Report of the Expert Group on the Judgment in the A, B and C vs. Ireland Case
Statements in Dáil Éireann on 6th December 2012
Deputy Dan Neville
I welcome the opportunity to contribute on this debate on a sensitive issue that causes extreme difficulties for many people. The decision of the Supreme Court in respect of Article 40.3.3° provided in law that the State must facilitate a termination where there is a real and substantial risk to the mother. This is the judgment of the highest court in the land and, therefore, is binding on all courts.
The Supreme Court stated that it was lawful to terminate a pregnancy if it was established that there was a real and substantial risk to the life, as distinct to the health, of the mother that could only be avoided by termination of the pregnancy. According to the X case judgment, no matter how high the probability that the mother will die, it is not and never can be a certainty. This point has already been discussed.
In 1996, a review group recommended legislation that would include definitions, protections for appropriate medical intervention, certification of real and substantial risk to the life of the mother and a time limit on the lawful termination of pregnancies. The 2009 Medical Council guidelines stated that abortion was illegal except where there was “a clear and substantial risk to the life of the mother” including suicide, in which event it directed medical professionals to “undertake a full assessment of any such risk in light of the clinical research on this issue”. This is one of the clearest statements on the matter. Clinical research is a developing area in which new information is coming to light.
The European Court of Human Rights legally obliges Ireland to put in place a legislative or regulatory regime to provide procedures to establish whether a pregnant woman is entitled to a termination if there is a real and substantial risk of suicide that can only be avoided by that termination. We must establish criteria and procedures for measuring real and substantial risks to life that can only be removed via terminations. This is key to the situation. There should be some type of risk index that consultants can examine to ensure that there is a real and substantial risk to a mother’s life. We accept that a medical diagnosis is not always a clear-cut process and does not exclude differences of opinion.
The constitutional obligation to defend and vindicate, as far as practicable, the right to life of the unborn must also be recognised and included in any consideration of the issue and the dignity of the foetus must be protected. As recommended, all of the steps involved in reaching a decision on a real and substantial risk to a mother’s life must be documented clearly. Extra regard should be given to suicide risks, given the clinical challenges involved in diagnosing suicidal behaviour. It has been suggested that two psychiatrists and perhaps an obstetrician should form the team that would make the decision, with the backup of other professionals, such as psychotherapists, and the involvement of the woman’s general practitioner, GP, who may have a great deal of knowledge about her. It will be argued that since two team members are sufficient for a medical situation, having three in a potential suicidal situation is discriminatory. While there is a case for this argument, we should accept that the team to decide whether there is a real and substantial risk of suicide should comprise two psychiatrists and one obstetrician, given the clinical challenges involved in diagnosing suicidal behaviour. There has been a great deal of debate on this issue.
It is understood that motherhood and pregnancy are protective influences against suicide, as borne out by studies in the UK and the US. One UK study shows that the rate of suicide among pregnant women is one sixth of the rate among women who are not pregnant. There are no figures to indicate whether suicides resulted from a real and substantial risk owing to their pregnancies, only that they died while pregnant. No figures are given for the number of terminations completed. Abortions are available under the liberal regime that pertains in the UK.
As such, we must temper any figures from the UK and the US on the basis of their liberal termination regimes which make abortion less strictly controlled than we intend to introduce. Consideration must also be given to the fact that a liberal abortion regime influences the number of suicides recorded during pregnancy. However, while there is substantial evidence from research that pregnancy reduces the risk of suicide, there is no evidence that pregnancy prevents suicide. Every life is important. The saving of one of the 600 lives of people who died by suicide last year would be welcome.
I am often critical of the psychiatric profession because of the way it deals with families. However, I have the utmost confidence in the psychiatric profession to diagnose mental illness in the most ethical and professional manner. I have confidence that the profession will not endeavour to subvert the law in any way in the course of coming to a decision on whether a pregnant woman is at real and substantial risk of suicide. Medical diagnosis is not a clear-cut process and there are clinical challenges to a psychiatric diagnosis of someone as a suicide risk. The Medical Council will have a key role in that regard.
I am a member of the advisory board of the College of Psychiatry of Ireland. I have been involved with psychiatrists for more than 20 years and I have the utmost respect for their ethical approach to the issue. It has been argued that women will attempt to deceive. That is debatable given the nature of the crisis situation. I do not believe women will be deceitful to the extent of persuading a psychiatrist that they are at a real and substantial risk of suicide which only a termination could avoid. I do not believe two consultant psychiatrists who are dealing with seriously mentally ill patients all their lives could be persuaded by someone who is not in that category that they are suicidal, and that they would come to a decision to grant a termination on that basis. A total of 4,000 women in this country with crisis pregnancies decide to have an abortion each year. That is another situation with which we must deal. I do not know the solution to the problem.
Reference has been made to the significant number of unplanned pregnancies in this country. That is the case, within and without of marriage. However, it does not mean they are unwanted pregnancies. We know of situations where people are in crisis because they had not planned the pregnancy but after a week or two their attitude changes and they look forward to having a new baby regardless of the initial shock they experienced on discovering their pregnancy. Whether pregnancies are unplanned is irrelevant to the issue we are discussing.
There has been discussion on whether we should introduce legislation or regulation. Whatever route we choose we must introduce rules to implement the decision of the Supreme Court, which has decided that termination in certain circumstances is legal in this country.
Discussion on the suicide aspect of the matter has been positive to date. We must consider vulnerable people with crisis pregnancies who are listening to or reading comments we make. We are aware of the copycat element of suicide where people with suicide ideation could be tempted to take their lives when otherwise they would not do so. We must consider whether what we say would make it more likely that women in a vulnerable situation would take their lives or seek help. Vulnerable people will listen to the debate and relate what they hear to their particular crisis.
We must also take into consideration how what we say will affect those who have been bereaved by suicide. Bereavement by suicide falls outside the normal range of human experience. It is an overwhelming loss which leaves the bereaved confused and helpless, overwhelmed by many emotions and unanswered questions. As well as the normal range of grief reactions, those bereaved by suicide often experience a sense of stigma, shame, loneliness or rejection. We must take that trauma into account when discussing the overall issue. A friend of mine is involved with public meetings on bereavement because his son died at 23 years of age. There is a stigma surrounding suicide. People say when someone dies from cancer or heart failure that they wanted to live but their illness got the better of them. One could erroneously say that someone who completes suicide wanted to die. Nothing could be further from the truth. People who complete suicide want to live as much as anyone else, but living becomes too painful. They do not want to die but they just cannot bear to live with the incredible pain their illness causes them. It is important for people to hear the message to clear up one misconception surrounding suicide. People think that suicide is a cop-out of life, but nothing is further from the truth. People who complete suicide are not copping out of life; they cannot bear the pain anymore. They have reached the end of their tolerance. They have fought long enough and hard enough and the time has come when they know no other way to end their pain. That is the issue we are discussing.
Suicide is no longer a crime. It was decriminalised in 1993. It is no longer a sin on the basis of the test I was taught going to school, namely, grave matter, clear knowledge, and full consent. It is certainly grave matter but hardly clear knowledge or full consent given the pain a person suffers. We must try to change the language we use. A person who dies by suicide does not commit a sin or a crime. He or she dies by suicide or takes his or her life. There has been a great improvement in the past 20 years in our campaign to change the language we use.
On 2 October 2009 a pastoral letter on suicide from the Irish Bishops’ Conference was published. It stated:
Life matters. It is commonly accepted that those die by suicide don’t want to die; they simply wish to end their pain. Suicide prevention is, therefore, a duty of everyone in our society. In this area we need to be particularly concerned for other people and sensitive to their difficulties. [Bishop Fleming concluded] I welcome the updated media guidelines … Everyone has a responsibility to treat the tragedy of suicide in a conscientious manner, being sensitive not to stigmatise it, understanding and supportive of those affected by it and at the same time avoiding its glorification.
I agree with the bishops.