THE OIREACHTAS COMMITTEE on Health and Children today began round two of its 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.
TheJournal.ie’s reporters provided updates throughout the day.
Good morning. Sinéad O’Carroll here to take you through the first session of today’s hearings. Thanks for joining us. We’re just getting started in the Seanad with chair Jerry Buttimer giving housekeeping instructions.
During this session we will hear from Minister James Reilly, as well as the secretary general at the Department of Health, Dr Ambrose McLoughlin and Ireland’s Chief Medical Officer Dr Tony Holohan.
Buttimer says he is hoping for three days of calm proceedings. He was widely praised for his work on the committee’s initial hearings ahead of the drafting of the heads of bill. “It is important to gather information and to engage and listen to the witnesses who have given their time,” he added.
As Buttimer talks about responsibility and dignity within the chamber, there is a protest ongoing outside the home of Justice Minister Alan Shatter. Gardaí are at the scene.
If you’re not entirely sure why we’re here today, here’s a brief crash course we put together earlier.
James Reilly has taken the stand. He notes that the committee’s feedback – which is due at the end of this month – will be used as the government works on the final wording of the legislation, which is required under the judgement in the ABC vs Ireland case at the European Court of Human Rights.
Reilly notes that the matters at stake are extremely complex and tells the committee that his department has already identified technical issues in the heads of bill that need to be examined.
James Reilly is going through the Heads of Bill, step by step. Here is the document in full and a briefer synopsis.
Reilly said a doctor’s hands should not be tied in an emergency circumstance because there were not enough doctors to sign-off on a procedure or that he/she was not working in the correct facility (a public obstetrics hospital). Therefore, a termination can be signed off in a physical medical emergency by just one doctor. However, that doctor must then document his/her reasons to the Department of Health.
Here’s another image of what’s happening outside of Alan Shatter’s home this morning:
Reilly says it is important that his department is notified when a medical procedure permitted under this Bill has been carried out. No names of the women involved will be used in this process.
Conscientious objection is for individuals only, and cannot be invoked by institutions – a clarification by Reilly. Therefore, entire hospitals will not be allowed claim conscientious objection for not carrying out a termination. If a doctor wishes not to perform a termination, then he/she must pass the case to a colleague.
Reilly is now making his concluding remarks. He notes that the only purpose of the legislation is to clarify what is already lawfully available in Ireland. “To set out clearly-defined and specific circumstances which a treatment can be provided.”
Reilly reveals that more than 50 drafts were composed before the draft heads that we have in front of us were published. He says he believes the government has reached a balanced proposal.
James Reilly will be leaving the chamber shortly, says Buttimer. Up now is Dr Tony Holohan.
Dr Tony Holohan, the Chief Medical Officer, says he wants to comment on matters of common medical practice.
Dr Holohan talks about the “more subjective process” when dealing with suicide ideation. Says this must be provided for with checks and balances.
Holohan says he believes in the integrity and professionalism of Ireland’s doctors, adding that he has confidence in them.
They are showing leadership at a scale and pace that would be impossible without their active engagement, he continues. He says it is hope and expectation that the doctors who give evidence over the next three days will remember their responsibility that the public is informed through evidence and science.
Now there will be questions from Committee members. First up is Billy Kelleher from Fianna Fáil. “Is there always an obligation on the medical team to make every effort to deliver a child alive and sustain the life of that child,” he asks.
He notes that sometimes the words sound “callous” when talking about suicide ideation in pregnancy. He asks about the decision-making process for the panels that will decide on whether a woman will be permitted an abortion – will the doctors have a relationship with the patient or will it be just a decision.
Caoimhghín Ó Caoláin from Sinn Féin now. He criticises the Minister for leaving the chamber before question-time.
Just a note on how procedures work. The questions are asked in bulk by Oireachtas members before they are answered by the witness. So Tony Holohan will have to remember all these questions and answer them all in-a-row when the TDs and Deputies are done.
TD Mattie McGrath asks what evidence given in the Oireachtas Committee’s first hearings was used to compose the heads of bill. He notes that there was evidence given that abortion is not a treatment for suicide ideation in pregnancy.
McGrath also says he is disappointed with the Minister for not staying for questions.
Holohan, in answering Billy Kelleher’s question, Holohan said there is absolute guidelines that a doctor does all he/she can to save the life of the baby, as well as the mother.
Holohan tells Ó Caoláin that he believes the draft heads fulfil the ECHR requirements.
Holohan said there will be examinations of technical issues, including the linking of doctors to particular hospitals and conscientious objection.
A doctor who believes they have a legitimate conscientious objection must ensure care of the patient is passed on, he says.
Holohan apologises that he has not taken comprehensive enough notes and asks for clarification of questions. He again notes that there are technicalities to look at within the heads of bill that the Department of Health have already identified.
Replying to McGrath, Holohan reiterates that the government must provide for the suicide grounds because of the X Case Supreme Court ruling.
On the question of providing care for children who are “unwanted” by their mothers, Holohan said there are already procedures in place.
My colleague Jen Wade has been finding out more about that protest outside Alan Shatter’s home. Read more here.
Deputy Denis Naughten asks how the appeal process will work in reality – can a woman keep going to find consultants that agree with her?
He also asks will the resources of perinatal psychiatrists be used for this “small cohort of women” to the detriment of other pregnant women with mental health difficulties.
Replying to Deputy Burke, Holohan says it is not proposed that the obstetrician has expert knowledge in psychiatry when assessing a woman for suicide ideation. But he/she will be needed because it will be him/her carrying out the termination if deemed necessary to save a life. Therefore, two psychiatrists are needed for certainty and an obstetrician for the reasons outlined.
Holohan points out that clinical psychiatry is a science. It is not a “hocus pocus assessment”, he says quite pointedly.
Naughten asks what “substantial risk” means – what percentage is it? Holohan said he will not put a percentage on it. Doctors must evaluate that risk, he explains. It is an evaluation or standard that must be upheld in the eyes of their peers if there is an examination of the case – as is common in medical practice.
Catherine Byrne, Dublin TD, asks what treatment is offered to pregnant suicidal women if they decide to carry on with a pregnancy?
She also wants to know how long the process will take from requesting a termination to receiving one?
Senator Jillian Van Turnhout also wants to know why there isn’t a statutory time limit for a decision. She suggests it should be set at seven days.
The Senator also asks for more clarification on what constitutes criminality in terms of the proposed laws.
Robert Dowds is the first to bring up women who are forced to travel to the UK for terminations if their babies have fatal foetal abnormalities.
“Is there any way this bill could be amended,” he asks, to provide for these women. ”Is it because of the 1983 Constitutional Amendment?”
Holohan back up now to answer those questions. To Senator Turnhout, he says there is a time-limit of 14 days for convention of panel, assessment and decision.
On fatal foetal abnormalities, he says he has enormous sympathy for women in that situation.
The 1983 Constitutional Amendment is a “component” of why it is not provided for in this Bill, he adds.
Peter Fitzpatrick asks, does a definition of an “appropriate location” mean the government can create arrangement with women’s clinics, such as the Irish Family Planning Association?
Tipperary TD Seamus Healy is the second to bring up the issue of fatal foetal abnormalities. The support group for the women was very disappointed not to be allowed appear at these hearings. We published a letter from a grandmother earlier this morning. Read it here.
Healy says he believes the penalties under Head 19 for people found guilty of an offence to act with intent to destroy unborn human life are excessive and require clarification.
Mary Mitchell O’Connor is the first to mention the “floodgates”. She asks what in Head 4 can stop this. Head 4 being the one that deals with suicide ideation.
Holohan tells Fitzpatrick that only hospitals governed by HIQA will carry out terminations and those listed by the TD are not at the moment.
Legislation is silent on gestational age, says Holohan, noting there has been much coverage in the media of this. He says doctors are the best-placed to make calls on viability and so it was better not to enshrine time frames in legislation.
It will not lead to late-term abortions, he says.
Holohan says the 7 days to convene a panel is an “outer limit” to allow for holiday weekends.
He says he will not get into numbers about how many people are likely to seek abortion for suicide ideation grounds.
“It is not likely to be significant,” he says, but adds that is is impossible to rule out that it would never arise.
Billy Timmins is the next politician to criticise Minister Reilly, saying he doesn’t know what could be more important than this hearing.
He believes that the clear message from the last Oireachtas hearings was that abortion is not a treatment for suicide, yet it was included in the heads of bill.
“Is there any point of us listening to evidence, when the legislation doesn’t reflect what happened?”
Michael Creed says the fears about the opening of the “floodgates” are valid.
Creed says that international experience shows that mental health grounds introduced in “good faith” have been exploited.
Holohan back up. He says we can all do a better job in looking after women with suicide ideation in pregnancy, and communicating pathways available to them.
Holohan says there are no figures kept on the number of children in care who travel to the UK for abortions. That was an answer to a direct question from Timmins.
Holohan says there is no resistance from doctors about being accountable to the department on terminations. He says they plan to report in public so evaluations of the impact of the Bill can be made.
Mullen says the separations of powers mean the Oireachtas can basically veto the Supreme Court’s ruling on the X Case so suicide grounds do not need to be included in the Bill.
Senator Ronan Mullen says Buttimer has been put in charge of an “express train”.
He asks why there isn’t a voice for the unborn in the appeals process.
Fine Gael TD Peter Matthews is another to ask for “specific examples” how the heads of the bill were influenced by the evidence given in the January hearings?
Terence Flanagan asks “what types of abortion” will be used in these instances. His first question dealt with hospital procedures and how they will change because of abortion.
He also wants “specific examples” about how the heads were influenced by previous hearings.
Senator Paul Bradford isn’t happy with the Minister either, stating it is bizarre he isn’t in the chamber this morning. For those joining us later, Reilly gave a statement and then left the Seanad before questions could be asked of him.
Bradford asks if the expert group was briefed about what answer it should bring forward, and whether they were told to remain in the confines of the X Case.
“I am worried the expert group’s hands were tied in order to bring about a pre-designed answer.”
Buttimer calms down proceedings and he tells hecklers that their shouting will be noted by the chair. He is really adamant to keeping these proceedings calm and civil, aware of the divisive nature of what is being debated.
Answering the multiple questions about “specific examples” of how previous hearings shaped the bill, Holohan says it is not his reading of the evidence that abortion is never a treatment for suicide ideation.
He said that the Supreme Court ruling in the X Case is not the only reason suicide grounds are included in the bill.
He said, we “simply cannot say” that a real risk to a pregnant woman’s life could never occur because of suicide.
Holohan says the legislation does not cover the “types” of abortion used by doctors.
Holohan says viability is very difficult to determine so it “would be unsafe to seek to define something that is likely to shift”.
It is currently the situation, without this legislation, that a pregnant woman can go to her consultant and an early-delivery is provided because of suicide ideation.
This legislation does not give arise to that circumstance and it makes it no more or less prevalent. He adds that he does not have figure to how often this currently occurs.
“Could we all take a collective deep breath and be calm and respectful of each other?” says Buttimer as Paul Bradford tries to ask a further question. Buttimer does not allow it.
After a bit more argy-bargy, Buttimer suspends hearings until 11.45am.
He also asks those sitting on one side of the room to switch to the other “as a matter of housekeeping”. A member quips from the back that he is happy if Senator Walsh stays where he is.
So that’s it from the first session of hearings. Buttimer has been strong with his committee again, not allowed interruptions or repeated questions. Generally, the proceedings were respectful and calm with just a few moments of raised voices. In the main, criticism was levelled at James Reilly, who did not stay in the chamber for question time. Here’s a few of the key points from the last two hours:
That’s it from me for the morning. I leave you with my colleague Michelle Hennessey who will take you through Session 2, featuring the regulatory and representative bodies.
Michelle Hennessy taking over the reigns of the liveblog now. Politicians and representatives of regulatory and representative bodies are just settling into their seats now.
Buttimer is reminding those present of the importance of “balance and calm” in the proceedings.
Professor Kieran Murphy, President of Irish Medical Council is the first to speak. He said doctors are expected to adhere to the council’s guide on abortion but it is not a legal code. The guide is designed to ensure doctors are aware of legal framework in which they operate.
Murphy said the council is of the opinion of the council is that Heads 2 and Heads 4 should be merged into a single head.
He asked for some of the wording in the heads to be amended, particularly in the wording of Head 4, which deals with the suicide ideation.
He said the council believes that Head 7 and Head 8, which deal with the review in physical illness and the review in cases of the risk of loss of life through self-destruction, should also be merged.
Murhpy said Head 12 should be expanded to ensure that the holding of conscientious objection does not resolve doctors of responsibility to their patient in emergency circumstances
Next to speak is Dr Fionnuala McAuliffe of the Institute of Obstetricians & Gynaecologists. “It is our absolute priority to ensure pregnant women receive the absolute best of care”, she says.
She said the institute remains “acutely aware of the potential negative consequences for the unborn”. She said that once baby reaches a stage when it can surive, every effort is made to support the life of that baby after birth. She said the institute does not see this law as providing in any way for late termination or destruction of a baby.
McAulifee is now listing a number of recommendations for amendments to wording in the legislation including the definition of obstetricians and gynecologists and the inclusion of general hospitals.
Dr Margaret O’Riordan, Medical Director of the Irish College of General Practitioners follows McAuliffe. She tells that the college believes that the decision to terminate a pregnancy is a last resort for women and that supports should be put in place for women dealing with a crisis pregnancy.
O’Riordan said GPs have knowledge of past physical and psychological health over a number of years and often their social circumstances. “Consultation with GP should only take place with a woman’s consent” and she stressed that confidentiality should be emphasised in all parts of the bill.
She also said the legislation should not be enforced until a proper referral process is put in place for women.
Now we have Dr Matthew Sadlier of the Irish Medical Organisation, which represents over 5,000 doctors across the country. He said the official position of the IMO has not changed since 20 years ago, but that its members operate within the legal framework in the country and the organisation accepts that the government is now moving to create a legal framework.
“The health and welfare of the patient is paramount”, Sadlier tells the committee and, like O’Riordan, he is stressing the importance of follow-on care for women who have a termination.
The period of the review for patients of 14 days is “too long” and Sadlier says the health of patients may deteriorate significantly during this time.
He said that though a number of the IMO’s members object to the proposed legislation, patients in need of emergency treatment can be reassured that they will receive the best of care and that doctors will work within the legal framework.
Professor John Crowe, President of the Royal College of Physicians of Ireland, is now speaking. He says it is important that legislation should not seek to “define pathways” that are better dealt with by medical discretion.
Buttimer has now handed over to politicians. Billy Kelleher is first. He asks if there should be an obligation on a GP to inform a patient, who may have reason to believe there is a substantial risk to their life, that they have an objection to suicide. He also asks if there are provisions for aftercare to be provided by someone other than a woman’s GP, if she didn’t want them to know that she had a termination.
He also asks if the maternity hospitals in Ireland currently have the capacity to implement this legislation, particularly as regards clinical staff.
Caoimhghín Ó Caoláin from Sinn Féin up now. He notes that notifications of all emergency terminations are to be sent to the minister currently, He asks if this should apply to other circumstances.
Now Seamus Healy is speaking. He seeks confirmation in relation to medical staff, particularly in smaller hospitals around the country.
Dr Fionnuala McAuliffe is back. She says it is important to remember that they are talking about “rare clinical cases” in the instance of a termination because of serious illness. If they did not want their GP to know, the aftercare is provided in the hospital anyway, but she said it would be rare for a GP not to be aware as these women would have complex medical disorders.
“We always get consultation with more than one person” for patients with serious medical orders, she says. It could be a telephone conversation, it could be a review, but a second opinion is always sought.
Dr Margaret O’Riordan says that while the autonomy of the patient is paramount and a woman has the right to choose her doctor, it is important to take into consideration the long-term consequences for women and this is where GPs will come in, for the months and years after a woman has had a termination.
Professor Murphy said that under current guidelines doctors should explain objections to termination to patients and give suggestions of other doctors.
Matthew Saddlier tells the committee, that Ireland is “significantly under-resourced” already compared to other developed nations but that he does not see this legislation adding much to the burden.
Labour’s Ciara Conway says for most women who are pregnant, their first point of contact is with their local GP. To ensure that we have compliance with international human rights law and under constitution, she asks the bodies present if we need to include a time frame for referral pathways from primary to tertiary care but also in relation to self-referral.
Dr O’Riordan says the need for referral pathway may not occur very often and so “it should be all the more timely” when it appears.
Professor Murphy said it is vital for the care of patients that the recommendation that doctors who object to a termination make women aware and then refer them onto other doctors is upheld.
Senator Peter Fitzpatrick asks about protection for doctors and about ethics of saving one patient at the cost of the life of another.
Labour’s Ivana Bacik up now. In respect of doctors concerned, she’s asking for clarification from the Institute of Obstetricians & Gynaecologists on the number of doctors they recommend are consulted.
On the review procedure she says important points have been raised about access and if the 14-day period should be reduced to six.
In circumstance where there is no fetal heartbeat, she asks should an obstetrician be able to make a decision, once it has been established that there is no possibility of life outside the womb.
Fionnuala McAuliffe says that two obstetricians should be consulted in cases where a termination takes place due to physical illness or suicide ideation.
“We certainly feel that this should be available in all government approved hospitals”, she says.
In terms of the unborn, if the heartbeat is absent, that is a miscarriage and there is no issue with removing the foetus, she adds.
Professor Murphy says the issue for the council is ensuring that doctors work within the framework of the specific practice. For example if there is a heart problem and it is judged by a doctor to be a real and substantial risk to the woman, and the only intervention is a termination, it may be appropriate that the two people best places to make the decision are cardiologists and says the same may apply with psychiatrists in assessing the mental health of a woman but that consultation with obstetricians should also take place.
Dr Saddlier said 14 days for a review does seem like a long time as most of these cases would be urgent but has no specific opinion on what this should be reduced to.
Mattie McGrath up now. He asks the Irish Medical Council if it is possible that a new council, to be put in place soon, will review the ethical guidelines. Is it possible that they could be amended to remove requirement to make woman aware of objection, he asks.
Denis Naughten asks if there needs to clarification regrading the issue of “destruction vs induction” of a baby.
He also asks about further delays to terminations due to waiting lists for appointments with obstetricians.
Senator Jim Walsh asks about records since the 90s for terminations for women who are suicidal and figures for women who died by suicide after a termination.
He also asks about will happen when a woman reaches 22-23 weeks and what the risks of an early delivery would be for a baby.
Walsh asks what the the view of the bodies are about the need for psychiatric care over a number of weeks for a suicidal woman who is close to giving birth, in order to ensure the woman can go ahead with the pregnancy.
On the issue of viability, McAuliffe tells the committee that is now about 23/24 weeks and it changes so she would not be in favour of a specific limit in legislation.
She says she is not aware of a case of suicide ideation after a termination.
“We have to take the mother and the foetal longevity of the life together and we do that every day, she says.
Dr Meabh Ni Bhuinneain clarifies the issue of three obstetricians in one small unit objecting. She says the network would be responsible for a referral but if there was not time for this then, despite their objection, the obstetricians would have to provide a termination.
Professor Murphy said that he could not comment on what the New Medical Council might do, responding to Mattie McGrath’s question about a possible review of its guidelines.
Addressing politicians he says it is their “role as legislatures to provide legal clarification to doctors”, and it would then up to other bodies to draft appropriate guidelines “to ensure the woman, who is at the center of all of this, is protected”.
Deputy Flanagan speaking now, asks about whether there should be a registry of doctors who do not have an objection to termination and “killing of an unborn baby”.
He also asks the bodies if there is any evidence to support the idea that abortion could be a treatment for suicide and whether doctors who have an objection to terminations be excluded from panels that determine if it should be considered a treatment.
Paul Bradford asks McAuliffe and O’Riordan if they have ever come across a case where suicidal ideation can only be resolved by abortion.
Peadar Tobín stresses the importance of creating “support mothers to make right choices for themselves”. He asks if representatives are aware of cases where a viable unborn child is brought to term prematurely in the event of suicidal ideation.
Rónán Mullen asks the Irish Council of GPs and the IMO to offer clarification about the opinion of members on legislation and guidelines at their most recent meetings
He also asks if the Medical Council if it would not prefer a situation where a woman experiencing suicidal ideation was protected to the end of her pregnancy, in the absence of any evidence that abortion is a treatment for suicidal ideation, when there is the “potential to protect the life of a person to end of pregnancy”
Peter Matthews up now. He asks why there has been no discussion of care for the “poor unfortunate girls who went to England for abortions” which he calls a “screaming void”
Dr McAuliffe said she has not been made aware of cases where abortion was deemed the only treatment for suicidal ideation.
“This legislation provides legal framework for existing medical practice”, she said, referring to a question on numbers expected.
Dr O’Riordan joins McAuliffe in saying that she is not aware of a case where termination was the only option for treatment of suicidal ideation.
Dr Sadlier says the position of the IMO is that it rejects abortion and this was upheld by members in its most recent meeting. However he stresses that it respects the “law of the land” and will engage on issues and accept the legal framework of the country.
McAuliffe, asked for clarification by Peadar Tobín on two points, says the assessment of the medical risk of suicide would be deferred to psychiatric colleagues, who will appear before the committee next week.
The indications are that capacity will not increase, she says, citing the figures of 40 per year in Northern Ireland. “We expect we will see low numbers as well,” she says.
And that’s it for the second session. The meeting will now re-commence at 3.45pm.
This session was somewhat calmer than the first one this morning, with a focus on some of the more technical details like wording of the legislation and medical definitions.
Let’s summarise the main points from that session, shall we?
This is Michelle Hennessy signing out and handing you back to my colleague Sinead O’Carroll who will tell you all about Session 3, which will have contributions from representatives of the larger maternity hospitals.
Good afternoon. It’s Sinéad O’Carroll back with you for the third session. This one will include Dr Rhona Mahony and Dr Peter Boylan from the National Maternity Hospital, as well as Dr Sam Coulter-Smyth from the Rotunda.
Dr Rhona Mahoney’s comments during the committee’s last hearings made headlines as she said she wanted clarification that she nor her patients would land in jail because of a treatment plan.
We’re running about 20 minutes behind schedule but Jerry Buttimer is now giving his instructions about mobile phones ahead of the start of the third session.
Buttimer tells the committee that 500 submissions were received by interested parties and apologises that a copy of each one could not be given to everyone.
He also thanked those who are watching the proceedings online or on UPC today.
First up is Dr Peter Boylan from the National Maternity Hospital. He lists his experience and resumé, says he is qualified to comment on this issue.
The witness says Ireland is in a unique position because of our proximity to the UK which allows terminations. He says Ireland’s laws remain unclear and that doctors currently interpret the Supreme Court ruling in the X Case in an ‘ad hoc’ manner.
It is a “wholly unsatisfactory and unreasonable” situation for doctors and women, he adds after citing the penalties that could be imposed.
For these reasons, he welcomes the intention to legislate.
Dr Sam Coulter-Smyth now makes his opening statement. He welcomes that the draft heads of bill do not use the word ‘abortion’ so that women who have to undergo the procedure are not stigmatised.
There are occasions that it may be necessary to terminate a pregnancy in hospitals that are not one of the 19 provided for in the heads of bill e.g. Mount Carmel in Dublin – a privately-run hospital, he says.
Dr Coulter-Smyth says he agrees that there should be no gestational limit included in the legislation where there is a medical, physical emergency.
The inclusion of suicide grounds in the legislation may increase the demand for abortion in Ireland, said Dr Coulter-Smyth.
Suicide in pregnancy is an extraordinarily rare situation, he says.
“Our psychiatric colleagues tells us that there is no evidence that abortion is a treatment.”
The fact that there is no gestational limit in a case of suicide risk is a major ethical dilemma, says the Master of the Rotunda. He gives two clinical examples to highlight this:
Firstly, in a patient in 25 weeks, if she is deemed sufficiently suicidal to receive a termination. It could lead to death of the child, or a child with development issues – this is a source of serious concerns for colleagues as their actions would have led to these results.
Second example: At a 20-week scan, if a non-lethal abnormality is discovered, then the obstetrician has a dilemma because the mother could then develop suicidal thoughts. In this situation, having no gestational limit would be appropriate.
Dr Coulter-Smyth says he and his colleagues are concerned that an unintentional consequence of this legislation would be an increased demand for abortion.
Next up is Dr Rhona Mahoney, Master of the National Maternity Hospital. She says sometimes pregnancy has a tragic outcome and maternal death is a reality.
“If she dies, the baby dies too.”
At present, there is no formal process for which a woman can access opinion on whether a termination could be offered if she believes she is dying.
Dr Mahoney commends the government for legislating for this complex issue.
Dr Mahoney says the obligation to save the life of the foetus has underpinned her practise for 17 years. Every effort is made to optimise survival of a foetus, she says.
Neo-natal survival is possible from as early as 23-week gestation, she adds.
“We do not destroy or kill foetuses. We deliver them. On occasions, delivery is necessary so early that foetuses will not survive. In this context, if a woman dies, her babies die too…The majority of women do not wish to lose their babies but they do not want to die.”
This bill is about saving lifes, not about suicide in pregnancy, insists Dr Mahoney.
Suicide is death, just as a death by infection is, she adds. “Women are dead.”
Dr Mahoney says she welcomes the inclusion of conscientious objection and the repeal of the 1861 Offences Against the Person Act.
Question time. First up, as usual, is Billy Kelleher. He says he is bringing up issues that the public has raised with him.
He asks if Dr Coulter-Smyth believes that termination is ever a treatment for suicide ideation.
He also asks all three if they feel inhibited by any part of the heads of bill.
On the broader issue of clarity of foetal viability, and when a foetus is on the cusp of viability, do obstetricians look at the viability of the foetus and that you can extend the time of intervention then the foetus has greater chance of living?
Lastly, he asks about how a termination is carried out – he mentions early inducement and C-sections.
Caoimhghín Ó Caoláin is asking questions again. He notes his surprise of the lack of intensive care units at hospitals across Ireland, as noted by Dr Boylan.
He asks if the practitioners feel the legislation is sufficient to cover ECHR concerns.
Mattie McGrath asks Dr Mahoney about late-term abortions. He gives a hypothetical situation where a woman who is 20 weeks pregnant presents with suicide ideation and is granted permission for a termination. He wants to know what procedure would be used in this case.
Buttimer pulls up McGrath for asking a question that does not relate to the heads of the bill. He wants to ask Dr Coulter-Smyth his opinions on how the media is treating this issue.
McGrath is also stopped before he makes reference to Dr Mahoney and Dr Boylan’s being related through marriage. He is asked to withdraw the question.
Dr Boylan takes answers first. He tells the committee not to take credence of evidence from non-experts. Do not be misled by bad science, he says.
He says he is “very satisfied” with the draft heads of bill.
On the question of foetal viability, he gives an example of a woman with seizures where the baby would be delivered at 23 weeks gestation to ensure she does not die. We cannot let a woman die before our eyes, he said.
The terminations of pregnancy would be done medically in the early weeks. “We do not set out to destroy life,” he adds.
Dr Boylan confirms that the three main maternity hospitals in Dublin do not have intensive care units but ensures that there is a good working relationships between local general hospitals.
“When you are in government, you will no doubt expedite” intensive care units, he quips to Ó Caoláin.
Earlier, McGrath was pulled up by Buttimer and the sighs of his colleagues for bringing up the fact that Dr Boylan and Dr Mahony are related through marriage. He said he would not withdraw his remark that there could be “group think” associated with their statements on this issue.
Dr Coulter-Smyth says he is unsure if we should be talking about suicide grounds today when discussing legislation on abortion.
He confirms that his hospital should have an intensive care unit so they can look after their sickest patients.
On McGrath’s question about a woman who is 20 weeks pregnant and suicidal, he said a discussion would have to be had if a termination was deemed necessary.
Dr Mahoney says that suicide should be included in the legislation, even if there was no X Case.
Again, she says suicide is death.
The outcome of suicide in pregnancy is so rare, there is no evidence and there cannot be evidence as any kind of study would be impossible. We defer to psychiatric colleagues, she adds.
Dr Mahoney says she is concerned that her message about the threshold of viability is not getting across.
“I have no desire to see late-term abortion coming into this county,” she says.
On terminations, she says: “We do not kill babies, we do not kill babies. We induce medically.”
On the intensive care units, Dr Mahoney says the hospitals are deprived of the necessary equipment.
Co-location is the way to go, she adds. That is an opinion backed up by expert reports by KPMG.
All government-approved hospitals have to be included in the bill, is the message from all three doctors at today’s hearing because of this lack of certain services.
From Senator Crown, one of the members of the Oireachtas committe on health, tweets from the chamber:
Labour TD Ciara Conway asks if suicide is a leading cause of death among pregnant women.
She also asks, “Will this legislation save lives?”
This one will probably baffle Dr Mahoney again as Senator Peter Fitzpatrick asks if every effort will be made to save the life of a child if it is delivered after the threshold of viability.
She has already said she is concerned that her message on this is not getting across.
Deputy Regina Doherty ask Dr Coulter-Smyth to expand on his words that there is an ethical dilemma in the case of terminations for suicide ideation. She wants to know if he would have this dilemma even if his colleagues had prescribed a termination.
Senator Colm Burke wants to know if there is adequate protection for doctors for the decisions they have to make, particularly if the person is under 18 years of age.
Deputy Denis Naughten brings up an earlier point made by Dr Tony Holohan, who said that a suicidal pregnant woman could currently receive a termination. He wants to know if this has happened in any of the hospitals of the three doctors present today.
Dr Mahoney is to answer that round of questions first.
To Conway’s questions she says it is difficult to estimate suicide figures because of ‘open verdicts’. There was one case last year in this country. It is extremely rare, she adds.
Legislation will provide legal protection and flexibility to do their jobs. It will give doctors peace and prevent hesitation. Doctors will always try to save a life but what is wrong is that they don’t have the necessary legal protection and that is what the bill is providing.
Responding to Fitzpatrick, she says: “We care for all babies, I have to keep saying this,” she says, adding that regardless of why the baby was born its life is vindicated.
“These are rare, complex cases” and we work as a team, adds Dr Mahoney.
The patient under 18 that was brought up by Senator Burke is “X”, adds the Master, recalling the harrowing facts from the landmark court case. “She needs to be listened to, believed and protected.”
“I have no wish to kill babies…but I also want to ensure that no woman under my care dies. Because if she dies, her baby dies too.” – Dr Mahoney is getting quite frustrated with questions about whether she will care for a baby who is born at the threshold of viability.
Mahoney: “This business that there is no evidence that termination is a treatment for suicide. We are not talking about treating, we are talking about risk of life.
“Take X, is everyone in this room absolutely certain that there is no way that X would kill herself? That she would not die?”
I am not, adds Mahoney.
A few technical issues there, unfortunately, has meant we’ve missed a few lines from Dr Coulter-Smyth. Apologies for that.
He says he is satisfied that the legislation offers protection. On the issue of underage pregnancies, he said the same multi-disciplinary team will be required for any major decisions.
Dr Peter Boylan says that CSO figures did not include pregnancy on death certificates. He also notes that some coroners leave the word suicide out of their verdicts out of consideration for families. He says this is understandable but not always helpful in other contexts.
Dr Boylan says that some campaigners are trying to suggest that this legislation could lead to late abortions, implying that doctors would deliberately kill a baby that could exist outside the womb. These views are extremist, have no basis in fact and are insulting, says the doctor.
Dr Boylan says on the risk of the life to the mother, the woman must be consulted. Some women will undertake a greater life to have a baby, he says.
According to Dr Boylan, the figures in maternity hospitals, are about one consultant per more than 1,000 deliveries. In the UK, the figures are about less than one in 500.
In a Finnish hospital of comparable size to the National Maternity Hospital (which has eight consultants), there were 30 consultants.
Regina Doherty asks for clarification on Dr Coulter-Smyth’s remarks that abortion demand may rise on the implementation of this legislation.
“I dont have any understanding of the numbers that could try to avail of the service of this country. There are currently more than 5,000 women a year travelling to the UK and we don’t know why they are going there and what there issues are…Some may be victims of rape or incest,” he says.
“I think it is unfortunate those areas aren’t covered in this legislation,” he adds.
The concerns centre on lack of resources and not being able to cope with demand, he clarifies.
Lots of confusion about a question from Deputy Fitzgerald. He wants to clarify the difference between medical interventions and terminations. Dr Coulter-Smyth cites oncology as an example.
Senator Ivana Bacik asks if the woman should be criminalised under new legislation.
Senator Walsh asks about Miss C who was in Leinster House yesterday to tell politicians that she regrets her abortion. He also wants to know if clinics like Marie Stopes could be used for terminations.
Senator John Crown stands up and says hearing politicians lecturing medical experts is an “eye-rubbing, blinking moment”.
He is told to stick to the matter at hand by the chair.
He then calls for reform of obstetric care.
Professor Crown tells Senator Walsh that he has been “repeatedly rude” throughout today’s hearings.
Buttimer reminds people that we are finished at 16.35 and there are more people to speak.
Dr Mahoney on those questions:
Termination of pregnancy can be harmful, Dr Mahoney tells the chamber. However, she adds:
In very rare occasions, it could save a life.
Dr Mahoney says there is a big disparity between the number of consultants we have in Ireland compared to the UK.
In the National Maternity Hospital, there is just eight full-time consultants. However, she said we have to be careful not to let important resource issues influence this important legislation.
This bill is not about legislating for suicide intent, says Mahoney.
“It is about the risk of life, be it physical or mental. It will largely cater for women who may die because of direct medical complications.
We may never see a woman with suicide intent go through this process – she will likely go to England.
On the resource issue, Dr Coulter-Smyth says that the midwife to patient ratio is about half of what it should be.
He says he has nothing to add to Dr Mahoney’s remarks about the criminality of abortion and the potential prison term for a woman.
It is important that gestation isn’t covered in terms of medical emergencies, says Dr Coulter-Smyth but it does leave it open.
Dr Peter Boylan believes the 14-day process needs to be shortened. It is too long when a life is at risk, he says.
If a woman is subject is to erroneous medical opinion, it would appear bizarre and contradictory to send her to prison for 14 years but she could travel to England for a termination and be protected under the constitution, he claims.
He says that he has come across circumstances (not in his practice) that a woman has died because she was not given a termination.
Dr Boylans says the climate of terminations is hostile in this country and that research is needed. He brings up those women who are grieving for wanted children, including mothers who were carrying babies with fatal foetal abnormalities and mothers with social and/or mental health problems.
They are not able to grieve properly, he says but adds that they do not fall under the remit of this bill.
TD Eamonn Maloney says he is uncomfortable with legislators interfering with the special relationship between doctors and patients.
He says he wishes the legislation dealt with cases of rape and fatal foetal abnormalities. It should and if “we were brave enough” it would, he says.
He also calls the State out for hypocrisy because it allows the free travel for something that is illegal here. He says that he does not think this legislation will be taken up by women.
Fianna Fáil’s Robert Troy asks why there is a need to separate mental and physical risks to life?
Dr Mahoney says it is extraordinary that in Ireland that 1861 stands and we haven’t legislated for X but that women are allowed to travel freely for abortions.
We seem to have gone to great lengths to avoid the reality of maternal death in pregnancy, she adds.
Dr Mahoney says she does not distinguish between mental and physical risk to life.
There is no balance of rights, says Dr Mahoney. If there is, then women will die because there will never be a termination allowed.
Dr Coulter-Smyth says again it is unfortunate that the serious problems of rape cases and fatal foetal abnormalities are not included in this bill.
This legislation should be all about protecting doctors when they are saving lives – no matter what the medical issue is, be it suicide, infection, medical complications, cancer etc, says Dr Coulter Smyth.
Dr Boylan says the hypocrisy of the State’s rules on abortion is not relevant to the bill.
He agrees with Dr Coulter-Smyth that it does not matter what the risk to the mother is (heart disease or suicide), if a termination is required, doctors need to be protected in that decision.
A brief pause of for a round of applause for Damien English whose wife had twins today.
Dr Peter Mathews up now. He says it was an honour to attend the birth of his four children. He references science that allows a “hybrid of human and animals”. He is asked to keep to the heads of the bill.
“My wife is very important to me when having pregnancies,” he adds. “We must respect the breath of life.”
Buttimer asks for language to be kept temperate. Mathews had started to drift into some philosophical musings on the importance of life. He noted that he would stop his job at the Oireachtas to help preserve a life.
Senator Paul Bradford now and he quotes from Prof McAuliffe that maternal health services are amongst the best in the world.
He invites Dr Rhona Mahoney to agree with him that abortion is death, just as she said that suicide is death.
Robert Dowds has a point of order. He says he appreciates the difficult job of Jerry Buttimer but asks him to insist that politicians stick to questions about the heads of bill.
The chair asks for a collective breath and says he is doing the best he can.
Dr Mahoney said she understands abortions can bring about grave psychiatric trauma but that is not at issue, what is at issue is the risk to life because of suicide.
“We are not talking about pregnancy for *any* reasons…Just a narrow context to save a woman’s life.”
She said it is a very rare context – about five such procedures are carried out each year at her hospital, one of the busiest in Europe.
She asks Peter Mathews not to be disingenuous with numbers.
“Don’t confuse us,” she responds to comparisons with UK abortion figures.
“The point of this is prevent two deaths,” she says. “I believe the woman has a right to be saved. We do not stand by and let two lives be lost.”
Dr Coulter-Smyth returns to the resource issue, says the hospitals are not fit-for-purpose. He uses the worlds ridiculous and crazy.
The results they get in these hospitals are fantastic, despite that, he said. That is down to the staff.
Dr Coulter-Smyth that the word abortion should not be used in this bill.
“To call an intervention to save a mother’s life an abortion is wrong.”
Dr Peter Boylan says that this is restrictive legislation and any suggestion that it would lead to liberal regimes is not true.
He says he has a fundamental personal objection to labels and being told he is not pro-life. He says he has spent his entire professional career caring for women and babies.
On the question of whether doctors would abort one twin, he dismissed the notion saying we are “getting into silly territory”.
Dr Boylan is told to be careful after he references (not by name) the Savita Halappanavar case last year. He says that in his expert opinion, she died because a termination could not be performed lawfully.
He also recalls a case when he was a junior doctor where a pregnant women had her own conscientious objection to a termination and she died after giving birth.
Senator David Norris up now. He says he is strongly pro-life and pro-choice. It is timid legislation, he says.
He regrets that rape, incest and fatal foetal abnormalities are not included. He also regrets that the health of the woman (as distinct from her life) is not provided for.
“If it was the health of the man, it would be quite a difference,” he adds. No question yet.
He has a question for Dr Coulter-Smyth now about the delivery of a baby at 25 weeks, which the doctor raised earlier. Would the ethical question be the same for a medical physical emergency as he claimed it would be on suicide grounds?
Fine Gael’s Michael Creed criticises Senator Norris for calling out the “buffoonery” of some of their colleagues.
He asks Dr Mahoney about the referral pathway and legal clarity. “What is it that you can do today that you felt you could go to jail for in January?” he asks her also.
Again, the TD references the fear of “unintended consequences” of this bill. And he asks if the figures emerge to be larger than expected, then can we surmise that the legislation is flawed?
He says the “chill factor” is important because without the provision for penalties, we could be facilitating a more liberal regime that is envisaged.
Senator Rónán Mullen now. Two of his questions:
“Would the guests mind telling us were they consulted post-expert group about the heads of bill?”
“Are guests in a personal capacity or speaking for colleagues?”
Senator Aideen Hayden says she is “at a loss” about how abortion could be prescribed if there is no evidence that it is a treatment for suicide ideation.
On the number of women who travel out of this country, she says there is a lack of evidence about their mental health and reasons for wanting terminations. She said they would be dismayed to hear that resources would be an issue if they were to remain in Ireland.
She is corrected for getting Dr Coulter-Smyth’s name confused/conflated (She said Dr Coulter-Crown).
Billy Timmins again now. He says the point of criminal law is to have a “chilling factor” not a “soothing factor”.
He says that the State isn’t always right. On the X Case, citing a psychiatrist he says that false positives in terms of suicide can be as high as 97 per cent.
He commends Dr Coulter-Smyth for his submission about Head 4. He wants to know if there would be a difficulty in implementing Head 4 at the Rotunda based on the knowledge of the staff there.
Peadar Tóibín says it is a double disaster that women travel to the UK – one because of the crisis pregnancy and two because of the loss of thousands of unborn children.
He wants to know if the doctors believe the bill can prevent an abuse of the system. He quotes a woman from the Women Hurt group that he met yesterday who said she was coached to say she was suicidal on going for a termination.
Dr Boylan says that doctors accept (and want) criminal laws against illegal abortions to remain on the statute books.
But a woman should not be criminalised if she follows medical advice. It is wrong and unfair, he adds. Particularly given the constitutional protection who travel to the UK for the same procedure.
We do have abortion in Ireland, says Boylan. It is just in the UK.
Dr Boylan addresses the idea of women being coached to fool psychiatrists. He says that there is no question of any psychiatrist being fooled – we have to trust our doctors, he said.
“Undoubtedly there will be mischievous people who are claiming to be suicidal who might not even be pregnant,” he adds.
Dr Coulter-Smyth says where there is a threat to the life of the mother through physical circumstances, the evidence is more clear than in the case of suicide.
Dr Coulter-Smyth confirms that he was not consulted on the heads of the bill ahead of their publication.
“It’s not a question of a psychiatrist rocking up and saying, ‘terminate this pregnancy’” says Dr Boylan.
Dr Mahoney says she really hopes by now that everyone is aware that doctors are not in the business of killing babies.
“We will exhaust every avenue open to us…to optimise babies’ survival…it is a fundamental part of our jobs.”
She says that she is still worried about the 1861 Act.
“We need legal clarity around the termination of pregnancy to save women’s lives…It is really important that people take on board that 1861 deals with women, as well as doctors.”
Dr Mahoney returns to the matter of suicide. She says that there cannot be compelling evidence when the numbers are so tiny.
She says randomised control studies offer the best evidence, or the gold standard, but this cannot be done. Should we randomise women, split them into two sections, give some terminations and not others and see who dies?, she says.
On the matter of women lying, she said she would be a bad doctor is she did not believe her patients when they presented to her.
Jerry Buttimer thanks the three witnesses and suspends proceedings for 10 minutes. Back at 5.50pm.
That’s it from me today. Gavan Reilly will join you momentarily to keep you up to date with the fourth and final session of the day. You can reach him in the comments section, on Twitter @gavreilly or by mail at gavan@thejournal.ie. Good evening, and thanks for reading.
So while Sinead O’Carroll goes to grab some well-earned food after that marathon effort, it’s Gavan Reilly sitting in for the last of today’s four sessions. The evidence in this last round will be given by medical experts who oversee obstetric care in some of the country’s smaller, regional hospitals.
The obstetricians attending this last session will be:
Dr Gerard Burke of Limerick gets us underway, complementing the members for hanging in there during a long day.
He says Ireland can expect roughly 100 maternal deaths over the next decade; perhaps two or three could be affected by the legislation at hand, he says. “This big intellectual effort is affecting a relatively small number of women,” he said, echoing John Crown’s earlier remark that Ireland has the lowest ratio of obstetricians-to-public in Europe.
“What is a real and substantial risk?” he asks. It’s not defined clearly in the bill, he says, and probably with good reason. “My personal preference would be an explicit statement saying, ‘that is a matter that cannot be defined in terms of real numbers’,” he says – calling for an explicit declaration that could be acknowledged by a court.
Burke says it is possible to have an ectopic pregnancy within the womb itself – including where a pregnancy develops in the scar of a previous caesarian – and comments that he operates in a standalone maternity hospital, meaning an emergency caesarian usually has to be carried out in the nearby general hospital.
Dr Mary McCaffrey of Kerry General Hospital in Tralee is next, and echoes the gratitude of Burke for those who drafted this legislation. She remarks that 12 out of Ireland’s 19 maternity units have three, or fewer, obstetricians on staff. (This is what defines a ‘small’ unit for the purposes of this hearing, by the way.)
Dealing with the risk to life from physical illness, she says this would refer to the likes of heart disease, or cancer. Most cases like this, she suggests, would be managed by larger maternity units – but nonetheless, in some tourist-friendly areas, emergencies can arise where people present for treatment who aren’t previously known to the medics there.
“Medicine isn’t always black and white, and that needs to be reflected to protect us under the legislation,” she says.
A small maternity unit with three obstetricians means that, most of the time, only one obstetrician will be available. This should be reflected in the rules, she says. McCaffrey says the legislation protects medics acting in cases like preeclampsia, which is to be welcomed.
Dealing with the suicide threat, McCaffrey remarks that “self-destruction”, as a choice of words, should be replaced with “suicide” – but that her own medical expertise, and those of other obstetricians, does not qualify her to recognise or treat a mental health difficulty.
There will be cases where a viable foetus is delivered under this clause, she says, and it’s important that this be done in a facility that has the adequate neo-natal care to deal with a significantly premature delivery.
McCaffrey moves onto the criminal sanction for someone who carries out an abortion outside of the appropriate setting. She points out that it might be difficult to find volunteers to act on a committee to govern a request for suicide if people face such sanction for acting in what they see is an appropriate way.
“Where the life of the mother is at risk, and medical care is needed appropriately, the care of the mother and baby will always be paramount to every doctor,” she says. A doctor with a conscientious objection will have the obligation and duty to hand over their patient to a colleague without such reservations.
McCaffrey mentions that doctors in the future, who have a conscientious objection to abortion, could find themselves having trouble getting work – if, for example, they are looking for work in smaller units where another doctor is not always immediately available to take over their patient.
McCaffrey says that as with any new medical procedure being introduced to a country for the first time, it is important that people are appropriately trained and feel they can work well within their scope of practice. Investigations in the UK have found that a termination can be dangerous in some circumstances.
Here is Dr Máire Milner from Our Lady of Lourdes Hospital in Drogheda, Co Louth, who says she will be “extremely brief”. “It is needed because there are areas of uncertainty encountered during our practice; they are not common but neither are they very rare instances,” she says, welcoming the laws.
“Women are now falling pregnant at ages and with diseases and on treatments that previously would not have been encountered . This gives rise to… difficulties for us as clinicians; this can give rise to instances where the life of the mother may be threatened. I welcome clarity brought into an area of uncertainty.”
Milner really was brief. Here’s Dr John Monaghan from Portiuncula Hospital in Ballinasloe, who has four points to make on the heads of the bill.
On the threat to maternal life from physical illness, Monaghan asks if a woman suffering from cancer is better served after this legislation than before it. He says the treatment of cancer during pregnancy has changed significantly in the last number of years – to the point where previous terminations may not have been necessary in today’s medicine – and suggests the legislation should ask that those with cancer be referred to a specialised central unit with experience of dealing with such cases.
Monaghan moves onto the threat of suicide: he doesn’t have any firsthand experience of psychiatry, but it would mark a departure from the norm to involve an obstetrician in the case of ending an otherwise viable pregnancy.
“My gut is extremely unhappy with the idea of being a mindless terminator for psychiatric reasons,” he says. The January hearings identified that nobody has ever committed suicide because of the refusal for a termination.
“I am not certain how a psychiatrist can reach a decision on this matter when, to date, no such evidence has been produced,” he says. The introduction of similar clauses in other countries has been widely abused – almost universally, he says.
Twice in the last few months, as a doctor, I’ve been told that a doctor should leave their conscience outside the room… conscience is not a religious concept. If you see a child being beaten on the street, and continue with your shopping, that’s a suspension of conscience.
There’s some interruptions when Monaghan suggests a politician (as a doctor) might take a bribe to move somebody up a waiting list. Monaghan withdraws the remark, and says his comments hadn’t meant to imply that this was a realistic practice.
Monaghan deals with the mechanics of how abortion has carried out; “surgical termination” is more dangerous than medical termination, he says, and suggests the act should forbid a doctor from killing a pregnancy where the child has the prospect of being delivered first.
With that, we move onto the questions from members of the committee.
Caoimhghín Ó Caoláin TD (SF) is first. He mentions the different degrees of medical care available to a pregnant woman, depending on where she lives. He asks if doctors in some more rural areas could be presented with situations where a doctor has a conscientious objection, for example, but there aren’t enough other professionals to stand in and administer the procedure.
He also mentions the shortage of resources in some areas – such as the fact that Dublin’s three standalone maternity hospitals don’t have life support facilities – and asks for some elaboration on the call for circumstances like an ectopic pregnancy inside the womb to be explicitly referenced in the Bill.
Billy Kelleher TD (FF) asks if any of the four doctors are aware of any circumstances where a patient was referred to the UK for an abortion because there was no enough legal clarity about the legality of a treatment in Ireland.
He also asks about the risk of the legislation over-burdening Ireland’s maternity services, and asks the four experts if this is a fear they hold.
Seamus Healy TD (WUAG) asks again about the impact that legislation like this could have on smaller facilities – standalone units with no psychiatric facilities, for example. “Is there enough personnel available in the smaller units to actually implement the provisions set out in the bill?” he asks. “If not, what other personnel might be needed?”
Mary McCaffrey from Tralee will begin and respond to the question of smaller units. “We all want more resources, and in an ideal world there should be no three-person maternity units in the country,” she says, but the small units all offer appropriate care whenever needed in an emergency. If someone walks in in an emergency, Tralee has the resources to deal with it, she says.
In cases like severe cardiac disease or cancer, it’s generally rare that a patient would need care in a major emergency (“in the next hour”, she says, by way of illustration). There are multidisciplinary teams, based across various hospitals, who deal with cases like this, she says.
On conscientious objection: This would never come into play in a case where a woman’s life is at a genuine risk. “We’d expect every doctor to look after an acute medical situation,” she says. In less acute cases doctors would be obliged to follow the guidelines and only refuse to carry out a situation if a substitute is available.
John Monaghan (Portiuncula) asks about referring a patient to England for termination: quite simply, the answer is no. He knows women are referred for treatment for specific rare conditions, but not for termination.
Portiuncula delivers 2,200 children a year and has perhaps one or two cases of serious maternal illness – “these cases don’t overburden the maternity service”, he says. Sometimes women need to be transferred to another tertiary centre with overcrowding, but unless there is an “explosion” of suicide claims under this act, the system has the capacity to cope, he says. In practice, he adds, any rural maternity unit is relatively close to a psychiatric unit.
On conscientious objection: “If one is prepared to allow a mother to die, one is guity of a very serious professional negligence.” Portiuncula hasn’t had a maternal death in 29 years. “To suggest that because obstetricians are conscientiously objecting…[and this] is leading to maternal deaths, is not true.”
Maire Milner of Drogheda says there’s a “huge amount of support and backup” between urban hospitals and rural ones, which helps the rural ones massively.
Gerard Burke of Limerick is last; “in my career I’ve never encountered a patient who is suicidal and brought to me to discuss a treatment that might include a termination. This has never happened to me in my career. The numbers are so small,” he says, remarking that an obstetrician isn’t likely to work with a psychiatrist whose work and record they are unfamiliar with.
Obstetricians are “not beholden to psychiatrists telling us what to do. We have to do this procedure ourselves; we’re going to be absolutely certain that it’s justified, medically and ethically.” If there’s a risk of maternal death, it’s taken so seriously that an entire hospital’s resources are prioritised to help the woman in need. Regarding ectopic pregnancies within the womb, his unit sees around two per year – they are “one of those issues that could come under this legislation.”
He doesn’t refer patients to England but many elect to go there for a second opinion – though if a pregnant woman is critically ill and unwell, doctors have an obligation not to send them to an inappropriate place and to send them to a university-class hospital.
Burke: “The people who are in at night, and the weekend, dealing with haemorrhages and impacted heads… we’re not waiting in the long grass, waiting to carry out terminations.”
Ciara Conway TD (Labour) thanks Burke for his final comment, which was an illustration that no doctor is eagerly awaiting the chance to begin administering terminations.
She asks if a woman with a pre-existing medical condition is likely to be referred to Dublin or Cork, and that it would therefore be less likely for a woman to have a medical threat to her life to end up needing treatment in a smaller hospital. She also asks John Monaghan to substantiate his comments linking the maternal death rate in the UK to conscientious objection, if in fact that is what he meant.
Senator Jillian van Turnhout (Ind) mentions a proposal to merge Heads 2 and 4 – those which deal with a threat to life from physical risk or psychological risk. If resources and availability – particularly in after-hours scenarios – are an issue, will a patient end up being referred to Dublin or a larger unit somewhere? She also asks about conscientious objections and the impact on smaller staff.
Regina Doherty TD (FG) mentions Dr McCaffrey’s comments on the introduction of a ‘new’ treatment: she says she interpreted the Masters’ comments to mean surgical termination wasn’t ‘new’ in Ireland at all.
Dr John Monaghan first, deals with the resourcing of smaller hospitals: most hospitals would probably have been three and five physicians, with nearby hospitals specialising in slightly different issues. If you have a serious medical problem, there would be enough staff in nearby facilities to deal with them and negate the need to send them to Dublin.
Regarding maternal deaths: There’s always been a difference in death rates between the UK and Ireland. Is this because of abortion? That’s not what he was suggesting – but if medically-mandated abortion improved women’s health, it follows that the maternal death rate in the UK should be lower than Ireland’s.
“An abortion culture, if it becomes widespread, significantly reduces recruitment into obstetrics and gynaecology,” he says. He says he was in the UK for two years and never encountered a younger doctor who wanted to be an obstetrician, largely because of the abortion culture in that jurisdiction and how it was “distasteful”.
Máire Milner says there are issues around the introduction of a new medical procedure. It’s not a “logistically, hugely difficult” challenge, she says, and surgical termination is employed regularly in some hospitals. “There are now many ways of dealing with miscarriage where the uterus has not started to empty itself,” she says, adding that in cases where a life is in danger, the uterus is likely to have already started to evacuate and begun the process of delivering the child within. You can use either medical or surgical means in pregnancy, but after 12 weeks you’re likely to use medical means because of the size of the foetus.
On the issue of pre-existing medical conditions, Mary McCaffrey says medical advances mean there are more and more people who can get pregnant and who have those conditions – but in examples where someone has had cardiac difficulties, it’s unthinkable that that person wouldn’t already be in the care of cardiac specialists. Someone with long-term conditions like this are also already likely to be aware of the risks associated with their pregnancy, she says.
Should people declare conscientious objections in advance? It’d be a shame if someone was discriminated against (in terms of finding work) because of their stance on abortion, she says. She adds that it’s important to train people in how to deal with abortions and afterwards, though she remarks that Irish doctors are already called in to act on Irish women in post-abortion difficulties arising from terminations carried out in the UK.
Gerard Burke says it “really, really behoves” politicians to build four new maternity hospitals by simply issuing a tranche of national solidarity bonds, illustrating the shortage of resources that exists in some part of the country.
Peter Fitzpatrick TD (FG) says Ciara Conway covered most of his questions; so we move onto Denis Naughten TD (Ind) who asks exactly how you determine what is a “real and substantive risk” and the percentages involved. Rhona Mahony said this legislation brought clarity; Naughten wants their feedback.
Naughten also asks: “Have you had any experience of early delivery based on suicidal ideation, or has that happened within your facility?”
He also asks about the threat to regional resources if more psychiatric wards were to be shut, whether the legislation could be a “Trojan horse” to remove smaller units from the health system, as he claims has been the HSE’s agenda, and also whether a conscientious objection could be used as grounds to stop someone from getting a job in the medical field in future.
Mattie McGrath TD (Ind) says this session has been more “relaxed” than the other fraught exchanges, and thanks the experts for that. He asks whether legislation runs the risk of being over-prescriptive, and also asks Dr McCaffrey whether she thinks abortion in the grounds of suicide risk is ever necessary.
(Almost predictably, Mattie takes the chance to criticise the delay in constructing the National Children’s Hospital. Jerry Buttimer calls him into line and asks him to stick to the subject at hand.)
Senator Jim Walsh (FF) says suicidality is a subjective area and asks the experts to comment on the manner in which the Minister for Health is informed about the number of terminations, and whether this system is transparent enough.
He also asks about whether medics who remove themselves from the panels, and professional discrimination, and follows up on Naughten’s question by asking where the legislation offers the clarity that Dr Rhona Mahony earlier mentioned. Plus, would this legislation have saved the life of Savita Halappanavar?
Senator Prof John Crown (Ind): Sometimes my colleagues here miss the point that maternal death is an extraordinarily rare event in the first world. The occurance of even one is a disaster, and if we must legislate to prevent it, we should do it. This isn’t like cancer or heart disease that claims massive numbers: it’s different, and must be treated differently.
The vast majority of abortions in the case of physical risk of life (which, Crown says, he has never encountered in the case of cancer) will deal with cardiac or renal emergency. There’s usually a warning – pre-eclampsia or other pressures. So in most cases there’ll be ample warning, and the scenario of a genuine risk to physical life will mean the patient is referred to Dublin.
Crown asks: Firstly, is that the case? Secondly, does anyone in those scenarios have the right to conscientious objection, given the immediate risk to life?
Senator Aileen Hayden (Lab) says the goal of this legislation is to oversee the introduction of a robust system. She wants to know exactly how many hospitals should procedures be available in; and should the definition of the ‘unborn’ be adjusted to acknowledge a foetus which is already dead.
On the need for the number of psychiatrists needed to evaluate a mental health risk, Hayden asks whether the requirement for two psychiatrists unduly onerous, and would it be unduly onerous to ask one of those doctors to come from a hospital where termination is carried out?
Finally, what are the experts’ thoughts on the timescales contained in the legislation, the proposal to merge the clauses regarding a physical and medical risk, and the penalties proposed for someone who carries out an abortion outside the circumstances given.
Billy Kelleher again asks whether any of the four have referred a patient to England.
Dr John Monaghan deals with Peter Fitzpatrick’s question, about whether hospitals have the neo-natal facilities to deal with a baby induced in a late-stage termination. If a child is delivered at 23 or 24 weeks, and survives, it’s significantly more likely to have cerebral palsy, blindness or other lifelong disabilities – he can’t say anything more than that.
On the absence of a definition of a ‘real and substantial risk’, Dr Monaghan says an experienced clinician will be able to use their experience to tell if this is the case (though an obstetrician, naturally, can’t diagnose a suicidal ideation.) He also says he cannot hypothesise about the issues that arise if a psychiatric unit might be shut.
Monaghan tells Prof Crown that maternal death has been rising in many countries recently, though Ireland has not followed this; this is attributed to many factors, such as sepsis, multiple births, and other circumstances which were previously more unusual. He adds there is no evidence that conscientious objection has led to a maternal death anywhere, worldwide (the Savita inquest report certainly did not deal with this, at least), and no knowledge of an early induction as a result of suicidal ideation.
Dr Maire Milner says psychiatric and psychological problems are becoming increasingly prevalent in obstetrics – to the point where midwives and obstetricians are now “involved in supporting women” and have a concern about mental health. She says it might be common to induce labour a couple of weeks early, on the grounds of mental health. In the threat of suicide, suicidal ideology is probably more common than expected, because so few people admit to it – whether they’re pregnant or not.
She’s aware of one case where a woman is in psychiatric hospital having attempted suicide due to the hormonal effect of her pregnancy – but not, she stresses, because she wanted to end her pregnancy. “You’ll see everything, if you live long enough, in your practice.”
On Crown’s point about difficult cases being referred to Dublin; this is true to an extent, but local hospitals must still be equipped to deal with a Sunday afternoon emergency, as she puts it, where being referred to Dublin isn’t a feasible option.
She has never referred a patient to England for treatment available there that isn’t in Ireland; as regards the clarity, she has previously had fears about treating a woman with sepsis and hoping “nature would deal with it” by a spontaneous termination so that she could sidestep the legal question of having to intervene.
Dr Gerard Burke mentions the issue of having to gauge a ‘real and substantial risk’ – analogising that if 10 per cent of Oireachtas members were told they might die, the chambers would be empty all the time. He says this illustrates the “ridiculousness” of trying to play the percentages of guessing if someone might die if left untreated, and this is why he’d like the law to include an explicit reference that the real and substantial risk cannot be mathematically quantified.
On Crown’s point, he says it’s not unthinkable that a perfectly healthy pregnant woman could suffer ruptured membranes, or similar, so it’s not always the case that a woman facing a grave risk to her physical health will have a ‘warning sign’ so far in advance and could be referred to specialised care in Dublin.
He supports the idea of merging Heads 2 and 4 – which discerns between physical and mental risks to maternal life – and thinks these procedures, in all the cases where they are necessary, should be available in all general hospitals and not just those which are part of a selective regime.
Finally, he mentions that in cases where someone has mental health difficulties, doctors always encourage them to try and bring the child to 37 weeks to avoid the risks of immaturity. This way there is minimal risk to the baby’s life.
Dr Mary McCaffrey asks Walsh to repeat his question; he asks if there is a risk that under-resourcing could lead to the infamous practice where forms are “pre-ticked” by obstetricians to permit an abortion. (There’s some disputes about whether Walsh is allowed to ask if Savita Halappanavar’s life would have been saved by this legislation.)
McCaffrey says smaller units would be mindful about transferring a patient to a hospital with a neo-natal facility, if there was the prospect of labour being induced early and an immature child is about to be delivered.
She again refers to the ‘Sunday afternoon’ cases where a pregnant woman, despite all of the best forewarnings, can fall seriously ill and needs immediate treatment at whatever hospital is closest to them. “An awful lot of our situations do happen very acutely”, she says – and no obstetrician would ever exercise a conscientious objection about acting to save a woman’s life in such cases.
McCaffrey adds that discrimination against applicants for jobs because of their stance on issues like this should be avoided at all costs, and personally has never seen a patient’s child delivered early because of the risk of suicidal ideation.
Now, we’re moving to questions from people who are not on the committee, starting with FG’s Bernard Durkan TD. She says the 1983 referendum was inherently ‘pro-life’, in that it tried to equate the life of mother and child. The Supreme Court made its ruling in respect of a rare case in 1992, he says.
Is it regarded that this legislation is necessary to add clarity in how medical staff can act in a medical emergency, he asks? To what extent is conscientious objection distributed between the right to life of mother and baby? Is it generally accepted that the rule of the Supreme Court is supreme and prevails, and that this legislation is therefore in line with that decision?
Durkan refers to surgical means and lethal injection, as mentioned by Dr Monaghan earlier. How often are either of these used? And finally, is it recognised that whatever treatment is recognised for a woman and baby is given to them, regardless of ethical or conscientious objections?
Durkan’s party colleague Billy Timmins TD says if there are two things that have emerged today, it’s how those who have needed to travel for abortion have suffered in silence, and that maternity hospitals in Ireland are chronically under-resourced.
Timmins admits to being “a tiny bit confused” about the confusion with Head 4, dealing with the threat of suicide. Is it possible for personal opinion to overlap or influence expert opinion, Timmins asks, or are they one and the same?
Senator Rónán Mullen (Ind) asks if non-members of the committee can get copies of the submissions made by the experts – there’s a procedural row about whether Billy Timmins is allowed to photocopy them and give them to anyone else who needs them.
Mullen deals with the quantity of how many pre-natal suicides take place – and asks if there are any tool a psychiatrist can use, absent of an underlying mental illness, to calculate whether an abortion is merited? In other jurisdictions, this aspect of medicine has been fudged to allow a more liberal regime, Mullen says, asking the four experts if they share such concerns.
Mullen further asks if an obstetrician is worth having in suicide cases at all – given that they have no medical role in diagnosing or determining mental illness – and asks if a pro-choice medical professional, in unclear cases, might be more likely to certify for an abortion in this case.
Dr John Monaghan is first, discussing with the rarity of cases. The relationship between law and medicine is “a very critical interaction” in this instance, he says – but if medical evidence does not support a procedure, and the law requires it, this decision goes beyond a medic’s responsibility (though a medical professional’s duty is always to act on medical evidence). The subtext here is that irrespective of whether suicide is legislated for, a doctor’s responsibility is not to take it up.
With regard to exactly how an abortion is carried out, Monaghan says the suction method – used up to 12 or 14 weeks – tends to be used in the UK predominantly because it is cheaper than a surgical procedure. He has no awareness, at all, of what procedures are used in Ireland and how regularly they are used.
Dr Monaghan says he has never come across a case, nor ever heard of one, where a doctor had a conscientious objection to abortion and allowed a mother to die as a result. This would be “unconscionable”, he says – by refusing to carry out the abortion, the doctor would have allowed both mother and child to die.
Monaghan concurs with Mullen’s observation that permitting abortion in an unquantifiable circumstance, like the risk of suicide, would pose the risk of the system being exploited – and that therefore, the Oireachtas has a big ethical questions on its hands.
Dr Máire Milner says there is no “universal” response that doctors can exercise in any case, including exactly what method of a termination would be used in individual cases.
(Apologies that the updates went missing there – we accidentally cross-posted a few updates to the Leinster v Stade Francais liveblog. Oops.)
Gerard Burke admits there is no “blood test” for suicidal risk, while Mary McCaffrey again affirms the point that everybody in a hospital “rolls up their sleeves” if a hospital is presented with an emergency case. It won’t change the way obstetricians go about their work, and doesn’t foresee a major increase in the number of requests on suicide grounds. Hopefully, she says, this would be a very rare event.
Peter Mathews TD (FG) is really happy with this session – it has given a real “sense of meaning about the whole thing”. This legislation is prompted by a particular case, in which the Supreme Court made a ruling based on a single psychiatrist’s report – forced to determine the law based on the outcome of a single case.
One thing that’s come out in this session and last is that the medical guidelines, which currently exist, have been doing a good job – occasional slips or errors are “unfortunate and tragic”, but if anyone’s life is under threat, “a whole fire brigade of medicine will be brought to bear” to save that woman’s life.
Mathews says the constitution, expressed in simple English, essentially requires the doctors to act according to the guidelines, based on the trust. “There has been the hi-jacking of a few setbacks to lead us back” to places we should not be, he says – in France, this has led to underage girls being able to get a legal abortion without their parents’ knowledge.
Arthur Spring TD (Labour) wonders if regional hospitals could be undermined because of the level of ability concentrated in the maternity hospitals in Dublin, and would like the four experts here to put this notion ‘to bed’. Spring returns to the question of resources, and whether circumstances could arise where someone is at risk of suicide but their hospital only has one psychiatrist available to evaluate them.
Terence Flanagan TD (FG) has some quick questions: Will every effort be made, in every case, to save a baby’s life; in the case of suicide, should there be a review under Head 4?; if under head 4 a termination was held at 23 weeks, would this be referred to a Dublin hospital to improve the child’s risk of survival; and if two consultant psychiatrists agree a patient is suicidal, can you envisage any situation in which you would disagree with them?
Senator Paul Bradford (FG) says we’re 11 hours through today’s sessions (personally, here in Journal Towers, our fingers are feeling it) and any outsider might think this is a major, landmark new law – which is not what the Taoiseach, Minister for Health and others have said. So is this about a change in law, a change in practice, or what is it about?
Dr John Monaghan is first up, and refers to Mathew’s observation about trust and how it’s slowly being sucked out of public life in various aspects. (Mathews didn’t put a question, so there’s nothing for Monaghan to answer.)
Dealing with Flanagan’s question: every doctor’s plan is to do their best for a baby delivered under any procedure like this. There are scenarios where a mother may not want their child born alive, however, and it is not unknown for women to say they are earlier in their pregnancy when they are in fact farther along. A 23-week baby would almost certainly be transferred to Cork or Dublin, he says.
Monaghan tells Bradford he disagrees that this doesn’t change the law – it’a a “very significant change” in that it is “the first time that deliberate abortion, as opposed to forced abortion, would be available in this country.”
Dr Maire Milner says all efforts are exhausted, within the medical margins of safety, are used to prolong a pregnancy in the foetal interest – so that when they are born they have the best chance of survival. Milner does not believe this legislation will lead to liberal abortion, though perhaps psychiatrists would be better to deal with this question.
To Bradford: Yes, a change in law is being proposed, but whether it changes practice is unknown. It certainly offers comfort for doctors and will arrive at an improved situation for patients.
Dr Gerard Burke says most obstetricians believe there is a problem with the clarity in the current law. Everyone sets out to continue a pregnancy for as long as possible; any termination is a “horrible outcome” so everyone wants to prolong the pregnancy as long as possible.
“We’re more likely to arrive at the right decisions if we have clarity about the decision-making process… we do feel under pressure at the marginal cases.”
The number of cases that will fall within this legislation is relatively tiny; those at the margins of a decision are smaller; adding the complications of psychiatry and it’s tiny. Burke has been a doctor for 30 years and X is the only case he can think of.
Dr Mary McCaffrey, by way of clarity for Spring: If any person, male or female, arrives at an A&E, all the services are rolled out for them. Some psychiatric services in small hospitals are concerned about a large number of review committees and review processes, and that the workload created by these reviews would have an impact on their daily duties. (The safety of the acute situation is not a concern here, she says.)
On the question of viability, a lot of pregnant patients could have their due date mis-determined, and the general practice in those cases would be to transfer a woman to somewhere with a neo-natal unit, or alternatively to induce labour and have a neo-natal transfer team then move the child to a specialised unit.
Clearly the introduction of a new statute means ‘changing the law’, she tells Bradford, but this legislation will nonetheless avoid the fear of having a “witch-hunt” outside someone’s door if they are required to act.
Terence Flanagan’s questions are given one addendum: would any experts support a right of review, on behalf of the unborn, in a suicide risk? Peter Mathews says there’s a contradiction between doctors welcoming ‘clarity’ and insisting that all possible actions are already done anyway.
John Monaghan says in a critical legal battle, there ought not to be a problem with the child being legally represented, in line with its existing constitutional rights. Maire Miler says it’s probably the psychiatrists should tease out. McCaffrey says Flanagan’s question is outside her expertise; Burke says the foetus is also his patient and every doctor would do their best to extend the life of the foetus as much as can be done.
In closing, Buttimer thanks the ushers, clerks and stenographers for keeping them in for such a late sitting, and adjourns until Monday morning. Phew.
So – what did we learn in this final session?
Some more conclusions:
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