatrick, FG, asks for more elaboration from the IFPA about the number of clients presenting with suicide.
Denis Naughten asks for clarification about numbers of pregnant women who present with suicide ideation, as well as clarification from the Institute about what they want to see happen with regard to emergency situations.
Tipp South TD Seamus Healy has one question for the Institute: its view on women who are carrying children who will not be viable outside the womb.
Deputy Robert O’Dowd asks McAuliffe if the referrals to England that she spoke about has to do with current legislation? Carrying on from that Regina Doherty asks how this group would be catered for in new legislation?
McAuliffe takes the previous questions first.
She says that one obstetrician’s opinion is sufficient in an emergency situation. She says the usual clinical guidelines are appropriate and documentation is often set aside until after the incident.
Answering the question about fatal foetal anomalies, she said the Institute’s brief was just to look at the Expert Group’s response to the ABC judgement so would not be drawn on this different matter.
Answering the question about cases that were referred to overseas services, McAuliffe said there is no registry of these cases or a number per year. “A bit of legal uncertainty” was seen, however, in these cases where the patient was referred abroad for treatment. “It is important that we get a robust legal framework from government,” she added.
“In terms of immediate risk and so on, we feel that is where the medical expertise comes in.”
She said the Institute’s view is that if two obstetricians believe there is a risk to the pregnant woman’s life, then this is sufficient. She said they would not work with percentages or timelines as that would be impossible. Legislation should cover all situations where there is a risk, she concluded.
Niall Behan responds to Deputy McGrath’s question, saying that the IFPA has come to its opinion on abortion after years of interaction with pregnant women.
He said that criminal law does not serve any purpose in discussions about abortion. He said that it is a matter for a woman and her doctor (s).
Earlier, McGrath was rebuked by the Chair for calling the IFPA an abortion advocacy group.
Behan clarifies that two of their clients followed through with suicide ideation, attempting to take their own lives. Both failed in their attempts, thankfully, he said.
However, many more have presented with such thoughts during a crisis pregnancy.
Behan looks at abortion rates in Ireland over the past 10 years. They have been coming down, he said, due to contraception and better sex education.
There are 15 minutes left in this session. And Caoimhghín Ó Caoláin (SF) has more points to bring up.
He asks the Institute about the “overhanging threat” of the 1861 Offences Against the State Act and whether there is “discomfort” about those laws still being on the statute books?
He also wants elaboration from the Institute about its position on who will chair the proposed Review Panel.
Deputy Denis Naughten brings up smaller maternity hospitals again. Could a second specialist (not necessarily an obstetrician) sign off on a termination?
On the issue of suicide, he wants to know who should make the call in relation to suicide ideation in pregnancy?
McAuliffe says that doctors strongly feel they need robust legal framework to carry out their work. Although she is unaware of a woman dying because of the legal vacuum, she said legal framework is still needed.
Answering the question about the Review chair, she said the Institute has not come down on one side or the other.
Women will receive appropriate treatment in Ireland – regardless of where she is admitted and at what time, she continues.
Two obstetricians should be involved in the decision to terminate a pregnancy – regardless of the nature of the risk, be it physical or suicide – concluded McAuliffe.
Greene says it is easy to make decisions when someone is about to die – what is not easy is when the threat could be somewhere down the road.
Senator Colm Burke asks for further clarification on the Institute’s opinion on who is needed to sign off on a termination when the life of the mother is at risk.
McAuliffe repeats that they want two obstetricians, as well as anyone else necessary (depending on the circumstances of the case), i.e. a cardiologist if concerning heart issues, psychiatrist if suicide ideation or other mental health issues. This goes outside what is recommended by the Expert Group.
Senator Walsh is told he is “out of order” and “being unfair to the witness” by Chairman Buttimer by raising a question about an investigation into IFPA’s counselling services.
He says he will not allow the question.
IFPA and Niall Behan are coming under fire now. Senator Paul Bradford asks about the IFPA’s stated policy on abortion. Sarcastically says that he would not refer to the group as a “abortion advocate”.
Senator Fidelma Healy-Eames asks for more specific detail about the cases that have been referred abroad because of “lack of legal clarity”. She says that such detail could be helpful.
She also wants to know whether a timeframe would be helpful for a woman who believes she is suicidal.
Brief questions from TD Michael Creed: a) is the Institute asking for a statutory footing for the current medical guidelines? b) how long has it been the view of the Institute that legal framework is necessary – is it just a new position on foot of the ABC report? c) are we talking about referral for treatment abroad for terminations or are there other reasons?
Behan notes that many of the questions posed to him do not relate to the Expert Group but says he will try to answer them anyway.
He says that Ireland’s difficulty comes from the 1983 Constitutional Referendum because it has given the unborn more rights than the woman, in practice. And therefore, women continue to travel to abortion services.
“We wouldn’t be here without the ABC case. We wouldn’t be here today if C had got a termination from her own doctors,” he adds.
“From our perspective, we wonder what would happen in those cases if the women couldn’t afford to travel.”
With regard to the IFPA, he says it has always worked within the law of the land but added that this has not stopped it from advocating for its clients.
McAuliffe reiterates that it would be doctors’ preference to have the 1861 abortion laws repealed.
She said cases referred overseas are rare but are because of legal uncertainty. She notes one case where a pregnant woman had a termination in the UK and returned to Ireland for continued care.
Addressing the issue of whether regulation and legislation is required, she said they defer to their legal colleagues about the “nuts and bolts”.
Answering Deputy Creed’s question about when the opinion was formed, she gives details of the Institute’s December 2012 meeting and vote.
McAuliffe concludes the hearing by reiterating Ireland’s doctors provide care to pregnant women and their families in a team approach. She said to remember that if the mother dies, the baby dies so the best way of preserving life is to care for the health and life of the pregnant woman.
The last word was given to the Institute’s chair Professor Harrison who says that as the entity that will be dealing with the administration of this issue, he hopes to be invited to be actively engaged to provide input to the Department of Health in the coming weeks.
And that concludes today’s hearings. Christine Bohan is working on a wrap-up of the events in the Seanad chamber so make sure to check back in the morning for that.
There will be just three sessions tomorrow, all focusing on the legal aspects.
Up first, from 9.30am will be:
- Jennifer Schweppe, University of Limerick
- Ciara Staunton, NUI Galway
- Dr Simon Mills, Law Library
They will be followed by the Bar Council of Ireland and the Irish Council of Civil Liberties at 11.45am.
And then from 2.45pm, the committee will hear from Professor William Binchy of Trinity College Dublin and the Honorary Judge Catherine McGuinness.
TheJournal.ie staff will also be back to liveblog the meetings. Until then, good evening.
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