By Veronica O’Keane, Professor in Psychiatry TCD & Consultant Psychiatrist, Tallaght HSE Services.
The Protection of Life during Pregnancy Act (PLDP Act) was passed by both Houses of the Oireachtas and signed into law in July last year by President Higgins, and commenced in January 2014.1 This law was 20 years in gestation since the Supreme Court ruling in the X case in 1993, which allowed for lawful abortion when the mother’s life was at risk, including the risk to life from suicide. Two subsequent referenda were held in which the Irish people voted to support the Supreme Court decision that suicidality could be a legitimate reason for terminating a pregnancy.
The regulations and procedures about how theservice will operate are laid out in the PLDP Act1 , and inthe Statutory Instrument(s) (SI) that provide for theimplementation of the legislation. This includes forms to be used by women who want to access the service (SI539)2 and a “Certification” form (SI 538) to be signed by doctors, giving their reasons, why a woman is, or is not, in their view entitled to a lawful abortion.3 This all seems clear and straightforward.
However, a further hitch has come to light in the now 21-year struggle to enact procedures for a lawful termination for women in extremis: the HSE seeminglyhave to provide guidelines for clinicians on the new legislation. It is unclear from where the demand for such clinical guidelines has emerged. One may well ask why the need for guidelines, rather than just training, when the PLDP Act is in itself detailed and precise, and the forms are already prescribed in the SIs. The “Guidelines on Implementation Committee”, however, has been in existence since last year but has not yet produced “the guidelines”.
There are some minor professional issues related to training that remain to be resolved, but the real problem is the question of how women will access the service.This was brought to public attention in an article by Kitty Holland on Jan 3rd, 2014 (“College tells psychiatrists not to do abortion assessments”). The Irish college of Psychiatrists had expressed “extreme concern” at the absence of guidance for GPs in accessing suitable psychiatrists to assess a suicidal woman requesting an abortion. Let us imagine a hypothetical case. A woman, lets call her Kate, becomes pregnant following an act of sexual violence. Kate is distressed and inconsolable; cannot, and does not want to, contemplate the thoughts of continuing with the pregnancy. She is desperate and would rather die than continue with the pregnancy and forced motherhood following the rape. Kate is not depressed but she is suicidal because of being in an intolerable situation for which the only remedy for her is the termination of the pregnancy.
Where, and to whom, does she turn for help? Her first option is to go to her GP who under normal circumstances would refer Kate to her local HSE psychiatrist.Psychiatry services are provided on the basis of geographical location and patients are sent to whatever psychiatrist provides the service in their area. Lets suppose that Kate,in this process, is unwittingly referred to an anti-choice psychiatrist. This is the nub of the problem. We have had a public debate in which some psychiatrists have said that abortion is never a treatment for suicidality. This sound bite, although baffling to many of us, has endured. Professor Patricia Casey stated at the Oireachtas Hearingspreceding the PLDP Act that “there are no grounds for recommending abortion as a treatment to prevent suicide.”4 She has also made public her view that it is “deeply insulting” and “discriminatory” that some psychiatrists should be excluded from theprocesses for determining suicidality under the PLDP Act because of their “personal position on the issue” (Independent, 9th Jan, 2014,Pregnancy should not change the way we assess risk of suicide).
Let us return to Kate, who shattered by the inevitable refusal by the anti-choice psychiatrist to certify her for a legal termination, may have the resilience to request a review of this opinion, as is her right under the act. At the Review Committee stage, she may also encounter a psychiatrist whose “personal position on the issue” of abortion is that it is never a treatment for suicidality. Kate will now not only have been abandoned, as have so many women before her who were victims of sexual violence, but will also have been humiliated by our “pathways to care” within the HSE. She may not have any access to resources or she may be unable to travel abroad: she may be a refugee. She may feel desolate and unable to go on…and she may kill herself. We have no idea whether women who die by suicide in Ireland are at an early stage of pregnancy or not, in spite of all that was said during the debate that preceded the PLDP Act.
That dreaded debate…a “pro-choice” advocatepitched against a “pro-life” one, did not allow for any meaningful analysis of the issues, and left many serious questions unasked. There was no analysis of what “pro-life” and pro-choice positions mean. Many of the public figures that led the “pro-life” argument are leading members of The Iona Institute, the mission statement ofwhich is to “promote(s) the place of marriage and religion in society.” This conservative catholic position is a highly ideological one and informs the abstract moral nature of the arguments that they put forward.
I doubt, however, that even they can defend some of the intrinsic contradictions of such an absolutist position. Women in Ireland have the right to access information in relation to choosing to go abroad to have an abortion.One must assume that the “pro-life” lobby accept this right. This right is an acknowledgement of a woman’s right to choose the option of abortion, albeit it abroad and not in Ireland. If they do not support this right, do they believe that Irish women who access this information should be liable to prosecution and conviction?
What, on the other hand, does a pro-choice position mean? It is the belief that a woman herself should have the right to terminate her pregnancy, within certain limits usually. In almost all countries this is a legal right. It is usually counterbalanced by the legal rights of the fetus prohibiting abortion beyond a specified point in pregnancy, except in extreme circumstances, such as fatal fetal anomaly. An individual may be pro-choice and not believe in the right to an abortion except in exceptional circumstance, or may believe in the right to abortion only in the first 12 weeks of pregnancy.
When people spoke about the middle ground I think that they were referring to a position, on the one hand, cognisant of the difficult, sometimes harrowing, choices that some women have to make and, on the other hand, of the fear of a liberal abortion regime. However, understanding this quandary and the need for the availability of abortion services in some situations is a pro-choice position. It is a recognition that rigid moral positions fall apart when tested in the real world. It is a rejection of the doctrinaire reasoning that can be frankly cruel in the real world. The only reasonable position for a society to take that aspires to be mature and humane is one that recognizes the reality of human difficulties.
How many individuals in Ireland would deny Kate the right to end the pregnancy resulting from rape and to terminate the unbearable prospects, for her, of forced motherhood. In almost all countries worldwide, girls and women have the right to abortion in cases of rape and incest, and 75% of Irish people from what we knowsupport this right (June 2013, an Irish Times/ Ipsos MRBI). Refusing the right to end this pregnancy is exactly what the “pro-life” lobby advocated. This is an anti-choice position being promoted as “pro-life”.
How could we make our pathways to care for Kate less capricious? We could create a National Panel of psychiatrists, who would be screened to ensure that they would allow for the possibility that abortion may, under exceptional circumstances, be the only remedy to save the life of a pregnant suicidal woman. Kate could be referred directly to the National Panel so that she would be protected from those who are opposed “on any grounds” to her having a termination. This should ensure that Kate gets a psychiatric assessment that is focused only on her circumstances and her mental sate, is not bound by the constraints of ideology, but driven by the spirit of the legislation.
The anti-choice movement in Ireland continues to oppose abortion unless the woman’s life is at risk onlybecause of a medical or an obstetric problem. In this scenario, the obstetrician makes the call, so the choice is not the woman’s. In the case of suicidality, a scenario for which they say abortion is never a remedy, the anti-choice psychiatrist can only refuse a woman access to an abortion. The anti-choice doctors should leave this call to those of us who believe that being suicidal can be a legitimate reason for facilitating the request of a woman, like Kate, for a termination…as is the law. The conscientious objectors need to move aside now and allow the majority of doctors to conscientiouslyimplement the legislation.