Dr. Bernie McCabe on behalf of Professor Patricia Casey
Submission on Protection of Life during Pregnancy Bill 2013
Oireachtas Health Committee May 2013
Bio for Dr. Bernie McCabe
UCD Graduate. Working since 2006 in General Audit Psychiatry in South
Meath Mental Health Services.
Executive Summary
There is no evidence available suggesting that abortion is a treatment for those who are
mentally ill and suicidal.
Claims have been made that some women are suicidal simply because of the pregnancy only
and not because of any underlying illness. There is no scientific data on this group to assist
in predicting suicide. Psychiatry has little to offer this group beyond saying that mental
illness is absent.
Head 4 should be replaced by a clinical care pathway for suicidal women that does not
include abortion, so that they can readily access treatment
In the event that legislation as planned progresses, there are several aspects to Head 4 of
this bill and its explanatory note that require serious attention.
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Submission to Oireachtas Committee on Abortion
Consideration of Heads of Bill Head 4
I will consider Head 4 of this Bill since it is the only one that relates directly to psychiatry.
Head 4 deals directly with the provision of an abortion in the case of threatened selfdestruction.
The underpinnings of Head 4 (to be read in conjunction with the Appendix below)
In my opinion there is no scientific evidence to support the proposition that abortion is
necessary to prevent the loss of life by suicide in pregnancy either in those who are suicidal
due to mental illness or due simply to the pregnancy. No studies have been carried out in
this regard.
Prof. David Fergusson of Otago University, Christ Church, New Zealand is a researcher who
has carried out a number of studies into the relationship between abortion and mental
illness (Fergusson 2013). In the course of an interview on Morning Ireland on Tues. May 7th
2013, he stated :
I think it would be misleading for anyone to state emphatically that abortion does or does
not help suicidal women. So I'm really taking a position of sitting on the fence here, saying if
the research hasn't been done, we really need to adopt a neutral position on this argument,
until
better
information
is
available.
I have argued in detail in the attached Appendix that suicide intent in pregnancy is almost
always due to mental illness and that this should be treated in the same way as suicide
intent in any situation by assessment, possibly admission to hospital and treatment that
involves medication, psychotherapy or both. No research has been carried out on those who
are suicidal simply due to the pregnancy. Yet the Government is proceeding as if such
evidence exists.
The test that there must be a real and substantial risk to the life of the women that can only
be avoided by abortion cannot be met since suicide cannot be predicted, even in those with
mental illness.
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In those without mental illness there is absolutely no information on the risk factors or
likelihood of suicide. Since this group are not mentally ill psychiatry has nothing to offer over
and above that of those not trained as mental health professionals and accordingly should
not be involved. The role of psychiatrists in those who are not mentally ill has been
addressed in Law (P v Kehoe 1992).
Offering a pregnant suicidal woman an abortion if she says that the pregnancy is the reason
for this may seem to be common sense. However a large caution is required in this regard.
Interventions that seem intuitively correct may not turn out to be so. The classic example of
this is critical incident stress debriefing after trauma. It was be widely used in the 1980’s and
90’s only to be shown by subsequent research that not only did it not help in coping with
trauma but it made the impact worse. The lesson in this is that interventions, particularly
when the consequences are of such magnitude, are that we must rely on evidence rather
than common sense. Abortion as an intervention is irrevocable both for the woman and for
her unborn baby.
Conclusion: Head 4 as currently constructed should not be included in the current
legislation. It should be replaced by a clinical care pathway that would assist women who
are suicidal in accessing psychiatric assistance that is evidence based. Abortion as a
“treatment” for suicidality is not evidence based.
And 120 consultant psychiatrists have signed a letter agreeing with the statement
As practising Psychiatrists we are deeply concerned at the Government's stated plan
to legislate along the lines of the X-Case, as this will mean legislating for suicidality.
We believe that legislation that includes a proposal that an abortion should form part
of the treatment for suicidal ideation has no basis in the medical evidence available.
We as Psychiatrists are being called upon to participate in a process that is not
evidence based and we do not believe that this should be asked of the profession.
Any proposal being considered by the Government must be based on a rigorous
appraisal of the available psychiatric research and medical evidence.
Fourteen of our colleagues who responded disagreed.
Explanatory note for Head 4 of Protection of Life in Pregnancy Bill 2013
In the event that Government disregards the above concerns and recommendations and
proceeds to legislation I wish to outline my concerns about the current proposal.
1. The explanatory note (line 7, page 10) states that it is not necessary for the medical
practitioner to be of the view that loss of life is inevitable or immediate. This in my
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opinion is a very low bar – how far into the future should one consider the risk to
apply for? Should it be 6 months, 2 years, 10 years etc? This has the capacity to
sweep up almost anybody who threatens suicide since a psychiatrist can never be
sure that at some time in the future the person will not harm themselves despite the
rarity of suicide and the problem of prediction. The tendency of doctors to err on the
side of caution when suicide is threatened on the grounds that nobody can say
suicide will not occur leaves this legislation open to wide use and abuse.
2. In line 11 (page 10) the Explanatory Notes state that three doctors are required to
more accurately assess suicide intent. There is little difficulty with assessing intent or
in assessing risk factors and this is something that psychiatrists have competence in.
It is the prediction of when and whether that intent will be acted upon that is flawed
and it is not possible to predict this. The number of doctors used cannot improve an
inherently weak methodology (see Appendix).
3. In the last paragraph of page 11 the explanatory note says that where the unborn
may be potentially viable outside the womb doctors must make all efforts to sustain
life after delivery. However, that requirement does not go so far as to oblige a
medical practitioner to disregard a real and substantial risk to the life of the woman
on the basis that it will result in the death of the unborn…..it is a clinical assessment
as to whether the mother’s life….is threatened by a real and substantial risk that can
only be averted by a termination of pregnancy.
This wording is ambiguous and I want to tease this out a bit more.
4. The legislation as currently proposed has no time limits and abortions could be
carried out up to birth on physically healthy pregnant women and physically healthy
unborn babies, in women without mental illness who are adjudged to be suicidal.
Late term abortions are a major risk factor for subsequent mental illness in the
woman. They are banned in most jurisdictions.
On the other hand Minister James Reilly has stated that where a baby is potentially
viable it will be delivered and its life sustained. He indicated that should the baby
develop physical or intellectual disability as a result of prematurity that the State will
take it into care. This has potential legal consequences for the state. The whole idea
of delivering a potentially viable baby prematurely in a suicidal woman is
preposterous. It also ignores the reality that the reason the mother is seeking the
abortion is because she does not want the baby alive. Women do not seek abortion
other than to ensure that the baby is born dead and the Royal College of
Obstetricians and Gynaecologists has developed Guidelines to ensure that this
occurs in late term abortions. The suggestion that a near viable/viable baby would
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be kept alive was clearly made as a way of diluting the reality that the legislation will
allow abortions up to birth.
The time limits need to receive serious consideration in respect of suicide.
The possibility that this legislation will either allow late term abortions or the
premature delivery of potentially viable infants with the attendant risks associated
with this are both unconscionable prospects and induce revulsion. It points to the
flaws in Head 4 of this legislation.
Relevant issues not considered in Head 4
1. Selection of doctors: There is no information on how doctors carrying out the
assessments will be selected or on how they will consult with each other. The first
doctor could potentially call on two likeminded colleagues (either obstructers or
facilitators). How can this be avoided?
2. Exclusion of doctors: Will doctors with particular perspectives (facilitators or
obstructers) be preferentially selected for the initial assessment and for the appeals
panels? This has been suggested by some politicians and how will this be avoided?
3. Names of doctors: Will the names of doctors engaged in the assessments and in the
panels be provided under FoI inquiries in respect of the annual reports?
4. Information for reports: It is crucial that information on age, level of suicide intent,
prior treatments, gestation at time of abortion and so on is provided for the annual
Abortion reports. The number of refusals and the reason must also be provided.
5. Reimbursement of psychiatrists: The proposed reimbursement psychiatrists are to
receive for their work in respect of this legislation should be made public before the
final legislation is published. As with all doctors working the public sector the
reimbursements made to individual psychiatrists for this work should be made public
annually.
6. Benchmarking before legislation: Those who say that abortion will be rare and only
occasionally used need to provide information on the possible numbers of abortions
likely to take place annually. Similarly, those who claim there are large numbers of
suicidal women seeking abortions elsewhere need to provide possible figures. This
data must be provided before legislation is enacted so as to act as a benchmark in
allowing evaluating the use and impact of this service over time.
7. Evidence of abortion as last resort: What evidence will the assessing doctors have to
provide concerning treatments before abortion is recommended? What will the test
for the adequacy of these be – for example with it be sufficient to say that the
person has seen a counsellor? Will a detailed report from the counsellor have to be
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provided? How can it be shown that abortion is the last line of treatment? These
need to be addressed in the final legislation and specified in the legislation.
8. Abortion as a treatment in mentally healthy people: Following from 7 above, for
those who are not mentally ill but are suicidal only because of the pregnancy there
will be no other “treatment”. Psychiatrists will thus be expected to recommend
abortion as a “treatment” for unwanted pregnancy. The psychiatric profession
should have no role in this process beyond saying that the person has no mental
illness. This is an abuse of the profession in order to facilitate the requirements of
the State. Psychiatrists in the past have allowed themselves be used as a tool of the
state by incarcerating in mental institutions those who were unwanted, who were
single mothers, who were mentally handicapped or who were political dissidents.
We must not now be used by the state to duck the ethical and constitutional issues
that the X case ruling raises. Under the current proposals the reputation of the
profession will once again come into disrepute.
Conclusions
There is a dearth of information on the value of abortion in suicidal pregnant women and it
has never been studied. The Government is acting as though there is evidence to support
this.
Psychiatrists should not be involved except in so far as we can treat pregnant women with
mental illness. Psychiatrists must base their practice on evidence.
Should legislation proceed as proposed there are a number of concerns relating to Head 4
that must be addressed.
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APPENDIX
The purpose of the proposed legislation is to prevent suicide in those who have suicide
intent posing a real and substantial risk to the life of the woman that can only be averted
by an abortion.
What is suicide intent as opposed to suicidal ideation?
Passive death wishes are thoughts of wanting to be dead but without any desire to bringing
this about oneself. For example “If I died in my sleep I wouldn’t mind”.
Suicidal thoughts/ideation is defined as considering taking steps to achieve this. They may
manifest as thoughts of self-harm e.g. I thought I might take an overdose” or “I would like to
end it all but I have no plans” or more persistent ideas.
Suicide intent is a measure of the extent to which a person wishes to take their lives and its
assessment involves an evaluation of the extent to which a clear plan to achieve this has
been formulated along with the person’s view of the future, personal supports and so on.
The current legislation is in respect of suicide intent as distinct from suicidal ideation
(thoughts). There is little comfort in this since intent fluctuates and when a person is in crisis
it may be elevated only to reduce rapidly as distress falls. Its assessment depends on what
the person tells the doctor and how the person behaves. Anybody having high intent should
be hospitalised in order to ensure safety, to facilitate assessment of triggers and to arrive at
a diagnosis and management plan.
Is there evidence that abortion prevents suicide?
There is no evidence that abortion prevents suicide.
1. No textbook of psychiatry or of perinatal psychiatry says this. These include:
Modern Management of Perinatal Psychiatric Disorders (2009) Henshaw et al
Seminars in Liaison Psychiatry (2012) Guthrie et al
Handbook of Liaison Psychiatry (2007) Lloyd and Guthrie
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Seminars in General Adult Psychiatry (2007) Stein and Wilkinson
Comprehensive Textbook of Psychiatry (2009) Kaplan and Sadock
New Oxford Textbook of Psychiatry (2012) Gelder et al
2. No studies have examined the role of abortion in preventing suicide in women who
are suicidal during pregnancy. In the proposed legislation psychiatrists are being
involved in an assessment process for a procedure that has no research to ground it.
We are being asked to decide that a woman’s life may be saved by an abortion and
only by this.
Prof. David Fergusson of Otago University, Christ Church, New Zealand is a
researcher who has carried out a number of studies into the relationship between
abortion and mental illness (Fergusson 2013). He is a self-described pro-choice
atheist. In the course of an interview on Morning Ireland on Tues. May 7th 2013, he
stated the following:
I think it would be misleading for anyone to state emphatically that abortion does or
does not help suicidal women. So I'm really taking a position of sitting on the fence
here, saying if the research hasn't been done, we really need to adopt a neutral
position on this argument, until better information is available.
email correspondence with me on Sun. May 5th (published with his agreement) he
wrote:
In
Hi Patricia,
Thanks for your email. In response to your comments, I think that it is drawing a long bow to
claim that abortion may be an effective response to suicidal thoughts in pregnancy. As far as
I know there is no evidence to support this view and claims of indirect evidence seem
farfetched.
Both of these statements clearly urge caution as there is an absence of research to justify
abortion to prevent suicide yet the Government is proceeding as if there is evidence that
abortion helps in this.
Suicide intent in those with mental illness
High suicide intent most commonly occurs in those with mental illness such as depressive
illness, schizophrenia, bipolar disorder and so on. The management of this is in the usual
way, with admission to hospital for safety and assessment. The CMACE report from Britain
(reports of maternal mortality) (2011) show suicide in pregnancy is rare. Overwhelmingly it
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occurs in women with mental illness that is under treated or undiagnosed. These reports
point to the vital importance of early diagnosis and treatment with pharmacological, social
and psychological interventions. These reports also demonstrate that women die by suicide
in pregnancy even in countries where abortion is readily available.
Suicide intent in those without mental illness
We do not know the size of the group who are suicidal in pregnancy with no mental illness.
Current data shows that around 4,000 women travel to Britain (and it is claimed also to
Holland) for abortions every year. It is presumed that amongst these are women who are
suicidal. However there is no data to substantiate this claim since the UK abortion figures do
not include suicide as a specific ground.
No studies have been carried out on those who are suicidal but are not suffering from
mental illness. So the proposal to legalise abortion in this group is being enacted in a
research vacuum. For example we have no information on the risk factors for suicide in this
group let alone on our ability to predict who might actually die by suicide.
Moreover the suicidal thoughts/intentions in those with no mental illness could be driven by
other considerations such as having an abusive spouse or being coerced. In the recent past I
saw two such women who presented the Emergency Department of the Mater Hospital
having taken an overdose. In both instances they presented as wanting an abortion. On
assessment they both admitted they were happy with the pregnancy but were being
coerced, under threat of being abandoned (one by a parent, the other by a partner) unless
they aborted the baby. The distress of this led to the episode of self-harm. One, at the time
of the overdose, had selected a possible name for the baby. With support, both continued
the pregnancy and gave birth.
Psychiatrists have no particular provenance in dealing with those who have no mental
illness over and above those with no mental health training. This issue was adjudicated
upon in People (DPP) v Kehoe (1992) who said in the particular case “Jurors do not need
psychiatrists to tell them how ordinary folk who are not suffering from any mental illness
are likely to react to the stress and strains of life”. To involve psychiatrists in an area in
which they have no special expertise, apart from assessing the presence or absence of
mental illness, is a misuse of the profession.
Is there ever a situation where abortion is the only way to prevent suicide?
At the Oireachtas Hearings all three perinatal psychiatrists said that they have never seen a
suicidal pregnant woman for whom abortion was a treatment
In addition the submissions to the Health Committee in Jan 2013 of Prof. Kevin Malone UCD,
Prof. Lucey representing St. Patrick’s Hospital, Dr. Sean O’Domhnall and I all wrote/stated
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that there was no evidence that abortion was a treatment for those who are suicidal in
pregnancy.
The only evidence that has been presented to suggest abortion has a role in treating suicidal
intent in pregnancy comes from studies of the numbers of women dying by suicide in
pregnancy in decades past (Weir 1984) or in developing countries. The latest example of this
was a recent comment by a psychiatrist in the media that 10% of women dying by suicide
before the 1950’s were pregnant. This claim was rebutted in a letter to the Irish Times on
May 7th 2013Dr. Dermot Walsh, retired Inspector of Mental Hospitals responded:
The claim that from 1900 to 1950 10 per cent of Irish women of child-bearing age
dying by suicide were pregnant at death, recently reported in the media, rests on no
secure ground of which I am aware. In fact the first comprehensive survey of suicide
in Ireland of the modern era, although limited to Dublin, which I co-authored,
covering the years 1954-1963 appeared in the British Medical Journal in 1966.
Coroners’ inquest records and post mortem reports did not allude to pregnancy in
any of the 58 females of child-bearing age identified as dying by suicide. This does
not exclude pregnancy in these cases, given the cultural mores of the time. Nor do we
know the pregnancy status of the 66 similarly aged women recorded as dying by
suicide in Ireland in 2011.
Finally the ability of psychiatrists to determine the likelihood of transition from
suicidal threat to suicide itself, in the absence of any reliable biological marker, is
fragile at best.
No convincing evidence has been produced that abortion is necessary to treat suicidal
women in pregnancy yet despite this the legislation appears to be proceeding. And as stated
by Professor Fergusson no studies have been carried out to assess this.
How can a Real and Substantial risk be demonstrated?
The real and substantial test required by this legislation can never be met since we cannot
predict suicide due to it its rarity. While we can identify the risk factors associated with
suicide, turning these into predictors of who will die by suicide is impossible since these
same risk factors are also present in those who do not die by suicide (Owens 2005).
Research into this shows we over predict suicide even in high risk groups such as those with
mental illness (Pokorney 1983).
In those who are not mentally ill and saying they are suicidal because of the pregnancy
alone prediction is impossible – we have no idea of the risk factors for suicide in this group
and no tools to aid us in deciding who will and will not take their lives. So a test of what is
real and substantial is impossible since there is no information on suicide in those pregnant
women without mental illness.
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References
Centre for Maternal and Child Enquiries (CMACE). (2011) ‘Saving Mothers’ Lives: Reviewing
Maternal Deaths to Make Motherhood Safer: 2006–08.’ The Eighth Report on Confidential
Enquiries into Maternal Deaths in the United Kingdom. BJOG:118 (Suppl. 1):1–203.
Fergusson (2013). Does abortion reduce the mental health risks of unwanted or unintended
pregnancy? A re-appraisal of the evidence. Australian and New Zealand College of
Psychiatry. 1-9.
Owens (2005). ‘Mortality and suicide After Non-Fatal Self-Poisoning: 16-Year Outcome
Study’. British Journal of Psychiatry. 187, pp. 470-5.
People (DPP) v Kehoe (1992)
Pokorny. (1983). ‘Prediction of Suicide in Psychiatric Patients: Report of a Prospective
Study’. Archives of General Psychiatry. 40,3, pp. 249-57.
Weir (1984). Suicide during pregnancy in London. 1943-1962. In Suicide in Pregnancy. Eds.
Kleiner and Greston. Wright: Boston.
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