Doctors for Choice is an alliance of independent medical professionals and students advocating for comprehensive reproductive health services in Ireland, including the provision of safe and legal abortion for women who choose it. We are a feminist led organisation which believes in women’s moral agency and bodily integrity.

We believe that women should be supported to make their own decision regarding their sexual and reproductive health and to manage their own fertility, with doctors and nurses providing expert advice and care without judgement, recourse to the law or fear of criminal sanction.

We welcome your support. If you are a doctor or a medical student we will gladly welcome you into membership. You can contact us at doctorsforchoice@gmail.com

Statement on PLDPA (2013) Implementation Guidelines

Arising from our professional expertise and experience we believe that the UN Covenant Rights of Irish women are not being provided for in relation to access to appropriate abortion care. We would like to bring the following issues urgently to public attention. The Protection of Life During Pregnancy Act, 2013 (PLDP Act). There has been an apparent effort by the state party to legislate for access to abortion services in circumstances where a woman’s life is at risk because of a pregnancy. We believe that this legislation is fundamentally flawed. These intrinsic flaws have been amplified, rather than minimized, by the “Guidance Document” now being made available to assist doctors in the implementation of this legislation. The recent experience of the misapplication of the PLDPA in the case of a young woman requesting an abortion in the context of restricted travel and serial traumatisation by rape, denied access to abortion, forced pregnancy, an order for forced hydration and forced birth by caesarean section only serves to reinforce our view that the PLDPA is unworkable and particularly so in the context of the 8th Amendment to the Constitution, Article 40.3.3.

1. Section 9 of the PLDP Act: the issue of risk of loss of life from suicide. The PLDP Act requires that, following referral from a General Practitioner (GP), the woman concerned undergoes a minimum of three further medical assessments, from two psychiatrists and one obstetrician. These assessments are required to “certify” that a woman fulfills the requirements for a lawful abortion: that she is at risk of suicide should she be restricted from accessing an abortion. In contrast, in the case of risk of loss of life due to a medical condition, such as cancer or heart disease, only one assessment by a specialist doctor is required. The requirement for two psychiatrists, but only one oncologist or cardiologist, to assess risk of loss of life is not based in medical practice. Psychiatrists and GPs assess and manage patients at risk of suicide on a daily basis without seeking second opinions. It is stigmatising for women to be subjected to two separate assessments, and suggests that the doctors certifying the risk of suicide are suspect in a way that those certifying the risk of loss of life from cancer or heart disease are not. This intense scrutiny of these vulnerable women, who are both pregnant and at risk of suicide, is Cruel, Inhuman and Degrading Treatment (CIDT), and constitutes “arbitrary…interference with privacy”. It could take as many as 7 medical assessments before a woman obtained a final decision on access to abortion services.

We recommend that any legislation should be respectful of a woman’s autonomy and of her vulnerability and that informed consent is a priority consideration in the provision of any medical procedure or service. Doctors For Choice maintain our view that no medical certification is required for eligibility for access to abortion; only informed consent is required.

2. The Guidance Document (for the PLDP Act): The pathway to applying for an abortion is that women are referred by the GP to their locally based psychiatrist. In excess of 100 psychiatrists in Ireland have stated that they will not support this legislation. Some of these same psychiatrists have stated that, rather than being conscientious objectors (as provided for in the legislation, Section 9.4) and abstaining from doing assessments, they will make assessments under the PLDP Act. These psychiatrists will in effect be preventing access to abortion services for women at risk of suicide and are arguably conscientious obstructers, rather than conscientious objectors. For a woman applying for access to abortion services, it is a matter of geographical chance whether she will be assessed by such a psychiatrist. It is possible, if not probable; that such an encounter could increase her risk of suicide. Should a woman undergo a first or a second “assessment” by an anti-choice psychiatrist and have the resolve to persist in her application, she has the right to appeal to a Review Panel where she will be assessed by two further psychiatrists. This Review Panel may also contain anti-choice psychiatrists. A pregnant woman at risk of suicide may thus have to endure four psychiatric assessments and still not be “certified” to have an abortion. As only Dublin, Galway and Cork Child Psychiatry in-patient units are listed as approved centres for children (under 18) it is not clear if children can be seen in other areas in approved centres for adults and whether they would be seen there by Child Psychiatrists or Adult Psychiatrists. We recommend that, until the PLDPA is repealed, there should be a central panel of psychiatrists who are screened to ensure that they will work within the legislation. The availability of approved centres and Child Psychiatrists for the certification of children (under 18) also needs clarification.

3. An important factor that increases the risk of suicide in relation to abortion is restricted access to abortion services. Ireland continues to rely on this risk being lowered by access to abortion services in the UK and EU with an historic fall in the rate of suicide in pregnancy and the puerperium and in the rate of infanticide coinciding with improving access. The risk factors for suicide in relation to restricted access in Ireland are therefore the factors affecting ability to travel abroad to access abortion services, which are i) Ill health ii) Poverty iii) Youth iv) Disability v) Migrant status and vi) Pregnancy involving rape, incest or Foetal Anomaly.

We recommend that, as informed consent to abortion, and restricted access, are often the only relevant factors for certification of a risk of suicide under the Act, the guidelines should reflect this fact, to avoid further assessment unless otherwise indicated and with the patient’s explicit further consent.

4. The guidelines frequently mention the term ‘suicide/suicidal intent’ instead of the term ‘risk of suicide’ even though the term ‘intent’ is not mentioned anywhere in the legislation. Even though not explicitly stated in the summary of requirements (table C page 20), the frequent use of this term implies that ‘suicidal intent’ is required to certify eligibility to access abortion services under the Act (eg “cases arising from suicide intent” on p7 of the guidelines and “Risk from suicidal intent” in the referral flow-chart on page 10). This would place a higher threshold than that needed to certify a patient for involuntary detention under the Mental Treatment Act 2001 where suicidal ‘intent’ is not required in cases where a risk of suicide is the main grounds for detention. Second, the Supreme Court judgment in the X case specified that the risk of suicide did not need to be ‘imminent or inevitable’ and the use of the term ‘suicidal intent’ would imply imminence as a condition.

We recommend that the term ‘suicide/suicidal intent’ should be removed from the guidelines as legally inconsistent as well as potentially dangerous clinically.

5. A system needs to be established to review the care received in potential situations where a woman who is refused an abortion under Section 9 of the PLDP Act goes on to kill herself. The PLDP Act requires that all abortions carried out be notified to the Minister of Health (Section 20); but does not require notification of applications that have been refused. Consequently, there will be no information collected about women who have been refused an abortion or whether they subsequently kill themselves or attempt suicide or self harm as a result of restricted access to abortion services. Nor will there be any systems review that may inform better medical practice, as is the norm.

We recommend that a system be put in place to record requests for abortions that have not been approved, similar to the notification system for abortions that take place, so that we can record women who may die by suicide or engage in attempted suicide or self harm as a result of restricted access to abortion services.

6. The PLDP Act only provides for abortion in the case of risk of loss of life. As medical practitioners we think that there are several areas where abortion services are urgently required in order to prevent serious harm to the health, as opposed to the life, of the woman.

(a) The absence of legal abortion services for women who are pregnant as a result of rape or incest is “cruel, inhuman and degrading” (Article 7), amounting to “punishment” (Article 7).

(b) Likewise, forcing women to continue with pregnancies where there is a fatal fetal anomaly is cruel and inhuman, and has no medical justification.

(c) We believe that doctors in Ireland are not being allowed to practice medicine in line with the most basic of medical ethics. A majority of doctors in Ireland support the legalisation of abortion for rape, incest and fatal fetal anomalies.

We recommend that international human rights standards in relation to access to abortion services be upheld in Ireland. We recommend that the continued exclusion of a risk to health, rape and foetal abnormality as grounds for access to abortion services is not well-founded medically and continues to put women’s health and lives at risk and results in Cruel, Inhuman and Degrading Treatment (CIDT).

7. Section 6.4 of the Guidance Document states that when certification under the Act has been accepted, clinicians must proceed with induction or Caesarian Section cognisant of the ‘constitutional protection of the unborn’. Again and again the wishes of the woman are not considered at any stage. When a pregnancy is approaching viability, the guidance document recommends that a multi-disciplinary discussion will adjudicate on the  subsequent clinical management- not the woman.

Informed consent and the woman’s autonomy, is therefore breeched in this guidance document. It enforces medical negligence upon doctors who utilise it, through the denial of informed consent of the pregnant woman.

Until the PLDPA and the 8th Amendment are repealed, DFC recommends that any pregnancy certified through this legislation must be undertaken with the full informed consent of the woman; without coercion. Denial of that right, such as through enforcing an induction or caesarian section upon a vulnerable woman or delaying delivery to await gestational viability (if this is against the wishes of the woman,) seriously breaches principles of ethical medical practice; especially the need to protect a patient’s dignity, bodily integrity and personal autonomy.

 

Summary of Recommendations:

1. We recommend that any legislation should be respectful of a woman’s autonomy and of her vulnerability and that informed consent is a priority consideration in the provision of any medical procedure or service. Doctors For Choice maintain our view that no medical certification is required for eligibility for access to abortion; only informed consent is required.

2. We recommend that, until the PLDPA is repealed, there should be a central panel of psychiatrists who are screened to ensure that they will work within the legislation. The availability of approved centres and Child Psychiatrists for the certification of children (under 18) also needs clarification.

3. We recommend that, as informed consent to abortion, and restricted access, are often the only relevant factors for certification of a risk of suicide under the Act, the guidelines should reflect this fact, to avoid further assessment unless otherwise indicated and with the patient’s explicit further consent.

4. We recommend that the term ‘suicide/suicidal intent’ should be removed from the guidelines as legally inconsistent as well as potentially dangerous clinically.

5. We recommend that a system be put in place to record requests for abortions that have not been approved, similar to the notification system for abortions that take place, so that we can record women who may die by suicide or engage in attempted suicide or self harm as a result of restricted access to abortion services.

6. We recommend that international human rights standards in relation to access to abortion services be upheld in Ireland. We recommend that the continued exclusion of a risk to health, rape and fetal abnormality as grounds for access to abortion services is not well-founded medically and continues to put women’s health and lives at risk and results in Cruel, Inhuman and Degrading Treatment (CIDT).

7. Until the PLDPA and the 8th Amendment are repealed, DFC recommends that any termination of pregnancy certified through this legislation must be undertaken with the full informed consent of the woman; without coercion. Denial of that right, such as through enforcing an induction or caesarian section upon a vulnerable woman or delaying delivery to await gestational viability (if this is against the wishes of the woman,) seriously breaches principles of ethical medical practice; especially the need to protect a patient’s dignity, bodily integrity and personal autonomy.

8. We recommend particularly that the state party urgently repeal the PLDPA and the 8th Amendment and decriminalise abortion services in Ireland.

Doctors for Choice calls for independent inquiry into case of raped young migrant denied an abortion

​Doctors for Choice wishes to express its shock and outrage at what appears to have been a pattern of cruel inhuman and degrading treatment meted out​ to the young migrant woman rape survivor who was denied an abortion recently in Ireland. Reports in today’s Irish Times are horrific and numbing.

Dr Mary Favier said ‘We are particularly concerned that the only options that appear to have been available to this young woman were an enforced cesarean or a forced pregnancy. No other European country would countenance this barbaric practice.’

She added ‘We therefore call on the HSE to set up an independent inquiry and recall Professor Sabaratnam Arulkumaran to chair it. We recognise that Professor Arulkumaran has an eminent professional background and that he gained a valuable insight into the Irish Health Service having chaired the Savita Inquiry in 2013. We request that an independent inquiry be set up as a matter of urgency’ she added.

​Dr Peadar O’Grady said ‘In addition we request the Government  hold a referendum in 2015 to repeal the 8th amendment​. We believe that the​re is no bright line distinction between the​ health and lives of women- we believe doctors must practice a continuum of healthcare and that abortion should be decriminalised.’

He added ‘ The Irish Government continues to fail to meet two tests arising from the judgment of A,B and C v Ireland- there must be an effective and accessible procedure for abortion- the guidelines appear to not even guarantee an abortion for a woman at the risk of suicide.’

Furthermore ‘In addition the ‘chilling effect’ of 14 years prison for doctors and women in the Protection of Life during Pregnancy Act 2013 persists’.

Doctors for Choice express shock and outrage at ordeal of woman denied an abortion

While acknowledging the incomplete and uncertain facts in this tragic case, Doctors for Choice believe certain urgent questions arise that need to be addressed:

1 Why was the woman involved denied access to abortion?
2 Was she faciltated to avail of a panel assessment and an appeal?
3 Did the panel certify eligibility? If not why no appeal? If so why was abortion not carried out? Was there a delay in certifying eligibilty in order for the gestation to exceed 24 weeks?
4 Why was her consent to an abortion and refusal to consent to a cesarean not vindicated by HSE or courts?
5 On what grounds was an hydration order made?’

These questions raise very disturbing possibilities for the abuse of a vulnerable adult. There seem to have been reasonable grounds for the HSE to suspect that neglect of this young woman’s need to access an abortion would result in significant harm (suicide) as certified by two Psychiatrists. Was this Neglect of a vulnerable adult investigated and what was done by the HSE to protect her?’

Doctors for Choice wishes to express our shock and outrage at reports that a raped woman who went on food and liquid strike in Ireland was denied an abortion in line with the X Case. From reports it would seem that the only options afforded the woman were an enforced cesarean or a forced pregnancy.  It is reported that the woman  who became pregnant as a result of rape believes the state denied her access to an abortion for months, until the foetus became viable.

Doctors for Choice warned last year about the flawed panel review system which includes obstetricians who are not trained to adjudicate on mental health issues and excludes GPs who are trained to manage pregnancies in primary care up to 16 weeks.

It appears that the obstetrician in line with the Protection of Life During Pregnancy Act 2013 was allowed to veto the woman’s request for an abortion despite two psychiatrists certifying a risk of suicide as a ground for abortion. The UN Human Rights Committee recently characterised this panel review system route for vulnerable women as a form of ‘mental torture’.

Dr Peadar O’Grady, a Child and Adolescent Psychiatrist said ‘This is abuse of a traumatised and neglected woman. We have to repeal the 8th amendment and decriminalise abortion as the UN Human Rights Committee rightly advised. Do we need blue helmets to provide abortion services in Ireland?

Dr Mary Favier, a Cork based GP said ‘This case underlines the problems inherent in the legislation of balancing a woman’s rights with those of a foetus and threatening doctors with 14 years in prison for failing to do so. This is compounded by the requirement to use multiple doctors to certify eligibility (up to 7 medical assessments) and including an Obstetrician in certifying a risk of suicide.

She added ‘If a young, rape victim, certified as requiring an abortion due to the risk of suicide cannot access abortion services then the legislation and its implementation are clearly fatally flawed.’

 

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