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Dublin: 20 °C Tuesday 2 June, 2020


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THE OIREACHTAS COMMITTEE on Health and Children sat for day two of three days of public hearings on the government’s proposed new legislation on abortion, following its publication of the heads of the Protection of Life During Pregnancy Bill 2013.

Today’s proceedings – split into four sessions – heard from a number of psychiatrists and perinatal psychiatrists.

Here’s our log of the day’s events.

That was a long session with a lot of repetition in terms of both questions and answers. Here are some of the main points:

  • One of the big revelations for many politicians was that Dublin’s maternity hospitals do not have intensive care units and are dangerously under-resourced. “Not fit for purpose”, “ridiculous” and “crazy” is how they were described by Dr Coulter-Smyth. For this reason, all three doctors want all of Ireland’s hospitals included in the legislation, not just the 19 currently permitted.
  • Dr Coulter-Smyth raised a number of possible ethical issues because of the inclusion of suicide as a grounds for abortion. He said it *may* lead to an increased demand which would be worrying because of a lack of resources.
  • Dr Rhona Mahoney was adamant that this bill is not about suicide in pregnancy but about saving women’s lives. Suicide is death, just as death by infection is, was her message. She said that suicide should be included in the legislation, even if there had never been an X Case.
  • Dr Coulter-Smyth said it was unfortunate that rape, incest and fatal foetal abnormalities have not yet been provided for.
  • All three doctors are concerned that a woman can still be criminalised if her doctor provides an abortion that eventually is deemed illegal.

Good morning. Sinéad O’Carroll here to bring you all the updates from the first of today’s hearings. My colleague Aoife Barry put together a who’s who of today’s proceedings earlier – it can be found here.

And we’re right on time. Chair Jerry Buttimer welcomes the committee’s witnesses and goes through the usual housekeeping jargon. He reminds members that all questions should reference the heads of bill. He asks for temperate, moderate language. Last Friday’s hearings got a little tense at times.

Buttimer says he will be strict on time today. Some members will not get in for questions, he adds.

Dr Anthony McCarthy, president of the College of Psychiatrists of Ireland, is up first. He is a consultant child and adolescent psychiatrist. He says that among the college’s 864 members, there will be a divergence of opinion but says the official position of the college is outlined in its written submission.

“Suicide in pregnancy is real and a real risk,” says McCarthy. “It does happen. It is a tragedy…we must do everything we can to prevent such deaths.”

He continues: “Much will be made about a lack of evidence…there will never be statistical evidence because of such a rare event.

Reiterating remarks by Dr Rhona Mahoney last Friday, McCarthy says only a study of thousands of suicidal women – allowing half of them an abortion, and half of them not – would provide such evidence but such research could and should never be done.

Dr McCarthy says it is true that abortion is not a treatment for suicide, but he adds that counselling or anti-depressants aren’t treatments.

There is no treatment for suicide, he says. We have to try and prevent suicide by looking at reasons for suicide.

Is there ever a case that a woman will kill herself because of an unwanted pregnancy? This bill is to legislate for this very small but very real possibility, says McCarthy, who is a perinatal psychiatrist at Holles Street hospital.

Dr McCarthy says the bill will save women and children’s lives if it provides for better psychiatric care for patients.

Dr Joanne Fenton, a perinatal psychiatrist from the Coombe hospital, says she and her colleagues provide non-judgemental, compassionate treatment to pregnant women with suicidal intent.

She says she has seen many women who have had abortions – each has had a different experience and different impacts.

She says that termination of pregnancy is not a treatment for mental health. However, she cannot say that there will never be a case that a woman is so distressed by a pregnancy that she will not take her life.

Dr Fenton says that the timing for assessment and appeal as outlined in the heads of bill should be shortened.

She says the assessment by two psychiatrists is appropriate. But she notes that those who do not wish to partake in the assessments should be respected.

Dr Maeve Doyle, a consultant child and adolescent psychiatrist, is up now. She references the X Case, given the girl in question in that case was under 18.

She says it is important that the heads of bill defines the word ‘child’ as it currently does not deal with it.

Dr Doyle says clarity is needed for underage pregnancies and such events will have to be dealt with sensitively.

The likelihood of parents of a young girl who becomes pregnant to seek advice of psychiatrist is rare, says Dr Doyle.

Dr Anne Jeffers, director of external affairs and policy at the College of Psychiatrists of Ireland, now takes the stand. She is a general adult psychiatrist and says she will discuss the heads of bill as thus.

She notes that only in Dublin will a woman who is pregnant and suicidal be referred to a perinatal psychiatrist.

Dr Jeffers says the legislation is extremely restrictive and will not apply to the majority of women.

As psychiatrists, we are used to working within a legal framework, says Dr Jeffers. Seemingly commenting on a widely-used phrase, that this bill could open the floodgates to widespread abortion, she looks at Head 4 which “clearly states” that it would not be an offence to terminate the pregnancy, only if the psychiatrist decides in good faith that a termination is required as the only option to avoid risk to live.

This wording will restrict the use of this act to extremely rare cases, concludes Dr Jeffers.

Last to make his statement is Dr John Sheehan, who says that in a psychiatric emergency the early delivery of a baby is contrary to treatment. He says a patient should be advised not to make irrevocable decisions.

He adds that psychiatrists are doctors, not judges and that the bill could make them the “gatekeepers to abortions”.

It is likely, that women who currently travel, will be referred to psychiatrists as a result of the bill. The suicide ideation of mental health issues of that population is unknown, says Dr Sheehan.

It would be impossible for psychiatrists to predict what women will die by psychiatrists, says Dr Sheehan, and this could lead to a number of false positives.

On late abortion, Dr Sheehan says there is no gestation set out in the heads of bill. Late abortion, could have a detrimental impact on a woman’s mental health, he concludes.

Now for 70 minutes of questions. Buttimer says he will be strict on time.

Fianna Fáil’s Billy Kelleher is first up, as usual. He asks about the make-up of the assessing panel. He wants to know if the role will be both assessment and care and not just a “box-ticking” process. He says there is concern in this area and he would like to see clarity.

Another area he wants to question is the unknown number of women who go abroad for terminations of pregnancy. He says it could be a good thing that women in crisis pregnancy will search for support instead of making the “fatal decision” to travel.

Thirdly, he asks about resources if there is an increase in numbers presenting, seeking assistance and determination on mental status. Have we got them, he asks.

Caoimhghín Ó Caoláin now up for questions.

Will the issue of conscientious objection (especially in rural locations) present difficulties in terms of numbers of psychiatrists? He also wants to know who the guests believe should lead the assessment, the psychiatrist or the obstetrician?

He also asks if the timeframe for assessment is reasonable and workable? Dr Fenton has already said she believes it should be shortened.

Dr Mattie McGrath now. He got in some hot water last week for overstepping the mark with his questions. Let’s see what he says today.

He asks for research pointing to evidence about probability of suicide in pregnancy. Citing the X Case, he also wants

He quotes from Dr John Sheehan’s submission that in an psychiatric emergency, speedy delivery is contraindicated. He then asks about the calls for a shortening of the assessment and appeals process, querying whether it should be lengthened?

To answer Kelleher’s questions on abortion in the UK, Dr McCarthy says that within that group, there are women who could need psychiatric assessment.

“We completely disregard these people”, pro-life people completely ignore that population.

“We’ve seen some women suffer after abortion.” Some of their children might be alive today if we had not, he says, “and that would be a good thing”.

It is part of “our national ability to ignore big questions”. He cites stories recounted by women in their 80s who recall sticking knitting needles in themselves before abortion was available in the UK.

On the question of resources, Dr McCarthy says: “Absolutely, we need a huge increase in resources.”

If the result of this bill is better resources, then that is a good thing, he adds.

Dr McCarthy notes that between the three consultant perinatal psychiatrists, there is not one full-timer. All three are working in those roles on a part-time basis.

Dr McCarthy says that he is concerned that the appeals process is “two long”. He says that it could be dangerous to stretch it out for a woman with mental health issues.

Dr Fenton now. She says that psychiatrists will not be involved in a “box-ticking” exercises when making an assessment.

On women travelling to the UK for abortions, she says she knows there will be a number who have mental health issues, adding that we need to be able to provide and care for those women here.

Answering Ó Caoláin’s query about the panel, she says she is confident that there will be agreement and teamwork between the obstetrician and psychiatrists.

On the assessment and appeals process: “The longer we leave the woman in distress, the greater the risk of suicide.”

Dr Doyle says she has been accused of being a “broken record” on children but that she will continue to be. She notes that there are no figures about the number of underage girls travelling to the UK for abortions.

Those in the care of the HSE will most likely be subject to the process outlined in this bill – it has not been taught through adequately, she adds.

Dr Jeffers is fourth up to answer questions.

It is very clear that at least 4,000 Irish women travel to the UK for abortions each year. The vast majority are healthy – mentally and physically – but her concerns are for those who may have a mental health issue.

“We don’t have a culture or environment that a woman feels she can talk openly” about it, adds Jeffers. She also notes that some may feel the only alternative to the abortion is suicide.

“What type of State are we that would allow a woman to travel in that State?” This bill should be welcomed if it can deal with those women.

Dr Jeffers says it is most important is that women can talk openly about their concerns and their fears.

Dr Sheehan last up to answer questions.

He says there is a difficulty that we have no data at all about the state of mental health problems on the group of women who travel to the UK. Comments on this group is pure speculation, he says.

Anything that encourages those women to come forward to get help is to be welcomed.

He notes that Bressie and Alan Quinlan of Munster Rugby have come forward to talk about mental health issues recently. Anything that can be done to raise the issue is a good thing thing, he says.

Dr Sheehan says the time of an assessment/appeals process is the not the most important factor, but the state of the woman in question. He gives an example about a woman in distress because of a workplace problem. He says the decision to resign should always be put off until they are in a more calm place.

A rapid termination “flies in the face” of what we do every day, he says.

Senator Jillian van Turnhout says we have to be mindful of children when discussing the legislation.

Do we need to specifically elaborate in the heads of bill about children in care? She says she can envisage such children to be “suffocated” if they go through this process.

Now questions from Peter Fitzpatrick of Fine Gael.

Is a patient is suicidal – but not suffering from mental illness – what treatment is available?

Roscommon/Leitrim TD Denis Naughten says most of his questions have been asked already.

What happens if the issue of suicide has been brought up because of the non-fatal, serious foetal abnormalities? He mentions the threshold of viability and whether a decision would be made ahead or after viability.

Dr Sheehan up first this time.

“There is no clinical marker, like specifically, to assess suicidal risk,” he says. We do a risk assessment, including whether a person has a mental illness, examination of risk factors and alcohol/drug use. Gender and age also a part of the process as men four times more likely to die by suicide.

There are different scales, including the hopelessness scale, that are helpful.

Dr Sheehan says there are cases where homeless people say they are suicidal in hospitals because they want a bed for the evening.

It becomes much more complex when we are dealing with suicidal ideation where there is no mental disorder, he explains. It can be less certain and less accurate.

Infanticide is rare, continues Dr Sheehan. Early infanticide is when a mother kills baby within 24 hours of giving birth. In that situation, a woman is usually young and immature and not related to mental illness. Later infanticide is usually associated with psychosis.

Dr Jeffers says she doesn’t think people would ask an obstetrician to explain their day-to-day work.

It is difficult to distil down her training, expertise and experience to adequately get across the expertise of a psychiatrist in assessing suicidal risk, she adds. But she says she will given an example of women who present to her and her colleagues.

It is often a young woman who has extreme abuse in childhood, may have already had children taken into care. They are coming with the prospect of another pregnancy where the child will be taken into care. They do not have the normal social supports. They come to a multi-disciplinary team and between us all we will be offering support. It is ongoing care and support.

Dr Doyle says she is pleased with Senator Van Turnhout’s questions. We are here because of a predicament a child (X) found herself in, she reiterates.

She thinks there should be specific elaborations in the heads of bill to deal with adolescents.

It is not that the legislation is unworkable, we just need to flag up the extra layers that need to be considered, she adds.

Dr Fenton reiterates that she and her colleagues are trained and “very competent” at making assessments.

If a woman is psychotic and asking for a termination, it is the psychiatrist’s job to treat the psychosis.

Dr McCarthy says that suicide is a fact.

“We don’t have a clue” about figures about women who die by suicide or were at risk of suicide before a termination. Nothing captures “evidence” because abortion is readily available in the UK.

He says life is more complex than “black and white”.

“We are not naive…we are not fools…is she trying to test legislation?” says McCarthy when asked about a woman who would refuse all other treatments except a termination.

We’re used to being put under pressure…I love my work, it is really complex but it is also really human.

On issues of viability, Dr McCarthy defers to obstetricians.

The conversation between a psychiatrist and a patient will be very different if she is 6 weeks pregnant or 16 weeks pregnant, or 26 weeks pregnant.

He says that his profession understands mental illness and the “messy, horrible nature of life”. He brings up an example of a woman who is abused by the father of her unborn child. How does that woman protect herself, he asks. Does she get rid of the baby? Does she kill herself? Does she do both? Does she have the baby and is then stuck?

Dr McCarthy says he got a thank-you note from a priest for bringing up infanticide during the last proceedings.

Women found themselves in very difficult situations. He says Ireland’s treatment of unmarried mothers is “not great”, citing Magdalene Laundries and admitting that psychiatrists “colluded” in the system.

Senator Ivana Bacik asks about Head 4 and Head 19. She says as a criminal lawyer she is concerned about the criminalisation of women, especially for those who avail of abortion pills of the internet.

She specifically asks Dr Sheehan about his testimony on X. She asks if he is suggesting that such a girl should be taken into care – against her will – for the duration of her pregnancy?

Senator Colm Burke asks if the GP should have a greater role in this process? He also asks about how the consent issue for those in mental health difficulties is currently dealt with?

Thirdly, he asks about expectant mothers who are under the age of 18. What clarification is needed in the bill?

Mary Mitchell O’Connor asks Dr McCarthy about his submission and whether women will be pre-judged by the profession if this legislation goes ahead?

She also wants to know why 600-odd psychiatrists from the College of Psychiatrists in Ireland did not partake in a survey relating to this issue.

Could you forsee having to sign an involuntary confinement order for a suicidal pregnant woman, she asks.

Senator John Crown says the chamber has to include suicidality in the bill.

Addressing Dr Sheehan, he says that if there is a net transfer of women it will be for one of two reasons: that they are legitimately suicidal or that they are not and that they will try to “game ours system”.

He says he is confused by the statement that psychiatrists cannot decide if a patient will die by suicide. He says that one of patients died by suicide in the past and that he usually refers patients to psychiatrists if there is a “red flag”.

Senator Jim Walsh gets the final question.

He also queries the issue of consent and that abortion is an irrevocable decision.

He wants to know about advances in psychiatry since the X Case was heard 21 years ago.

Finally, he asks about a woman who presents at 26 weeks and is suicidal. She is not happy with early inducement, she wants an abortion. What is satisfied in this regard?

Dr McCarthy on the criminalisation of women in the case of using abortifacients: “Fourteen years seems extraordinary. We know women are doing it here. That is the truth.”

To TD Mary Mitchell O’Connor, he says the survey sent to College of Psychiatrists members “was not a survey worth answering” as he could not stand over it scientifically. He notes that it “selectively quoted” him.

He says that he has seen women stab themselves in the stomach and not because they were suffering from mental illness, but because they were distressed. He wants to dismiss the notion that we can neatly differentiate distress and mental disorder – they intertwine sometimes, he adds.

Dr Doyle notes that only one third of children in care actually have a GP and that needs to be looked at.

On the issue of resources again, Dr Doyle says that the child psychiatrists working in Ireland are not currently attached to the centres labelled as “approved hospitals”.

Dr Jeffers reiterates the need for this to be address for adult psychiatrists too. She says it is sufficient for one of the psychiatrists on the panel to speak to a patient’s GP ahead of a decision.

On the survey brought up by O’Connor, Dr Jeffers says it was “difficult to answer in a reliable way”. We have to be aware of bias, she said. What was the author’s thinking? she asks.

In psychiatry, our decisions are more accurate than in other fields of medicine, she adds. We understand where our patient comes from, she says.

Dr Sheehan to Bacik on her questions about X: “Prediction is very difficult, I use the word impossible.”

“I don’t think any doctor can say a certain person will never commit suicide…Equally impossible to say, that person will commit suicide.”

He says prediction of the future is different to risk assessment.

Deputy Terence Flanagan asks if “any significant consideration been given” to the flouting of mental health provisions in other provisions’ abortion laws.

Should the new legislation be cognisant of this?

What possible basis can we be assured that head 4 will not be abused in the way it has in California, he also asks.

Senator Rónán Mullen has the same “housekeeping question” as he had last week – were the guests consulted by the government ahead of the drafting of the draft heads of bill.

He asks Dr Sheehan about his statement that “speedy deliveries are contraindicated” – are we legislating for something a psychiatrist shouldn’t do?

He also asks whether this legislation could lead to greater demand for abortion for what can be termed as “social reasons”?

Senator Fidelma Healy-Eames asks Dr Doyle for clarification – could you grant a 14-year-old girl an abortion without a parent’s consent? And what if the parents disagree?

Are we not in danger of loading another injury on this young girl knowing that post-abortion girls have suicidal thoughts?

To Dr Sheehan, she cites the tragic passing of anti-suicide activist Donal Walsh: are we in danger of normalising suicide by passing a law providing for it to be a mechanism to get something else ?

She gives an example of hypothetical legislation which would allow for a write-off of mortgages if the borrowers were suicidal. She said that would be of interest to many people.

The Senator is the first of the day to mention the “floodgates”.

Dr McCarthy says he cannot say that any one psychiatrist will not “flout the law”.

He says he cannot promise it of a politician, either.

He says that anyone who does that is breaking the law, citing the Constitutional right of the unborn. Society should be alert that individuals may flout the law.

Dr McCarthy tells Senator Mullen that he received one phone call from the government ahead of the drafting of the heads of bill – and that was to check that Ireland currently only has three perinatal psychiatrists. This was in relation to claims that up to 12 psychiatrists would be involved in the assessment and appeals process.

He said he went on the radio about such proposals because he said it was “frankly his responsibility”.

He asks what the legislators were thinking? He says the woman who turns up to his office could be abused, raped, the victim of incest or that she may have tried to stab herself in the stomach.

Dr Doyle answers Healy-Eames’ question 14-year-old girl. She says she cannot carry out a psychiatric assessment without parent’s consent for anyone under the age of 17.

Dr Jeffers says psychiatrists do not want to get involved in anything that is not their job. People who this law applies to will be coming to us anyway, she explains.

She notes that she has not had any contact from the Department of Health ahead of the publication of the draft heads of bill.

Dr Jeffers says the psychiatrist is there to protect both the woman and the unborn.

Echoing Dr Mahoney’s statements last Friday again, she says: If the woman dies, the baby dies.

Dr Jeffers says that many people have completed suicide because of financial difficulties over recent years, in answering Healy-Eames’ claim that the law could be flouted.

Dr Sheehan says we cannot say with any accuracy how this legislation will work in practice. He explains that we have no research or data on the women who travel outside the State to gain access to abortion services.

Dr Sheehan says there is evidence to show that abortion can lead to mental health difficulties.

That has to be balanced by many women who have post-natal depression after a normal delivery, he adds. There are many thing that will increase risk of mental health difficulties, he adds.

Suicide has become an option for people, particularly young people. He says it is an interesting and relevant viewpoint that this legislation could normalise suicidal threats.

Billy Timmins says there is “clear division” within psychiatrists on the issue of suicide ideation in pregnancy. He asks for more clarification on the survey of the College which is likely to come up again and again today.

Michelle Mulherin asks if the evidence given in the X Case would have been sufficient to be granted an abortion under this proposed legislation.

Buttimer tells Fidelma Healy-Eames she is not allowed “get in again” as she tries to speak. The chair asks for the speaker to be respected.

McCarthy says those who made the most noise against the College’s council’s decision each made a submission to the council which were all discussed.

Dr Fenton says that if a woman presents to her with suicidal ideation, she says she will not wait for paper but assess the lady to her best of her ability. The decision will then be taken with the whole team.

Dr Doyle says it is impossible to know if X would be granted an abortion under the terms of this legislation.

Dr Sheehan says it would be almost impossible to do trials to provide evidence-based research about suicide in pregnancy. Says there is no studies to back abortion as a treatment for suicide.

He says that number can be quantified by looking at UK figures, noting four deaths in pregnancy – all of which were related to mental health illnesses.

And we’re running just six minutes overtime today as Buttimer holds up his promise to keep to time limits during today’s hearings. A brief recap:

  • During this morning’s hearing, Ireland’s three perinatal psychiatrists were keen for their audience to understand theirs is a field of medicine, just as obstetrics is and the decisions they make are distilled from training, expertise and experience.
  • There was much focus on the 4,000+ women who travel to the UK each year to access abortion services, with witnesses stating that this legislation could mean we know more about these women and their mental state.
  • Dr Sheehan argued that abortion is not a treatment for suicide but his colleague Dr McCarthy countered that there is no treatment for suicide. Prevention is the key, he said.
  • Dr McCarthy described a 14-year-sentence for any woman found guilty of procuring an abortion as “extraordinary”, especially knowing that there are women in Ireland purchasing abortifacients online.
  • Dr Sheehan said it was an important and relevant point to say that this legislation could “normalise” suicide.

That’s it from the first of the day’s sessions. The meeting has been suspended until 12.20pm when‘s Michelle Hennessey will report in for live-blogging duty. I hope you’ve found this morning’s updates helpful and informative. A list of the next witnesses can be found here.

Good afternoon.

You’re with Michelle Hennessy now and we’re staring back with four more consultant psychiatrists:

  • Dr Yolande Ferguson, Consultant Psychiatrist, Tallaght Hospital
  • Dr Peadar O’Grady, Consultant Child & Adolescent Psychiatrist
  • Professor Veronica O’Keane, Consultant Psychiatrist, Tallaght Hospital & TCD
  • Dr Eamonn Moloney, Consultant Psychiatrist, Cork University Hospital

Buttimer again asking for brevity and for members not to interject more than once.

Dr Peadar O’Grady is first to speak. He is giving a statement on behalf of Doctors for Choice. He says he has experience in certifying young people in terms of their eligibility for access to abortion under X.

Opinion of many psychiatrists is that the risk of suicide is increased by lack of having to travel for abortion. Restricted access to abortion services in Ireland is most likely to be because of having to travel. Those that are too poor or ill to travel are at a disadvantage.

Costs of travel for an abortion are higher for children because they require a parent to go with them and there are other costs related to the special care they require.

Doctors for Choice are concerned about the” unnecessary delay” to access to services in the bill, O’Grady says. In the case of illegibility in the case of a risk of suicide, an assessment by three doctors causes undue delay.

“All psychiatric emergencies are medical emergencies,” O’Grady tell the committee.

Doctors for Choice are “at pains to point” out that a 14 year criminal sentence is !not a moderate or temperate element” of the legislation.

The inclusion of a criminal sanction will” hamper good practice and  increase the risk of suicide in vulnerable patients”.  O’Grady says the notion that women forced to travel for an abortion because of fatal foetal anomaly are carrying out the equivalent of a gravely serious crime is “offensive”.

Dr Yolande Ferguson from Tallaght hospital is up next. We have extensive experience in assessing patients, we routinely defend decisions in tribunals.

Two doctors being involved in assessment would not differentiate psychiatry from other medical practices.

She is now discussing the wording of the legislation on the attachment of psychiatrists to medical institutions.

The woman or child could have seen up to for doctors including her GP in the entire process. The time period for appeal process should be shortened to 72 hours for each part of the appeal, she says.

This legislation should aim to “alleviate the distress” to women and children and not add to it, she concludes.

Dr Eamonn Moloney of Cork University Hospital is speaking now. This legislation could be practically implicated.

On  the issue of the number of medical opinions: Two psychiatrists and an obstetrician is “excessive”. Two medical opinions should suffice – one should be a GP and the other a consultant psychiatrist.

He says GPs have a huge amount of experience dealing with people who are suffering emotional distress, and experience in carrying out an assessment of the woman’s mental state. GP likely to have considerable experience assessing the risk of suicide and referring a patient on.

Second doctor should be drawn from panel of consultant psychiatrists who do not object to the legislation.

The assessment by a GP and then a consultant psychiatrist is the “usual and ideal care pathway” for all suicidal patients, likely to be the least distressing for the pregnant women and a process that is practical.

In mental health services through world, it is ultimately the consultant psychiatrist who makes decision about suicide risk.  Involvement of obstetrician is not appropriate and outside of their area of expertise.

Moloney echoes Ferguson’s suggestion that appeal process should be shortened to 72 hours for each part of the appeal.

He says the decision should be taken by majority vote.

Professor Veronica O’Keane, Consultant Psychiatrist at Tallaght Hospital & TCD is up next.

Sole purpose of the legislation is to provide primary legislation for decision during the X case. Women who are suicidal because of “unintended or unwanted pregnancies” or crisis pregnancy, will be the main users.

A consistent argument among legislators is that allowing the suicide clause will remove the barrier of abortion on demand and that some psychiatrists will be complicit in this or won’t have requisite skills to predict suicide. Also that abortion is not good for you and will underline suicidal tendency.

These are “deeply problematic assumptions” of the credibility of women and psychiatry.

“Young women in crisis do kill themselves”. 20 per cent of deaths in young women in Ireland are through self destruction.

Treatment implies a doctor prescribes or recommends intervention and that the doctor is involved in active advice. In this case it is the woman requesting the procedure. No one, either GP, assessing psychiatrist or obstetrician is advising her that she ought to have an abortion. There are no treatments for suicide, we manage the underlying risks.

The studies that have been the subject of public debate have all been done in countries where abortion services are available. In countries where abortion services not available, unwanted  pregnancy is a leading cause of death.

The floor is opened up to members now. Billy Kelleher is first.

In relation to locations, he asks for clarity on recommendation by O’Grady that psychiatrists shouldn’t be confined just to location prescribed in legislation.

No point in denying women are travelling for abortion. But how would you see a woman presenting herself, assessing suicidality or assessing and providing treatment.

Caoimhin O’ Caolain is asking about the importance of an enhanced role for GPs, something Ferguson spoke about. View expressd that two of heads should be merged so that the differentiation between medical approach and psychiatric approach is removed.

To O’Grady he asks about the area of obstetricians should not certify eligibility for abortion because of suicide ideation. Why should it be done by either a GP or a psychiatrist?

We’re told that this doesn’t present, only in the most rare of cases, could you give us an understanding of it?

Seamus Healy: On the question of accessibility, would you be happy that the legislation provides accessible pathway?

Dr O’Keane answering Kelleher’s question about reasons a person would be suicidal in pregnancy. It is “credible” that someone would be suicidal because of crisis pregnancy. Also possible series of stresses, and when you add an unintended pregnancy that could add to that but may not be the cause.

When the assessment takes place it won’t be uni dimensional. A psychiatric evaluation is complex and multi-layered. We intervene at whatever level is appropriate and the care pathway depends on what is assessed as being the problem and the patient’s needs.

“Terribly important” that we make sure that the service is accessible and that is why the role of GP is so vital and will become more important in healthcare that is provided to citizens of Ireland. The way to make it most accessible is to say ‘go to your GP, they know you, they will be able to evaluate if this is a real crisis or requires counselling’.

Dr O’Grady is next. There is a misunderstanding in terms of where viability fits in in abortion. It should be done before viability it becomes an issue, it is extremely rare, even in US. 1 in 1000 abortions involves an issue of viability.

GPs are the people who will start off the process of advising them about their state of health, including if they are pregnant. Leading reason for any delay is a delay in the diagnosis of pregnancy.

The major restriction that raises the risk of suicide in women and children, may be that travel is restricted.

In terms of assessing people, GPs are first to respond and psychiatrists are happy to take that and when they need our help they’ll contact us.

Restriction of travel for children in state care is an issue because of difference in parenting arrangements and the decision of travelling with child was more uncertain for carers than for a parent. Suicidality in children is a “very serious public health concern” in Ireland.

Dr Moloney stresses the importance of psychiatrist’s assessment. If the woman has a severe depressive illness, a termination would not be recommended as the priority is to treat the mental illness.

Dr Ferguson highlights that obstetricians would have an equal right to assess suicide risk under the legislation. “They are not experts, that’s what we are.”

It is important that they have a role obviously and our role to consult with them, we do this all the time.

Like her fellow psychiatrists today, she emphasises the importance of the role of the GP.

She says there is confusion about psychiatry, that it is somehow outside medicine. “We are all medically trained doctors, and are as able to make decisions as anyone else.”

The floor is opened up again and Ciara Conway is first. How long would it take me to get to see you if I was in a crisis pregnancy and was suicidal?

We do not want to criminalise women who seek life-saving abortion but want to address cases where it may be abused.

Peter Fitzpatrick asks about criteria for assessing a woman who is suicidal in cases where they have a mental illness, and where they don’t.

What are the steps taken to deny a termination?

Dr Moloney said that it would lessen burden on woman to have just one psychiatrist but seeing two would not make it unworkable.

Dr O’Grady on pathways and delays. Concerned that elements of legislation are either designed to delay could be used to delay processes.

How long to see one consultant? How long to see two?  Is this medically necessary? I think we’re clear that it’s not.

Certainly it does seem dangerous having criminality hanging over a woman. They may be restricted from sharing medical details openly which we rely on constantly and it adds to stigma.

There is no need to specific laws to criminalise bad practice. If a registered practitioner engages in poor practice there is already a process to deal with that.

“Women are hurt by abortion”. By the last estimate by the WHO, 47,000 women died in 2012 from unsafe abortions and 5 million were disabled by unsafe abortions.

There is no right response to pregnancy or abortion, we support people no matter what their decision.

O’Keane again repeating the recommendation about having a GP and just one psychiatrist assess a woman. Potentially slows the process, adds unnecessary emotional distress as the woman has to repeat her story twice. The process of opening up” is actually quite painful”.

Also could mean the difference between a medical and surgical abortions because of delays.

If we allow the first group of practitioners not to give an opinion, a review panel may also be able to do that. The onus should be on the group of practitioners who see her initially to come to a decision, even if it’s negative.

Ivana Bacik asking about children in care making use of the legislation. Asks for clarification on suggestion of one GP and one psychiatrist.

What do we do in situations where a girl in care does not have a GP? One in three don’t.

Denis Naughten up next. He asks about suicidal ideation in pregnancy, it peaks at the end of the first trimester so would this not lead to more medical terminations and not surgical?

What happens with woman who is not mentally ill whose suicidality is based on the fact that she is pregnancy with baby that has foetal abnormality.

Regina Doherty asks about the sudden onset suicidal intent. The psychiatrists don’t treat intent, they manage the issues and deal with those isues.

Asks psychiatrist to describe, when a woman presents to her GP with suicidal intent, at what point does the treatment kick in or do we just go straight to assessment of eligibility for a termination?

She would be happy to accept this if it was a last option, after all treatments were exhausted.

Jim Walsh how can we avoid corruption within the practice, that would lead to a liberal abortion regime?

O’Keane: No one here today advise woman whether or not she should have an abortion. We are employed by state to determine if she is eligible under the legislation.

Everyone who comes to us will be treated, with psychotherapy, visits from home treatment nurses, access to immediate psychiatry. We can bring together teams of professional carers and assemble them very quickly. We want rapid access to minimise the distress to a woman.

Dr O’Grady tells the committee that the question around consent for children and whether they can give and refuse consent is not restricted just to this area of medicine.

There is a coincidence between suicides and pregnancy on the missing of the woman’s second menstrual pregnancy. We are likely to get cases where suicide risk as an issue arises in first trimester and in this case medical abortions would be carried out.

On fatal foetal abnormalities: “viability is the moot point”. It often doesn’t happen until second trimester and sometimes not until third. He says it is very distressing for women because it is generally a wanted pregnancy and all of a sudden a baby becomes a foetus.

I do object to this notion to women being like water flooding the place – O’Grady taking issue with the term ‘floodgates’.

Those with a personal ethical objection to abortion, we should pay careful attention to. If they have chose to have an abortion these are people we should follow up carefully, because they are likely to suffer feelings of regret. We detect risk, engage with the risk and follow up the risk and support them no matter what their viewpoint.

Dr Moloney: Suicide is associated with certain conditions for which treatment is available. We’re not talking about abortion as a treatment.

Like O’Grady he is also criticising the ‘opening of the floodgates’ phrase and “conspiracy” theories.

Dr Ferguson should as much as possible follow normal pathways of care, eligible for all treatments that are available to everybody.

The notion of psychiatrists facilitating abortion on demand: It is important to me that psychiatry is respected. None of us want to see our profession discredited.

Deputy Flanagan: If a woman refuses treatments, will you certify thattermination is appropriate treatment even though no evidence it will have positive effect on woman?

What do you expect you accuracy to be in determining if a woman is actually suicidal and termination is the only treatment?

Can abortion make women suicidal?

Peter Mathews is next to ask questions. The “big gaping gap in these hearings”, is the women who had this experience and had requested to be at the hearings but we declined. He adds that we don’t have to rush into this.

Another deputy asks if there evidence to suggest, with conscientious objection, that  women may find themselves unable to access treatment from a psychiatric point of view or medical point of view.

Reminds committee that we are all bound by the Irish Consitution.

Michael Creed asks O’Grady how many times he would have certified terminations and about the times when he was requested to but declined to under X case criteria.

Fidelma Healy Eames asks O’Keane about situations where abortion services are not available as the doctor said pregnancy is a leading cause of suicide in these instances. She asks for evidence to back this up.

She asks for clarification on the issue of a GP making a recommendation for a termination, should this not be a referral to a psychiatrist?

Paul Bradford: What other treatments would have been offered to patients before a termination?

Dr Ferguson said looking at women who are more likely to seek abortion it is not surprising because of a number of factors including mental health issues.

It’s a very “cynical approach to women” that they would refuse other treatments just to get an abortion.

She’s suggesting a panel for dealing with objections by doctors.

Dr Moloney: We spend our working days talking to people, we have experience in assessing people.

He tells the committee that he thinks it is “spurious” to talk about predictive values for assessing the risk of suicide. We have the ability to assess suicide risk and manage that

I wouldn’t say we’re rushing into anything, it’s 20 years since the X case.

O’Grady says the final decision is most safely left in the hands of a woman and he does not consider that abuse.

It is true that women who suffer mental health problems and violence are more likely to be in a situation where they consider abortion.

He quotes research that says there is no evidence of abortion causing mental health problems. There are women who have negative feelings about it but for specific reasons, like coercion for example.

Healy-Eames interrupts O’Grady as he talks about research concluding that with eligibility there should be a loosening of restrictions.

Deputy Mathews also interjects and Buttimer calls for order in the chamber.

O’Grady says we can get too abstract and should look at alternatives available, the alternative in the X case would be to force someone through a pregnancy.

O’Keane refers to the refusal of treatment: if a patient refuses treatment in the context of serious mental illness we would involuntarily detain them and give them the treatment but if the do not have a mental illness, it is their right to do so.

We are here to help the legislators bring in a law that is effective and accesible to women, we’re not here to break the law or help people abuse the law.

150,000 women had abortions in Ireland and the majority are not hurt. It is “patronising” to assume women being pressurised into having abortions. This is a service for women, women are not being pressurised, they are making their own decisions against the odds.

In response to Healy-Eames, she says the studies she quoted come from countries, not just where it is not legally available, but in countries where women are too poor to get one. She said she will happily pass those onto the Senator, and also recommends some supplementary reading.

We do everything we can to prevent a person from killing themselves, nearly everyone who comes to us is at risk of it, the fact that 97 per cent don’t is exactly what we’re aiming for.

Buttimer is being heckled by Deputy Timmins who did not get to speak. This session has already gone five minutes over time so he calls this one to a close and it will now be suspended until 3.30pm.

So here are some of the key points from that second session:

  • Just like the medical representatives last week, psychiatrists emphasised the important role of GPs who already have experience in assessing the risk of suicide in patients, particularly in patients they have been treating for years.
  • All of the psychiatric professionals present expressed concern about possible delays caused by having to see two psychiatrists, saying that this is unnecessary medically and would cause undue distress for the woman.
  • Like their colleagues this morning they stressed the danger of the inclusion of a criminal sanction with a 14-year sentence.
  • A number of the psychiatrists shot down suggestions that the legislation would be abused by medical professionals to allow for abortion on demand.
  • They stressed that abortion is not a treatment for suicide and they would never advise a woman to have a termination – their jobs is purely to assess their eligibility.

And that’s it from Michelle Hennessy. I’ll leave you in the capable hands of my colleague Christine Bohan who will take you through the next session from 3.30pm.

Afternoon all, and thanks for sticking with us as we reach the half-way point of today’s hearings. I’m Christine Bohan and I’m going to be covering the third of the four sessions today as the TDs and Senators hear from four more consultant psychiatrists:

  • Professor Kevin Malone, Consultant Psychiatrist, St Vincent’s University Hospital & UCD
  • Dr Bernie McCabe, Consultant Psychiatrist, Navan Hospital
  • Dr Jacqueline Montwill, Consultant Psychiatrist, Mayo Mental Health Service
  • Dr Sean O’Domhnaill, Consultant Psychiatrist

Chair Jerry Buttimer starts the session by appealing to members once again to keep things civil. He asks TDs and Senators to ask questions based on what’s put before them, rather than just making statements.

Professor Kevin Malone of St Vincent’s Hospital and UCD is the first to speak. He begins by saying the legislation is based on a 20-year-old assessment of risk of suicidality (.e. the X case) and excludes 50 per cent of the population: men.

He says he has been studying suicide in Ireland for the last 10 years and says this legislation could inadvertently increase the suicide risk among men in Ireland. The legislation may lead to a greater loss of life rather than life-saving, he says.

He asks how mental health literature will be taught in schools, saying suicidality will be legitimised for women in some circumstances, but not for men, despite their much higher rate of suicide.

Next up is Dr Jacqueline Montwill who begins by saying her understanding of this law is that it is to “reassure Irish people that no Irish woman is going to be denied life-saving treatment because of her pregnancy”. She says that in her opinion, “we do not need this law”. She says psychiatrists already have full clarify about their role.

She says Head 4 of the bill is seriously flawed for three reasons: she says the treatment it proposes is not a treatment, the treatment is not the only treatment, and thirdly, if truly suicidal, the patient may not be able to give a valid consent.

Dr Montwill says the proper care of a suicidal woman would entail care both during the pregnancy and after delivery. Longer-term intervention may be needed depending on the circumstance. “but the point is that this woman will not be abandoned,” she says.

It is illogical to say that the only treatment for suicidal intent during pregnancy is abortion, says Dr Montill. She says it is important to make the distinction that a psychiatric emergency is fundamentally different to any other surgical emergency, and this is because of the nature of the disorder. In a true psychiatric emergency, the patient is often impaired, she says.  Therefore, it would be highly unethical to impose a permanent intervention while the patient is undergoing a period of mental illness, she says, describing it as a potential failure in the duty of care of psychiatrists, who should be protecting a patient during a period of mental illness.

She says that direct abortion is not a clinical response but is a social solution.

Dr Bernie McCabe of Navan Hospital is speaking now. She says she wishes to present her concerns around the legislation.

As a consultant psychiatrist, she says she has to provide a non-judgmental and evidence-based treatment. These ideals are grounded in the governing bodies for psychiatrists, she says.

On an side, she says that a growing number of members of the College of Psychiatrists of Ireland no longer feel that the speaker from the College is representing their views at the Oireachtas hearings, and says the College has been informed of this in writing.

Dr McCabe says there is no evidence of abortion as a treatment in suicidality. She says there is a major problem because suicide cannot be predicted, even in people with mental illness.

Dr McCabe ends by saying that there is a dearth of evidence on the use of abortion in treating suicidal women. Psychiatrists should not be involved, she says, except in so far as they can treat women with mental illness, which must be evidence-based.

The final of the four speakers, Dr Sean O’Domhnaill, begins by questioning whether the legislation is meaningful if the government does not take the evidence it is being presented with into account.

He says that “we should nail the lie” that Ireland has any obligation under the ruling by the European Court on Human Rights to legislate for abortion, saying that the judgment asked Ireland to “clarify” the situation.

The bill has been mis-named, he says. It won’t protect a woman’s life, but will provide a legal basis upon which the deliberate ending of one life is carried out. He says:

Abortion has no place in modern medicine. It’s a medieval solution in modern medicine.

Dr O’Domhnaill is describing what happened in California when laws were changed in that country to allow for more abortions to be carried out. He draws a parallel with Britain, and says that the experiences there were comparable to California and other countries where abortion laws were changed.

“We need to be honest, something that’s been lacking to a large degree in this debate so far, and stop fooling ourselves that things will be any different in Ireland” than in any other country that has sought to “walk down this particular path,” he says. He adds:

My own experience has been that abortion can be harmful to women and this is largely ignored by those supporting this legislation.

Dr O’Domhnaill says that anyone who has “witnessed the corpses” left behind from the victims of abortion would not want this legislation. This bill seeks to turn doctors into abortionists, he says.  He begins to describe the medical procedures used in terminations.

First up, as per usual, is Billy Kelleher of Fianna Fáil. His first question is brief: he asks the psychiatrists if they are aware of any cases where a woman has taken her own life because she was in a crisis pregnancy.

His second question: He says that other psychiatrists have also said that termination is not a treatment for suicide – but equally, in rare circumstances, that it may be the only option left to save the life of the woman. Why would you be concerned that this would results in higher numbers of abortions if all the evidence is that it is not a treatment for suicide, he asks.

Next up is Caoimhghín Ó Caoláin, whose name I hope to one day be able to type without having to google the spelling. He says there has been an implication that the decision will be left to medical professionals, but says that women will always have the final decision.

He raises up an interesting point from earlier. He quotes something said by Dr Bernie McCabe when she said psychiatry has nothing to offer women who are suicidal due solely to their pregnancy, and says he would have thought that that was the exact situation when psychiatrists could and would be able to assist and help a woman in that situation in order to stop her from taking her own life.

Mattie McGrath asks if the psychiatrists know of any studies where abortion has been found to be the only way to stop a woman from taking her own life, or where it has been found to be a treatment for mental health problems. He then asks them to expand on their concerns they have about issues the government has ignored in the hearings, and whether they think that guidelines would have sufficed rather than legislation.

Dr Montwill says there is no data to answer Billy Kelleher’s question about any cases where a pregnant woman has taken her own life.

She says there are three groups of people psychiatrists are likely to encounter with regards to this legislation. The first two she describes are women with severe mental illness, such as psychosis, and women with severe adjustment reactions, who may be depressive with suicidal ideation. Both of these are classified in terms of mental illness. The third type is someone who has a crisis in their life but has no mental illness. The issue here, she says, is one of consent. Consent to carry out an abortion has to be done when there’s no impairment of judgment and the capacity to make a judgment there, and this may or may not be present in some of these groups.

She says that she has “grave reservations” about colleagues who have said that they want to see the timeframe of the appeal process for an abortion (14 days under the proposed legislation) reduced.

Dr Sean O’Domhnaill describes how he has worked in other jurisdictions where he says he saw consultants signing off abortions in advance and says one colleague had a stack of “pre-signed forms” on his desk to use. He says that the ideology of this indinvidual was so completely pro-choice that they had little regard for the unborn child. He says that his concern is about the reduction in the value of the life of the unborn, which he says this bill seeks to do.

This is the first time there has been legislation that seeks to allow a human being to be killed, he says. The only person in Ireland who can currently have a death warrant signed is an unborn child, he says.

Ciara Conway asks what the psychiatrists think should be done for women who present as suicidal. She also asks if she were one of the people in a crisis pregnancy, how long would it take her to access the services of the psychiatrists.

Senator Jillian van Turnhout says that her role as a legislator is to protect everyone, even if they’re in a tiny minority.

Mary Mitchell O’Connor asks whether any women coming before any of the four psychiatrists will be “pre-judged”. She also asks if any of the four have ever signed a form allowing for the involuntary detention of someone who has been deemed to be a danger to themselves.

Senator Colm Burke takes issue with a point made by Sean O’Domhnaill who had questioned why the Master of the Coombe Maternity Hospital had been excluded. Senator Burke says she had been invited but had indicated that her views would be represented by the Institute of Obstetricians and Gynaecologists.

Dr Montwill answers first. She takes up Ciara Conway’s question, who had asked about her use of the phrase “social solution”. She talks about the treatment of a crisis pregnancy, and says that a “proper support care pathway” is the best alternative for a woman with a crisis pregnancy.

She says that suicide in pregnancy is a real risk which psychiatrists deal with all the time, particularly in the post-partum period – but that’s not what this is about. This isn’t about women with mental illness, she says. This is about women with a firm belief that they don’t want to be pregnant.

Dr McCabe says if psychiatrists offer abortion when we know that there is no evidence base, they are not being fair, right or just to their patients.  It is not the right thing to do , she says, because we won’t have the evidence base. Would you want to receive a treatment that is not evidence based, that has not been proven? she asks? “No, I thought not,” she tells the hearing.

Dr Sean O’Domhnaill questions Senator van Turnhout on her point about the tiny number of cases involved and why lawmakers have to legislate to protect them. “How many lives are you prepared to sacrifice for that one case?” he asks. Once you open the gate… they’re open, he says. “And looking at Britain from 1967… we know the price that they paid. It’s over 4 million”.

Why do we have the fear about abortion, asks Dr Sean O’Domhnaill. “Ideology is an incredibly strong thing – and there are people who can’t see beyond their ideology”.

Hi there, Jennifer Wade here and I’m going to be covering proceedings as they continue this afternoon…

Dr Jacqueline Montwill, in response to questions, says that if any patient presents with a severe mental illness and threatening suicide, that during that emergency time –  and that time alone – her judgement is impaired. Therefore she must be properly assessed or treated before the question of the termination of pregnancy is approached.

We always believe what a patient says, Dr Montwill insists, but would you offer a woman who is so distressed that she is acutely suicidal an abortion when she is in that state?

You cannot say that abortion will only be the only treatment – that makes no sense, there are lots of different treatments, says Montwill.

We have no real way of knowing who is going to proceed to suicide, says Dr McCabe. We are advised to be overly-cautious, but we know will never be able to predict who will take their own life.

We don’t “not believe” our patients – but that doesn’t mean we don’t assess them. For some people [that assessment] might take two hours, for some people two weeks, or two months. These things are not written in stone, says McCabe.

Prof Malone reiterates the belief that experts will never be able to construct a predictive model for suicidal intent or risk in pregnancy.

He adds that, based on studies over 15 years, they have found a ‘two year lag’ in relation to suicide rates in Ireland. When male suicide rates increase in Ireland, female suicide rates increase follow two years later, he says.

Having voted for Fine Gael, I’m a little bit upset at finding myself here speaking about a bill I was assured would never be found before the Oireachtas, says Dr Sean O’Domhnaill.

Senator Healy-Eames congratulates the psychiatrists on their ‘holistic’ approach and asks “how many babies’ lives do we have to take” to save one in 5,000 lives of women – who may or may not have been helped without abortion.

She adds: are we in danger of legitimising suicide?

Terence Flanagan asks the panel: do you think that abortion is the only treatment for a suicidal pregnant women? If not, what is?

Michelle Mulherin asks: will this legislation actually give clarification on the matter? She also asks if there is a treatment for someone in a heightened state of distress who = believes they need an abortion.

Montwill: We’re in a quandary because we have to make a distinction here… With this law, there will be women who will believe they are entitled to an abortion and will threaten suicide but who do not have a mental illness. It’s very difficult situation. This person doesn’t have a mental illness that we can treat, but they do have other problems that can be treated in other ways.

Dr McCabe says psychiatrists are very poor at predicting suicide and that they tend to “over predict” the likelihood of the risk.

Prof Malone says he thinks it’s unfair to say this law would ‘legitimise’ suicide, but that it would nevertheless have ramifications societal attitudes.

Addressing the question of how to deal with a person who says they will take their own life if they cannot acquire an abortion, Dr Sean O’Domhnaill says “I’ve worked for many years in Dublin’s north inner city and have had many people look me in the eye and told me they would take their own lives, usually when they were seeking particular chemicals (drugs)…” He says that instead of giving access to what they are demanding, the person needs “time to come down from that heightened state in order to look at their situation with a little more clarity”.

In terms of assessment time for a pregnant woman reporting suicidal thoughts, Dr Montwill describes 72 hours as “far too short” an amount of time, adding such a timeframe would be “an abomination”.

Prof Malone says there is “quite a substantial evidence base” for treatment for suicidality, including cognitive behavioural therapy.

Dr Montwill says: “We want to save the life of all people who are suicidal – but this bill is not about suicidality, it is about providing abortions.”

In response to a question about the humane response to a victim of rape and her family, Montwill  underlines the need for quality treatment and support.  “And for that 14-year-old girl (aka the X Case) that’s what should have happened. A problem shared is a problem halved.”

Montwill says there will be “a bias” with all proposed panels to which a pregnant suicidal woman reports. She adds that “there is no way to say which women will kill themselves” and therefore the request would be granted.

The proceedings will now rest until 6.30pm.

Now the Committee will hear from experts from other medical specialties, namely:

  • Claire Mahon, President, Irish Nurses & Midwives Organisation
  • John Saunders, Chair, Mental Health Commission
  • Dr Kevin Walsh, Consultant Cardiologist, Crumlin & Mater Misericordiae Hospital
  • Dr Janice Walshe, Consultant Medical Oncologist, St. Vincent’s University Hospital

John Saunders, the Chair of the Mental Health Commission, opens by outlining the purpose and remit of the body. He says there is “no role” by the Commission in relation to any heads of the bill, but that it has a number of general comments about it.

They include questions relating to the definition of the term ‘self-destruction’ –  as no legal or medical dictionary definition exists – and also about what constitutes ‘appropriate qualifications and experience’ required of the HSE employee tasked with compiling an assessment panel.

The heads of the bill is silent in relation to children detained under the mental health act, Saunders adds.

Dr Janice Walshe, Consultant Medical Oncologist, St. Vincent’s University Hospital says that cancer complicates about 0.1 per cent of pregnancies – but  that it’s likely that this number will increase as the average maternal age increases. A range of cancers arise during pregnancies, she says.

Walshe  recommends that two practitioners along with obstetrician be part of assessment panel.

Mattie McGrath TDs complains that TDs and Senators did not have enough time to eat their dinner in the canteen before attending the Committee.

Proceedings have been suspended for a few minutes in order to admit Dr Kevin Walsh, who was held up.

Dr Kevin Walsh, Consultant Cardiologist, Crumlin & Mater Misericordiae Hospital, says there are 17,000 adults alive with complex congenital heart disease in Ireland today. Pregnancies in such women present a variety of significant challenges to their health, and can result in foetal abnormalities, miscarriage, or the woman’s death.

Pre-conception therapy usually begins with such women after puberty, he said.

Dr Kevin Walsh says that, thanks to the Mater Rotunda team, no woman with a congenital heart disease has died during pregnancy in past decade.

Responding to questions, Dr Kevin Walsh says there’s nothing about the different situation of children (ie females under 16) who are pregnant covered in the bill – and that this is a significant oversight.

Dr Janice Walshe says that she and her team come across a lot of cases of “physiological distress” amongst women with cancer who are pregnant. When it is explained that a termination of the pregnancy will not significantly impact the affect of the cancer and that she can continue with the pregnancy, the patients tend to become less distressed, she added.

Jennifer Wade has gone to take a breather so it’s Gavan Reilly here to finish up this evening’s events.

Senator Jillian van Turnhout is asking how a fair system of medical regulation can be drawn up without essentially adding doctors to two lists – one which will carry out an abortion and one which will not. Regina Doherty is asking any of the experts if they have seen a patient travel to England for an abortion where one was available, and wants to know if nursing practice would change under the proposals.

Dr Janice Walsh is explaining that she’s like to see a second medical practitioner consulted in cases where a pregnant woman’s life may be at risk of cancer – she says the condition is so rare that many haematologists and oncologists may never have come across such circumstances, and so a second opinion would be preferable.

She says she’s known of patients who have travelled to Britain for an abortion, though it is “exceedingly rare”; in those cases the pregnancy was in the first trimester and there were concerns about significant foetal abnormalities.

Dr Kevin Walsh – Ireland’s only current specialist in congenital heart disease – says requiring two medical professionals, in some cases, could be impractical if a woman’s life is at risk, simply because the rare circumstances where this would apply mean there simply might not be two doctors you can ask.

Peter Fitzpatrick wants to know if doctors citing a conscientious objection face a risk to their livelihood, discrimination in their careers, and whether the father of the unborn child should be consulted as a legal requirement.

Denis Naughten, following up, wants to know how often the psychiatrists intervening in a case of suicide risk might be the specialist perinatal psychiatrists based in Dublin, and wonders if a senior midwife could be considered qualified enough to offer a second opinion wherever one is sought.

John Crown says this session has been “particularly learned, [and] focused” and addresses the difficult issue of ‘quantifying’ exactly the degree of risk to a woman’s life. He wonders if some medics have any sort of guide which tells them how an individual condition can incrementally increase the risk to life, and the percentage threshold at which someone’s life is in immediate danger.

John Saunders is first to respond, and says it appears the Mental Health Commission won’t have a very significant role in the system created by the current legislation.

Janice Walsh says there is no question that doctors need to make ‘small compromises’ when trying to quantify the degree of risk, but the real concern is in situations in the first trimester when the risk to life may be more urgent. Dr Kevin Walsh adds the percentage risk to life varies depending on the condition, but in some cases a “5 to 10 per cent risk” is more than enough to merit an intervention.

Eileen Lawrence says a senior staff nurse is “an expert in her field” and says their medical knowledge should be taken into account wherever it’s appropriate.

The last political contributors will be senators Colm Burke (FG) and Jim Walsh (FF). Burke wonders what structure might be put in place, under the new legislation, to deal with pregnancies when the mother is under 18, and asks for clarity on Janice Walsh’s comments on the circumstances where two doctors’ experience may be necessary to make a call.

Jim Walsh wonders if the provisions in the bill will broaden the availability of abortion, or merely reflect the current medical practice already in Ireland, and also wonders whether the word “reasonable” should be left in front of “opinion” (he does, personally). He also deals with Miss C, the child who was brought to Britain by the State to undergo an abortion against her parents’ wishes – should the legislation do something to stop this from happening again in future?

John Saunders says the legislation does avoid the question of children, and says this is unusual – most ‘social’ laws do have a specific clause relating to how children are treated, given their vulnerability. Dr Janice Walshe, dealing with the question about two medical professionals needing to sign off on some medical emergencies, says it cannot but be helpful if a doctor dealing with unique circumstances has the opportunity to consult a colleague.

Dr Kevin Walsh says the introduction of an Irish system of abortion could only be an improvement on the status quo where pregnant women in difficult circumstances face the financial and emotional strain of travelling to Britain.

Questions from non-members now, starting with Fidelma Healy-Eames, who wants to know what medical options were available to C (in the A, B and C case), the woman who had cancer and won a case at the European Court of Human Rights. (That court’s ruling specifically said the absence of clear legal guidance in Ireland was a breach of C’s human rights.) She also asks whether a suicidal woman, not of sound mind, has the correct standing to even submit a request for an abortion.

Terence Flanagan wants to know how regularly a cancer patient’s pregnancy can be safely managed to completion, and whether Head 4 (the one dealing with the risk of suicide) undermines the current model of conscientious objection.

John Saunders says the issue of the capacity (of a suicidal woman) is exactly what is assessed by the people treating that woman. (He notes that the Oireachtas has been due to pass laws reforming the mental capacity system for some time now, but has yet to even see such laws, let alone pass them.)

Dr Janice Walsh, dealing with the question on the C case. She would present to her oncologist and be given a prognosis, where the risks to her and the foetus are discussed. The resources available are fairly uniform, but there is no specific information that would be available to such a patient (simply because the condition is so rare). She doesn’t think the legislation will actually change practice.

Here’s Senator Rónán Mullen, who asks if any of the experts have a concern that a refusal for an abortion can be appealed, but an approval is not. Should there be “parity of esteem” given that both the mother and child have an equal right to life? Mullen also wonders why the Freedom of Information Act is being neutered in this case, when all sides should welcome transparency.

Peter Mathews: “What sort of word games are going on here?… No matter what the Supreme Court said in regard to the X Case… every event in history is a unique event. To legislate for an event that was a unique event, that’s not going to recur, is logically absurd.”

(Mathews’ question, by the way, asks why we’re bothering with this legislation “when we know what we’re about”.)

The final questioner is Senator Paul Bradford, who refers to the “mantra” that the legislation is about “saving women’s lives”. He follows up on Mathews’ points – if the legislation is not simply about saving women’s lives, and the legislation does not change medical practice, “are we presently in the situation where we’re not saving women’s lives?”

So, in response; John Saunders deals with the question about the provision for an appeal if a request for an appeal is granted – and says the legislation departs from the norm by not allowing the courts to deal with any appeals, irrespective of the outcome of the original request. He says the application of the Freedom of Information rules isn’t much of a concern, as the legislation already debars personal information in any case.

Dr Janice Walshe says the likelihood of the legislation being enacted in her area (consultant oncology) is exceedingly rare, but nonetheless the legislation is necessary. Dr Kevin Walsh says sending a patient with heart problems to the UK is generally introducing a complication which isn’t needed.

Dr Kevin Walsh says the legislation would introduce small changes to the status quo, given that it would absolve some women in difficult medical conditions from the need to travel to Britain if they felt it necessary to do so.

“We’re not in Ballymagash,” Jerry Buttimer bafflingly utters, as Fidelma Healy Eames looks for further clarity on the last remarks, and closes with his gratitude for the experts and the Oireachtas staff who are working pretty long hours this week.

With that, the committee is adjourned for the day.

So – that’s our lot for today. Thanks again for reading and for all your comments – again, way too many to respond to individually. We’ll be back with the final day of the hearings tomorrow morning.

Until then, on behalf of Sinead O’Carroll, Michelle Hennessy, Christine Bohan and Jennifer Wade, this is Gavan Reilly signing off – thanks for reading.

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