Draft Irish Abortion Law: Protection of Conscience

Testimony before the Joint Committee on Health and Children

Houses of the Oireachtas (Tithe an Oireachtais)

17 May, 2013

Redacted Agenda:

• Policy: Overview of Head of Bill
• Regulatory and Representative Bodies
• Obstetric Care Facilities: Larger Hospitals
• Obstetric Care Facilities: Smaller Hospitals

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Policy: Overview of Head of Bill

Redacted Witness List:

• Deputy James Reilly: 
  Minister for Health

• Dr. Tony Holohan: 
  Chief Medical Officer

Deputy James Reilly:  Head 12 deals with conscientious objection. In this regard, professional health personnel, namely, medical and nursing personnel, will not be obliged to carry out or assist in carrying out lawful terminations of pregnancy if they have a conscientious objection, unless the risk to the life of the pregnant woman is immediate. Where a doctor or other health professional has a difficulty in undertaking a required medical procedure, he or she will have a duty to ensure another colleague takes over the care of the patient, as is normal in current medical ethics. I should note that the right to conscientious objection is a human right, which is limited to persons only and cannot be invoked by institutions.
[P. 4, accessed 2013-05-27]

Deputy Caoimhghín Ó Caoláin:   It must have some structure. What is Dr. Holohan's understanding of the lead practitioner in that regard and what is the situation regarding conscientious objection which may present regarding one or other of the psychiatrists, and particularly where the requirement is that one of the psychiatrists would be attached to an institution where such a procedure is carried out?

Deputy Caoimhghín Ó Caoláin:   The requirement is that one of the psychiatrists would be attached to an institution where the procedure is carried out. What if the situation presented where that person, the only person then available, was a conscientious objector? It is not beyond the bounds of possibility.
[P. 6, accessed 2013-05-27]

Dr. Tony Holohan: Yes, there are some technical issues to which the Minister alluded, that we will be looking at in the context of these linkages between doctors and locations of practice. That is the first part of the answer to that question. The other part is that doctors who raise a conscientious objection are not free of obligation to the individual in that situation. They must make appropriate arrangements to ensure there is an appropriate onward referral. They cannot simply step away from the care of that woman. The woman in that situation where the doctor has a legitimate conscientious objection will not find herself in a situation where there is nobody to care for her. That is the intent of this legislation but we will be looking at some of those technicalities to which the Minister alluded.
[P. 6, accessed 2013-05-27]

Deputy Billy Timmins:  With regard to the issue of conscientious objection, if, for example, staff in a hospital in Ballinasloe or Tralee or wherever decide that they will avail of this clause, where does that tie-in with the fact that the hospital cannot avail of that facility? If all the staff oppose it, what is the solution to meet the requirements of the legislation as proposed?
[P. 10, accessed 2013-05-27]

Dr. Tony Holohan:  Deputy Timmins asked in regard to the numbers under the care of the HSE. We do not maintain numbers in regard to that point, therefore, I am not in a position to answer that question. I think the scenario Deputy Timmins painted regarding the conscientious objector is one where all practitioners in a given setting might conscientiously object. I guess that is a theoretical problem and I would see it as one. It is unlikely to become a practical problem and in that situation there will still be a duty on the provider, which would be the HSE or perhaps one of the voluntary institutions, to make arrangements to ensure that the woman - let us remind ourselves that this is a woman who is in a situation where there is a real and substantial risk to her life - has access to an appropriate service, even if that is not available at that particular location, but I rather doubt that this situation will arise in clinical practice.
[P. 11, accessed 2013-05-27]

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Regulatory and Representative Bodies

Redacted Witness List

• Professor Kieran Murphy:
  Irish Medical Council [Written Submission]

• Professor Fionnuala McAuliffe:
  Institute of Obstetricians and Gynaecologists [Written Submission]

• Dr. Méabh Ní Bhuinneáin: 
  Institute of Obstetricians and Gynaecologists

• Dr. Margaret O'Riordan:
  Irish College of General Practitioners [Written Submission]

• Dr. Matthew Sadlier:
  President, Irish Medical Organisation [Written Submission]

Professor Kieran Murphy:  In regard to head 12, the Medical Council is of the opinion that subheads 8(1) and 8(4) are largely consistent with the Medical Council's 2009 "Guide to Professional Conduct and Ethics for Registered Medical Practitioners", which states:

10.1 As a doctor you must not allow your personal moral standards to influence your treatment of patients.

10.2 If you have a conscientious objection to a course of action, you should explain this to the patient and make the names of other doctors available to them.

[P. 15, accessed 2013-05-27]

Professor Kieran Murphy:  The Medical Council suggests head 12 be expanded to ensure the holding of a conscientious objection does not absolve the registered medical practitioner from his or her responsibility to a patient in emergency circumstances. The view of the council is that the right to conscientious objection must be balanced against the right of the patient, particularly in the case of a medical emergency. The Medical Council's Guide to Professional Conduct and Ethics for Registered Medical Practitioners states: "10.3 Conscientious objection does not absolve you from responsibility to a patient in emergency circumstances". The text of subhead (1) should be amended to specifically include the term "conscientious objection". It is not clear whether subhead (1) applies exclusively to the carrying out of the procedure or whether it also applies to involvement by certifying registered medical practitioners in the assessment of risk, the certification process and the review process. Subhead (2), as drafted, is unclear.
[P. 16, accessed 2013-05-27]

Professor Fionnuala McAuliffe:  Head 4 concerns the risk of loss of life from self-destruction. The Institute of Obstetricians and Gynaecologists does not differentiate in terms of logistical arrangements between physical or mental reasons for considering a termination. One obstetrician would be required to examine the patient and sign the documentation, and the support of a second obstetrical opinion would have to be sought. We accept there is a need for two psychiatrists, however, as it would be their expertise that the obstetricians would rely upon to determine whether suicidal ideation is true intent and poses a real and substantive risk to the life of the mother.

. . .Head 12 pertains to conscientious objection. We endorse the current Medical Council Guidelines of 2009, 10.1 to 10.3, inclusive, regarding the options and responsibilities for clinicians with a conscientious objection to participating in certain clinical treatments.
[P. 17, accessed 2013-05-27]

Dr. Margaret O'Riordan: Current obstetric practice does not place a patient in the care of an obstetrician until 16 to 20 weeks gestation.
[P. 17, accessed 2013-05-27]

Dr. Matthew Sadlier:  . . . we have a number of general concerns regarding the legislation: that the patient's health and welfare is of paramount importance; the legislation must provide adequate clarity and protection to health care professionals who must operate under it; the legislation must be practical and realistic for application in a hospital and health care environment; the legislation must be sufficiently resourced; where issues of morals are concerned, such as in abortion, the laws must provide adequate flexibility to ensure that an individual can abstain from engaging in an activity which he or she may deem, in conscience, to be immoral without jeopardising the right of the relevant patients to all the facilities and treatments for which the law provides.

I will give a brief summary of our issues in respect of each head of the Bill. In head 1, we believe the term "reasonable opinion" should be replaced by the term "opinion" and the term "unborn" replaced by the more medical term "foetus". In head 2, the opinion of two medical practitioners is required to certify jointly that there is a real and substantial risk to the life of the mother and where the risk can only be averted by the termination of the pregnancy. Where a pregnant woman presents with a physical condition that poses a real and substantial risk to her life, clear clinical guidelines are required in order to identify, monitor and treat such patients. While such cases are rare, public obstetric units must be appropriately resourced to ensure that patients are adequately cared for according to clinical guidelines and that no delay to life saving procedures arises due to under-resourcing. A system should be in place to allow medical practitioners to declare a conscientious objection and protocols must be in place to deal with situations of conscientious objection as they arise.

Medical practitioners who have no conscientious objection must receive appropriate training either during postgraduate training or as part of compulsory CPD programmes organised and resourced by the State. The health and welfare of the patient is paramount and therefore women must be provided with appropriate follow-on care, both physical and psychological, following any termination.

. . . Finally, head 12 deals with conscientious objection. Recent debate at the IMO's annual general meeting shows that there are a number of physicians who object strongly to the termination of pregnancy on moral and ethical grounds and the IMO welcomes the provision for conscientious objection under head 12. However, patients who present with life threatening illness must be reassured that they will receive adequate care and the necessary termination to protect maternal life. Clear protocols must be in place to ensure appropriate and timely referral of patients to other colleagues in the case of conscientious objection.
[P. 18, accessed 2013-05-27]

Deputy Billy Kelleher:   . . . In terms of GPs having conscientious objections, should there be an obligation on a GP, when a patient arrives at a surgery and has reason to believe there is a substantial risk to her life because of pregnancy, to inform her of his or her conscientious objection to a termination of pregnancy in the context of a threat to life by suicide or physical health grounds?
[P. 20, accessed 2013-05-27]

Deputy Seamus Healy:   Several contributors referred to the provisions regarding appropriate locations, which refer to public obstetric units where there is a mental health facility. The witnesses have indicated a preference that this be broadened to include public hospitals in general. Will they elaborate on this? Will they comment on the availability of medical personnel to operate the system as outlined under the heads, particularly in smaller hospitals in locations throughout the country? Will Professor Murphy elaborate on the issue of conscientious objection?
[P. 20, accessed 2013-05-27]

Dr. Margaret O'Riordan: In response to Deputy Billy Kelleher's questions, the Medical Council guidelines are very clear in regard to conscientious objection. A general practitioner would have to inform a patient if he or she had a conscientious objection.
[P. 20, accessed 2013-05-27]

Professor Kieran Murphy:  Deputy Healy asked a specific question on conscientious objection, so I will outline the current Medical Council guidance on the issue. There are a number of points taken from the guide to professional conduct and ethics for registered medical practitioners, and members may recall that during our submission in January, we circulated copies of the guide. We have not done so this time because we assume they have seen it already. If Members wish to see copies of the guide afterwards, we would be very happy to circulate them. With regard to conscientious objection, the guidance is as follows:

10.1 As a doctor, you must not allow your personal moral standards to influence your treatment of patients.

10.2 If you have a conscientious objection to a course of action, you should explain this to the patient and make the names of other doctors available to them.

That addresses the point made by Deputy Kelleher, which was also addressed by Dr. O'Riordan in her response. The council wishes to see this particular head extended in regard to the Medical Council's third point in the guidance, "10.3 Conscientious objection does not absolve you from responsibility to a patient in emergency circumstances." As we noted in our submission, the Medical Council suggests that head 12 should be expanded to ensure that the holding of a conscientious objection does not absolve the registered medical practitioner of responsibility to a patient in emergency circumstances. The view of the council is that the right to conscientious objection must be balanced against the right of the patient, particularly in the case of a medical emergency.
[P. 21, accessed 2013-05-27]

Senator Jillian van Turnhout:  Conscientious objection is something everyone can understand and appreciate but should we consider a requirement that as a general rule a practitioner would declare his or her conscientious objection rather than waiting until a situation got to a certain point? How do we ensure that hospitals would have an adequate number of medical professionals who have not declared a conscientious objection?
[P. 22, accessed 2013-05-27]

Professor Fionnuala McAuliffe: . . . In terms of doctors who are conscientious objectors, in a large number of these cases we are talking about emergency situations and the practice and care currently being delivered around the country. We do not have any difficulty with the provision of emergency care around the country. We would defer to the Medical Council in terms of conscientious objection for non-emergency cases.
[P. 22, accessed 2013-05-27]

Dr. Margaret O'Riordan: In response to Deputy Conway's question, we must remember that this is a very small group of women where there is a real and substantive risk to the life of the mother. Therefore, the need for the referral path may not occur very often in the average GP practice. That is all the more reason it should be clearly defined and timely when we need to avail of the referral pathway.

To answer Deputy Byrne's question, the situation is no different from any other situation and it is normal practice for patients to approach the health service through their general practitioners. In the vast majority of instances it is through the general practitioners in the first place.
[P. 22, accessed 2013-05-27]

Professor Kieran Murphy: With regard, first, to Senator van Turnhout's question, I am very pleased that she agrees with the Medical Council position that heads 2 and 4 should be merged. As Professor McAuliffe has outlined, that is also the position of the Institute of Obstetricians and Gynaecologists.

On Senator van Turnhout's question on the difference between a registered practitioner and a non-registered practitioner, the Medical Practitioners Act, which regulates the profession, specifies that all doctors have to be registered. If one practises in this country and one is not registered, it is a criminal offence. It is very important for the legislation that it makes reference to the fact that all doctors working in this country must be registered.

To reply to Senator van Turnhout's question on conscientious objection, the Medical Council guidance on conscientious objection, item 10.2, specifically says that one must explain to the patient if one has a conscientious objection and make the names of other doctors available to them. This is an important provision because it protects the woman and ensures that she is able to access the most appropriate treatment for her. Care should not be dependent on any moral value the practitioner might hold.
[P. 22, accessed 2013-05-27]

Dr. Matthew Sadlier: . . . On Senator van Turnhout's question on conscientious objectors, as the representative body for doctors we would be insistent that our concerns regarding the use of information on whether a doctor is a conscientious objector would not become a stigmatising or discriminatory element in the interview and recruitment process to posts within hospitals.
[P. 22, accessed 2013-05-27]

Deputy Peter Fitzpatrick:   I thank the witnesses very much for making themselves available. My first question is whether doctors and nurses who wish to have no part in abortions under head 4, either directly or indirectly, will be protected in their profession and livelihood?
[P. 22, accessed 2013-05-27]

Professor Fionnuala McAuliffe: In response to Deputy Peter Fitzpatrick, it is fair to say the lack of evidence on the role of termination in the treatment of suicidal pregnant women is an ethical concern for our members. However, we need to remember that we are talking about pregnant women, in respect of whom after consultation two senior obstetricians, plus or minus physicians or psychiatrists, feel there is a significant risk to her life which can only be averted by termination of pregnancy or early delivery of the baby. We are talking about a small number of cases of very sick women who need access to life-saving treatment. The general view of the institute - the majority view - is that we will not differentiate between causes of risk to life, whether they be mental or physical.
[P. 23, accessed 2013-05-27]

Professor Kieran Murphy: I will deal with Deputy Peter Fitzpatrick's questions first. He raised issues regarding the guidance on conscientious objection and also the guidance on abortion. As I previously read the detailed guidance for doctors, I do not propose to waste the members' time by going over the issue again. I have dealt with that issue previously.
[P. 23, accessed 2013-05-27]

Dr. Matthew Sadlier: On conscientious objection, if legislation is passed it is meaningful only if it has sufficient resources and mechanisms to action what it contains. It is very much the responsibility of employers to have a system in place which includes professionals who do not have a conscientious objection, thus protecting those who do from engaging in practices with which they have a difficulty.

Deputy Denis Naughten:   . . . With regard to conscientious objection, what happens if in smaller units all three existing consultants decide they are not prepared to get involved in these procedures? Does this mean for any new posts created people's personal opinions would have to be determined before they could be recruited?
[P.24, accessed 2013-05-27]

Dr. Méabh Ní Bhuinneáin: Emergency treatment excluded, the smaller hospitals are networked - now formally, previously informally. If it turns out that there are three conscientious objectors in one unit, the network and institutions will have to decide, where care is delivered, if it is safe and timely to hold that decision to treat until the woman can be transferred. If it is not safe and timely to hold the decision to treat, under current Medical Council standards, even conscientious objectors must provide care, because guideline 10.1 is essential - one must not allow one's moral standard to determine the care provided to the woman.
[P. 26, accessed 2013-05-27]

Dr. Matthew Sadlier: I will try to be as quick as possible. In response to Deputy Naughten's comment regarding employment of staff, we would be very opposed to a doctor's status of conscientious objection being a criterion in whether he or she attains a post in a facility. We would view that as similar to discrimination based upon religious, gender or other grounds.
[P. 26, accessed 2013-05-27]

Deputy Terence Flanagan:   The ICGP's submission asked how doctors who are willing to refer patients requesting a termination will be identified. Do they propose that there be a register of doctors who have no objection in principle to the direct and intentional killing of an unborn baby? . . . In their comments on head 6 they suggest that "practitioners who declare a conscientious objection must be excluded from review panels". Is it the IMO's position that doctors should be screened for pro-life values and excluded on that basis, or that review panels should be made up exclusively of doctors who have no principled objection to the direct killing of an unborn baby? To be intellectually consistent as well as being fair in terms of the equal right to life of the unborn child, should practitioners who declare support for general abortion rights be excluded from panels determining whether abortion is an appropriate treatment for a threat of self-destruction?
[P. 26, accessed 2013-05-27]

Professor Fionnuala McAuliffe: In terms of the lack of evidence, an issue raised by Senator Rónán Mullen, the institute acknowledges that there is a lack of evidence of the role of termination of pregnancy. This poses an ethical dilemma for our members. We went through a planned consultative process and we represent the majority view within obstetrics and gynaecology in Ireland. Members will have an opportunity this afternoon to hear views from individuals and individual units, but the view presented in our submission is the majority view that emerged from a consultation process that involved consultation with the executive members and representatives of each of the 19 maternity units involved. Members are, therefore, hearing the majority view within the specialty this morning.
[P. 28, accessed 2013-05-27]

Dr. Matthew Sadlier:  We welcome the fact that there is a provision for conscientious objectors and that doctors can object to engaging in this process and are not being forced to engage in a process to which they object, notwithstanding their obligations under the Medical Council ethical guidelines which Professor Murphy alluded to previously. If they agree to participate in this process, whatever morals and ethics they use to inform their decisions is a matter for them. Obviously, they are guided by the Medical Council guidelines and those of their own colleges and specialised information.
[P. 29, accessed 2013-05-27]

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Obstetric Care Facilities: Larger Hospitals

Redacted Witness List:

• Dr. Peter Boylan:
  Clinical Director, National Maternity Hospital [Written Submission]

• Dr. Sam Coulter-Smith:
  Master of the Rotunda Hospital, Dublin

• Dr. Rhona Mahony:
  Master of the National Maternity Hospital

Dr. Sam Coulter-Smith:  In respect of loss of life from self-destruction there are a number of issues that need to be raised. First, this is an extraordinarily rare situation with the incidence of suicide in pregnancy of the order of one in 500,000 pregnancies as per United Kingdom figures. Second, our psychiatric colleagues tell us that there is currently no available evidence to show that termination of pregnancy is a treatment for suicidal ideation or intent and, as obstetricians, we are required to provide and practice evidence-based treatment. . . It, therefore, creates an ethical dilemma for any obstetrician who has requested to perform a termination of pregnancy for the treatment of someone with either suicidal ideation or intent. Third, this legislation, I am sure, is designed to create clarity and reassurance for both health professionals and patients alike.
[P. 31, accessed 2013-05-27]

The fact that there is no gestational limit in respect of the third scenario relating to suicidality is a major ethical issue for obstetricians. I will illustrate this with two scenarios. First, let us consider the case of a patient who is 25 weeks' gestation. If she is deemed to be sufficiently suicidal to require a termination of pregnancy by one or more psychiatric colleagues, an obstetrician who is tasked with dealing with this situation is faced with an enormous ethical dilemma. Delivering a baby at 25 weeks' gestation could lead to death, due to extreme prematurity or it could lead to a child with cerebral palsy or with other significant developmental issues for the future. This outcome would be entirely iatrogenic and the responsibility of those clinicians who have agreed to be involved in the process. This is a source of serious concern for myself and my colleagues.
[P. 31, accessed 2013-05-27]

Another clinical scenario which provides a difficult ethical dilemma is a situation whereby at a woman's 20 week anatomy scan a significant but non-lethal malformation is discovered. The patient, for a variety of reasons, may decide that she cannot continue with the pregnancy and it is causing her significant mental health issues with risk of suicide. The obstetrician is left in the unenviable position of, by law, having to look after the best interests of the baby but also the understanding of the mother's issues. It would, therefore, seem appropriate in a case where there is a risk of self-destruction that there is no gestational limit applied in this situation as this creates a major ethical dilemma for us.
[P. 31, accessed 2013-05-27]

My overriding concern, however, in relation to the whole area of self-destruction and termination of pregnancy to prevent same, relates to the lack of evidence to show that termination is of any assistance in this scenario and that we as obstetricians and gynaecologists must be able to stand over the decisions we make as being based on good medical evidence. . .
[P. 32, accessed 2013-05-27]

. . .Each of our Dublin maternity hospitals delivers approximately 9,000 women per year. The midwife to patient ratio is approximately half of what it should be, the consultant to patient ratio is also half of what it should be. We have seen an increase in the delivery rate in Dublin of about 30% over the past six years and this has put an enormous strain on the infrastructure of our hospitals. The increase in the number of women delivered is now leading to a huge increase in the demand for gynaecology services to the extent that waiting lists for routine gynaecology outpatient clinics are currently well over a year and growing. The combination of these factors means that it would be extremely difficult for us in the maternity hospitals to take on any additional service which would require input from staff in an outpatient setting in terms of assessment or in theatre time to cope with an increase in the number of termination procedures.
[P. 32, accessed 2013-05-27]

In conclusion, I welcome this draft legislation, particularly in the area of real and substantial risk to the life of the mother which pertains to physical illness. I think, however, that there are significant concerns in all areas of the medical profession in relation to this Bill when it comes to suicidality. Our overriding concern relates to the lack of evidence to show that termination of pregnancy is an appropriate treatment for women who are deemed to be at risk of suicide. As obstetricians we are expected to practise evidence-based interventions and first and foremost to do no harm. This legislation should help in providing clarity and reassurance to professionals and patients alike. To enact and underpin the idea that termination of pregnancy is a solution or a treatment for a patient at risk of committing suicide when there is no evidence to support that intervention creates an ethical dilemma for our profession.
[P. 32, accessed 2013-05-27]

To make matters a little more difficult there is no gestational limit mentioned in the draft at which this termination might happen. This opens the possibility for iatrogenic prematurity with all the risks of infant morbidity and mortality. Who will be responsible for these interventions? I also confirm to the committee that we as a profession, and particularly in my hospital, have concerns about the potential for increased demand for termination services in this country as this may be an unintended consequence of this legislation in its current form.
[P. 32, accessed 2013-05-27]

Dr. Rhona Mahony: Chairman and members of the committee, I thank you for the opportunity to comment on the draft heads of the protection of life during pregnancy Bill. I am the master of the National Maternity Hospital. I am a practising obstetrician, having practised for 17 years, and am a specialist in foetal and maternal medicine. I have practised as a consultant at the National Maternity Hospital since 2008. . . .

. . . The indications for termination of pregnancy prior to foetal viability include situations such as infection, choreoamnionitis, blood pressure that we are unable to control, haemorrhage, treatment for some cancers and management of severe medical disorders in pregnancy such as heart disease. These situations are very complex and very rare. At the National Maternity Hospital, which is one of the busiest maternity hospitals in Europe, we have annually up to five cases.
[P. 32, accessed 2013-05-27]

Dr. Rhona Mahony:  I am pleased to note that conscientious objection is addressed in the Bill.
[P.33, accessed 2013-05-27]

Dr. Peter Boylan: . . . If a woman is referred to me by a psychiatrist whose opinion I respect - an opinion which is not driven by ideology but by care for the woman, taking everything into account - and if that psychiatrist believes the only way she will be prevented from killing herself - it is her life I am talking about - is by terminating that pregnancy and if I trust the psychiatrist's opinion, I will terminate the pregnancy. If the mother dies through suicide, so too does the baby. This is about the protection of life in pregnancy. That is my comment in that regard.

. . .Foetal viability is considered in all of our clinical decisions. This arises, for example, in the case of women with extremely severe hypertension. In that case if a mother has seizures, she may well die or she may effectively become brain dead or blind if we do not deliver the baby. We will deliver a baby at 23 weeks in order to save a mother's life. As I said, we cannot allow a woman who is pregnant to die in front of our eyes. We cannot allow her to get to a situation where she may kill herself. If she kills herself or she dies, the baby dies too. . .
[P. 34, accessed 2013-05-27]

Dr. Rhona Mahony: I will answer the questions Deputy Kelleher raised. If the X case did not exist, would we still legislate for suicide? Suicide is death. We are legislating here for the substantial risk to life. If one commits suicide, one dies so, inherently, when someone plans to take their life, they are at risk of dying. I make no distinction between medical and physical risk to life. I am not talking about mental health disorder but about the intent to commit suicide which can occur without a history of mental disorder.

In terms of suicide and all the evidence we talk about, the incidence of suicide is about one in 500,000. There is no evidence. When a condition is that rare, it is impossible to perform adequate research or studies which inform one because the condition and the outcome are so rare. If one was to truly examine the issue of suicide, one would have to take a group of women who planned to kill themselves and randomise them to termination of pregnancy to prevent them from killing themselves or to not being allowed have termination of pregnancy. I suggest that studies should never be done. What we do instead is we defer to our psychiatric colleagues who are expert in the assessment of suicide ideation and they use their clinical experience and acumen.
[P. 35, accessed 2013-05-27]

Dr. Rhona Mahony:  I am not a psychiatrist, but with regard to this business that there is no evidence that termination of pregnancy is a treatment for suicide, we are not talking about treating - we are talking about the risk to life. If members want to remove suicide from the legislation, in the X case, involving a 14 year old girl, is everyone in the room absolutely certain there was no way that X would kill herself and no way that she would die? In the case of a woman who does not want to be pregnant and who is so distressed by her pregnancy that she tells us that she wants to kill herself, can we all sit here and say we are absolutely certain she will not kill herself? I cannot.
[P. 37, accessed 2013-05-27]

Dr. Sam Coulter-Smith:  We have talked in detail about the consultant-patient ratio. Our midwife-patient ratio is also approximately half of what it should be. The internationally recognised appropriate ratio of midwives to patients should be between 1:25 and 1:30. In our hospital at present it is approximately 1:50. That is in a situation where, at our peak levels of activity, there were 42 deliveries in a 24-hour period last December.
[P. 40,, accessed 2013-05-27]

Dr. Peter Boylan: Deputy Robert Troy asked why we should separate medical from psychiatric illnesses. I have always felt, like my colleagues Dr. Mahony and Dr. Coulter-Smith, that if a particular procedure is required to save the life of a mother, the reason the procedure is required should not depend on whether the risk to her life is a consequence of a medical condition such as a congenital or complex heart disease or the consequence of an imminent danger that she will kill herself.

An issue we have not covered in great depth is that of conscientious objection, which I propose to deal with briefly. It is important to note that this issue also applies to the mother. We, as doctors, may make a decision that a mother is very likely to die, unless there is a termination of pregnancy, but the woman herself may refuse that termination because she is willing to take the risk or she has a conscientious objection to undergoing a termination of pregnancy. As doctors, we will respect that wish. Likewise, the wishes of doctors and midwives who have a conscientious objection to being involved in a termination of pregnancy will be accommodated. Those of us who have trained abroad, in the United Kingdom and elsewhere, have personal experience of this and not faced any difficulty when it has come to performing terminations of pregnancy, primarily for social reasons in the United Kingdom. There is no problem with this and no need for people to be afraid. Nobody will be forced under this legislation to do anything against his or her conscience. Everybody should be reassured about this. We are adult, professional people.
[P. 42, accessed 2013-05-27]

Deputy Terence Flanagan:   Dr. Mahony argued strongly before this committee in January that greater clarity is required in the law governing the termination of pregnancy, and that all the heads of Bill do is simply quote verbatim the X case test without offering any assistance in interpreting this, including what constitutes a real and substantial risk. How does this provide the clarity she said was needed?

I ask all the witnesses how the proposed legislation currently stands if two psychiatrists rule that a woman needs an abortion. Would an obstetrician feel comfortable overruling their professional opinions? How is the role of the obstetrician envisaged in that type of scenario? If a woman presents in the 20th week of a pregnancy with twins, states she is suicidal and requests an abortion for one twin - what is described as a "selective reduction" in the UK - would doctors be willing to carry out such a termination? If two psychiatrists told a doctor to abort a child at 20 weeks' gestation, would it be done, or could the doctor request that the termination be delayed in order to give the child a better chance of survival?
[P. 43, accessed 2013-05-27]

Dr. Rhona Mahony: . . . The Deputy commented on the number of terminations performed elsewhere in the world. That is disingenuous and does not add anything to today's debate. We are not talking about termination of pregnancy for any reason; we are discussing termination of pregnancy within a very narrow and confined context of risk to life, where terminations of pregnancy are performed to save a woman's life. These instances are rare. In my hospital, which is one of the busiest maternity hospitals in Europe, we perform approximately up to five of these procedures every year. Please do not confuse us with figures of 7 million or other large numbers. That is disingenuous.
[P. 43, accessed 2013-05-27]

Dr. Sam Coulter-Smith: I do not have anything further to add to Dr. O'Mahony's comments directed at Deputy Mathews. Deputy Terence Flanagan asked what is a real and substantial risk to the life of the mother, which is very difficult to identify. We should leave that up to our very competent doctors in obstetrics and gynaecology, oncology and cardiology and any other specialty dealing with very sick patients. We have a very high standard of medicine in this country and it is appropriate to put legislation in place to protect our doctors and let them do what they do best in treating women and all patients to the very best of their ability. We do not need to be prescriptive on those lines.

We were asked if an obstetrician would overrule a psychiatrist. We do not have the expertise and experience in the psychiatric area to overrule a psychiatrist, so I cannot see that happening. However, we do have conscientious objection to protect us in that regard.
[P. 43, accessed 2013-05-27]

Dr. Sam Coulter Smith:  Yes, our results are excellent and remarkable. I stressed earlier that this was down to the skill and dedication of our midwives and the excellent doctors who work from facilities that are absolutely not fit for purpose any longer. To tell the committee about the Rotunda Hospital, we have nine delivery rooms when we should have 16. Our public postnatal wards were built in 1757. The infection control risks we face on a day-to-day basis are ridiculous. It is absolutely crazy in this day and age that we are providing modern-day obstetric services out of a building which is no longer fit for purpose, but the results are fantastic. That is down to the staff.

When we are talking about saving mothers' lives, we should not use the terms "abortion" and "saving mothers' lives" in the same sentence, full stop. It is a dreadful reflection on anyone who would actually do that. This is about saving mothers' lives, preserving dignity and not stigmatising anybody. These are wanted pregnancies, loved pregnancies, and intervention has to be made to save the mother's life. To call it an abortion is wrong.
[P. 44, accessed 2013-05-27]

Dr. Peter Boylan: The legislation is incredibly restrictive by international standards. Any suggestion this is a liberal legislative programme needs to be utterly rejected. Comparisons with the United Kingdom or any other country in Europe - in fact, any other country apart from Malta - are disingenuous and false. This is incredibly restrictive which everybody needs to recognise. I have a fundamental problem with people abrogating the term "pro-life" to themselves and trying to paint me into a corner where I am held up as not being pro-life. Nothing could be further from the truth. As I have spent my entire professional career trying to care for and save lives, I have a fundamental personal objection to this.

. . . An obstetrician feeling uncomfortable can invoke the conscientious objection clause. That is not an issue. Questions were asked about whether we would terminate a single twin if the mother asked for it. No, let us not go there, as that is getting into silly territory.

Senator Paul Bradford made reference to the health of the mother. This is about the life of the mother; not about her health. We are concerned that if a woman is not allowed to have a termination of pregnancy, she will die, not that she will be unhealthy. This is about death. Stop introducing the term "health" because it is irrelevant.

Ireland is not a chilling place. It is very good, but it is not because of the facilities available or anything else; it is in spite of what Dr. Coulter-Smith has very eloquently and repeatedly drawn attention to in terms of deficiencies in services.

I was asked if I had ever been unable to intervene because of the current legal situation, to carry out a termination of pregnancy and the woman had died. I have not, but I have personal, inside information and knowledge from the west of a woman who died last year because the doctors were unable to terminate the pregnancy because of the law.
 . . I also have personal experience as a junior doctor of a woman who died during pregnancy because she had a conscientious objection to termination of pregnancy. She was so desperate to give birth to a child that she did and then she died. That happens too and we, obviously, respected her wish.
[P. 44,, accessed 2013-05-27]

Dr. Peter Boylan:  We were asked if we would ask a psychiatrist to delay a termination if the duration of the pregnancy was 20 weeks. We are obliged under this legislation to take due care to do all we can to preserve the life of the baby. It is not a question of a psychiatrist rolling up and saying we should terminate a pregnancy without any discussion between us. We do not act like that. It is not a professional way to behave and we do not behave like that. These will be joint decisions taken in consultation with our psychiatric colleagues, whose opinions we respect and trust.
[P. 46, accessed 2013-05-27]

Dr. Sam Coulter-Smith: My comments on the first question would echo those of Dr. Boylan. Senator Norris asked about babies being left to die or deliberately killed. There is absolutely no question of that happening in this country. He also asked if termination of pregnancy was the equivalent of the death of a child. It is not, because it depends on the gestation at which it occurs. We dealt with that earlier. He asked about the different clinical scenarios. Where there is a threat to the life of the mother based on a physical illness, in all likelihood the evidence will be much clearer. Where there is a risk of suicide, the evidence is a little less clear and it makes that situation much more challenging and difficult to deal with. That is where the expertise of our psychiatric colleagues is required. Senator Norris is absolutely correct that whether the intervention occurs because a woman has a physical illness or because she is suicidal, the outcome of that situation will be the same at a particular gestation.
[P. 46, accessed 2013-05-27]

Dr. Sam Coulter-Smith:  On head 4 and intervening in a case of suicidality, no obstetrician would have an issue with intervening and performing a termination of pregnancy if it were to save the life of the mother and if every other avenue had been explored and there were no others. [P. 47, accessed 2013-05-27]

---

Obstetric Care Facilities: Smaller Hospitals

Redacted Witness List:

•  Dr. Gerard Burke: 
  Mid-Western Regional Maternity Hospital [Written Submission]

• Dr. Mary McCaffrey: 
  Kerry General Hospital in Tralee [Written Submission]

• Dr. John Monaghan: 
  Portiuncula Hospital in Ballinasloe [Written Submission]

• Dr. Máire Milner: 
  Our Lady of Lourdes Hospital

Dr. Gerard Burke: . . . On the issue of resources, in the next decade we can expect in the order of 100 maternal deaths in Ireland. It is possible that one, two or three of these potential maternal deaths might be affected by the legislation before us. In terms of the number of possible deaths, therefore, this great intellectual effort will affect a relatively small number of women. It is important that the Oireachtas would at some point address the state of the maternity services. The unit in Limerick which I represent, for example, has the lowest number of obstetricians in the whole of Europe at two per 100,000. This shortage of resources will likely lead to some difficulties in the future.

We have identified two minor technical issues that should be addressed, the first of which relates to the question of an ectopic pregnancy. It is possible to have an ectopic pregnancy within the womb, in the cervix, in the neck of the womb or in the scar of a previous caesarean section. We are seeing more and more of the latter as the rate of caesareans has risen. One can have a pregnancy that is ectopic but within the womb, and that is an extremely dangerous condition which could fall under this legislation.
[P. 48, accessed 2013-05-27]

Dr. Mary McCaffrey: I thank the Chairman and the committee for the opportunity to contribute to the discussion. Like Dr. Burke, I commend the Government and the legal draftsmen on putting together these legislative proposals under such difficult circumstances. My submission is intended to reflect on how the proposed legislation might impact on the practice of obstetrics in small to medium-sized units, that is, in units with three consultant obstetricians on the staff. There are 12 such units out of the total of 19 in the country, and they deliver approximately one third of all babies. Therefore, they make up a significant number of deliveries. I will not dwell too much on the issue of resources other than to say that, in general, we would tend to be very under-resourced.
[P. 48, accessed 2013-05-27]

Dr. Mary McCaffrey: Regarding head 3, risk of loss of life from physical illness in an emergency situation, sadly, in the course of our work we deal all the time with patients who have severe impending infection, severe pre-eclampsia or haemorrhage. The legislation now protects us in a way that we were not protected before so we welcome it for those cases.

. . . For a significant number of colleagues with whom I have discussed head 12, conscientious objection, this is a really significant area. There are many obstetricians in the country who have conscientious objections to being involved in providing termination of pregnancy. This must be respected. Under Medical Council guidelines, they are entitled to have conscientious objections. The important point is that the public will know that where the life of the mother is at risk and where medical care is needed appropriately, the care of the mother and her baby will always be paramount for every doctor and that if a doctor has a conscientious objection, he or she will have the facility to provide access to another colleague in a timely manner. That is very important.

Over the past couple of months there has been some suggestion in the media and elsewhere that doctors should have to declare their moral and ethical objections to being involved in termination of pregnancy prior to taking up employment. This has caused fear for a number of colleagues, not those of us currently employed because we have our jobs but people in the future might feel that they would be disadvantaged or discriminated against at interview by an employer who feels that a certain doctor is not going to do terminations but one who will do them is needed on the staff. This has to be taken very seriously because under subsection (3) of head 12, "No institution, organisation or third party shall refuse to provide a lawful termination of pregnancy to a woman on grounds of conscientious objection". If there is a hospital management structure that for whatever reason feels all of its doctors must provide terminations, no doctor should fear that if he or she applies for a job there and has a particular ethical point of view, he or she will be discriminated against in getting a job. That is very important. A few people would like to know who is the "third party" referred to in that subsection because that was not clear to us.
[P. 49, accessed 2013-05-27]

Dr. John Monaghan:  My second point refers to head 4, which deals with the risk of loss of life from self-destruction. The other reason we are here today is the Supreme Court case of X, which occurred 22 years ago. As an obstetrician, I do not have any first-hand experience of psychiatry. It reflects an enormous change in obstetric practice that an obstetrician is being asked to intervene in a physically healthy pregnancy. While it appears from the legislation that an obstetrician would be involved in the decision-making, he is referred to otherwise possibly as a technician, suggesting that maybe he should be involved so he does not feel like a technician. However, my gut is extremely unhappy with the idea of a mindless terminator for psychiatric reasons. This decision was made 21 years ago. From the hearings that were held in January, I do not believe any case of suicide associated with refusal of termination has ever surfaced. The evidence from my reading of it seems to be extremely poor. Many of the speakers earlier were happy to take the expert advice of a psychiatrist to act if required. I am not certain how a psychiatrist can reach a decision on this matter where to date I do not believe any evidence has been produced.

The psychiatric or suicide risk clause has been brought in in other jurisdictions and has been widely - I would say universally - abused. Last year, The Daily Telegraph did an exposé of the abuse of psychiatric reasons in the UK, with the use of pre-stamped forms. People went to one doctor to get a form stamped, then to another to get it stamped and then got a termination. I can see no reason, despite the safeguards built into this legislation, that culture could not arise in this country in the future. I am extremely concerned as an obstetrician that I would be drawn into a situation in which a termination of pregnancy will be done for psychiatric reasons without very clear evidence that this is to the patient's benefit. If the baby is going to lose its life in this circumstance, then I would want to be very clear that there is a clinical benefit to the mother. To date, I can see none of that. That is my big issue with the heads of the Bill.

The other matter which I would like to deal with is the question of conscience, which Dr. Mary McCaffrey mentioned as well. I use the term "conscience" rather than "conscientious objection" because the latter implies that this is a problem. Twice in the past few months, as a doctor, I have been told that a doctor should leave his or her conscience outside the room. I would ask the committee to reflect on what it means if a doctor suspends his or her conscience faculties. Conscience is not a religious concept. If one sees somebody beating a child on the street and one continues to do one's shopping, then there is something wrong with one's conscience. It is an obvious thing. For example, if I decided to suspend my conscience with a patient on a waiting list and he offered me €300 to go up the list, then that is a very tempting, painless and invisible transaction which I am sure occurs in the political world. The only thing that will stop a practitioner-----
[P. 50, accessed 2013-05-27]

In relation to the conscience matter, conscience has been under attack in the past five years or so in the medical literature. I have attached two articles on conscience to my submission - one hostile to and one supporting conscience. The Bill to be produced should recognise the importance of conscience rather than the importance of conscientious objection, on which I would be happy to answer questions.
[P. 51, accessed 2013-05-27]

Deputy Caoimhghín Ó Caoláin: . . .In terms of a smaller number of professional colleagues, does this create particular situations, given the larger body of colleagues those from the major Dublin-based hospitals would have to call on? For instance, I refer to the issue of conscientious objection, to which Dr. Monaghan referred. Are there given situations where the witnesses may not have the complement of necessary professionals to make the evaluations?
[P. 51,, accessed 2013-05-27]

Deputy Seamus Healy: . . . I have a related question on how smaller units might be affected by conscientious objection. Could such objections result in personnel not being available in smaller units to undertake the provisions of the Bill?
[P. 51, accessed 2013-05-27]

Dr. Mary McCaffrey: I represent the second smallest unit. Clonmel is a little behind us. The questions asked by Deputies Ó Caoláin and Healy about smaller units are quite similar. I think we need to step back and look at the three indications which are outlined under this Bill. When we talk about the risk of loss of life from a physical illness in a medical emergency, we are looking at women who have severe infections, bleeding or severe pre-eclampsia. As I said already, sadly we deal with this every year in all of the small maternity units throughout the country. We deal with it appropriately and in a manner that is clinically appropriate.

. . . Conscientious objection would never come into play when someone's life is in danger there and then. That has always been our practice at the time the woman is dealt with. Nothing will change in that regard. Obviously, we would expect every doctor to look after an acute medical situation. In a less acute situation, we would expect doctors to meet their requirements under the Medical Council guidelines. If they are not going to look after a patient, we would expect them to ensure someone else looks after that patient in a timely manner. I would be disappointed to hear there is any unit where a person would suffer due to a conscientious objection of all the staff. I do not think such a unit exists. We will always look after the life of a mother and the life of a baby. . .
[P. 51, accessed 2013-05-27]

Dr. John Monaghan:  The Deputy also asked about the overburdening of the maternity services. Our unit at Portiuncula Hospital delivers approximately 2,200 mothers a year. We might encounter one or two cases of serious maternal illness where the pregnancy has to be ended. I think the figure given for the Dublin hospitals was 30 a year. Such cases do not overburden the maternity service. If a patient has a very serious fulminating pre-eclampsia, for example, she might need to be transferred to a tertiary unit in Galway or Dublin. There may be problems with the transfer if there is overcrowding in the tertiary centre. I do not envisage that this legislation will overburden maternity services significantly unless there is an explosion in the number of terminations of pregnancy under psychiatric or self-destruction grounds. . . .
[P. 51, accessed 2013-05-27]

. . . The Deputy also asked about conscientious objection. As Dr. McCaffrey said, if one is prepared to allow a mother to die, one is guilty of very serious professional negligence. There has been no maternal death in my hospital, or death of a woman who was transferred out of the hospital, for 29 years. I am sure that is the norm throughout the country. It is not true that the conscientious refusal by obstetricians to offer necessary treatment which might involve termination of pregnancy is leading to maternal deaths. I am sure it has been pointed out already that this country's maternal mortality rate has always been significantly lower than the rate in the UK, regardless of the figures one uses. Similarly, the maternal mortality rate in Northern Ireland, where the UK Abortion Act does not apply, is lower than the rate in the rest of the UK. I do not think conscientious objection could be considered to endanger women's lives in any way. We do not know where conscientious objection would arise in psychiatric cases. I do not know how an obstetrician would deal with an emergency precipitated by suicide. I cannot imagine that scenario.
[P. 51, accessed 2013-05-27]

Dr. Gerard Burke: This has never happened in my career and I do not expect that it will. The numbers are so small, most of us will never see this in an entire career.

The idea that you would have a patient arriving into your office with two abortion tickets from random psychiatrists is nonsense. That is not the way that medicine works. We would have a working relationship with the psychiatrist. If you did not know the psychiatrist and did not trust them you certainly would not be doing anything near terminating a pregnancy. The institute has made a suggestion in this regard, there would be a second obstetrician involved and I would support that. I can tell you, there are very few of us in the country - 125 consultant obstetricians - and we are not beholden to psychiatrists telling us what to do. We have to do this procedure ourselves so we are going to be absolutely certain that it is thoroughly justified, medically and ethically. That is the way medicine operates.

. . . In regard to resources, we have very few obstetricians. When the country was awash with imported money a few years ago not a red cent was voted to improve the resources by this House. The Deputies were aware of the issues because the numbers were well known but not a red cent was put into maternity services. . .

. . . A conscientious objection would not arise in my unit. There are eight of us and I do not think there will be any difficulty about providing opinions and care. . . 
[P.53, accessed 2013-05-27]

Senator Jillian van Turnhout:  I fully respect conscientious objection and it is important. Do we need to consider, when we are examining geographically appropriate locations, whether we will have an adequate number of professionals employed who have not declared a conscientious objection?
[P.53, accessed 2013-05-27]

Dr. John Monaghan:  A related issue which I have studied slightly myself is the problem with recruitment into obstetrics and gynaecology in the United Kingdom for the last 35 years. The matter is well written up in the reports of the Royal College of Obstetricians and Gynaecologists. Another study which was published in the British Journal of Obstetrics and Gynaecology showed that recruitment into obstetrics and gynaecology was highest in Northern Ireland and lowest in places like Leeds and Oxford. Certainly, Dr. Jim Clinch, who was one of the doctors who was keen to come today but could not, is of the opinion that if an abortion culture becomes widespread, it seriously affects recruitment into obstetrics and gynaecology. That would have been my experience. I worked in the NHS for three and half years in total. Certainly, in my time in the north of England, I used to speak to medical students and ask them if they would consider a career in obstetrics and gynaecology. During the two years I was in the north of England, no student said he or she was interested in a career in obstetrics and gynaecology. When asked the reasons, fear of being sued and a hard-working rota were cited, but the single biggest factor was that students did not like the abortion culture, not for particularly ethical reasons but because it was distasteful to them. [P.54, accessed 2013-05-27]

Dr. Mary McCaffrey:  I am not sure what the right answer is to whether people should declare conscientious objections in advance. It would be disappointing if people were discriminated against and disadvantaged. The situation will be extremely rare.
[P. 55, accessed 2013-05-27]

Deputy Denis Naughten: . . . There are normally three consultants in smaller units. Do the witnesses fear that if the three consultants had a conscientious objection to carrying out procedures and one was to retire, there would be an agenda to ensure a new consultant does not have a conscientious objection and would be recruited on that basis?
[P. 55, accessed 2013-05-27]

Senator Jim Walsh:  . . . Dr. Mary McCaffrey mentioned the conscientious objection issue and, in particular, people opting out. That is a concern if people of a particular disposition exclude themselves from the panels. As we have seen in the media over many months, the medical profession have people on both sides of this argument so the outcomes could be skewed as a consequence. I wish to link that with the comments about the lack of resources which have been made by all the groups appearing before the committee. Resources often lead to shortcuts being taken. Therefore, while it might start in a very thorough fashion, as happened in other jurisdictions, that will change within a short space of time.
[P. 56, accessed 2013-05-27]

Senator Jim Walsh:  Finally, I have a question for Dr. Monaghan and, indeed, all the witnesses. Has there been any case in their experience where they have been so inhibited by current legislation that they were unable to deal with a mother whose life was at serious and substantial risk? Previous speakers were asked that question and only one case was cited, which was the recent case in Galway. I understood the coroner said in that case that, in fact, it was different issues rather than the legislation. Are any of the witnesses familiar with that case to shed more light on it?
[P. 56, accessed 2013-05-27]

Senator John Crown:  . . .  in western countries maternal mortality is an extraordinarily rare event. In Ireland in recent decades we have had entire years with no maternal mortality. The occurrence of one maternal mortality is a disaster. If we have to legislate to prevent one maternal mortality, we should do it. This is not like cancer or heart disease mortality, where there are thousands of deaths per year. This is different and we must treat it differently.

In the previous hearings, I got to the crux of the matter by putting the Dublin folks through a detailed interrogation. We worked out that, although figures are not kept, there are approximately 30 abortions per annum in Ireland within the legal parameters of our Constitution, that is, to preserve the life of the mother. They reckoned there were six to eight in each of the Dublin maternity hospitals and, with a little extrapolation, that is what we reckoned to be the probable total. I have asked some of my colleagues about this and my understanding is that the great majority of these will be for cardiovascular complications, blood pressure emergencies, renal failure emergencies, occasionally haemorrhage and sometimes cancer.

Incidentally, in a long career of practising cancer medicine I have never had to send anybody for an abortion to save their life. It is not typically the way it happens. Many of my patients have made a decision to have an abortion and I have supported them in their decision, but I have never said to them that they need it to save their life.

Of the 30 cases per annum, the great majority will fall into the categories I outlined. My best guess, and I ask my colleagues to comment on this, is that in the majority of those cases it is not a sudden, out-of-the-blue event where a previously normal healthy pregnancy suddenly deteriorates. There is usually a warning - the woman has had pre-eclampsia, which is a blood pressure and kidney problem occurring in pregnancy, or it is discovered that the placenta is dangerously misplaced or that there is cancer-----

My understanding is that in the great majority of cases there will be warning, so the scenario of this type of occurrence occurring in one of the smaller hospitals is very unlikely because the hospitals will generally refer the patients to one of the larger, specialist units at an earlier stage in their pregnancy where they will be cared for by the high risk people. In those rare cases where it will occur in the smaller hospitals, it will be category one or the emergency. It is the one where the patient is either bleeding or dying of blood pressure, the doctor cannot consult, there are no psychiatrists and the patient is not suicidal. The doctor sees a woman whose life will drain from her body in the next few hours if they do not end the pregnancy, something which is very rare. That is my understanding of the only cases the witnesses will see. Is that the case? Should anybody have a right to conscientious objection in that setting? If they do, they should not be in that job.
[P. 56, accessed 2013-05-27]

Dr. John Monaghan:  Consider the question of having a right to conscience in a smaller department or rural unit. As I said, there is no evidence that conscientious objection has led to any maternal death. Senator Jim Walsh asked about the case in Galway. Certainly, there was no mention of the word "conscience" in the inquest report, which I read.
[P. 57, accessed 2013-05-27]

Dr. Máire Milner:  On the question of where I can find clarity in the Bill, I am not a lawyer. I have simply read the heads of the Bill. In several situations in my career I had a worry at the back of my mind about a woman who was very sick with sepsis, in circumstances very similar to those in the Galway case, and I had hoped nature would deal with it. In fact, that is what happened, very happily. Nineteen times out of 20, nature does deal with things, but, unhappily, it does not always do so. For me, my patients and the staff on my team, the Bill gives my practice more clarity. I note this from having talked to my colleagues.
[P. 57, accessed 2013-05-27]

Dr. Máire Milner:  On the conscience clause, I again refer to the comments of all of my colleagues. First and foremost, we save the woman's life. We do not set out to terminate a pregnancy, but one does what has to be done to save the woman's life. There may be time to play with and one's conscience can come into that in some way. It is as likely to be one's skills as one's conscience that will come into play. As Dr. McCaffrey said earlier, if one does not feel one is able to deal with something, if one has time to play with one can refer to another colleague. The woman has a right to life, and that is the primary right. I have dealt with most of the questions.

Senator Jim Walsh:   Dr Burke mentioned that conscientious people can opt out. If they opt out of the panels, given that politicians and medical personnel can be broken down onto one side or the other-----

-----that might skew the outcomes because of the particular opinions of individuals involved. There is also the question of a lack of resources giving rise to a short-circuiting of the system. In other countries, all procedures were fully followed at the start, but within the space of 12 months people were taking shortcuts and notes were being left at reception already signed. A lack of resources generally gives rise to such developments. Do the witnesses know, in regard to the Galway case, whether a lack of resources-----

Chairman:   We are not-----

Senator Jim Walsh:   Dr. Boylan put on the record that in one instance that he knew of-----

Chairman:   Sorry, Senator-----

Senator Jim Walsh:   Or the lack of legislation-----

Chairman:   I ask the Senator to take his seat. He is straining again.

Senator Jim Walsh:   Is that true or untrue?

Chairman:   To be fair, when Dr Boylan made that remark this afternoon I asked him not to reference it.

Dr. Mary McCaffrey: I thank Senator Walsh. Ironically, I thought about conscientious objection before I came to the committee today, and how the panels would be put together. As I understand it, the personnel who will go onto the panels will be nominated by the various institutes. Obviously, that will be the role of the institute, and it would be nice if there was a balanced approach as to who was on the panels. That would be important.

. . . I want to be quite clear about something which has not been said. It is illegal for a doctor in this country to refer anyone to anywhere for termination of pregnancy. It is almost unfair to ask us whether we have referred patients because----- We have never referred women because it is illegal to do so.
[P. 58, accessed 2013-05-27]

Dr. Mary McCaffrey:  In regard to the screening of job applicants, interview processes should put the best candidates forward for the job. Providing for rare circumstances is one aspect of the care we provide. What one would want is to have people in these jobs who will ensure the safety and health of the mother. I worked in the United Kingdom for a number of years and one is not allowed at interview to ask questions such as those suggested. I recall only one interview at which I was asked a question like that. I did not get the job and I never knew whether it was because I said I would not do a termination of pregnancy. We would have to be careful of discriminating against people.
[P. 59, accessed 2013-05-27]

Deputy Bernard J. Durkan:  In regard to conscientious objection, to what extent is that principle equally distributed between the right to life of the mother and the right to life of the as-yet-unborn baby, bearing in mind that the Supreme Court has made a particular decision in a rare situation?

Will the witnesses indicate whether, in the event that a close relative of anybody in this Chamber were to present in an emergency situation at a maternity hospital, it is recognised that whatever treatment is required for that woman and that baby will be given to them regardless of ethical or conscientious objections?
[P. 59, accessed 2013-05-27]

Senator Rónán Mullen:  We have talked a great deal about the conscientious objections of those who might not want to carry out or certify terminations. If there is a subjective element to a psychiatric determination in this case do any of the experts believe it might arise that a person who, as a matter of his or her personal philosophy, is pro-choice, might take the precautionary approach when a person presents, given that it would appear that he or she lacks an objective basis on which to certify? Is it possible that a person with that philosophical mind-set might be more likely to certify that the abortion is necessary as a matter of precaution?
[P. 60, accessed 2013-05-27]

Deputy Bernard J. Durkan:   The other question was about conscientious objection, the equality of the unborn and the mother.
[P. 60, accessed 2013-05-27]

Dr. John Monaghan: While the State recognises the equality of the mother and the foetus I have never come across, or heard of, a situation in which a doctor would have allowed a mother to die because he or she had a conscientious objection to abortion. That would be an unconscionable action for a doctor. In terms of the management because the child cannot survive without the mother the doctor must act to save the mother's life and in instances the baby loses its life as a consequence.
[P. 60, accessed 2013-05-27]

Dr. Máire Milner: Correct. Somebody asked about a close relative and whether it is recognised that appropriate treatment would be given regardless of conscientious objections. I cannot speak for every colleague in every situation.
[P. 60, accessed 2013-05-27]

Deputy Arthur Spring: One of the issues which is pertinent is conscientious objection. One has quite a small psychiatric unit and quite a small maternity unit in a regional hospital. If a psychiatric unit is not adequate to deal with a patient presenting with suicidal ideation, does that mean the patient should be referred to a hospital where there is a substantial psychiatric unit? How would that impact on the ability of that person to be able to obtain the services should she merit a termination due to the fact that suicidal ideation is a reality?

Dr. John Monaghan:  Deputy Spring raised the question of conscientious objection between two psychiatric units - in other words, if a person was suicidal, she would be moved to another psychiatric hospital. Is that correct?
[P. 62, accessed 2013-05-27]

Deputy Arthur Spring:   If there was not adequate provision in a regional hospital, would the person be moved to a larger hospital?
[P. 62, accessed 2013-05-27]

Dr. John Monaghan: I am sure that would depend on the condition of the patient and so on. As far as I know, there is not a huge amount of transfer between psychiatric units. If one develops a mental illness, one would often stay in the same hospital. I do not think there is sort of specialist centres like there would be for neurosurgery or something like that. I thought the Deputy was referring to the question of conscientious objection in one institution and whether the patient could go to another one, but that was not what he was asking. I would not be able to answer that question. I think it would be best asked of a psychiatrist.
[P. 62, accessed 2013-05-27]