Submission to the Oireachtas Hearings May 20th 2013 , Dr Jacqueline Montwill
Introduction:
Chairman, members of the committee, ladies and gentlemen, thank you for
the opportunity to address your committee, on this important issue.
Head 4 of the proposed Bill, “risk of loss of life from self-destruction”, is
seriously flawed ; the treatment it proposes is not a treatment , the treatment
it proposes is never the only treatment , and if truly suicidal with mental
illness, the patient may not be able to give a valid consent .
1) The treatment it proposes under law is not an Evidence based
treatment .
There is no evidence to support the view that Abortion has any mental
health benefits, there is evidence to support that in some women Abortion
may be associated with small to moderate increases in risks of mental
health problems including suicidality. There is an ethical problem in offering
a procedure as a life saving treatment to a suicidal woman, where that
intervention also poses risks of suicidality as an outcome.
2) It is absolutely incorrect to say that Abortion could ever be the only
treatment for stated suicidal intent.
Suicidality is multifactorial. Our treatment packages are multifactorial.
We have worked in Multidisciplinary teams for over 20 years and the
different skills from all our team members are essential for the full
assessment and treatment of our patients. Best Practice treatment for
mental illness is, and always will be ; appropriate full assessment,
psychological support or intervention , and medication if needed.
Remember we have social workers, occupational therapists and
psychiatric nurses who work with people in their own homes and
communities. When discharged from hospital, we continue to work with
the patient in the community as long as it’s needed. The proper care of a
suicidal pregnant woman will entail support and treatment throughout
her pregnancy , delivery and in the post partum period. Longer term
intervention may be required , depending on the circumstances.
We are very aware that Mental Health Intervention must include
assessment of all the stressors in the patient’s life at the time in
question .
These stressors can include relationship difficulties , poverty ,
unemployment or lack of occupation during the day , accommodation
issues , difficult dynamics within the family currently or in the past , and
lack of other supportive relationships .
It is within this holistic view that the treatment package for a suicidal
pregnant woman would be appropriately assessed and delivered.
Therefore , it is completely illogical to say that the only treatment for
suicidal intent during pregnancy would be an Abortion.
3) Valid consent to an Abortion may not be possible while acutely suicidal
due to mental illness.
 It is most important to outline to you clearly that a Psychiatric
Emergency or Crisis is fundamentally different to any other medical or
surgical emergency. This is because of the nature of the Disorder. In a
true Psychiatric Emergency, the patient’s judgement is
frequently impaired. Our role at that time is to administer the most
appropriate psychiatric treatment and support. It would be highly
inappropriate to impose an irrevocable intervention at that time, when
the patient may not have sufficient mental capacity to give a valid
consent to that intervention. The patient ‘s right to bodily integrity is
paramount . It cannot be argued that a Termination is a life saving
procedure in suicidal states in mental illness, as suicidality responds to
other treatments .It can also never be argued that a Termination must
occur at that time , as suicidal intent can fluctuate over time , and
resolve. There is no inevitable decline to suicide that can be accurately
predicted.
 It is my view that if a Termination was prescribed and given at that time ;
the patient would be in a strong position to accuse their treating team
of failure in their duty of care . It could be rightly claimed that we as
Psychiatrists, failed in our duty to adequately protect the patient during
a period of mental illness. Do not forget that mental illness responds
to treatment. Acute crises respond to treatment and they settle
down, often in a short period of time. Any impairment of judgement in
these situations will resolve with treatment.
 Even in mild Depression, not necessarily in a suicidal state , a patient
can have very negative thoughts about their life. During such periods,
we routinely tell our patients: “Do not dump your boyfriend. Do not
leave your job at this time. Do not make any major life decisions now.
When your mood has lifted in a few weeks time, you will see things
differently.” In a state of true suicidal intent, these negative feelings are
exaggerated even more , but with treatment and time , they will also
resolve.
A particularly effective Psychological treatment that works for patients
who feel hopeless and helpless in their life is CBT, “Cognitive Behavioural
Therapy. “ which teaches Patients to recognise how their mood affects
their thoughts and behaviour, and how to change this . This is an
example of how psychological intervention for a brief period of time ,
empowers the patient to have a marked role in their recovery.
With this law, the focus will be directed away from a full and proper
assessment of the patient and directed instead to an assessment for a direct
Abortion. As treating Psychiatrists , we do not assess suicidality for any reason
other than to prescribe the appropriate psychiatric treatment. Society should
do the same. Society should validate an expression of extreme psychological
distress, not normalize it. Mental illness is just as important as physical illness ,
perhaps even more so . Because it affects your thinking , your relationships and
your ability to function .It is exceptionally important to state : The proper
response to stated suicidal intent should always be appropriate evidencebased clinical treatment. Direct abortion is not a clinical treatment , it
is a social solution.
 We must be very clear, this law will do damage way beyond the
boundaries of simply legislating for a medical treatment that is without
the foundation of medical evidence and good clinical practice. It will
directly target and profoundly damage the very nature of the
doctor-patient relationship. The interaction will change from
therapy to judgement interviews for an Abortion . It will put the patient
in an impossible situation where outside demands will impact on her
treatment , taking her out of the proper therapeutic alliance with her
psychiatrist and treating team.
We have discussed where patients have mental illness with suicidal
ideation and intent . It has been correctly stated that suicide in
pregnancy is very rare. When it occurs it is due to mental illness, and
the appropriate treatment , not an Abortion , would have saved those
lives . However , in my opinion , these are not the patients who will be
asking for an Abortion under the proposed Law . The majority of patients
who will avail of Abortion in this way are most likely to be those who
have no mental illness , and do not wish to be pregnant. We have no
tools to predict who will kill themselves . It is likely that requests from
these patients will be processed through the proposed Law , and this
will result in widespread direct Abortion .
In conclusion ; for those patients with Mental Illness ;
There is no evidence that Abortion is a treatment for suicidal intent ,
there is no situation where it would be the only treatment indicated ,
and the issue of valid consent to an Abortion while truly suicidal due to
mental illness, poses serious ethical concerns.
In my opinion, the patients who will avail of termination of pregnancy
through this law are most likely to be those patients who have no
mental illness, but who do not wish to be pregnant.
Dr Jacqueline Montwill , MRCPsych
Consultant Psychiatrist
My name is Dr Jacqueline Montwill, I have worked in Psychiatry for 17 years ,
over 8 years at Consultant level. I am a Member of the Royal College of
Psychiatrists and I am on the Specialist Register for Psychiatry of the Medical
Council of Ireland and the General Medical Council (UK ).
I have worked in services both in Dublin and outside Dublin . I have provided a
Consultant liaison service to the Obstetric departments in the Hospitals I have
worked in , and would also have managed many patients in our clinics
throughout their pregnancies , before and after delivery .
I have worked in Addiction services in Ireland and the UK , and been involved
in the management of pregnant women with Addiction disorders and mental
illness . I have also worked very briefly as a Consultant in a Perinatal Psychiatric
Service.
Treatment plans and delivery of psychiatric care always involve the MultiDisciplinary Team . Routine practice for Consultant Psychiatrists working in
services where there are no Perinatal Psychiatry services would include
accepting referrals from GPs , Public Health Nurses and Obstetricians &
Gynaecologists .Conditions assessed and treated would include women
considering pregnancy or in any of the Trimesters of pregnancy presenting
with Anxiety Disorders , Mood Disorders and Psychosis . Occasionally women
are referred who have been traumatised by previous difficult or distressing
pregnancies or deliveries. These patients are managed through their next
pregnancy and often have a very good outcome .