​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’.

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.’

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.

4.(http://www.oireachtas.ie/parliament/media/committees/healthandchildren/PatriciaCaseyOpening.pdf)

Some interesting articles that we’ve been reading over the last few weeks:

• UN urges states to remove ‘unnecessary’ restrictions on abortion – http://www.hurriyetdailynews.com/un-urges-states-to-remove-unnecessary-restrictions-on-abortion.aspx?pageID=238&nID=62676&NewsCatID=373
• Olivia O’Leary in the Irish Times: http://www.irishtimes.com/news/politics/sometimes-you-must-fight-for-your-rights-if-you-want-to-win-1.1699063?page=1
• Dr Jacky Jones article in the Irish Times: Pregnancy still a crisis the State can’t seem to deal with – http://www.irishtimes.com/news/health/misogyny-behind-state-controls-on-women-s-reproductive-rights-1.1381768
• Professor Veronica O’Keane from Doctors for Choice article in the Irish Times regarding anti-choice psychiatrists http://www.irishtimes.com/news/health/anti-choice-psychiatrists-undermine-abortion-law-1.1690750

Upcoming Events:

Dr. Peadar O’Grady will be speaking for Doctor’s for Choice at the NWCI Soapbox slot between 2 and 3 on March 8th at the GPO in Dublin. For more information check: http://www.nwci.ie/learn/event-detail/on_our_soapbox_for_international_womens_day

Article by Dr. Paedar O’Grady in the Irish Times

Oireachtas should amend Bill’s criminalisation of women and doctors

Article by Dr. Mary Favier and Dr. Ciara Flynn in thejournal.ie

The new abortion law attempts to add clarity, but the Savita case could happen again

As the Oireachtas Committee on Health and Children met this afternoon (28 May 2013) to finalise its abortion law report to Government, medical, legal and policy experts from three leading groups told TDs and Senators of the “remaining flaws” in the legislation.

Doctors for Choice (DFC), the Irish Council for Civil Liberties (ICCL) and the National Women’s Council of Ireland (NWCI) joined forces in Leinster House today to provide TDs and Senators with their expert analysis of the General Scheme of the Protection of Life during Pregnancy Bill 2013.

Dr Mark Murphy of DFC said “GPs alone manage uncomplicated pregnancies until 16 weeks gestation. If a woman presents in early pregnancy with a crisis it will be GPs in liaison with psychiatrists who will be managing her care. Obstetricians will not and need not be involved, as the pertinent issue will be mental health rather than obstetric health. GPs will not be “consulted” in clinical reality but will be the key clinician involved in the crisis pregnancy. The role of General Practice needs to be recognised and included in a redrafted Bill’.

DFC’s Dr Peadar O’Grady added that Doctors For Choice “recommend that two doctors certify, or not, the procedure in the situation of a threatened suicide: a GP and a Consultant Psychiatrist. We also recommend that the criminal sanction of 14 years for both woman and doctor be dropped from the proposed Bill, and that women with fatal foetal anomalies should be included in the scope of a redrafted  Bill”.

Deirdre Duffy, ICCL Senior Research and Policy Programme Manager said:

“By and large, we consider that this Bill is faithful to the settled constitutional position established under the X case. Not only would the very constitutionality of the proposed legislation be called into question by the omission of the suicide ground, it would be likely to leave Ireland in continuing breach of its international human rights obligations.”

“The ICCL is also obliged to point out that the State’s obligations in relation to abortion under the Convention run deeper than merely implementing the European Court judgment in A, B and C. The current treatment of women with pregnancies involving a defined set of lethal foetal abnormalities potentially falls foul of Ireland’s human rights obligations. The ICCL considers that it is constitutionally permissible under Irish law to provide for the termination of such pregnancies”, Ms Duffy concluded.

NWCI Director Orla O’Connor said: “We are extremely critical of the invisibility of women’s voices and women’s experiences in discussions on the Heads of Bill. Women must be at the heart of the debate.  In reality women will have real difficulty invoking their constitutional right to an abortion under the onerous procedures proposed by this Bill.”

“The NWCI have great concern over the continued criminalization of abortion in this country and the detrimental effect that it has on women’s physical and mental health. Criminalization will affect women accessing health services and deepen the chilling effect on both women and their doctors. Head 19 must be removed from the Bill to provide for full decriminalization of abortion in Ireland.”

Doctors for Choice today have joined with Action on X and other groups in criticising aspects of the proposed Heads of the Protection of Life during Pregnancy Bill 2013.

Doctors for Choice welcome any improvement in the care of women who choose to have an abortion however it remains unclear whether this Bill would provide an ‘effective and accessible’ procedure for a woman in the position of Savita Halappanavar or in the X case.

Dr Peadar O’Grady has said “The inclusion of a criminal sanction of up to 14 years against women or doctors will hamper good practice and increase the risk of suicide in vulnerable patients through stigma and its emotional consequences: fear and distress.Fear of prosecution, a noted ‘chilling factor’, can onlycause further delays in access’

‘The notion that women who are forced to travel for an abortion in a situation of a fatal fetal anomaly are carrying out the equivalent of a gravely serious crime is particularly offensive’ he added.

‘The prospect of prosecuting children and/or their parents or those carrying out a home abortion with medication bought on the internet is also very concerning’ he said

He noted ‘The overwhelming support in 1992 for the constitutional right to travel for an abortion confirmed that Irish people do not consider abortion a grave crime; as did the lack of any prosecutions before then for abortions ‘procured’ abroad’

He added ‘To our knowledge, criminal sanction has not been seriously advocated by any party to the debate on access to abortion services. As criminal sanction is dangerous, offensive and manifestly absurd, it should be removed from the Bill’.