Protection of Conscience Project
Protection of Conscience Project
Service, not Servitude

Service, not Servitude

Dáil Éireann

Report Stage Debate (Resumed): 5 December, 2018

Health (Regulation of Termination of Pregnancy) Bill 2018

Extracts re: Conscientious objection (P. 269-294)

Copyright the Houses of the Oireachtas. Reproduced under the Oireachtas (Public Sector Information – Open Data) Licence. Links, comparative tables and annotations added by the Protection of Conscience Project.

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[P. 259]

Deputy Michael Healy-Rae

I move amendment No. 47:

In page 15 and 16, to delete lines 36 and 37 on page 15, and on page 16, to delete lines 1 and 2 and substitute the following:

“24. (1) A medical practitioner, nurse or midwife shall not be obliged to carry out or to participate in carrying out a termination of pregnancy in accordance with section 11, 13 or 14 to which he or she has a conscientious objection.”.

Bill text Amendment 47

Conscientious objection
24. (1) Subject to subsections (2) and (3), nothing in this Act shall be construed as obliging any medical practitioner, nurse or midwife to carry out, or to participate in carrying out, a termination of pregnancy in accordance with section 11, 13 or 14 to which he or she has a conscientious objection.

Conscientious objection
24. (1) A medical practitioner, nurse or midwife shall not be obliged to carry out or to participate in carrying out a termination of pregnancy in accordance with section 11, 13 or 14 to which he or she has a conscientious objection.

[Protection of Conscience Project comparison]

This is about people in the medical profession who have a difficulty. They want to carry out their functions, but if they have a conscientious objection to participating in a termination and they are forced to do so or to make a referral, then one is as bad as the other. I have visited hospitals in recent days and met people who have been at the coalface working in maternity wards for many years. They are genuinely concerned about what will happen to them and their jobs when this legislation is passed. We must think of these people. I do not know of people in any other sector in society who could have a conscientious objection on an issue and still be forced to participate in something that they did not want to do.

Of all the amendments that are being tabled, this is one that Deputies should consider. They should think of the people involved and who have come out and spoken. More than 500 nurses and midwives working in maternity services have signed a petition calling for this amendment to be examined closely and supported by Deputies, who should take in account their views when voting.

That is all I wanted to say. I will leave five minutes for the people who are accusing us of doing something we are not.

Deputy John Brassil

As a practising pharmacist and healthcare professional, I believe that if a person wants to opt out, he or has has the conscientious right to do so. I will break my contribution into three parts.

I will deal, first, with the pharmacy issue. I know that the Minister is very well aware of the duties and responsibilities of a pharmacist. Dispensing drugs is not like handing out chips in a chip shop; rather, it is an issue of professional responsibility, particularly in hospitals. I am informed that the drug potassium chloride may be needed at a later stage during pregnancy. As it is highly toxic, it is highly controlled in its prescription, dispensing and administration to avoid inadvertent toxicity or death. The role of the pharmacist in its dispensing, if it is to be used in an abortion, is extremely important and we really need to establish whether pharmacists can exclude themselves from the process. I, therefore, ask for clarification on the issue. On Committee Stage the Minister referred to the code of conduct of the Pharmaceutical Society of Ireland, PSI. Unfortunately, to my knowledge, the code does not explicitly mention freedom of conscience or conscientious objection for pharmacists.

[P. 260]

Therefore, I would really like to receive clarification on the issue. If further legislation is needed to protect pharmacists - I believe they deserve protection - it needs to be progressed immediately.

The legislation states a doctor shall make such arrangements as may be necessary for the transfer of care of a pregnant woman to enable her to avail of a termination. What exactly does that mean? I would like to receive a specific explanation on the floor of the Dáil. Some doctors might regard the giving of the number of a helpline as not including them in the process, while others would. If those doctors deem it to be against their beliefs and judgment, they should be protected and not subject to a legal challenge. They deserve to be protected. The same goes for midwives.

I want to refer to a few scenarios because this issue is worrying. The majority of abortions will be carried out with the use of an abortifacient, a pill which consists of Mifepristone and Misoprostol. The research tells me that the earlier the drug is given, the more effective it is. It is 98% effective in the first eight weeks, 96% effective between eight and nine weeks and 93% effective from nine to ten weeks on; therefore, it is not 100% effective. A situation may arise where somebody in the ninth or tenth week of pregnancy avails of this tablet or a set of tablets and they do not work. She then enters the next scenario because up to nine weeks, she will be dealt with at GP level, but between nine and 12 weeks, she will avail of a different route. I am concerned that some woman in seeking to avail of an abortion service will move from the GP service to the hospital setting. I will use County Kerry as an example. Is the service in County Kerry set up for this? Are there enough obstetricians in the county opting in because if there are not, we have a situation that we need to deal with? I would hate for a situation to develop where somebody seeking a termination starts the process before 12 weeks but cannot have a termination before 12 weeks expire. The last thing we want to do is bring about a situation where somebody will finish up in tragic circumstances, as happened when the eighth amendment was in place, and a new debate erupts. It is extremely important that we receive clarification on the issues raised. I firmly believe that if a healthcare professional wants to opt out of the process, he or she should be allowed to do so without fear of a legislative or legal challenge.

Among some elements in the House, there is a rush to get this legislation over the line. There is an old saying - "act in haste, repent at leisure". I do not want to see a situation develop where somebody seeking a termination will finish up in a scenario similar to those that developed after the introduction of the eighth amendment into the Constitution. We need to know how many doctors, hospital obstetricians and midwives are available to take part and whether all 11 hospitals that provide pregnancy care are suitable to take on this role.

The drug mentioned is to be provided by a doctor. Right now most doctors do not have the facility to order it. They must use the pharmacy. They do not have licences or contracts with manufacturers. Today is 5 December. If this legislation is to be in place by 1 January, we are really beginning to push things out.

Deputy Bobby Aylward

I add my voice in support of the amendment. This legislation is flawed. On the issue of conscientious objection, it is a real ask of the medical professionals to whom I have spoken, be they nurses, pharmacists, midwives, obstetricians or clinicians. When they qualified, they took an oath to protect life - in this case, the lives of the mother and the unborn child. If they want to opt out of providing this service, they should be given that right. I do not think that, as legislators, we or this House should force anyone to go against his or her morals, ethos or beliefs. That is what we are doing in enforcing this provision. I, therefore, ask the Minister and the Government to reconsider.

[P. 261]

Nobody should be forced to do something he or she does not want to do.

Last week I received a telephone call from an obstetrician in St. Luke's General Hospital in Kilkenny. He told me that a vote had been taken in the hospital and that two obstetricians, four clinicians and 82 nurses had said they did not want to take part in any act connected with abortion. We should respect their decisions. If a woman presents for an abortion in St. Luke's General Hospital, is it safely guaranteed if that number of individuals object to taking to part in the process and is it morally right to force them to take part in it? I was told by the same obstetrician that a vote had also been taken in two other hospitals. He named them, but I will not do so here because it is up to them to talk about the matter. The obstetrician told me that the results were the same. It is morally wrong. We all know that the proposal that the eighth amendment be deleted from the Constitution was passed by the people and we must respect that decision.

Conscientious objection is something we must take on board. Each person, male or female, should be given that right. I ask the Minister and legislators in this House to consider this and not to force people to do something they do not want to do, that is against their principles, and that they believe is against their oath, morals and ethical beliefs. I ask that to be taken on board here. I, for one, could not support that.

Deputy Peadar Tóibin

A group of more than 640 GPs have signed a petition seeking conscientious objection. Over the weekend, up to half a meeting of doctors in an emergency general meeting walked out, leaving the meeting in disarray.

Hundreds of GPs on the ground do not believe that general practice is the appropriate setting in which to deliver abortion services for many reasons, not least because of the lack of capacity in an area that is already overstretched, the lack of training for what is involved and the lack of availability of ultrasound. There is also the very serious issue of delivering genuine freedom of conscience, protecting doctors who do not want to get involved in this.

How this has happened is mind-blowing. The first that GPs heard about abortions being GP led was when the Minister announced it on radio. That is the first time these GPs stated they heard of it. From that day to this, this group of GPs has never once had a chance to discuss the matter with the Minister. He is imposing abortion on that particular sector.

Despite requests from pharmacists' representative bodies, the Irish Pharmacy Union and the Hospital Pharmacist Association of Ireland, there has been no engagement with the Minister for pharmacists who have conscientious objections.

Deputy Simon Harris (Minister of Health)

That is not true either.

Deputy Peadar Tóibin

It is also important to realise that more than 500 nurses and midwives on the Nursing and Midwifery Board of Ireland, NMBI, register have signed a petition to call on the Minister to protect freedom of conscience and support the amendments relating to it. Nurses and Midwives for Life Ireland has claimed the Minister, Deputy Harris, and the leader of Fianna Fáil, Deputy Micheál Martin, have refused to meet them to discuss their concerns with conscientious objection legislation. If the Minister were to introduce a Bill on hedge cutting, he would take about a year's worth of consultation within that sector before he brought the legislation through. It is phenomenal. For such a Bill, the stakeholders of that particular sector would be consulted for a year and yet these doctors, nurses and pharmacists have all been denied access to discuss directly with the Minister the issues that they have. These are the people on whose shoulders the health service sits. These are the people who are filling the gaps created

[P. 262]

by the disastrous funding in the health service at the moment. Despite this, the Minister, who has spoken about little else in the past two years, is pointing to them and asking them to take the weight on this particular issue.

I spoke to a few of those nurses and midwives and they told me a values clarification workshop is being rolled out in the hospitals, asking the nurses and midwives to reassess their own particular values with regard to the introduction of this service. There is an Orwellian feeling around this, when we are going to people who studied, strove and worked to protect and save life to reassess and re-evaluate their values on such an important issue.

The Minister has been a unifier in many ways. There are 750,000 people on hospital waiting lists, 10,000 people on hospital trolleys last month, 2,500 children waiting over a year for their first mental health appointment and now the people working in that sector are also being attacked by the Minister. He was on the radio today and said that these people had conscientious obstruction, not conscientious objection.

Deputy Simon Harris

I did not say that. The Deputy should withdraw that.

Deputy Peadar Tóibin

It is incredible that the people who are working in the health service, who want to do a day's work, save and protect people, are being attacked in such a manner.

This is a terrible accusation to level at a doctor or nurse as they seek to defend a conscientious objection and we have to remind ourselves of the import of what they are being asked to do. The Bill states that termination of pregnancy is the ending of a life of a foetus. It shocks me that we have not had that level of consultation at all. If something is built without that level of consultation, I guarantee there will be problems in it. The purpose of consultation is to iron out the difficulties that could arise in future.

I know the Minister is hungry to get this through. He has probably staked a bit of his reputation on the timescale of this being pushed through. This is surely more important than the reputation of a Minister and whether it happens on 1 January or 1 February. Surely the outcomes and potential pitfalls are the important issues that we, as Deputies, should be focusing on.

This amendment that we seek to provide here reframes the Bill so that there is a positive and substantive protection for the freedom of conscience. The current section 24(1) states that nothing in this Bill obliges a doctor, nurse or midwife to participate in carrying out a termination under sections 11, 13 or 14. However, it leaves a significant gap in the protection of those people because it merely says the Bill itself does not force doctors, nurses or midwives to participate. It therefore does not prevent the imposition of such a compulsion by an employer, a professional body or even an individual seeking to get promoted, or get through a particular piece of work. Accordingly, the amendment that we have tabled fills that particular gap.

The Minister should never say we do not listen to him because we do. The way we have framed this amendment is by using the direct words he used at the Committee on Health. He said that what he wants to see this level of protection for doctors, nurses and midwives included in the Bill. We decided that, rather than go for the yellow pack1 conscientious objection that exists in the Bill, we would lift the Minister's words from the blacks of the committee, put them into the amendment and slot them into the Bill itself.

I will tell the Minister one thing. This is the most dangerous aspect of the implementation of his Bill. As a number of other Deputies have stated here, there are a large number of healthcare


 professionals who will not implement this as laid out. They will refuse to implement it. The problem here is that the abortion service that the Minister seeks to provide will be as chaotic as the health service over which he presides.

Deputy Bernard J. Durkin

I would be the first to recognise the rights of people with a conscientious objection. We have always recognised that, through the debate that took place a year ago in the Joint Committee on the Eighth Amendment of the Constitution and the debate that took place in the health committee a week or ten days ago, and I think we have all listened carefully and sympathetically.

Unfortunately, I received an email the other day to the effect that I was being accused of turning a deaf ear to expressions of concern from pharmacists and doctors. That is not the case. I would be the first to recognise their rights.

Deputy Peadar Tóibin


Deputy Bernard J. Durkin

We need to recognise something else, including Deputy Tóibín, who is now leaving. We need to recognise that the women in a crisis pregnancy also have rights. In the event of a woman in a crisis presenting at a particular time, as has happened in the not-too-distant past, and a decision has to be made as to whether that woman is entitled to the provision of services as envisaged under the heads of the Bill that were published before the referendum, what do we say to that woman? What do we say to her family? Do we apologise, and tell them nobody is around to provide the services that she now requires? Do we say we are sorry that she has a terminal illness and tell her we cannot do anything about it, nor advise her where to go?

I presume that people with genuine conscientious objections will recognise that, in those circumstances, the hippocratic oath prevails and that woman has a right to the provision of services to support her life as well. It is very simple. We need to put ourselves in the position of that woman.

[7:00 o'clock]

Incidentally, the very interesting coroner's report in the Savita Halappanavar case goes into great detail in setting out the exact circumstances as they unfolded. The members of last year's committee will remember this. I know the Minister has committed to recognising and acknowledging the rights of people who have conscientious objections.

All of that being said, there must be somebody somewhere who will provide these services, as envisaged and approved by the people when they voted with the heads of the Bill on the horizon. What do we do? Do we say to women who may find themselves in a crisis that we are very sorry, but there is a little problem and we cannot help them? I sincerely hope nobody intends that this will occur. I sincerely hope we do not have a repeat of that kind of situation, which we have had in the past. I sincerely hope there is a general recognition that a woman who has a crisis pregnancy needs to find some solace somewhere and should be guaranteed to get services. Somebody should refer her to a place where she can avail of the services she requires. We must remember that any pre-existing conditions she may have, like high blood pressure or diabetes, will be at the back of her mind. The clock turns very quickly in such circumstances. Within a very short period of time, it may be too late for her, and for everybody else as well.

We all have to examine our consciences in this respect. We have to acknowledge the rights

[P. 264]

of people with a conscientious objection and provide for those rights. We also have to acknowledge the rights of the people of this country who voted in the clear knowledge that certain legislation would be passed. It was not by a hair's breadth or a narrow majority that they approved the referendum proposal. It was a clear decision. It can be presumed that the people who voted knew what they were voting about. I hope we can justify the confidence they expressed in us when they made their decision by making provision to allow for conscientious objection while also making adequate provision to ensure women in these circumstances are not ignored.

Deputy Simon Harris

There are quite a few amendments in this grouping. I want to try to deal with a number of issues. I noted the comments that were made yesterday by Dr. Peter Boylan, who is a former chairman of the Institute of Obstetricians and Gynaecologists and a former master of the National Maternity Hospital. Along with the HSE, I appointed Dr. Boylan to lead the roll-out of these services. As Dr. Boylan pointed out on national radio yesterday, his view is that many doctors are ready and willing to provide this service. I share that view. While all the media attention at the weekend was on the minority of doctors who walked out of a meeting they had sought, the overwhelming majority of doctors stayed in the room, asked questions and worked their way through it.

Deputy Peadar Tóibin

That is not the case.

Deputy Simon Harris

I note that many of the doctors who are now leading the charge on some of the issues referenced by Deputy Tóibín were among those who led the No campaign, and that is fine. It is not a criticism; it is just a fact. They do not want abortion in this country because they do not support it. That is their right as citizens. I will defend forever the right of a doctor or healthcare professional to object conscientiously, but I will not stand over conscientious obstruction. I have spoken about the fundamental difference between the two. It is beyond doubt that every medical professional has the right to object conscientiously.

Deputy Peadar Tóibin

It is a qualified right.

Deputy Simon Harris

I do not think there is anybody in this House who disagrees with that. Are we going to continue to talk about conscientious objection as if we had a referendum on doctors? We had a referendum on women and on women's healthcare. Maybe we should actually think about the woman. Are we going to have a situation in which a woman who has been raped turns up at her doctor's surgery and is shown the door, given the cold shoulder and told "out you go"?

Deputy Peadar Tóibin

That is an aspersion on doctors.

Deputy Simon Harris

Despite the Deputy's best efforts, we have moved very far away from that in Ireland, thankfully. I am very proud of that.

I would like to be very clear in response to the legitimate questions that have been asked by people right across this House, including Deputies Aylward and Brassil. The law on abortion is changing, thankfully. The law on conscientious objection is not changing. Deputy Brassil asked me for clarification on the wording that is being used in relation to the transfer of care, etc. It is the same wording that was used in the Protection of Life During Pregnancy Act 2013. When wording like this is put into legislation, the Medical Council, as the regulator, transposes it into guidelines based on how it interprets it. Doctors are not regulated by me, by the Government or by the Oireachtas, but by the Medical Council. I referred at the committee on many occasions to page 35 of the Guide to Professional Conduct and Ethics for Registered Medical

[P. 265]

Practitioners, which defines what conscientious objection is and what the obligation is. It reads:

You may refuse to provide or to take part in the provision of lawful treatments or forms of care which conflict with your sincerely held ethical or moral values. If you have a conscientious objection to a treatment or form of care, you should inform patients, colleagues and your employer as early as possible. When discussing these issues with patients, you should be sensitive and considerate so as to minimise any distress your decision may cause. You should make sure that patients’ care is not interrupted and their access to care is not impeded. If you hold a conscientious objection to a treatment, you must:

- inform the patient that they have a right to seek treatment from another doctor; and

- give the patient enough information to enable them to transfer to another doctor to get the treatment they want.

If the patient is unable to arrange their own transfer of care [perhaps he or she is unconscious],2 you should make these arrangements on their behalf.

In an emergency, you must make your patient’s care a priority and give necessary treatment.

That is what conscientious objection is. It is not the convoluted thing that some people have tried to make it out to be.

We have gone further by providing for a helpline that will be staffed by healthcare professionals 24 hours a day, seven days a week. Here is another bit of interesting information. Women do not want to be going from doctor to doctor as they try to find someone to help them. As functioning intelligent people, they would like to be able to pick up the phone or go on the Internet and find out where they can legally access legal and safe healthcare services in this country. The 24-7 helpline will provide non-directional information and will signpost in a way that significantly lessens the situations in which doctors will find themselves and, much more importantly, the crisis situations in which women will find themselves.

Two amendments in this group are in my name. As Deputies will be aware, I am defending the right of conscientious objection for doctors, nurses, midwives, student doctors, student nurses and student midwives. Student doctors were already covered because they are registered with their council. I am proposing amendments Nos. 52 and 53 to be absolutely certain that student nurses and student midwives also have a right to conscientious objection.

Deputy Brassil raised some issues with regard to pharmacists. As a pharmacist, he is very well informed on all of these issues. I remind the House that the code of conduct for pharmacists provides that "in instances where they are unable to provide prescribed medicines or pharmacy services to a patient they must take reasonable action to ensure these medicines/services are provided and the patient’s care is not jeopardised". The Pharmaceutical Society of Ireland, which regulates pharmacists, put information about the referendum that was held in May on its website to outline how its statutory code of conduct for pharmacists will work in this regard.

Can we dismiss the idea that I do not interact with GPs? Deputies do not have to take my word for it. Perhaps they will take the word of the clinical director of the Irish College of General Practitioners who debunked that myth on RTÉ's "Morning Ireland". I have met representatives of the college on several occasions to discuss this issue. Deputy Tóibín is right when he says I have not met individual groups of doctors who have different views on these matters.

[P. 266]

Deputy Peadar Tóibin

We are talking about thousands of doctors.

Deputy Simon Harris

I have met representatives of the training college that trains our GPs. I think that is what my responsibility as a Minister is.

I want to make it clear that conscientious objection is a long-established and important principle in this country. I will defend the right of a healthcare professional to object conscientiously and I would expect an overwhelming majority of Members of this House to do likewise. I will also defend to the death the right of a woman to access healthcare in our country. We need to make sure those two rights do not trump each other. Under the system of conscientious objection we are providing for, those who opt out will need to provide information. We are setting up a 24-7 helpline to help them to do that. This is reasonable. There are some people who want to stymie and delay it and prevent it from coming in. They are going to throw the kitchen sink at their efforts to prevent this from happening. Conscientious objection is fully respected. Conscientious obstruction of the democratic will of the people and of healthcare for women will never be tolerated.

Deputy Kate O'Connell

The Minister has quite usefully read the pharmacists' guidelines from the Pharmaceutical Society of Ireland. Like Deputy Brassil, I am a registered pharmacist. I would like to explain the normal procedures for GPs getting medication into their surgeries. It is normally done by means of stock-order dispensing from a pharmacy of the GP's choice. This should not arise, in the sense that the arrangement will be there.

If for some reason a doctor who wants to conscientiously provide for a termination of pregnancy encounters a dispensing chemist who will not do it, there are plenty of others to go to. Therefore, I do not see it arising.

With reference to the hospital pharmacist's role, in practice misoprostol has been used for years in the dilation and curettage process after miscarriage. I understand a licensed drug has come on the market in the past week.

On supply issues, if a company has sought a licence for a drug, it is more than likely that in the interests of the bottom line it will have it on the market. Therefore, I do not see it as a concern. As the Minister said, it is about access to termination of pregnancy, not the denial of a service. It is about enabling doctors to act in the best interests of their patients, while also protecting themselves in the process.

There was some commentary about the Minister not meeting stakeholders. The stakeholders are the women of Ireland, all 52% of us, and the men in our lives. The Minister engaged and showed great leadership on that front. I do not believe the comments about his reputation. It has never been to the fore. If it was the case, it would have been easier for him not to have done this.

Comments were made about the service being GP-led. It came directly from the committee, nowhere else. I speak as one member of the committee. It was done in order that there would be no targeting of abortion clinics, as happens in other jurisdictions. Instead of copying the methods of other jurisdictions, we set out to have an Irish method - a bespoke method - that would be suitable for the year and which would apply the learning from processes in other countries. There is nothing rushed about it. Deputy Fitzgerald who is sitting beside me has reminded me that it has been 35 years. I doubt that she sees it as being rushed. I clarify and confirm what the Minister said. This is a change to the law on termination of pregnancy. There is no change to the law on conscientious objection. Many of the emails which many of us have

[P. 267]

received, some of which appeared to be very reasonable, are designed to obstruct because there is no need for the amendment.

Deputy Brid Smith

I received a well worded tweet from a person who asked when conscientious objection was expanded to mean that only the consciences of the objectors were to be considered in preference to those of the rest of us. It is a very poignant way of putting the argument. As has been pointed out, the question of conscientious objection is dealt with in medical regulations. In including it in the Bill we would just be restating what is already in place. What is being inserted into the Bill is the requirement to refer onwards, but it is not worded in that way. It states, "shall, as soon as may be, make arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination". That could mean referring her to the 24/7 helpline.

It is absolutely essential if we are to give structure, legislation and rights to people following the repeal of the eighth amendment, that all women have access to the choice to terminate a pregnancy. That may mean a woman in an isolated rural village, a woman in a direct provision centre, a woman who does not have good command of the English language or a terrified young woman who has been raped. It could mean anyone. Anybody who paid attention to the deliberations of the Citizens' Assembly and the committee will remember the many hundreds of cases in which a woman or girl may have sought an abortion and the circumstances they faced. I may be wrong, but the kind side of me cannot imagine that there are hundreds of doctors who do not want to provide abortion advice or for referrals, who would turn away women or young girls who are absolutely desperate and not give them information to allow them to access an abortion service through another doctor or the helpline. I find it hard to imagine that there are 600 or 700 cruel professionals who do not give a damn about their main patient, the patient who is alive and kicking. That patient is often working and has problems or a crisis. She may have other children. Most of the time she has other children she has to attend to and also has a job and a life. I cannot imagine that it is the case that when she finds herself in a crisis, she will be told by these 600 or 700 cruel and inhumane doctors to go to Hell, that they do not care about her, that she is one of their two patients, that they care more about the other and that they will not refer her onwards.

I refer to the statement that the Minister would take longer to deal with a Bill on hedge cutting. Give me a break. Was the Deputy comparing women's lives to the cutting of hedging?

Deputy Peadar Tóibin

I am saying it is more important.

Deputy Brid Smith

Is it becoming that ridiculous and inhumane? We need a reality check and to think about what we are saying.

My final comments will be on waiting lists. Waiting lists in the creaking and crumbling health service are being used as an excuse not to provide women with what is rightfully theirs and what they deserve. It is what is rightfully theirs according to the outcome of the referendum. I will make a plea to the Minister about the plight of doctors. There are some areas, particularly in rural Ireland and some working class areas in the cities of Dublin and Cork, where the average number of public patients per doctor is more than 1,200. It is too many for a decent health service to function. If we add the women and girls who may try to access abortion services, we are asking a lot of doctors. As a result of the FEMPI legislation, during the years of austerity their payments were cut by up to 25%, although there are disputes about how much. This needs to be taken into consideration. Austerity cuts have hit GP services and made some

[P. 268]

GPs bitter about the way they have been treated. This may add to the numbers who say they will not buy into the scheme because they have too many patients. They are stuck in poor working class areas of Dublin or rural areas of County Laois or County Offaly and nobody notices what they have to go through. It illustrates a danger in the 72-hour waiting clause and a return visit being absolutely necessary in law. In addition to the strain on GP services, we are adding in the requirement to make a second visit within three days. It needs to be extended to include midwives and nurses being able to administer the abortion pill, which is a medical abortion rather than a surgical abortion.

There are lots of flaws in the Bill. If there are flaws in it, it is because it is not universal enough to deliver the health service women need. I recognise the existence of conscientious objection in medicine, but, as the women who tweeted me said, conscientious objection does not extend to the objectors being able to have their way over the consciences of the vast majority. The vast majority have said in no uncertain terms what their consciences tells them. They tell them whether they would choose to access abortion services. They tell them not to stand in the way of every woman and girl being able to make that decision for herself. Therefore, the services we deliver should not stand in her way.

Deputy Declan Breathnach

I express my abhorrence of the vilification, disrespect, disparaging and name-calling during this debate in the House. When I came into the Chamber, I had freedom of conscience in how I voted on whether a referendum should be held. In that vote one third of those who voted, 32 out of 110, were not in favour of holding the referendum. When it was held, one third of the people voted in a different way and were in the minority. These figures suggest that at least one third of those involved the medical profession have a conscientious objection. If we base it on the numbers in the vote in the House and the referendum, we can expect a similar figure in the medical profession.

The Minister went some way towards clarifying certain points in his earlier intervention by providing confirmation and guarantees. However, I am keen to push him further on these points. He referred to the code of practice of practitioners. I imagine there are numerous codes of practice in other areas of the health profession. The Minister has gone some way in this regard already, but will he reassure me that conscientious objection will apply to all junior, trainee and student doctors as well as student nurses and pharmacists? This point has been alluded to already. I refer in particular to rostering, especially in acute settings. Some staff might be rostered on shifts. Will they be able to conscientiously object? Will provision be made for them as well?

On the issue of the call helpline, our experience with the 24-hour service provided in the health services in recent years has been good. People can contact this service anytime. I know it might be a little nitpicky on my part but I am seeking clarification from the Minister on whether the helpline will be completely separate from the call-out services currently available in the system.

We all have to respect that there may be people who have serious issues. We have serious people on both sides of the divide and I imagine it is no different in the medical profession. No one should be embarrassed in this situation. Many people, especially nurses and doctors, have written to me since the result of the referendum seeking to ensure that conscientious objection would be included. I am satisfied that it is, but I am unsure about circumstances in which people, for reasons of religion or otherwise, do not necessarily want to deal with this. It is important that the 24-7 call line would be almost a first port of call for a person who might

[P. 269]

feel embarrassed in the knowledge that her general practitioner is a very religious or concerned person who would not want the embarrassment of having to refuse. The helpline may not necessarily be a first port of call but it could be a special port of call if a woman was in doubt about her GP. I am seeking clarification on that point.

Deputy Eugene Murphy

This is probably one of the areas on which I have received most representations. I remind Deputies that these representations have been made by eminent doctors, nurses and midwives. It is not simply a question of me asking a "What if?" question and setting out what I believe. I know many of these people personally. They are eminent people who have looked after people very well for many years.

The Minister has explained a good deal to us about this amendment but we should explore the implications for doctors, nurses and all other healthcare professionals if their right of conscience is not respected in law. Every person has a right to freedom of conscience. No person can be compelled to perform or facilitate an action that he or she believes to be morally wrong. The right to freedom of conscience acknowledges that we are responsible for our free actions and the associated consequences inasmuch as we can foresee them. It acknowledges that we cannot disclaim responsibility for our free actions simply because we are obeying the will of another person. Freedom of conscience is respected in a democratic society. There is the right to refuse to perform or participate in an action with which the person in question does not agree. We must accept that many doctors have profoundly held convictions about the right to life, and we must acknowledge that. It goes very much against their conscience to be involved in the practice of abortion.

It is disingenuous to imply that because a doctor, midwife or nurse does not wish to participate in abortion, he or she is a blocker or some type of obstructer. The Minister did not imply as much but maybe others have done so. It is a matter of conscience for the person.

Abortion information should be in the public domain and perhaps not restricted to medical personnel. Deputy Breathnach spoke about information helplines being available and people being aware of them. As healthcare professionals, doctors, nurses and others, as far as I can establish, wish to provide compassionate care for all patients. Often, they try to give positive alternatives to abortion. We cannot claim to be a pluralist society if professionals believe they are being coerced into facilitating something they do not believe in.

Has the Minister considered the implications for the health service if a high number of GPs and nurses believe they are unable to practise and leave the profession? That suggestion has been made clear to me. I am not being alarmist. I have spoken to a husband and wife GP team who are abroad at the moment. They were talking about coming back to the west of Ireland in the coming months to practise there and raise their young family. Given elements of this particular legislation, however, they are having second thoughts.

What will the Minister do for patients who are left behind without a GP? That is an important question as well. We must understand the situation for many doctors. We must have freedom of conscience. It is a fundamental part of living in a democratic society. Routine general practice is not an appropriate place for this service if it could be easily provided by family planning groups instead. Doctors should be afforded the choice to opt in or opt out. That approach works well in New Zealand.

I hope the Minister can clarify some of those points for me and take on board the points I

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have made. By the way, many of these points have been made to me by female professionals. Fewer representations were made by male professionals.

Deputy Danny Healy-Rae

I too am glad to get the chance to speak on this important matter. I have met midwives and nurses. Doctors have spoken to me, including GPs, who are highly concerned about this. It is clear that the Minister is rushing through this Bill with no pre-legislative scrutiny. We have been criticised in the House for talking about all the various amendments, including some of the amendments we had earlier. I imagine we will get criticised for talking about this amendment as well.

I will explain what I see wrong with it. The Minister is saying that the medical profession will have to refer on people. That is where the bother lies. If he was so sure that GPs could provide the service and that there were enough GPs, midwives, nurses and other healthcare officials signed up to provide the abortion service, there would be no need to force or bully people into doing something they conscientiously object to doing.

I met some midwives in Buswells Hotel who came in to meet us. They were crying. There were two of them together. I picked a particular day. They said they loved their job.

All of a sudden they are being forced to turn around because the Minister has not taken the time to organise teams throughout the country that will carry out abortions without being forced to refer people onwards. That is wrong.

Deputy Simon Harris

That is not true.

Deputy Danny Healy-Rae

It is right and the Minister should not shake his head because what I am telling him is correct. He should have taken time to talk to doctors. A week ago he had not spoken to many of them. I do not know how many to whom he has spoken since. He has left it very late to start a service at the beginning of January. Your Taoiseach was trying to blame healthcare officials-----

Deputy Simon Harris

The Deputy is referring to the Taoiseach.

Deputy Danny Healy-Rae

-----and trying to deny them their right to have time off during the Christmas period. Christmas is coming and people generally take a number of days off. They are entitled to do so after working for the whole year. It minimises the amount of time available in which to create a functioning service by 1 January. The Minister is in a bind because people have not signed up to this proposal. He has not had enough conversations with them. That is the truth and the Minister should not shake his head. We have met doctors and nurses. Two nurses told me that they were really worried about refusing to participate. They will go to work on a Wednesday morning. There might be a number of normal births and perhaps two or three terminations of pregnancy. The nurses are given their tasks for the day-----

Deputy Simon Harris

That is not something that happens in the health service.

Deputy Danny Healy-Rae

-----and if they refuse to take part in terminations of pregnancy, they believe they will be treated like the two nurses in Scotland who were forced to leave their jobs because they would not do what they were being forced to do. That is how serious the matter is for them. They were brought up and taught how to protect life, save it and bring it into the world and all of a sudden they are being made to do what they do not have a mind to do.

The current proposal has already been opposed by over 600 GPs, many of whom have indi-

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cated that they will not co-operate with a duty to refer for an abortion. The Minister has created a completely unnecessary showdown with doctors on a subsection of the Bill that is, in reality, not practical. As a matter of pragmatism, the country cannot afford to lose a large number of GPs, midwives, nurses and other healthcare officials. As it is, we do not have enough of them and we do not want to lose any more. The health service is a disaster in County Kerry. It has emerged today that people have died because of the neglect of the HSE which has failed to provide a proper service in County Kerry, in particular at Kerry General Hospital.

The Minister is forcing people to press ahead and requiring doctors to make arrangements for women to access abortion services against their deeply held beliefs. A legal challenge is inevitable. It is very obvious that there will be a challenge if this matter is not corrected in the Bill, which will delay the legislation further. It is very possible that it will happen. I am again asking the Minister to set up a team, if he believes he can, to carry out the service without bullying or forcing doctors, midwives, nurses and other healthcare officials to do something they were never trained to do in the first place, that they do not want to do and that they will never will do.

Deputy Peter Fitzpatrick

The Government seems to maintain that the freedom of conscience provision in the Bill is operating. That is patently false, as evidenced by the simple fact that huge numbers of doctors have publicly said there are not enough of them. This also applies to pharmacists, midwives, nurses, carers and all other healthcare professionals. The Minister should be aware of what happened at the EGM of the Irish College of General Practitioners at the weekend. A large number of GPs walked out at the meeting because of the attitude of those conducting it. There are photographs and videos of the event that show an almost empty room while the issues were being discussed because a majority of GPs had left in protest. The Government must listen to GPs on this issue. There are huge concerns about how it is being dealt with.

For decades medical professions have operated a two-patient model. In treating a pregnant woman a GP has two patients - the mother and her baby. Under the proposed legislation, GPs will be forced to refer both patients to another GP in order that one of them - the baby - will have his or her life ended. Surely it is not difficult to see why so many GPs have a problem with this. How can be it a surprise to the Minister or anyone else that doctors might object to having to refer a patient to another doctor to have his or her life ended?

There is a very disturbing truth at the heart of this issue. The Minister and other pro-abortion campaigners will not admit that they think doctors should have the right in the first place to object to involvement in abortions. Pro-abortion campaigners view abortion as good, a right to which women are entitled and think any doctor who cannot see this is clearly in the wrong and should be brought to heel. That is the attitude that has pervaded the abortion debate in many countries in recent decades. Legal actions have been mounted against the rights of medical professionals to opt out of abortion services. In the United States there have been concerted efforts to dump such doctors out of the profession. This has resulted in a huge drop-off in the level of interest among young people who are thinking about entering the medical profession owing to their fears that they will be pressurised into taking part in an abortion. Are we going to see a similar pattern here? Thankfully, the tide may be turning on this issue internationally. Recent decisions of the Supreme Court in the United Kingdom and Norway were strong rulings in favour of the right of healthcare professionals to refuse to participate in abortions.

The very notion that GPs should be forced to provide abortion services in their practices

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is reprehensible. Why can we not operate an opt-in system, as is the case in New Zealand? Under this method, the approximately 25% of GPs who wish to provide a service could do so. It would surely give enough coverage in each county for the service to be carried out. The National Association of General Practitioners has already called for the introduction of an opt-in system and has stated the provision of abortion services should not become a standard part of GP practice. It seems that the Minister and the Government want to ignore both positions. An opt-in system for GPs is operated in other areas. For example, GPs can choose to opt in or out of the medical card scheme. Some 1.6 million people have a medical card, yet GP practices can opt in or out of the service. The Government has estimated that 12,000 abortions will be performed per year, yet all GPs are being forced to either provide a service or make a referral. Allowing GPs to opt out of the medical card scheme has not led to its collapse. Why is the Government persisting with the notion that abortion services will be untenable unless all GPs provide them? What is the reason for the difference in treatment?

It seems that the Government is trying to prove a point. The Minister and the Government view the introduction of abortion services as being so important and vital and such a great advantage in the provision of healthcare that GPs must be brought to heel from day one. We should provide for the introduction of an opt-out system in order that the public at large would know which GP will and will not provide a service. This would prevent the need for a fundamental attack on a doctor's freedom of conscience by forcing him or her to refer. The Oireachtas Joint Committee on Health is frightened by this matter because it exposes how unprepared the health system is for the introduction of abortion services on the scale envisaged. Representatives of the medical profession were in unanimous agreement that the health system was totally unprepared for the introduction of abortion services in January.

Medical facilities are lacking in training, resources, equipment and so on. We read in The Irish Times this morning that regulations governing this area will not be ready for January's deadline either. Why on earth is this legislation being rushed through in these circumstances? Would we rush in any other medical treatment or programme without the proper personnel, equipment and resources being in place? Let us say, for argument's sake, that a new screening programme for a form of cancer was to be introduced. Would we do this without having adequate personnel, equipment, training and monitoring in place? The very notion is ridiculous. To operate health policy in this way would amount to gross negligence and would expose women to danger. In rolling out abortion services in such a hurry, that is exactly what we are doing. I strongly support the amendment. The Oireachtas needs to trust the judgment of doctors in all cases and must not compel them to act against their conscience.

Deputy Éamon Ó Cuív

We are discussing several amendments. I welcome the Minister's amendment extending the right to conscience to the candidate division of the registrar, in other words, to students. That is a small step in the right direction. I listened with great care to my colleague, Deputy Brassil. Having listened to the Minister's explanation, I do not think he dealt with the issues raised by Deputy Brassil.

Conscientious objection is the nub of the issue. Over my lifetime, I have known many medical people - nurses, midwives and doctors - who had a total commitment to the protection of human life. In the case of a pregnancy, they have always seen two human lives to be protected as far as practicable. I do not want to be provocative, but I have to take issue with what Deputy Durkan said on a number of grounds. Any medical intervention required to save the life of the mother was traditionally carried out by good medical practitioners. I have known people who were totally committed to the concept of two patients but would never have hesitated to

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intervene if the mother' life was at risk. It is interesting to ask whether that constitutes termination within the terms of this Bill. The purpose of such an intervention is to save the life of the mother. The definition of a termination in the Bill is as follows: "“termination of pregnancy”, in relation to a pregnant woman, means a medical procedure which is intended to end the life of a foetus". As such, the purpose in those cases is not to save the life of the mother.

Deputy Bernard J. Durkin

It is.

Deputy Éamon Ó Cuív

It is to end the life of the foetus. The Bill is direct in this regard.

Deputy Peadar Tóibin

Deputy Durkan is wrong.

Deputy Éamon Ó Cuív

It is on lines 12 and 13 of page 6. That was what I always understood it to be. It was traditionally the practice of good medicine in Ireland, and anyone who says anything to the contrary does not know what really good medical practice was about. This goes to the core of the dilemma facing medical practitioners, midwives, nurses and doctors. Are there two patients or one? As I have said from the very beginning, there are people here who believe that there is only one patient and the other human life does not count. Some people believe it counts in some way but not really. One of the Deputies here this afternoon - I admire her honest and her integrity on this - referred to the "main patient". Others believe that in human existence that is a very slippery slope to start down. When one starts differentiating between people and talking about main patients and not-so-main patients we know where that kind of thinking leads.

The Bill provides that a doctor must refer a case on. Many medical people, particularly the doctors who are tasked with referring on, know from medical science that there are two human beings. Referring on the so-called care of one of these human beings is to refer the other to certain destruction. If one does not believe there are two human beings, that is not a dilemma. If one believes that one totally has control over the right of the other and that the other has no right - in other words, the unborn has no right - that poses no problem. Most of these cases concern people who do not have any medical conditions that require a treatment of that kind, because the whole Bill provides for abortion for no reason. We know the vast majority of abortions are carried out-----

Deputy Bernard J. Durkin

On a point of order, there is no such thing as an abortion for no reason and it is not provided for in the legislation. In fact, there are very strict reasons.

Deputy Ruth Coppinger

Why are we rerunning the referendum?

Deputy Bernard J. Durkin

I agree.

Deputy Peadar Tóibin

Let us dispense with the Parliament.

Acting Chairman (Deputy John Lahart)

Why are Deputies not speaking through the Chair?

Deputy Ruth Coppinger

Rather than talking about the legislation, we are rerunning the referendum.

Deputy Bobby Aylward

Everyone has a right to speak.

Deputy Mary Butler

Everybody is entitled to speak.

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Acting Chairman (Deputy John Lahart)

This is a sensitive issue for both sides. Everybody has an opportunity to speak through the Chair. If Deputy Ó Cuív wants to resume, I will add 30 seconds to his time.

Deputy Éamon Ó Cuív

The interruptions lasted for closer to a minute. Doctors do not want to be forced to act against their conscience. This is the only issue here. I accept the result of the referendum. I have always said so. I also accepted the result of the referendum in 1983, which some people boast about not accepting, but that is as it may be. To force medical people to act against the interest of one of their patients, as they see it, is in itself an unethical provision. Many fine people who went into medicine in the past, among them some of the most caring people I have known, will find this a very chilling medical discipline in which to be involved.

Deputy Mary Butler

I will also speak to the amendments, as I have done all week. Section 24(3) states: "A person who has a conscientious objection referred to in subsection (1) shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary...". Deputy Brassil raised the issue of what exactly the transfer of care is. Deputy Donnelly raised it several times on Committee Stage and I am still not satisfied with the answer. This is the nub of the issue. Does the transfer of care mean the handing over of a telephone number by a receptionist or does it mean a doctor handing over the files of his patient? What exactly is transfer of care? I am not satisfied with the answer I have been given so far.

I have spoken in person to many doctors, nurses and midwives who have grave concerns. As Deputy Ó Cuív put it, when they look at the patient they see two patients. Not everyone does but that is the reality. The reason they find it very difficult to refer this person on is that they know another life will be ended.

I am aware that the people have spoken. They spoke strongly in large numbers. The eighth amendment no longer exists within the Constitution and abortion is a reality in this country. At the same time, there are serious issues in the health services with recruitment and retention, and if these medical practitioners are not listened to, the situation will get worse.

Recently I met a midwife who told me that she will no longer carry on as a midwife in the new year but she has asked to be transferred to the care of the elderly because she has a serious conscientious objection. She is pro-life. She feels that, through no one's fault, she may find herself in a position one day where she may be asked to participate in an abortion or that she may be in a room where a baby is being born and another baby may be being aborted in the room next door, and she just cannot put herself in that situation. She is a nurse of 14 years but she has decided, because she cannot put herself in that situation, to opt for the care of the elderly. Others will follow her.

I welcome the clarity in relation to the student doctors, student nurses and student midwives. It was an important amendment I had worked on with Deputy Donnelly.

The Minister stated that he believes he has been in consultation with the GPs, but all through this referendum, I believe, from day one, there was no consultation with the GPs. That is regrettable. Their voices were not listened to. It does not matter whether they heard it first on Committee Stage, on the radio or in the media. At the end of the day, they should have heard it first from the Minister or from the Department of Health. They should have been consulted.

The right to freedom of conscience is a fundamental right and it is protected by the Consti-

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tution and the European Convention on Human Rights. No person should be required by force of law to take an innocent life. I believe that these medical practitioners, these nurses, doctors and midwives, have genuine concerns. It is very important that they are listened to. As I stated last week when speaking about older people, we face a winter of discontent in the health service and we certainly do not want to lose any more health workers. It is very important that their voices are heard in this.

Deputy Louise O'Reilly

Last night, in Limerick, a group of doctors who want to provide the service - perhaps they are conscientious providers rather than conscientious objectors - and want to provide healthcare for women were hounded out of the original venue for their training. The good news is that they found a place. That emphasised the need for us to include exclusion zones, if not as part of this legislation then as part of legislation that must follow, because there are people, not necessarily Members in this Chamber, who cannot understand or accept the result of the referendum. They are just not quite there yet. We need to provide protections for those doctors and healthcare professionals who wish to provide the healthcare for women for which we voted.

With regard to a comparison that was made between legislating for hedge cutting and legislating for women's healthcare, I do not think any offence was meant but it was an unfortunate turn of phrase. It is not true to say that this debate is being rushed. We have been having this debate for 35 years. All of my adult life up until recently, I was on the losing side of that debate and I had simply to suck it up and deal with it, or regroup and keep campaigning. No one could say that this is rushed or that there are arguments that have yet to be rehearsed. We have made all of those arguments.

I have been contacted, just as other Deputies have been, by doctors and healthcare professionals who may be seen on social media using the hashtag #wewillprovide. What they say, to women, legislators and their colleagues, is that a significant majority of doctors and healthcare professionals are willing to provide terminations and access to terminations and abortion healthcare for women, which is a good and positive development. One of them contacted me. I will not use his name but he asked me to state that saying nothing does not meet professional standards, and that while doctors are perfectly entitled to hold a conscientious objection for religious, moral or other reasons, they also have a duty of care. That duty of care is to ensure that those sitting in front of him get access to the healthcare that they need. In that regard, conscientious objection provides for them not to be the provider of that service but they must refer on. Anything less - this comes from a doctor, not me - will fall below what is required by professional standards.

I have heard that no GP will be compelled to provide this service. We need to make clear that no person will be compelled to provide that service. There is already a facility for conscientious objection in place. I do not know the purpose of the amendment because the facility to object conscientiously already exists.

I do not believe that there is a significant majority out there who do not want to provide this service. The majority of doctors and healthcare professionals want to provide it. In any event, nobody will be compelled to provide it. We need to ensure that where there is a conscientious objection, that is respected but that the person who requires healthcare can access that healthcare. As it was said to me, saying nothing does not meet professional standards.

Deputy Ruth Coppinger

I will start off be alluding to the meeting of pro-choice doctors

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that took place in Limerick last night that was harassed and hounded and had to change venue. There is a boycott campaign being waged against the Savoy Hotel. I just want to put on the Dáil record that is not the hotel where the meeting took place, if the anti-choice people could stop boycotting it. The reason I mention those tactics is that if one listened to some of the recent speakers, one would think doctors were being forced and coerced into carrying out abortion whereas, in fact, under current medical guidelines they can conscientiously object, and that is not being changed.

We are hearing a great deal about the rights and freedom of conscience of medics, but I want to put the other side of it, that is, the impact of this conscientious objection provision on women and those who are pregnant. I weighed up whether I would completely oppose conscientious objection being allowed at all because it is not allowed in public health in Sweden, Finland and Iceland. If somebody does not want to provide abortion, he or she can go into the private sector and work in whatever sphere he or she likes. There is a reason for that. The Deputies can all be clear: this applies only to women's health and reproductive rights and not to any other area of medicine. We do not hear Deputies railing about the rights of doctors to object conscientiously to anything relating to male health.

8:00 o'clock

It applies only to women's reproductive rights. Conscientious objection is not allowed in countries which have a long-established high threshold for women's rights because they will not allow those rights to be subordinate to religious beliefs, which is what is being proposed. Although we will be able to cope with conscientious objection in Ireland because there will be enough doctors to provide services, I ask Members to spare a thought for women in countries such as Mexico, which introduced abortion in the first trimester but has a shortage of doctors because it is a poor country with a low ratio of doctors to the general population. The National Action Party, a conservative right-wing political party there, began a campaign to pressurise doctors to opt out. It stated that abortion might be guaranteed in law but it would ensure it does not happen in practice. A similar situation pertains in Italy. The stigmatisation of abortion in a manner similar to that which we have heard from some in the Chamber over the past few hours forces doctors to opt out and conscientiously object. A campaign by right-wing forces in Italy has led to it being very difficult for women to access abortion across swathes of the country, resulting in some women travelling abroad for a termination. I would like to hear a little more about the vote we mobilised in May which was about women's individual right of access to abortion and right to choose, whether some Members like it or not.

There has been reference to a showdown with doctors. A similar situation arose on the legalisation of contraception. It was well known that a doctor in general practice for a long time near where I lived in Blanchardstown would not provide contraception to women who needed it. The idea that doctors will suddenly be forced to provide services does not stand up.

It is important to send the message that there will be enough doctors to provide services. What one hears in this Chamber is rarely representative of the views of the majority of society, but it certainly has not been for the past few hours. There will be enough doctors to provide the services. A survey of doctors carried out in the summer of 2012 was presented to the Joint Committee on the Eighth Amendment of the Constitution. Some 76% of GPs surveyed were willing to provide terminations in all or most circumstances. One would imagine that those attitudes have moved on since the summer of 2012, which was pre-Savita Halappanavar and the repeal movement.

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The Minister is not currently present. Women in Ireland are finding out that they are pregnant. They may be in their bedroom or bathroom and faced with a crisis pregnancy. Some Members may not like it if such people choose to have an abortion but the people voted to change the law and allow them to make that decision. It is imperative that they have access to such services in January as was the impression they were given. We should prevent any delay in that regard. The Minister must ensure that the necessary training takes place such that doctors feel sufficiently trained to provide these services, that ultrasound facilities are available where required and that the 24 hour phone line is in place.

Deputy Fitzpatrick asked why we cannot ask doctors to opt in. The country did not vote for that. The majority of the people did not vote to stigmatise abortion as strange and outside normal healthcare. The discussion very clearly revolved around healthcare as a right of women and for that reason we must ensure that we do not have an opt-in policy. Can one imagine, given the harassment that has already been experienced in hospitals, what would happen to doctors who opted in? They would be absolutely hounded by some of those who have spoken tonight and it would be quite dangerous for them to opt in. If doctors wish to opt out, that is fine and they can do so, but it is very important that we do not have a list of doctors who opt in as an exception.

Debate adjourned and resumed
Deputy Billy Kelleher

This issue has been discussed in great detail. Many people would

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have considered its discussion in advance of the referendum disingenuous. Until the Irish people adjudicated on the eighth amendment it would have been very difficult for and presumptuous of this House to discuss it. Of course, the decision having been made, it is now up to Members to put forward their views on the interpretation of that decision. In my view, the interpretation is very clear. The proposed detail in heads of the Bill was available to the people and they voted emphatically to support the proposals and the promised services. Those services must now be made available to the people.

Reference has been made to doctors not having been consulted on conscientious objection. The majority of those who gave evidence before the committee on the eighth amendment were doctors or experts in women's healthcare. Similarly, the majority of those who advocated for change to the eighth amendment and to make abortion services available in this country were doctors and representatives of the governing bodies of the various medical disciplines such as the Institute of Obstetricians and Gynaecologists, the Irish College of General Practitioners and many others. I accept that within those bodies there are people with differing views.

Conscientious objection is enshrined in the legislation as proposed. However, its interpretation in Medical Council guidelines is critically important. For us to legislate beyond that would be very dangerous. We would run the risk of being too prescriptive in healthcare. Parliament passes laws and the Medical Council interprets them and puts guidelines in place for its members.

In much of this debate, we seem to have forgotten the patient, the woman.

Deputy Simon Harris

Hear, hear.

Deputy Billy Kelleher

The reason conscientious objection is very important and must not be abused is that women may find themselves in very vulnerable positions and unable to access the healthcare they need. If a doctor fails to refer a woman on, it could leave her in a very vulnerable position. Not every woman has an ordered life. The lives of some are very chaotic, with some women enduring abuse and violence. Some women may not have English as their first language and may feel very isolated in this country. There can be many reasons for seeking a termination. It would be fundamentally wrong not to obligate a doctor to, at least, refer on a woman seeking a termination. The idea that one would just give such women a telephone number and close the door is unacceptable.

Deputy Bernard J. Durkin

Hear, hear.

Deputy Billy Kelleher

Doctors with a conscientious objection should be obliged to refer women to another doctor. To legislate for conscientious objection in the manner proposed in the amendment such that a medical practitioner could decline to assist a woman who presents is against the basic principles of good medical ethics in the view of the professionals who made the case for this legislation at the eighth amendment committee and during the debate across the country before the referendum. I accept that a cohort of medical professionals such as doctors, midwives, nurses, pharmacists and other healthcare providers will conscientiously object.

I have to be honest, however. I have had interactions with them as well. They are people who are conscientiously obstructing the potential roll-out of this service. There is a fundamental difference between the two positions. People are entitled to object conscientiously and not partake but obstructing the rolling out of the services in a way that is against the wishes of the Irish people and, more important, threatening the health of Irish women is anathema to basic,

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genuine, ethical medical guidelines.

For all these reasons, I do not want us to be too prescriptive in this area. I want the Medical Council, which is charged with regulating doctors and oversees all the registration and the interpretation of medical guidelines, to put what I suggest into effect. It has said at hearings of the health committee and at other fora that it will continually review the guidelines in respect of conscientious objection. As far as I can ascertain, however, conscientious objection has been a fundamental principle in medical guidelines for a long time. I hope it will continue to be. We certainly cannot allow conscientious obstruction, however. I believe some people are now involved in it as opposed to promoting the fact that they are entitled to a conscientious objection.

Let me return to the practicalities. For 35 years, women have had to go abroad for a termination, and their lives were put at risk because of that journey. That is a fact that was presented to the committee on the eighth amendment. Women's lives and health were being put at risk by their having to travel abroad. Our concern was not great, or our conscience was not exactly scratched, when that was happening for many years. At this stage, as we wind down the debate towards the end of our consideration of the legislation, irrespective of whether it finishes tonight, we certainly need to focus on the fact that this legislation is about healthcare for women. Doctors, nurses and others are obligated to comply with the law and medical guidelines. The medical guidelines do enough to ensure conscientious objection is protected and that, importantly, women's lives and health are to the fore in any guidelines that are reviewed or updated from time to time.

Deputy Margaret Murphy O'Mahony

One of the main factors contributing to the success of the Yes campaign in the latest referendum was the introduction of the word "choice". I refer in particular to young girls saying, "My body, my choice." I have no intention of rehashing the whole referendum argument but wish to make a quick point about the word "choice". The word swung the whole debate in favour of a "Yes" vote. Our doctors, nurses and pharmacists are now asking for choice — the choice not to be forced or not to be made feel guilty for not getting involved in something they fundamentally believe to be wrong. I ask the Minister to listen to this point and take it on board. He should give those concerned their choice. Some doctors, nurses and pharmacists do not want to get involved in this in any way, and they should have a choice in this.

Deputy John Curran

I shall confine my comments directly to the amendments. I am conscious that Report Stage is not a rehashing of the referendum debate or Second Stage speeches. It would be remiss of me, however, not to contribute because I, like everybody else in this House, have heard significant numbers of medical professionals, including doctors, nurses and trainee nurses and doctors, raise concerns about this matter. The issue of conscientious objection is not new; it is one that the Minister indicated quite clearly from an early stage. It was in the heads of the Bill and is referred to in section 24. The real question is whether the Bill delivers what it sets out to do.

I was not a member of the committee on the eighth amendment, nor am I a member of the health committee. In my party, much of the information for guidance and discussion comes from our health spokesperson, Deputy Donnelly, who liaised directly with the Minister on what conscientious objection would mean. It is fair to say the Minister fully subscribes to the concept of conscientious objection, and that is why the section is in the Bill. I do not doubt that in any sense whatsoever.

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The Minister referred to this matter on a number of occasions. He talked about the 24-7 helpline, the referral line, and to general practitioners being able to opt in and out. I listened to a number of Members speaking tonight on this very issue. They said specifically there will be a referral line and that this is how one will deal with conscientious objection. Deputies O'Reilly and Kelleher referred to the same thing. The key point, however, concerns subsection 24(3), which was referred to earlier. It states: "A person who has a conscientious objection referred to in subsection (1) shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination of pregnancy concerned." That is somewhat different from what the Minister is talking about. He is giving an interpretation of what that might mean. My concern is that when the Minister and I pass through here and someone reads this law in time to come, he or she may not have the same interpretation and understanding as the Minister. Will that individual understand that the transfer of care involves the telephone line or another mechanism? I am concerned that when we pass this Bill tonight, the legislation as drafted and presented will mean something different.

I am aware that there are a number of amendments tabled tonight. Since I do not believe they will be carried, my question for the Minister is very specific. He probably cannot answer it tonight and I do not want him to. I want him to reflect on it. I want him to examine subsection 24(3) and become satisfied, with the draftspeople and Attorney General, that it delivers the types of services the Minister referred to without the placing of any additional demands or obligations on medical professionals who have decided they do not want to provide the services. This is important. We will vote on amendments tonight and the Minister knows the probable outcome but I am genuinely concerned that the subsection might not deliver in the way the Minister has interpreted it. The legislation should be drafted in such a manner that it does not depend on my interpretation or that of the Minister. It should be quite clear but I do not believe the subsection is clear.

I share some of the concerns of those in the medical profession, including junior doctors and trainee nurses, who have made up their minds. I have not questioned why they have a conscientious objection. That is their personal concern. My specific concern is that, as we vote on amendments tonight — the Minister knows the outcome — subsection 24(3) will remain. When the Minister brings the legislation to the Seanad, will he satisfy himself, through the Office of the Attorney General, that it will do as he has said it will do without the placing of any additional responsibilities on those who might be conscientious objectors?

Deputy Mattie McGrath

Forcing doctors or other healthcare professionals who have a conscientious objection to arrange for an abortion to be performed is not respecting freedom of conscience. It makes them party to taking the baby's life. The referral obligation forces general practitioners, in violation of their sincerely held convictions, to be involved in a process that destroys that life. Under the Bill in its current form, doctors would not only be entitled, but also obliged, to act in violation of the most fundamental principle of medicine, the obligation to do no harm. They would be penalised for respecting life and exercising their constitutional right to freedom of conscience.

The current proposal has already been opposed by over 600 general practitioners. Many of them have indicated they will not co-operate with a duty to refer for abortion. Indeed, the Irish College of General Practitioners carried out a survey that suggests 25% of general practitioners will not refer. That amounts to between 700 and 800 general practitioners approximately. Therefore, the Minister is heading down a cul-de-sac. He has created a completely unnecessary

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showdown with doctors over a subsection of a Bill that is, in reality, superfluous. Given the way he treats them, I am aware he does not have great respect for them anyway.

Even as a matter of pragmatism, the country cannot afford to lose a large number of GPs because there are simply not enough of them practising here as it is. If the Minister lived in rural Ireland, he would know this and he should know it given that he represents Wicklow. If he presses ahead with requiring doctors to "make arrangements" for women to access abortion against their deeply held beliefs, a legal challenge seems inevitable as a result of an obvious and easily corrected flaw.

New Zealand law allows doctors with a conscientious objection to abortion not to refer. In US federal law, the Public Health Service Act and the Weldon amendment prohibit the funding of discrimination by public authorities against any "health care entity", which term includes doctors and medical trainees, on the basis that the entity refuses to provide referrals or make arrangements for abortions. We can quote international law when it suits us. In Britain there is no obligation to "make arrangements" to help women avail of an abortion either, and the absence of such an obligation has clearly not impeded access to abortion services there.

The Minister has suggested that the referral obligation is in line with paragraph 49 of the 2016 edition of the Medical Council's Guide to Professional Conduct and Ethics for Registered Medical Practitioners. This is simply wrong. Paragraph 49 states that doctors "may refuse to provide or to take part in the provision of lawful treatments or forms of care which conflict with [their] sincerely held ethical or moral values". The obligation on the doctor in these circumstances is first, to inform the patient that there are options for treatment elsewhere and, second, to give the patient information to allow him or her to transfer himself or herself to another doctor to obtain the treatment. The doctor is only obliged to assist with the transfer where the patient is unable to transfer himself or herself. It is an entirely new departure in Irish law to require someone who objects to the ending of a human life to ensure that that life is ultimately ended by someone with no such objection.

The Government has decided to introduce an opt-in system for the provision of abortion services. There is no basis for mandatory referrals because direct access will be provided. The Minister's scheme will enable women who want an abortion to identify healthcare workers who will provide one, and prospective patients will be able to self-refer. This is quite obvious. There is no rational basis for the argument that respecting conscience rights will prevent access to abortion in Ireland. This amendment would align our law on this point with that of other countries, such as those to which I have already referred.

Amárach Research polling in the wake of the referendum showed that just over 50% of adults, excluding "don't knows", disagree with a referral obligation.

A group of pharmacists recently called on the Minister to specifically recognise the right to freedom of conscience for pharmacists in the practice of their profession in the health Bill before the House. A recent PharmaBuddy poll of pharmacists registered in Ireland showed that 60% of respondents supported the extension of freedom of conscience protection to the pharmacy sector. The Minister knows this better than I do. As a group of healthcare professionals, pharmacists are involved in every aspect of the manufacture and supply of medicines and in the counselling of patients. Pharmacists will therefore play a critical role in the implementation of any future abortion policy. Despite requests from the pharmacists' representative bodies, namely, the Irish Pharmacy Union, IPU, and the Hospital Pharmacists Association of Ireland, HPAI, there has been no engagement whatsoever on the part of the Minister-----

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Deputy Simon Harris

That is not true.

Deputy Mattie McGrath

-----on this fundamental change to healthcare ethics and practice. He has displayed a blatant disregard for the rights of dedicated healthcare workers. He will meet any group from the other side that comes up tonight and wants to meet him, but he refuses to meet the professional bodies of our doctors, pharmacists or nurses or anyone else. Such contempt for our healthcare profession is appalling. He listed the groups he has met. He would bring any group from the other side in to meet him so long as there were two or three of them. Such bias is shocking. A spokesperson for the group of pharmacists, Dr. Orla Nolan, a Dublin pharmacist, stated:

Freedom of Conscience is a widely recognised human right. However, there is no explicit acknowledgement in the draft legislation of this right as it pertains to Pharmacists. The legislation denies Pharmacists their right to Freedom of Conscience and compels them to produce, distribute and dispense drugs that they know will be used for the express purpose of ending a life. This is unacceptable, and will place many pharmacists in an untenable position, forced to choose between practicing their profession and following their consciences.

Dr. Nolan called on the Minister and the Dáil to amend the legislation to explicitly protect the conscience rights of pharmacists, but he is not listening. He has closed ears and a pure, one-track vision of this. Someone said this is a trophy project. It looks like it, but to undermine and trample over all these professional people is an outrage and a total affront to democracy and the healthcare professionals on whom we depend day in and day out up and down the country. It is ignorant and disgraceful that the Minister will not listen to them.

Deputy Michael Collins

A group of pharmacists has called on the Minister to amend the abortion Bill to protect the conscience rights of pharmacists and other healthcare professionals. The Health (Regulation of Termination of Pregnancy) Bill 2018, as currently drafted, does not provide for the conscientious objections of pharmacists. Pharmacists will therefore play a critical role in any foreseeable abortion regime as all the methods of abortion provided for in the Bill involve prescribing, dispensing and administering medication. Although their conscience prevents them from intentionally ending the life of an unborn baby, they will be required by law to collaborate in this very act. The legislation in its current form interferes with the exercise of pharmacists' professional clinical judgment and denies their right to freedom of conscience. Freedom of conscience and religion is recognised and protected under Article 44.2.1° of Bunreacht na hÉireann and Article 9 of the European Convention on Human Rights. At present, however, there is no acknowledgement in the legislation of this right as it pertains to pharmacists. An alarming aspect of the proposed legislation is that our legislators believe that the only people in the health service who have consciences are doctors and nurses.

The group of pharmacists has called on the Minister and Members of the Dáil to amend the legislation to protect the conscience rights of pharmacists by creating an opt-in system for all aspects of abortion services established under the new law such that those pharmacists who choose not to opt in will not suffer any disadvantage in respect of their employment rights or career progression.

A recent poll revealed that over 60% of pharmacists voted for the right to freedom of conscience in supplying or dispensing medications used to induce abortions.

At this stage, the Minister has made no reference in the legislation as to how his abortion

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proposals will work in practice. He has proposed a GP-led regime which a majority of GPs oppose and most GPs believe is unworkable. He has failed to consider the most basic practical issue of how the medications used in abortions will be manufactured, provided and dispensed. He has not consulted pharmacists on this fundamental change in healthcare ethics and practice and has, to date, displayed a combination of disregard and contempt for the conscience rights of the dedicated pharmacists and healthcare workers who conscientiously oppose abortion. Pharmacists have a human right to freedom of conscience, religion and belief. Their right to freedom of conscience must be included and protected in the Health (Regulation of Termination of Pregnancy) Bill 2018.

Deputy Carol Nolan

Go raibh maith agat, a Chathaoirligh, as ucht an deis labhairt. The right to conscientious objection is, as has been said a number of times tonight, a fundamental human right. It is one we cannot forget about or dismiss, but that this is what is happening. I fully support the doctors, pharmacists and nurses and all other healthcare professionals who have stood firm on this. They have a right to conscientious objection. GPs are being treated very badly in this whole ordeal, as are other healthcare workers. If they are being more or less forced and bullied into becoming involved in a referral process, that means they are involved in the whole process, in which they want no part. Many of these GPs are dedicated and committed and work long, hard hours. Let us also remember that they are working in difficult conditions because our health service is absolutely disgraceful at present. It is of Third World standard in some areas.

These doctors and nurses are working in difficult conditions every day. They are being told that they have to be involved in a process to which they have a genuine conscientious objection. That is not right and needs to change. We hear much talk in this Chamber about choice, equality, respect and democracy. When it comes to the crunch, unfortunately, none of these is to be seen. This is another example of that.

The group of doctors who organised the petition of more than 640 GPs that led to Sunday's emergency general meeting, EGM, of the Irish College of General Practitioners, ICGP, claimed that several hundred GPs have lost confidence in the ICGP board and that a serious crisis now exists. The Government can longer ignore this crisis in the rolling out of GP-led abortion services. I will read from their press statement after the EGM. I am sure the Minister has a copy. It gives us an insight into what is happening. I, and many other Deputies in this Chamber, met many of these GPs some months ago and they expressed their concerns to us. They are very upset and angry but they also are strong in their resolve. There is no way they will allow themselves to be forced on this issue.

The press statement states: "Hundreds of GPs on the ground do not believe general practice is the appropriate setting in which to deliver abortion services because of lack of capacity in an already overstretched environment, lack of training and availability of ultrasound, and delivering on genuine freedom of conscience protections for doctors who do not want to be involved in overseeing abortions taking place." They do not want to be involved in any part of that process. The first time GPs heard that abortion services would be GP-led was when the Minister announced it on radio. Imagine treating our doctors like that. They work hard every day in a creaking health service. The disrespect they have been shown is appalling.

From that day to this, GPs have not been consulted on the matter. From 1 January, however, the Minister will impose abortion services on general practice. GPs will face the full rigours of the law from the new year if they conscientiously object to becoming involved in any way. That is disgraceful in this day and age when we are talking about the new Ireland and the new republic. It is some new republic if we are to bully and marginalise people simply because they have

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conscientious objections. Fair play to those GPs for standing firm. They are entitled to do that.

I do not know whether the Minister realises that this crisis will lead to a mass exodus of GPs. It was stated here that there are enough GPs. I and many others do not share that belief and I will explain the reason. In rural counties such as Laois and Offaly, it is getting very hard to recruit and retain GPs in many of our towns and villages. This has been an ongoing issue and many Deputies, on both sides of the debate, have raised the issue of the chronic shortage of GPs in rural counties. The Minister will cause a mass exodus and that will put the health of many people in jeopardy.

Many people are already suffering and languishing on long waiting lists. The Minister will now add to that problem by trying to bully the GPs, pharmacists and nurses who want no part in this process. I stand with those people. They are entitled to their conscientious objection and I support them fully. It is shameful that respect is only given if a certain view is held. That is some democracy in this new republic. As an Irish woman, I am absolutely ashamed at times that we think it is okay to marginalise people and to dismiss their concerns if they do not share our views. That is not right. I stand in full support of those healthcare professionals. I hope the Minister will see sense, see the light and treat them properly.

Deputy Stephen S. Donnelly

Conscientious objection is an important issue, which has been well rehearsed in this debate. I fear we are beginning to stray back into Second Stage speeches. If I may, I will bring it down to the legislation. Conscientious objection is incredibly important and it is fully protected. It is in the legislation. There are two parts to it. There is the right of the medical practitioner not to be involved. It is as clear as day that this right is provided for and I have heard no one, on any side, suggest that it is not. The second issue is what obligations are required in respect of transfer of care. This will apply mainly to GPs. The Minister confirmed to me on Committee Stage that a GP will have met his or her objections on transfer of care by providing the woman with the number for a 24-7 helpline. There may be GPs who believe even that is too much. The vast majority of GPs who will conscientious object and have approached me have said they are satisfied with an obligation on transfer of care which concerns nothing more than giving the woman a 24-7 helpline phone number. That is it. It is very important but it is relatively straightforward.

I will speak briefly now about the amendments. Amendment No. 47 gives medical practitioners the ability to conscientiously object. I agree with this amendment from Deputies Mattie McGrath, Nolan, Tóibín and others but I will not support it because it is almost exactly, word for word, what is already in the legislation. I have checked and double-checked and I can find no difference. I agree with it. The wording in the legislation, however, has been passed by the Office of the Attorney General and professional drafters, and this amendment has not. For that reason, I will stick with the legislation. The amendment is a restatement.

Amendment No. 48 quite reasonably refers to pharmacists and seeks protection for them. Pharmacists must be able to conscientiously object. The Minister might confirm, as he did on Committee Stage, that conscientious objection for pharmacists is fully protected in the legislation and guidelines governing pharmacists.

Amendment No. 49 is my amendment. We discussed this on Committee Stage. I wanted to be certain not only that the right of doctors, nurses and midwives to conscientiously object will be completely protected but that the right of students to do so will also be protected. I have discussed this with the Minister. I acknowledge that he has, in turn, tabled amendments Nos.

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52 and 53 to do that. For exactly the same reason as I stated in respect of amendment No. 47, namely, that the Minister's amendments have been passed by the Office of the Attorney General whereas mine has not, I will withdraw my amendment and support the Minister's because that is the version approved by the Office of the Attorney General and the Government. My understanding is that will give full conscientious protection to all students. That is very important.

Amendment No. 50 requires someone who conscientiously objects to notify the Minister for Health that he or she has done so. I do not believe that is a reasonable thing for people to have to do and I will not support the amendment.

Amendment No. 51 proposes to delete the obligation for referral. The ability of a GP, midwife or a nurse to conscientiously object is fully protected. The Minister confirmed on Committee Stage, and he might do so here again, that it is protected in general practice. It is also protected in an acute care setting. A midwife, nurse or doctor can inform his or her employer that he or she is conscientiously objecting and cannot therefore be roistered on or be coerced into being involved. That, too, is very important. Amendment No. 51, however, would delete any obligation of referral. I will not support it for a few reasons. My understanding from the doctors I have spoken to is that it is standard medical practice, here and around the world, that doctors will not simply wash their hands of a patient and leave him or her in a particular situation. As Deputy Kelleher said earlier, while that might not pose too much of a problem for some women presenting in Ireland, there are others for whom it could present a problem. They could be in great distress. They may have been raped or may be under coercion. There are all manner of reasons that women in vulnerable situations will present to a GP. It is not reasonable for any doctor to state he or she is simply not getting involved and off the patient should go. The doctor has an obligation, which in this case requires no more than that he or she tell the patient that there is a 24-7 helpline staffed at all times by qualified medical professionals who are able to talk about counselling and the options available and, if the patient wishes, to direct that patient to a GP who has opted in.

If the only thing the doctor has to do is provide that telephone number, that is absolutely reasonable. I do not believe the referral measure should be deleted. I will be supporting amendments Nos. 52 and 53 from the Minister because they ensure conscientious objection covers students, which is important.

Amendment No. 54 concerns pharmacists and I will not support it. Pharmacists should be protected and I hope the Minister will clarify the legislation under which they are protected. Will he provide clarity on the various pressing issues raised?

Deputy Bernard J. Durkin

I am a little disconcerted by some of the points made about this group of amendments. It appears that in recognising the right of a conscientious objector at all levels, a point with which I agree, it is seen by some as a means of frustrating the purpose of this exercise, namely, compliance with the decision of the people in the referendum. That is a serious matter.

Deputy Ó Cuív made a remark which concerned me a little on the question of two lives being involved. There are, but it should not be forgotten that this is what the eighth amendment was about - equality. History showed that equality when it came to the right to life did not work. Instead, it ended tragically and it has to end tragically for one or other patient. In order to ensure the concept of equality was carried through, practitioners had to wait until such time it was too late and two lives were lost. That did not happen on just one but on several occasions.

I do not have a daughter, but if I did, I would be concerned if I were to come to a conclusion

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that there would be a debate on the eighth amendment again before action might be taken to intervene in the case of a woman who had presented with a crisis pregnancy. I thought we had had that conversation. I thought our obligation was to comply with the decision of the people. They decided with no force put on them. They made up their own minds clearly.

Deputy Thomas Byrne

This is an interesting debate. When conscientious objection is made into an issue, some are under the impression that there is no conscientious objection clause in the Bill. I have read it and it has been mentioned here, but it is being covered over. The fact is that no doctor, student doctor, nurse, midwife or, as the Minister said, pharmacist will be required to take part in any of the Bill’s provisions. They will not have to take part in an abortion. That fact is being lost. It is a point which is worth fighting for and should be acknowledged. The Bill’s provisions will not apply to any professional who does not wish to take part. That is absolutely clear and I am satisfied that the Bill’s provisions on conscientious objection are broadly based.

Will the Minister set out the position on pharmacists? He gave assurances on Committee Stage that the provisions would apply to pharmacists. Why is he not tabling amendments in that regard? Will he explain clearly why they do not need to be mentioned in the legislation, despite the fact that he says the provisions apply to them? I certainly want reassurance before I vote.

The issue of referral came as a complete surprise to me at the start of this debate. When the 2013 legislation was going through, there were several amendments on the issue. There were certainly some Members on the pro-life side of the debate in the Seanad who put forward straightforward amendments proposing that there be referral to another medical practitioner. Now other Members want in their amendments to delete the obligation to refer. There is a division of opinion, matters move on and people grab on to particular issues.

I have not heard a complaint about practice in the past five years from some doctors who feel there was a breach of their right to conscientiously object. If there has been a problem, will somebody set it out? No doctor has been obliged in any circumstance to take part under the 2013 legislation, just as they will not be obliged to do so under this legislation. No problem in that regard has been demonstrated. I stand to be corrected, but I have no evidence which shows that there has been a problem. I wonder how great an issue this will be in practice.

Not every doctor will be happy with the final legislation. However, the Minister has given assurances that the mere provision by a doctor of a helpline number to patients will mean that he or she was fulfilling the requirement to refer. My understanding from talking to doctors is that the majority who conscientiously object will be satisfied with this. I wonder just how many will think it is a step too far for them. If I were a doctor, I would probably conscientiously object. However, I would certainly have no difficulty with referral. It is for others to deal with their consciences. This is not a matter on which one individual in the medical profession or the Dáil can dictate to anybody else, particularly in the light of the referendum result.

We need to be absolutely clear with the public as there is much confusion. Yesterday an upset nurse rang me. She was worried that she would have to take part in abortions when she would conscientiously object to it. As a lawyer and a legislator, I gave her my assurance that in no circumstance would she have to take part in abortions. She was reassured by me. However, there is so much misinformation on what people will be obliged to do or not to do that we need to keep going back to what is actually included in the law, not what people might fear might be in it.

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I will reserve my position on voting until I listen to what the Minister has to say. For the majority of doctors who conscientiously object, the Bill will be satisfactory.

Deputy Joan Collins

I was not going to intervene in this debate because I had made a conscious decision to let it go through, even with some of the comments made by anti-choice Deputies in the Chamber. However, I want to make the important point that a referendum was held and that one of the key issues was trusting women. The people were clear that women should not have to travel abroad to have an abortion, as well as on the periods of 12 weeks, 24 weeks and fatal foetal abnormalities.

Savita Halappanavar’s husband said in his evidence that one of the nurses or midwives in the theatre had said they could not perform an abortion on his wife because we were living in Catholic Ireland and that it was illegal. Let us take as an example an emergency in dealing with a pregnancy at 2 a.m. and three of the emergency team are conscientious objectors. If amendment No. 51 were to be accepted, we could have a situation where those three medical practitioners would be able to say they did not have to pass the case to anybody else. Then what happened to Savita Halappanavar would happen again. That would be the logical conclusion of accepting the amendment.

The potential consequences of amendments that are not thought out or do not reflect the essence of what the legislation is trying to achieve must be taken on board. There are major problems with our health service. I am the first Deputy every week to raise in the House the crisis in our health service. For example, I have challenged the Minister of State, Deputy Finian McGrath, about services in the community healthcare organisation, CHO, 7 area. The crisis is the reason I am an advocate of Sláintecare. In that context, what this amendment could mean must be considered.

Deputy Eamon Scanlon

I will not delay the debate and will only make a few comments. Like many, I have listened to the debate for the past 18.5 hours. In that time, everyone who has spoken on both sides has done so from the heart. Some of the cases raised are not what I would like to see happening, but the people have spoken.

A number of amendments have been tabled, most of which I have supported. Regarding this amendment, we have discussed doctors, consultants, midwives, trainee nurses and so on, but the other hospital staff, for example, hospital porters, should also be considered. It is only fair. People have asked us to make provision for conscientious objection because they do not want to work in that situation. Those of us who have spoken, particularly on the pro-life side, have been asked to make their feelings known. The House has dealt with 46 amendments, many of which have been voted down. There are a further 19 to go, and they will be voted down. As politicians who have been elected to the House to represent people's views, we are obliged to make their feelings known. That is what is happening. It is only right that we have that opportunity. I have listened to everyone respectfully. Everyone who has contributed has said what he or she believes. I am doing the same. People with a conscientious objection should have the option of opting in. That is what I believe. I will not go on for any longer because we do not want to delay the debate unnecessarily.

Deputy Michael Fitzmaurice

I will not speak for long. I just want to make a few points. In recent weeks, many Deputies have met doctors, nurses, midwives and others in the health care sector. We are used to listening to different scenarios. Some of the people we met have stated that they may have to leave work. That happening in any country would be sad.

We could have done this in a way that allowed people to opt out completely while we still

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ensured that the service was provided in every part of the country. Even pharmacists have expressed deep concern about this legislation. We must ensure that people are not pushed into situations against their firm beliefs. People on different sides of the House have their views on various issues and respect the other sides. I ask that the Minister take that concern into account in the context of this amendment.

Deputy Michael Harty

Conscientious objection is an important issue and this section of the Bill is vital, as shown by the number of Deputies contributing on the debate. Doctors' individual rights and beliefs are not absolute. They should not trump the legal rights or beliefs of others and certainly should not trump the beliefs of doctors' patients. That also goes for all nurses, midwives and allied health professionals. Doctors do not have an absolute right to object. This is the central issue.

The Medical Council is clear on the question of conscientious objection and its medical guidelines have not changed, nor will they. They read:

[A doctor] may refuse to provide or to take part in the provision of lawful treatments [...]

If you have a conscientious objection to a treatment or form of care, you should inform patients, colleagues and your employer [...]

You should make sure that patients' care is not interrupted and their access to care is not impeded. [This aspect is important to our debate.]

If you hold a conscientious objection to a treatment, you must:

  • inform the patient that they have a right to seek treatment from another doctor; and

  • give the patient enough information to enable them to transfer to another doctor to get the treatment they want.

If the patient is unable to arrange their own transfer of care, you should make these arrangements on their behalf.

In an emergency, you must [prioritise the patient above the doctor's own objections] and give the patient all the necessary treatment.

The relevant section in the Protection of Life During Pregnancy Act 2013 is the mirror image of the section in this Bill. It reads: "A person who has a conscientious objection ... shall make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the medical procedure concerned." I am not aware of this provision in the 2013 Act having caused any problem and I cannot see how it would cause a problem if this Bill were enacted.

Thus, the obligations of those who have a conscientious objection to the termination of pregnancy have not changed. What has changed is the fact that the termination of pregnancy will be provided in Ireland and will no longer be transferred to another jurisdiction. What has also changed is the fact that medical professionals will now have to face this reality in Ireland and work out how best to accommodate the new, lawful termination of pregnancy. This new reality will take some time for people to accommodate and for the medical profession to develop the accommodation that the new law will introduce. The conscientious objection requirements have not changed. They are not going to change. However, the reality of the provision of

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termination of pregnancy in Ireland is changing, and the medical and nursing professions will have to accommodate that. The Medical Council guidelines allow them to do so. Now that terminations will take place in Ireland, doctors must ask themselves the question. They cannot avoid the medical guidelines laid down by the Medical Council, as their beliefs do not trump those of patients who access a legal service.

Some general practitioners, GPs, will provide this service, but it will eventually be delivered in clinics or hospitals. GPs are self-employed. They have a contract with the General Medical Services, GMS, scheme. The provision of termination of pregnancy services in general practice will have a separate, opt-in contract. If a GP wishes to provide the services, he or she will take out the contract. If he or she does not wish to provide them, the GP does not take out the contract. If a GP is a conscientious objector, the GP places a notice in his or her waiting room saying that he or she is not participating in the service. A GP does not need to include an explanation if he or she does not want to, but the GP should inform patients that he or she is not participating in the service. If a patient should seek the service from the GP, though, he or she is obliged to help the patient and give that person information on where to access the service, be that by directing the patient to a helpline, a HSE website or a colleague. Conscientious objection does not absolve a GP of that requirement. In summary, GPs have an opt-in contract and the only requirement on them is to provide information.

9:00 o'clock

The Minister says that arrangements can be accommodated by just providing information. It will soon become quite obvious to people who is providing the service and who is not. People will not subject themselves to the humiliation of going to a doctor knowing that the doctor is not going to assist them but the doctor does have an obligation to provide them with information.

However, there is an issue relating to employees of the HSE. They are in a slightly different situation because there is the possibility that they could be forced or pressurised to participate or assist in abortion services. This must be clarified by the Minister. It should not affect their employment, employment prospects or promotion prospects. The Minister must make it clear that should a conscientious objector be an employee of the HSE, it will not affect his or her career in any way.

To go back to my fundamental point, the rights of a doctor do not trump the rights of a patient. The beliefs of a doctor do not trump the beliefs of a patient. The doctor must assist his or her patient and I believe the Medical Council guidelines on conscientious objection cover that.

Deputy Joan Burton

Since this debate began a very long time ago, it has always been clear on the part of people who objected to the eighth amendment and believed it put women's lives at risk and was not in the best interests of women and indeed children and Irish people that the right of conscientious objection was always recognised and given freely and generously. What I would say to people here who have taken a conscientious objection position is that this is their right but it is also my right to be a conscientious supporter of proper facilities being available to women when they need that support. Staff in medical institutions, hospitals and practices throughout the country have the right to conscientious objection, but they should acknowledge the right of conscientious supporters. This is not an easy subject. It is a subject where people agonise and weigh decisions as to what is best for them, their families and their future. We do not have absolute insight into everybody's decision but those who righteously profess conscientious objection should also look at the righteous right of other people

[P. 290]

to support conscientiously this legislation and the changes it brings.

I was a member of the Government at the time of the 2013 Act. Deputy Fitzgerald, the former Attorney General, Máire Whelan, and I were the only women there and, obviously, were the only people with experience of giving birth to children and all the joys, risks and difficulties that involves. We came at it from a practical point of view. How many of us who read the story of what happened to Savita Halappanavar and her husband and thought if only someone had indicated to them to get in the car and drive to Dublin where someone would possibly look after them, rather than the endless confusion and contortion of events that happened which resulted ultimately in her dying when I believe she need not have died had a better path been open to her?

Yes, people have the right to conscientious objection, but from everything I understand about people in the medical and health services, that does not mean that one can then abandon the patient. All that is being asked here is that the patient would be able to be referred to people who conscientiously can address their needs. That referral is a just referral. It does not undermine the conscience of the person who has an objection. That is and was accepted by everybody on this side of the debate from day one years ago. I am so glad that it has been included so positively in this legislation.

In respect of the different grounds that are contested here, I do not agree that when a woman's life is in danger during pregnancy she should be left to die. I am talking based on my personal experience of living in Africa where every year, hundreds of thousands of women die in childbirth. They die from situations in childbirth that are no longer a problem here such as breech births or the lack of midwives or trained doctors. Do people who work in medical services in those countries really say that given all their skills, they will stand by and let every woman who is at risk die? We are in a very special situation in Ireland where we have fantastic doctors, nurses and staff in all our hospitals who are available to people who want home births as well, but what if something goes wrong and the woman's life is in danger? One can even talk to people who are very religious. What if that woman has other children? That is often the situation in Africa. What if she has other children? Are they saying let her die and let those other children go motherless?

I do not think a lot of the people who have put the argument this evening personally believe that because these are complex decisions. They are not easy decisions for anybody but what we are seeking to do in this legislation is put in place a framework where women and their partners and families can be assured that in the relatively rare cases where something goes wrong, they will get the proper attention. That is what we are talking about. We are not talking about some ideology. We are talking about real women and possibly children whose lives are under threat in a situation of pregnancy. We must address that core question.

I recognise conscientious objection but, equally, I recognise the right of women to get treatment that is appropriate to their situation. The people voted for that, which is what gives us our authority to come into the Chamber and say this with all due care and consideration to the people who think differently from us. There are very simple and easy procedures to pass on records and make the information available. We should remember that way back during the time of the eighth amendment, the judges decided in a Supreme Court case and the people decided in a referendum on the right to information and the right to travel. If someone decided on the right to information and travel, he or she had actually decided to allow people to proceed but to do it in another jurisdiction. This Bill simply brings it back home and provides for it here.

[P. 291]

Deputy Peadar Tóibin

I will address the points made by Deputy Donnelly and Deputy Harty. I know they put questions out there.

Acting Chairman (Deputy Declan Breathnach)

Address the Bill.

Deputy Peadar Tóibin

The reason this is considered yellow pack conscientious objection is because the Bill states that there is nothing in the Act that will be construed as obliging any medical practitioner to carry out or participate in an abortion. That only means that there is nothing in the Act. It does not mean that there will be nothing anywhere else that will influence a person to carry an abortion, so it is a very weak form of conscientious objection. Our amendment says there will be nothing in the Act and everywhere else within society that will force a person to participate in an abortion.

The other point that was mentioned was that the Protection of Life During Pregnancy Act contains the guidelines. That Act is of a different order. That Act looked to legalise abortion in the case where there is a threat to the mother's life. This Bill is of a totally different order.

It is to allow for abortions to happen without indication. That is a completely different scenario and has to be understood in that context. Deputies were saying that a person may die in a case of conscientious objection. There is no example in the history of the State of any doctor stating he or she had a conscientious objection to something and a person dying as a result. There is no example of that ever happening.

In a liberal democracy, the right of one person is limited where it damages the right of another person. What the Government is seeking to do is force one person to proceed with the ending of the life of another person at some level. The issue of arrangement is said not to be a big issue. The Bill states that termination of pregnancy is the ending of the life of a human being. If I was to arrange for the ending of the life of another human being, I would be legally and morally culpable and complicit in that action. We can imagine, therefore, that doctors who consider abortion to be what the Bill states it is would feel culpable and complicit if they proceeded in that way.

That pharmacists have not been included is again a case of us saying somebody else can do it but we will not do it. Thousands of health professionals have stated that they do not want to proceed with this. The Minister is on a collision course with the people working in our health service.

Acting Chairman (Deputy Declan Breathnach)

I ask Deputies to stay within the time limits. We are back to the second round of two-minute contributions and I encourage people not to be repetitive.

Deputy Michael Healy-Rae

During the course of the debate on this amendment, I had to leave the Chamber on a number of occasions to take calls from people in the medical profession, both ladies and men, who are watching the debate tonight. They could not believe some of the comments that were made here this evening. We are elected representatives and we can say what we like. People have differing opinions but to say that some of those who called me were concerned, worried and upset would be an understatement.

When this amendment is put to the floor, it is up to people to vote whatever way their conscience takes them. People in the medical profession have made their arguments strongly and eloquently explained why this amendment should be passed and why they wanted us to put it forward in the first place on their behalf. We are not doing this as politicians. We are doing it

[P. 292]

after consultation. We met groups as individuals and as a group. We listened to their concerns and it would be very remiss of us if, after meeting these people, taking their concerns on board and believing in what they want to achieve for themselves and their work, we did not do what we are doing here this evening.

Deputy Mattie McGrath

Deputy O'Connell asked us to show her the evidence regarding women hurt by abortion. The Fergusson report is a 30-year longitudinal study which shows negative mental health consequences after abortion. The report was done by a well known and respected healthcare professional. Professor Fergusson was actually pro-choice. Those were his words. Deputy O'Connell is not here to hear that, but I hope the Minister will pass on to her that there is ample evidence.

Deputy O'Connell then spoke about Dr. Abigail Aiken, who is also pro-choice and came before the Special Committee on the Eighth Amendment of the Constitution. The Deputy pronounced Dr. Aiken some kind of independent when she was not. Like all the others who were brought before the committee, she was one-sided. Such a shambles and disrespect I never saw the like of. The committee could not get one pro-life doctor. Dr. Aiken, as well as being pro-choice, wrote a submission for Deputy Coppinger seeking to abolish the three-day waiting period which the Tánaiste dreamt up when he was on his journey across the River Lee and back. There is the independent evidence that Deputy O'Connell is telling us about. Dr. Aiken wrote a policy paper for Deputy Coppinger to remove the three-day waiting period. She was supposed to be independent at the committee. The people watching this are aghast.

This is even stranger still. Dr. Aiken's evidence on the safety of abortion pills was directly contradicted by none other than Dr. Rhona Mahony at the committee. It was all over the place. Deputy O'Connell was talking about making things up and the fictional idea of abortion regret. I ask the Minister why did he not meet those people? Why will he still not meet them? He should meet them. He only meets people who back him and hides and cowers away from people who have real issues and are suffering as a result of abortion. It is a case of speak no evil, hear no evil and see no evil. He will not engage with the pharmacists in any way, shape or form. These are professional people and he is treating them with total disrespect. I suppose the Minister is so used to disrespecting everybody in his health services that it does not matter to him anymore. He has no respect for anyone who is struggling to get any kind of service from the health system. His record is abysmal. He will go down as the worst Minister in the history of the State. That is my considered opinion and that of many thousands of people. He can laugh all he likes, but those are the real facts.

Deputy Simon Harris

That is right.

Deputy Ruth Coppinger

The deputy is over time.

Acting Chairman (Deputy Declan Breathnach)

I have already called time. If people do not show respect for the time, it is a problem.

Deputy Ruth Coppinger

When people are using the maximum-----

Deputy Danny Healy-Rae

I will be brief. We did not dream up these amendments on conscientious objection. It is doctors, midwives, healthcare officials, pharmacists and all the healthcare people, many of whom came to us worried about this. That is why we have put the amendments down and spoken on them. We feel strongly on behalf of these people who are entitled to their rights and are worried they may be forced or bullied into doing something they were

[P. 293]

never trained to do. That is why we have gone along with these amendments. We feel very strongly about this issue on behalf of those people.

Deputy Peter Fitzpatrick

GPs, pharmacists, midwives and nurses, all medical professionals, are conscientiously committed to both patients and will remain so regardless of sanctions. Nobody should be forced to end life. I do not think the Minister will do that. He should be fair and look at the situation a woman is in. These people are not looking for headlines. They have a conscience. Doctors and nursing staff have paid for their education, trained and put in big efforts. They were trained to save lives, not to end them. Nobody should be forced to end life.

I am a very lucky individual. I have a family that is pretty healthy. People are going away and professionally training to be doctors, nurses or midwives. Sorry, is there a problem here? I am trying to make a speech here and it is not nice when someone on my right-hand side, especially as it is the Minister, is not showing respect. I am not trying to be smart.

Acting Chairman (Deputy Declan Breathnach)

Please allow Deputy Fitzpatrick to continue without interruption. His time is running out.

Deputy Peter Fitzpatrick

I showed the Minister great respect. I have been here all evening and listened to everything he said. Nobody should be forced to end a life.

Deputy Michael Collins

The Minister said that GPs would hold stocks of all abortion drugs so that women would not need to go to a local pharmacy to have their prescriptions filled and therefore pharmacists do not need to be included in the conscientious objection provisions. Do we know that this will be the case? Where does the legislation make this clear? Can the Minister guarantee that no local pharmacist will be expected to stock and dispense these drugs for the purpose of inducing an abortion. What if a GP does not have sufficient quantities in stock? Will he or she expect the local pharmacist to supply them? Hospital pharmacists will, no doubt, need to be involved in abortions, involving a variety of chemicals and drugs from nine weeks onwards.

Why are they not covered under section 24 of the Bill?

Deputy Kevin O'Keefe

I will be short and brief. I just want to support this amendment. I suppose the Minister will admit that we must try to bring the whole of society along on the issue that is before us today. While there are two sides to the argument, it is only fair for the Minister to give time and to accept this amendment. Maybe things will progress and there will be changes down the road, but we will still have the issue. No one is denying that women's healthcare is at stake here. People like me still believe we are doing away with the right to life of the unborn. I think the Minister should bring such people along as much as possible by accepting this amendment. As we have seen in recent days, it is not about the money. These people work hard at their jobs. We have been told about how much money will be made available to those who perform their duties if they decide to take up this part of their practice. These people are not in business for money. They are looking for the right not to perform a duty where they see that the right to life is being taken. I ask the Minister to consider this amendment.

Deputy Joan Burton

I support this Bill because I think people have to support the health professionals who have a conscientious commitment to caring for people and to providing care. We recognise the objections of the people who object, but equally we have to recognise the conscientious commitment of medical professionals to caring for women.

Acting Chairman (Deputy Declan Breathnach)

The Minister is waiving his entitlement to speak again on these amendments.

[P. 294]

Deputy Michael Healy-Rae

I appeal to Deputies to think very seriously before they vote. I thank the Chair for the fair way in which he has been chairing this debate.

Deputy Simon Harris

Hear, hear.

Deputy Michael Healy-Rae

I know it is a contentious issue for many people. I want to thank the Ceann Comhairle, the Leas-Cheann Comhairle and the other Deputies who have chaired these debates. People have to do what their own conscience leads them to do. I certainly hope they will support this amendment. I know that some Deputies who did not support other amendments are going to support this amendment. I am grateful for that. I omitted to speak about the many pharmacists who have grave concerns as well. I have been dealing with them on this issue on a continuous basis over recent months. They are very worried about what is happening in here this evening. I do not want to delay the matter.

Tá [Yea] 30; Níl [Nay] 75; Staon [Abstain] 1.  Amendment declared lost

Notes (provided by the Protection of Conscience Project)

1.  Term popularly used in Ireland for a cheap, low grade product. See Wikipedia entry "Yellow Pack."