Submission in relation to the general scheme of the PROTECTION OF LIFE DURING PREGNANCY BILL
2013.
AUTHOR.
Dr John Monaghan is a consultant obstetrician/gynaecologist in Portiuncula hospital, Ballinasloe,
County Galway, a general and maternity hospital delivering 2200 mothers annually.
A graduate of Trinity College Dublin in 1976, he trained in Ireland, the UK and Nigeria. He was
assistant master at the National Maternity Hospital from 1983 to 1986 and has been a consultant for
27 years, currently a member of the Irish Medical Council.
Introduction.
This submission relates to 4 principal items related to the heads of bill as published.
These are:
Head 2
The question of "clarity" as it relates to the findings of the European Court of human
rights.
Head 4
The question of suicide, or self-destruction as it relates to obstetric practice.
Head 12
The question of conscience, or "refusal of treatment"
Head 19
The offence of destroying unborn human life.
Head 2 THE QUESTION OF "CLARITY".
In the case of A, B and C v Ireland, the case of the woman referred to as "C" was successful in the
European Court of Human Rights(ECHR). This was a woman who had been treated for cancer. She
was unable to obtain clear advice as to the effect of the pregnancy on her health, or the effect of
medical treatment on the fetus. Arising from this judgement the Expert group stated: "Ireland is
under a legal obligation to put in place and implement a legislative or regulatory regime providing
effective and accessible procedures whereby pregnant woman can establish whether or not they are
entitled to a lawful abortion".
As it appears that C was unable to establish the degree of medical risk involved, I would question
whether these Heads of Bill offer any further clarity in resolving what is a medical issue, in other
words would such a patient have access to appropriate medical advice under the proposed
legislation?
There has been a considerable amount of published work on the question of cancer in pregnancy
and it is clear that therapeutic opportunities and new treatments have made a substantial change in
the treatment of cancer in pregnant women. A series of articles published in "the Lancet" in 2012
are attached to this submission. While three of them are of a technical nature, the leading article
gives a fairly clear picture of how this field is changing. The lead author, Dr Frederic Amant, has
spoken in Ireland.
It is clear that pregnant women with cancer should have access to a specialised service, led by an
Oncologist, but with expertise from a multidisciplinary team including surgeons and radiotherapists.
Such a service is available in other countries, most notably, as can be seen from the attached
literature, in Belgium.
In the context of The Protection of Human Life During Pregnancy Bill, the development of such a
service should be seriously considered by the Committee on Health and Children. It is clear from
these papers that many of the circumstances were abortion was practised in the past, it is no longer
necessary, with the availability of new regimes of chemotherapy and directed surgery which does
not harm the uterus and the unborn child.
If it is the priority of this Bill to protect women's lives, then the committee should be seriously
concerned with the development of a specialised National unit to manage cancers in pregnancy,
which are becoming more frequent. It appears likely that an existing Centre of Excellence could offer
this service without great costs. It is a matter of acquiring expertise rather than any specialised
equipment or other resources.
In the context of the ECHR and "Clarity", offering a woman the best treatment for cancer in
pregnancy, in a specialised centre, would serve a womans' needs, and those of her child, much more
effectively than an abortion law.
Head 4 The Supreme Court and the X case.
The second reason for bringing forward this legislation is the Supreme Court judgement of 1992,(
Attorney General vs X). In the X case the stated risk to the woman's life was the threat of suicide.
While the stated risk of suicide is a matter for the expertise of psychiatrists, it is proposed that an
obstetrician be involved in the decision-making, and the proposed termination of pregnancy would
be undertaken by that obstetrician.
It is a matter of grave concern that no evidence supporting a medical benefit to a suicidal patient
appears to have emerged during the first round of hearings held by the Health Committee in January
2013.
In contemporary medical practice any course of treatment must be based on evidence, from the
best quality research, which shows benefit from a course of treatment given to the patient.
An obstetrician, though not the expert in mental health, if he or she knows that there is no medical
evidence of patient benefit, and possibly harm, will find themselves in an impossibly conflicted
situation ethically if required to terminate the life of a normal fetes where no benefit to the mother
exists.
It would be of the gravest importance that the Committee on Health and Children satisfy themselves
on the evidence on this matter before enacting any legislation that relates to suicidal ideation in
pregnancy.
If the evidence presented to the Committee shows that abortion is not beneficial to the mother, or is
harmful, then it is impossible for this Head of bill to stand as it is. In particular the sentence "It is not
necessary for medical practitioners to be of the opinion that the risk to the womans life is inevitable
or immediate " would appear to be open to the widest exploitation and abuse. While a doctor, in the
case of, for example, heart disease, may be able to anticipate future deterioration as pregnancy
progresses, this could not be said to apply to the question of suicidal ideation.
There is a serious problem with an increasing suicide rate in Ireland, media reporting, for example
may affect suicidal ideation in people who exposed to it. To link pregnancy, particularly unintended
pregnancy, with suicide would appear to be dangerous.In other words to relate a crisis pregnancy
situation to suicide in a legislative act, may of itself increase suicidal ideation in some women who
are pregnant and vulnerable .
Head 12 Conscientious Objection.
The question of conscience in medicine has a long history. It is not question of conscientious
objection, but that physicians should behave in a conscientious manner. Medicine in the past has
many examples of the appalling failure of doctors to behave with conscience. Doctors have been
involved in the deliberate infection of patients(with syphilis for example), forced sterilisation or
abortion, illegal experimentation, torture and mass murder. These events, well documented, have
given insights to doctors which profoundly influence the practice of medicine today.
Arising from the atrocities of World War II a series of declarations came into existence in, the
Nuremberg Principles(1947), the Declaration of Geneva(1948) Helsinki(1964) and Tokyo (1975).
These were designed to lay down rules to prevent unconscionable behaviour by doctors. A recent
conflict between State authority and the medical profession related to the torture of prisoners at
Guantanemo Bay in Cuba (see attached article, British Medical Journal). The notion of Conscience
has recently come under attack, mainly because increasing numbers of doctors find abortion
ethically unacceptable. ( see article 4 and 5 attached)
Head 12 (1) in stating that "no medical practitioner, nurse or midwife is obliged to carry out or assist
in a termination of pregnancy", acknowledges conscience
The notes which follow Head 12 however appear to undermine this, in stating that this right to
conscientious objection does not apply in emergency situations. The question of emergency or not
does not affect the rightness or wrongness of any clinical act. That a doctor would refuse to treat a
patient whose life was in danger on conscientious grounds, is an irrational assumption, because if
the mother dies, the baby invariably dies. To refuse to treat a woman because she is pregnant has
been rightly been regarded as professional misconduct.
Head 19 The Offence of Abortion
(1) "it shall be an offence for a person to do any act with the intent to destroy or unborn human
life".
This is a most important statement vindicating the right to life of the unborn child under the Irish
constitution. It gives legal force to 2 statements given in the explanatory notes of Head 2. "An
obstetrician/gynaecologist is obliged to care for the pregnant woman and the fetus and, therefore
has a duty of care to both patients" (page 7) and: "in circumstances where the unborn may be
potentially viable outside the womb, doctors must make all efforts to sustain its life after delivery".
(page 8)
It has become practice in some countries to kill the child with a lethal injection before delivery, so
that he, or she cannot be born alive. ( example: "Feticide should be performed before medical
abortion after 21 weeks and six days of gestation to ensure there is no risk of a live birth " ) While
termination of pregnancy may be necessary to save the life of the mother, this has to mean that to
the offence: "act with the intent to destroy human life" applies in all circumstances, notwithstanding
that it may be necessary to deliver the child to save the mothers life. By this the doctor would not do
any act to kill the unborn child. I believe that this should be explicit in all parts of the Act, i.e. that a
doctor does not kill an unborn child in the womb in any circumstances.
Other Comments in relation to the Heads of Bill.
Head 1: "reasonable opinion" means an opinion formed in good faith, and based on evidence that
the intervention is an appropriate treatment for the medical condition in question and which has
regard to the
obligation to preserve the life of the child as far as practicable.
Head 4: If the serious problem of any medical evidence to support termination of pregnancy in cases
of suicidal ideation is confirmed, this section should be removed.
Head 9: The powers conferred on the Committee under subhead (1) appear extremely broad as in
"may direct any relevant medical practitioner to produce to the Committee any document or thing
in his possession………" . (This is a legal matter)
Head 10: Last explanatory note: last sentence beginning "Furthemore , if it were……" This may
contain misprint.
Head 12: Professionals other than doctors , midwives and nurses have rights to exercise conscience
also such as: counsellors,social workers, clerical staff and porters. Everybody should be permitted to
exercise their conscience where innocent human life is concerned.
End of written submission