Many of the country's leading medical experts have criticised the abortion Bill proposed by the government while giving evidence at the Oireachtas Committee hearings. These are some of the most important points made, while a more complete text of their evidence can be found below.

The Master of Dublin's busiest maternity hospital, Dr Sam Coulter Smith, said there were 'major ethical and moral dilemmas' arising for Obstetricians from a law that would allow abortion on suicide grounds.

He said that many of his colleagues had serious concerns regarding the proposed legislation, and warned that it may lead to a surge in abortions.

Fellow Obstetrician, Dr John Monaghan of Portiuncula Hospital, said that the proposal would bring "an enormous change in obstetric practice that an obstetrician is being asked to intervene in a physically healthy pregnancy." He added that  he was extremely unhappy with the idea of Obstetricians becoming a "mindless terminator for psychiatric reasons".

Dr Monaghan warned that the "psychiatric or suicide risk clause has been brought in other jurisdictions and has been widely - I would say universally - abused".

Top perinatal psychiatrist, Dr John Sheehan, said that patients who were suicidal needed professional help, not an urgent termination of pregnancy. The proposal would make " psychiatrists the gatekeepers to abortion", he said, adding that it was impossible for psychiatrists to predict the future and that "being unable to predict who will die by suicide is, therefore, likely to lead to multiple 'false positives'".

He warned that there was no time limit set in the heads of Bill, and late term abortion could have a very negative  effect on the woman's mental health.

Dr Sheehan also said that abortion could "increase the risk of mental health problems" amongst women.

Renowned psychiatrist and Ireland top expert on suicide and its causes, Professor Kevin Malone, gave compelling evidence to the hearing. He said that the proposed abortion legislation could accelerate suicide rates in younger men, and that "contrary to the notion of it saving the lives of an extremely small number of females it may be placing a greater number of young male lives at risk."

He told the Committee that abortion was not an evidenced based treatment for mental illness and asked "as a clinician, I wonder how then it can overnight become a recommended psychiatric treatment in Ireland."

Dr Seán Ó Domhnaill, a consultant psychiatrist, said that the proposed law would make abortionists of doctors and that abortion was a "medieval solution to crisis pregnancies". He also warned that "it is a fact that there are some psychiatrists who are ideologically supportive of abortion and who believe it should be available on request or on demand to Irish women. It stretches the boundaries of credibility to suggest that those psychiatrists would not be more likely to approve abortions if the Bill becomes law." Dr Ó Domhnaill said that he had worked in other jurisdictions where consent forms for abortion had been pre-signed by doctors.

Psychiatrist Dr. Jacqueline Montwill said that "with this law, the focus will be directed away from a full and proper assessment of the patient towards an assessment for a direct abortion." She said the proposal to legalise abortion on suicide grounds was "seriously flawed" since abortion was not a treatment, and patients who were truly suicidal with mental illness may not be able to give a valid consent.

Her colleague, Dr Bernie McCabe, said that rather than legalising abortion an "evidence based clinical care pathway that would assist women who are suicidal" should be put in place "because abortion as a treatment for suicidality is not evidence based."

She noted that "what seems to be intuitively correct may not be so" and that if psychiatrists "offer abortion when we know there is no evidence base, we are not being fair, right or just to our patients. Our patients deserve that we be just."

Dr. Rhona Mahony, who favours abortion legislation, admitted that the legislation would not change practise in relation to physical illness arising in pregnancy.  "On the question of whether it would alter my practice if we passed the legislation, the answer is 'No'" she said.

Her brother-in-law, Dr Peter Boylan, who is the other obstetrician publicly supporting the abortion legislation also admitted that in his practice he had "not come across an instance where a woman has died because we have not terminated her pregnancy."

What they said

Dr Sam Coulter Smith Ob/Gyn

In respect of loss of life from self-destruction there are a number of issues that need to be raised. First, this is an extraordinarily rare situation with the incidence of suicide in pregnancy of the order of one in 500,000 pregnancies as per United Kingdom figures. Second, our psychiatric colleagues tell us that there is currently no available evidence to show that termination of pregnancy is a treatment for suicidal ideation or intent and, as obstetricians, we are required to provide and practice evidence-based treatment.

It, therefore, creates an ethical dilemma for any obstetrician who has requested to perform a termination of pregnancy for the treatment of someone with either suicidal ideation or intent.

The fact that there is no gestational limit in respect of the third scenario relating to suicidality is a major ethical issue for obstetricians. I will illustrate this with two scenarios. First, let us consider the case of a patient who is 25 weeks' gestation. If she is deemed to be sufficiently suicidal to require a termination of pregnancy by one or more psychiatric colleagues, an obstetrician who is tasked with dealing with this situation is faced with an enormous ethical dilemma. Delivering a baby at 25 weeks' gestation could lead to death, due to extreme prematurity or it could lead to a child with cerebral palsy or with other significant developmental issues for the future. This outcome would be entirely iatrogenic and the responsibility of those clinicians who have agreed to be involved in the process. This is a source of serious concern for myself and my colleagues.

My overriding concern, however, in relation to the whole area of self-destruction and termination of pregnancy to prevent same, relates to the lack of evidence to show that termination is of any assistance in this scenario and that we as obstetricians and gynaecologists must be able to stand over the decisions we make as being based on good medical evidence.
  
It is my view and the view of many of my colleagues that the inclusion of suicidality within the legislation may, and I stress may, in the long term lead to an increase in demand for termination in this country.

I also confirm to the committee that we as a profession, and particularly in my hospital, have concerns about the potential for increased demand for termination services in this country as this may be an unintended consequence of this legislation in its current form.

When we are talking about saving mothers' lives, we should not use the terms "abortion" and "saving mothers' lives" in the same sentence, full stop. It is a dreadful reflection on anyone who would actually do that. This is about saving mothers' lives, preserving dignity and not stigmatising anybody. These are wanted pregnancies, loved pregnancies, and intervention has to be made to save the mother's life. To call it an abortion is wrong.

Dr Gerard Burke Ob/Gyn

It is important that the Oireachtas would at some point address the state of the maternity services. The unit in Limerick which I represent, for example, has the lowest number of obstetricians in the whole of Europe at two per 100,000. This shortage of resources will likely lead to some difficulties in the future.

Dr John Monaghan Ob/Gyn

It reflects an enormous change in obstetric practice that an obstetrician is being asked to intervene in a physically healthy pregnancy. While it appears from the legislation that an obstetrician would be involved in the decision-making, he is referred to otherwise possibly as a technician, suggesting that maybe he should be involved so he does not feel like a technician. However, my gut is extremely unhappy with the idea of a mindless terminator for psychiatric reasons. This decision was made 21 years ago. From the hearings that were held in January, I do not believe any case of suicide associated with refusal of termination has ever surfaced. The evidence from my reading of it seems to be extremely poor. Many of the speakers earlier were happy to take the expert advice of a psychiatrist to act if required. I am not certain how a psychiatrist can reach a decision on this matter where to date I do not believe any evidence has been produced.

Part of my reason for bringing this up is that the medical risks involved with cancer in pregnancy, which is one of the major threats to a woman’s life that may lead to a need for termination, have changed dramatically over the past few years. A Belgian doctor, Dr. Frédéric Amant, has spoken in Ireland several times on these developments and there are several publications in The Lancet on the matter from last year, which I attached to my submission. While they may be technical in nature, I added them for two reasons. The first is that they describe the changes in the treatments available and the second is that they deal with the problems of treating cancer in pregnancy. The three that are listed are under-treatment because of fear of treating the baby, late diagnosis and the carrying out of terminations of pregnancy when not required.

The psychiatric or suicide risk clause has been brought in other jurisdictions and has been widely - I would say universally - abused. Last year, The Daily Telegraph did an exposé of the abuse of psychiatric reasons in the UK, with the use of pre-stamped forms. People went to one doctor to get a form stamped, then to another to get it stamped and then got a termination. I can see no reason, despite the safeguards built into this legislation, that culture could not arise in this country in the future.

I was asked about maternal deaths. There has always been a difference, as is well known, between Ireland and the United Kingdom. The question was whether this was because of abortion. I am not suggesting it is because of abortion, but I suggest that if abortion was a significant factor in the improvement of maternal health, the figures should be better in the United Kingdom than they are in Ireland, especially given that a very large number of terminations are done in UK. I suggest that the results should be better in the UK than they are here if medically mandated abortion improves women's health.

A related issue which I have studied slightly myself is the problem with recruitment into obstetrics and gynaecology in the United Kingdom for the last 35 years. The matter is well written up in the reports of the Royal College of Obstetricians and Gynaecologists. Another study which was published in the British Journal of Obstetrics and Gynaecology showed that recruitment into obstetrics and gynaecology was highest in Northern Ireland and lowest in places like Leeds and Oxford. Certainly, Dr. Jim Clinch, who was one of the doctors who was keen to come today but could not, is of the opinion that if an abortion culture becomes widespread, it seriously affects recruitment into obstetrics and gynaecology. That would have been my experience. I worked in the NHS for three and half years in total. Certainly, in my time in the north of England, I used to speak to medical students and ask them if they would consider a career in obstetrics and gynaecology. During the two years I was in the north of England, no student said he or she was interested in a career in obstetrics and gynaecology. When asked the reasons, fear of being sued and a hard-working rota were cited, but the single biggest factor was that students did not like the abortion culture, not for particularly ethical reasons but because it was distasteful to them.

Deputy Durkan also asked about surgical means. I did not check on the lethal injection but I did consult with a colleague yesterday on the question of surgical termination as in suction termination whereby the baby is sucked out and destroyed. This is the sort of technique that has been in use for many years in the UK since abortion was legalised. I asked my colleague whether this is commonly done and she said it is, principally because it is cheaper, even though the medical means are more appropriate. I cannot give any figure for the lethal injection but I know that patients of mine have availed of that and it is not rare but I cannot give any figures on frequency of use.

Deputy Bernard J. Durkan:   At what stage of a pregnancy could it have been done?
Dr. John Monaghan: The suction termination would be up to between 12 and 14 weeks. The other would be from then on, up to term in some cases.

During the week the trial of an American, Dr. Gosnell, showed there are ferocious breaches of trust and dishonesty associated with what one might call the abortion industry and it would be appalling if that came into this country.

The question arises, in particular in the psychiatric area, where the patient does not want the child to be born alive. That is why I suggested earlier that it should never be the situation that the child is directly killed in the uterus at any stage of gestation. It would not be unknown for babies to be born supposedly at 17 weeks but to be found to be several weeks further on, particularly in the circumstances of psychiatric illness, uncertain dates and so on. I would strongly advocate that there should be no possibility that a child would be eliminated before it was born. At 23 weeks, certainly if a child was going to be born because of serious maternal illness or because of a foetal reason, it would be transferred to a large Dublin hospital, or to Cork or Galway.

I think there is a very significant change [in medical practise]  in the proposed legislation. For the first time, deliberate abortion, as opposed to forced abortion, will be available in this country. I refer to termination of pregnancy in a formal legal sense, rather than in dealing with medical emergencies. It remains to be seen what effect this will have. I think it is very difficult to predict. As I said before, I am very concerned about the ability to control the psychiatric aspect of it.

It has been the situation in the United States where legal representation has been provided for a foetus that is under threat. One of the questions that is also unanswered is what is the role of a father in a situation where termination of pregnancy is to be undertaken.

Dr John Sheehan Consultant Psychiatrist

In a psychiatric emergency such as when a patent is depressed and has suicidal intent, the patient may have impaired capacity and should be advised not to make irrevocable decisions. The patient probably cannot give informed consent. Those of us who see people with suicidal intent often see people who feel overwhelmed, unsupported and hopeless and who are often desperate and agitated. The person often has what is called cognitive constriction and can see no other option in front of them except ending his or her life. Such a patient needs professional help, not an urgent termination of pregnancy.

Second, psychiatrists are doctors, not judges. If head 4 is enacted, psychiatrists will be asked to determine if there is a real and substantial risk to the life of the mother in order that she may procure a termination of pregnancy. This is a role in which Irish psychiatrists have not been involved to date. Many will not see this as their role as medical practitioners. The role could be construed as making psychiatrists the gatekeepers to abortion. Psychiatric practice relates to assessment and treatment of patients, not assessment and adjudication. Psychiatrists are not judges.

My third point relates to the women who currently travel abroad for terminations. In the submission to the committee earlier this year, the three Irish perinatal psychiatrists - Dr. McCarthy, Dr. Fenton and myself - stated that with more than 40 years of combined clinical experience, we had not seen a single case where termination of pregnancy was the treatment for a mental disorder. If head 4 is enacted, however, it may well change the patient profile currently seen by Irish psychiatrists. It is likely that women will be referred from that population who currently travel for abortion. The extent of mental health problems and suicidal ideation among that population is unknown and, hence, the utilisation of the proposed legislation by that population is unknown.

Fourth, it is impossible for psychiatrists to predict the future. The explanatory notes for head 4 state, "It is not necessary for medical practitioners to be of the opinion that the risk to the woman's life is inevitable or immediate". The risk of a woman dying by suicide in pregnancy is between one in 250,000 and one in 500,000 live births.

The risk is exceedingly small. In practice, therefore, it would be impossible for any psychiatrist to accurately predict which woman will die by suicide in pregnancy. Being unable to predict who will die by suicide is, therefore, likely to lead to multiple "false positives". Psychiatrists are trained to assess and provide evidence-based treatments not to predict the future.

My final point relates to the potential adverse effects on the woman's mental health due to late abortion. There is no time limit set in the heads. That is, termination could, theoretically, occur up to a very late stage of pregnancy. Late abortion could potentially have a very deleterious effect on the woman's mental health.

[The heads of Bill] propose that someone who is deemed to have suicidal intent is able to make a decision about having a termination of pregnancy. It is completely at odds with what one would call standard good practice in psychiatry.

There seems to be this notion that because a person is expressing suicidal intent that the response has to be a rapid termination of pregnancy. That flies in the face of what we do at work every day of the week. It is exactly the opposite of what is regarded as good practice.

{Responding to questions] I will reply to some of the questions that have not been covered so far. Senator Bacik asked if I could state that X would never commit suicide. I do not believe any psychiatrist or doctor can ever make a statement that a certain person will never commit suicide. It is equally true, however, that it is also impossible for a doctor to state that somebody will commit suicide. The position in which psychiatrists are potentially placed by the legislation is to state that there is a real and substantial risk that the person will complete suicide. Even studies that looked at very high risk populations, which do not include the population we are discussing, show that in such very high risk populations an expert will be wrong in 97 cases out of 100. Prediction is, therefore, very difficult; in fact, the word I would use is "impossible".

I will try to deal with a number of the questions. The first was whether the abortion safeguards could be flouted. At face value, the heads appear to be restrictive. Yet the international experience is that what initially appeared to be very restrictive, in practice has turned out to be not restrictive. At face value one could say the heads appear restrictive, but how it might work in practice is a different question. Again it ties into the point I made earlier on the application of the law to women who travel. We do not know the extent of mental health problems in that group or the extent of suicidal ideation. Therefore we cannot say with any accuracy how this will work in practice. On face value it looks restrictive, but the practice is another question.

Again, as mentioned earlier we would detain a person in his or her own interest, which would not impinge on other rights. On the evidence of termination of pregnancy increasing the risk of mental health problems, there is evidence to show that termination of pregnancy can increase the risk of mental health problems. We see many women who suffer post-natal depression following normal delivery. The answer to whether termination of pregnancy could increase the risk of mental health problems, is "Yes, it could". There are many things that would do that.

The point made by Senator Healy Eames is interesting. It ties into the nature of our society. In my personal opinion, one of the reasons for the dramatic increase in suicide, particularly among young men, is because it is now an option. In other words, it has become "an option". There are a lot of very complex social factors as to why this is so. When one looks at the legislation and the message it sends out, that is a most interesting viewpoint in terms of whether this is potentially normalising suicidal threats. That is a serious aspect of this that probably has not yet been discussed or fleshed out here today. It is a relevant point.

Professor Kevin Malone Consultant Psychiatrist and Expert on Suicide

Based on the research evidence from my studies on this problem in Ireland for the past ten years - Ireland is unique and somewhat different from other countries with regard to this type of research - it is possible that this legislation could inadvertently accelerate suicide rates in younger men, where the real problem lies. Members should note that the problem of male suicide in Ireland is at least sixfold that of the theoretical problem of female suicide, which is rare.

Contrary to the notion of it saving the lives of an extremely small number of females it may be placing a greater number of young male lives at risk. In terms of legislating for the whole of society, I bring this to the committee's attention. Overall, at a macro level the effect of legislation may be a greater loss of life in Ireland than life saving. Surely, that would be a law of unintended consequences. I wonder how mental health literacy will be taught in schools, in terms of explaining that suicidality is legitimised for women in certain circumstances, in respect of which the rate for pregnant females is 2 per million, but not for young men in respect of which the rate is 350 per million, or 150-fold.

My second point is whether abortion is an evidenced based treatment for mental illness in Ireland. My understanding - again I highlight this problem not from the point of view of either side of the debate but based on my clinical research experience - is that four psychiatrists in Ireland have been looking after perinatal psychiatry in Dublin for the past 30 years, including Dr. McCarthy, Dr. Joanne Fenton, Dr. John Sheehan and my late father, Professor Sean Malone who cumulatively have been in clinical perinatal practice in Dublin for close to 30 years. My father was consultant psychiatrist for 40 years at two maternity hospitals, the Coombe Hospital and Holles Street Hospital. They are all on record as saying that they have not observed one clinical case where abortion was the recommended psychiatric treatment. As a clinician, I wonder how then it can overnight become a recommended psychiatric treatment in Ireland.

I do not think it is a treatment. If it comes into law and it is approved that psychiatrists are expected to deliver or to sign-off on it, one is proposing de facto that as part of a treatment plan. There is no evidence to support that.

   
Dr. Jacqueline Montwill Consultant Psychiatrist

Head 4 of the Bill is seriously flawed for three reasons. First, the treatment it proposes is not a treatment. Second, the treatment it proposes is never the only treatment. Third, if truly suicidal with mental illness the patient may not be able to give a valid consent. We have already heard that abortion is not an evidenced-based treatment for suicidality. Unfortunately, this Government is proceeding as if it is. There is no evidence to support the view that the abortion has any mental health benefits. There is evidence to support the view 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 very intervention also poses suicidality as an outcome.

With this law, the focus will be directed away from a full and proper assessment of the patient towards 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 rather than normalise an expression of extreme psychological distress. Mental illness is just as important as physical illness. Perhaps even more so. It affects a person's thinking, the ability to relate and relationships and the ability to function. It is exceptionally important to state that the proper response to stated suicidal intent should always be the appropriate evidenced based clinical treatment. That is what we do when we assess patients who threaten suicide. Direct abortion is not a clinical treatment. It is a social solution. 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.

There is a sentence that this Bill is about saving lives. It is not about saving lives because we want to work to save the life of anyone who is suicidal regardless of the costs. This Bill is about providing abortion procedures.

I remind the committee that the IMO defeated all those motions and during that time a motion was put to the IMO to change the words "abortion procedures" and to put instead "evidence-based, life saving treatment" and that was refused. All of the motions that wanted abortion procedures were defeated by the IMO and the ICGP.

We must consider whether there is evidence of an illness that leads people to commit suicide when pregnant, such as severe mental illness or psychosis. The two women in a million are not women with crisis pregnancies but with severe mental illness.

Considering maternity rates in the UK, it has been indicated in research that the women committing suicide have severe mental illnesses that are either under-diagnosed or inappropriately diagnosed. There is no reduction where abortion is freely available. They are not getting full and proper treatment, which is the issue. These women need best practice and full assessment. We should not skimp on that but this law will skimp on it.

The criteria that the Government has put into this legislation are not true criteria to assess suicidality. They are pretend criteria that it has made up to assess eligibility for abortion, but no such criteria exist. We cannot tell who will commit suicide, but we can say to every one of our patients that we will treat them as if they are going to commit suicide and we will make it as safe as possible for them.

It was stated that I said there were no medical criteria for assessing crisis pregnancy. I am pretty sure I did not say that. If I did then I must have been nervous. No; there is no question of anybody not getting the proper assessment, and that is the issue here. The problem is that the discussion is now moving from women with mental illness to women with no mental disorder. I have a little bit of an issue here, because I wonder at what point a woman will be completely over her crisis, will be completely adjusted and will have no mental disorder. My colleagues described that scenario earlier this morning, and I can see the scenario in front of me. It is a woman who comes in and says, "Doctor, I have an unwanted pregnancy. I have a right under this law to an abortion and I am telling you now that I am going to kill myself." We say, "We will treat you anyway, but we are going to put you through the pathway to see the panels." We ask the patient if she will see our psychologist, if she will give us the full background, and if we can talk to her partner or family. She says, "No, I don't want any of that. I just want the abortion. I am telling you now I am suicidal." In those circumstances we will continue to offer treatments, but the woman will now go through into this process. In law there is no psychiatrist on the panel - as we said, we cannot guarantee anything - who will be able to say the woman will not commit suicide, so it is a direct pathway. What is happening, though, for that woman in crisis? Why will she not allow the assessment? What are the pressures being put on her? It would not be out of the range of possibility that a partner has urged the woman to go in there and tell us she is suicidal. That is my point. She is not getting a proper assessment.

Dr Seán Ó Domhnaill Consultant Psychiatrist

I will now turn to the Bill, which, I believe, has been misnamed. While every person wishes to protect women in pregnancy - I would support absolute clarity for those medical practitioners, including me, caring for pregnant women - the primary purpose of this proposal is not the protection of life during pregnancy but to provide a legal basis upon which the deliberate ending of one life may be carried out.

[I]t is time for a reality check. I have enormous respect for Irish medical practitioners, particularly during these difficult recessionary times, who are invariably working under extremely difficult conditions and in under-resourced hospitals. However, I would like to introduce some clarity in respect of head 4 of the Bill. It is a fact that there are some psychiatrists who are ideologically supportive of abortion and who believe it should be available on request or on demand to Irish women. It stretches the boundaries of credibility to suggest that those psychiatrists would not be more likely to approve abortions if the Bill becomes law. As matters stand and from the submissions that have already been made, they are demanding that only psychiatrists who are in agreement with them ideologically should be allowed to participate in the assessment panels outlined in the heads of the Bill.

Dr Bernie McCabe Consultant Psychiatrist

As it is currently constructed, head 4 should not be included in the legislation. It should be replaced by an evidence based clinical care pathway that would assist women who are suicidal in accessing psychiatric assistance because abortion as a treatment for suicidality is not evidence based.

I repeat that what seems to be intuitively correct may not be so. In the past we have had debriefings for people who were involved in crises en masse, which has proven to be damaging. It looked good and sounded right but it was damaging. We now offer that service to people who want it. If we offer abortion when we know there is no evidence base, we are not being fair, right or just to our patients. Our patients deserve that we be just.