Second Day of Hearings

7/28/2019 Second Day of Hearings

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AN COMHCHOISTE UM SHLINTE AGUS LEANA

JOINT COMMITTEE ON HEALTH AND CHILDREN

D Luain, 20 Bealtaine 2013

Monday, 20 May 2013

The Joint Committee met at 09.30 a.m.

MEMBERS PRESENT:

Dept Catherine Brne, Sentor Ivana Bacik,*

Dept Ciara Conwa, Senator Colm Brke,

Dept Regina Dohert, Senator John Crown,

Dept Robert Dowds, Senator Imelda Henr,

Dept Peter Fitzpatrick, Senator Jillian van Trnhot,

Dept Seams Heal, Senator Jim Walsh.*

Dept Bill Kelleher,

Dept Mattie McGrath,

Dept Sandra McLellan,

Dept Eamonn Malone,

Dept Denis Naghten,

Dept Caoimhghn Caolin,

Dept Mar Mitchell OConnor,

Dept Robert Tro,

* In the absence of Senators John Gilro and Marc MacSharr, respectivel.

In attendance: Depties James Bannon, Ra Btler, Michael Creed, Clare Dal, BernardJ. Drkan, Terence Flanagan, Dominic Hannigan, Kevin Hmphres, Colm Keavene, Pal

Kehoe, Finian McGrath, Peter Mathews, Olivia Mitchell, Michelle Mlherin, Sen Fearghaland Aodhn Rordin, and Senators Pal Bradford, Terr Brennan, Aideen Haden, FidelmaHeal Eames and Rnn Mllen..

DIL IREANN

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HEADS OF PROTECTION OF LIFE DuRING PREGNANCy BILL 2013: PuBLIC HEARINGS (RESuMED)

DEPuTy JERRy BuTTIMERIN THE CHAIR.

Heads of Protection of Life during Pregnancy Bill 2013: Public Hearings (Resumed)

Psychiatry and Perinatal Psychiatrists

Chairman: As we have a qorm we will begin in pblic session. I thank all present forbeing here bright and earl on a Monda morning and I particlarl welcome or gests. I re-mind everbod that mobile phones shold be switched off rather than being in silent mode asthey interfere with the broadcasting of proceedings, which is unfair to the staff. This is our fth

session in the series of hearings which the Oireachtas Joint Committee on Health and Childrenhas been asked to condct in discssing the heads of the protection of life dring pregnancBill 2013.

I welcome the witnesses to the meeting this morning, as the are here to assist s in anals-ing the heads of the Bill. I welcome Dr. Anne Jeffers, Dr. Maeve Dole, Dr. Joanne Fenton,Dr. Anthon McCarth and Dr. John Sheehan, who will be here shortl. I remind members thatwe are discssing the heads of the Bill and an comments or qestions shold be referenced tothose heads. To members in particlar I sa that the langage we se shold be temperate andmoderate, and we shold tr to avoid being nfair to each other and witnesses. I wold appreci-ate if members cold keep that at the back of their minds. I will be ver strict with time toda,

as I reviewed the hearings on Frida. The time allocations will be 70 mintes and 30 mintesand I will end the sessions at the appropriate times. That will mean some members will not beable to make a contribtion at certain times, for which I apologise in advance, bt we mst befair in the application of time.

Before beginning I remind members and witnesses that witnesses are protected b absolteprivilege in respect of the evidence the give to the committee. However, if the are directed bthe committee to cease giving evidence on a particlar matter and the contine to do so, theare entitled thereafter to only qualied privilege in respect of their evidence. They are directedthat onl evidence connected with the sbject matter of the proceedings is to be given and theare asked to respect the parliamentar practice to the effect that where possible the shold notcriticise nor make charges against an person, persons or entit b name or in sch a wa asto make him, her or it identiable. Members are reminded of the long-standing parliamentary

practice or rling of the Chair to the effect that the shold not criticise, comment on or makecharges against either a person or persons outside the House or an ofcial either by name or insuch a way as to make him or her identiable.

There are 50 mintes for opening statements so I ask Dr. McCarth to begin.

Dr. Anthony McCarthy: I am Dr. Anthon McCarth, president of the College of Pschia-trists of Ireland and a specialist in perinatal pschiatr at the National Maternit Hospital, Hol-

les Street. I am also the psychiatric assessor for the condential inquiry into maternal deathsin Ireland.


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Or written sbmission has detailed comments on the heads of Bill and we recommend thatclose attention is paid to these points. Some practical points will need to be addressed and willreqire some technical amendments to the Bill. This sbmission was agreed b the concil ofthe college, the sole organisation recognised b the Medical Concil of Ireland as being respon-sible for the life-long training of all pschiatrists in Ireland. This concil is the elected decision

making bod of the college and we know that among or 864 members there will be a widerange of opinions with regard to the sensitive issue of abortion, reecting the deep divisions insociet in general abot this isse. Man of these views will be heard toda bt the sbmissionis the ofcial college position.

This Bill is abot saving womens lives. We recognise that the Bill is restricted onl tocircmstances where the life of the mother is at risk rather than her mental health. We recom-mend that an woman who has sicidal ideation in pregnanc mst be enabled to readil availof expert pschiatric assessment, and that assessment mst be individal, comprehensive, com-

passionate and not prejdged. Ever maternit nit in this contr shold have sch services,and there is a signicant lack in such provision currently, as outlined in our written submission.

As so mch will be said and heard toda abot the risk of sicide in pregnanc, I wish tomake some brief overall points as someone who has been working as a specialist perinatal

pschiatrist for more than 16 ears in a service seeing in excess of 500 women ever ear.Sicide in pregnanc is real; it is a real risk and it does happen. This is alwas a traged as atleast two lives are lost and many others are affected signicantly. We must do everything wecan to prevent sch deaths. Mch has been made and will be made abot the so-called lackof evidence with regard to abortion and whether it will ever prevent a sicide. I believe therewill never be statistical evidence to prove this point one wa or other becase tring to proveanything statistically for such a rare event is extremely difcult, if not impossible. Only a study

involving thosands of women who were expressing sicidal ideation in pregnanc and wantedan abortion, and where half of them had that abortion and the other half did not, for example,if the were prevented from travelling to the uK, cold answer this qestion abot statisticalevidence. This std will almost certainl never be done, I hope.

As doctors, we mst alwas be aware of research bt also be ver aware of the limitationsof research and of the qestions which it cannot answer. In or clinical work, we search alwasfor clinical evidence and not statistical evidence. As doctors, we assess sicidal risk as part ofor everda work and we rel on clinical evidence, or clinical skills and or experience andtraining in assessing each woman or child individall. There are extra challenges in assess-ing anone in emotionall intense sitations and where there are potentiall serios otcomes,

whatever the assessment concldes. Again I stress that we do these sorts of assessments reg-larly, even if most psychiatrists do not do so in this specic circumstance. Part of suicidal riskassessment alwas incldes assessing the presence or absence of a mental disorder or mentalillness and an assessment of the capacit of the individal to make an informed decision. Thatwill be essential here too.

We also alwas assess for what are called pschosocial stresses, or life stresses. However,some in this debate have tried to present the case that these are somehow mtall exclsive, asif a woman who is at risk of sicide is either mentall ill and hence needs pschiatric treatmentor that she jst has a pschosocial stress - an nwanted pregnanc - and is then either not reallsicidal or her case has nothing to do with pschiatr. Clinical realit and life realit is thatfreqentl there is a complex interaction between major life stresses, mental distress and mentaldisorder. It is sometimes black and white bt most often it is not so. Attempts to present it as


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such not only does a great disservice to any women who may nd themselves in this particularposition bt also to an person at an time in life who is sffering from major stress, depressionor other mental disorder. The too reqire a comprehensive mental health assessment and treat-ment, one that does not focs exclsivel on the presence or absence of a mental illness bt onan holistic assessment and treatment which recognises the individalit of that person.

I will specically discuss a phrase that is being quoted frequently at the moment that abor-tion is never a treatment for sicide. This is tre, and abortion is never a treatment for sicide,

bt neither is conselling, pschotherap, antidepressants or anthing else. There is no treat-ment for sicide. What societ needs to address in general, and what we as pschiatrists haveto do specically, is try to prevent suicide, and this requires looking at the causes of suicide andwhat can be done to address those cases. The qestion is not whether abortion treats sicide

bt is there ever a case where a woman will kill herself becase of an nwanted pregnanc, andif so, what can we do to save her life, and wold that ever be a termination of pregnanc? ThisBill is abot legislating for that ver small bt real possibilit.

There are concerns among man pschiatrists that somehow this legislation will reslt inthem being placed in very difcult clinical circumstances. For some this is because of theirreligios, philosophical or ethical beliefs, and these mst be respected. I welcome that thoseviews will be heard toda as well. For others, there is a fear of increased workload for theiralread overstretched services, and doing this with no extra resorces. For others it is a fear of

being faced with very difcult clinical issues and dilemmas where, for example, a woman maybe geninel highl distressed, sch as after rape, and wants a termination bt is assessed as notbeing activel sicidal becase she does not want to die. This woman ma jst want an end tothe pregnanc bt she will have to be refsed an abortion nder this legislation. That will bedifcult for her and us as clinicians. These are real concerns and difculties but they still must

be addressed. The cannot simpl be ignored or denied b or profession or b societ, andwill not be b the college.

Man in the profession see this isse as being predominantl a social and political isse,which pschiatrists are now being asked to solve or arbitrate pon, an isse which societ asa whole and the Legislatre need to address, and are addressing, which is to be congratlated.As pschiatrists, we want to be there to care for and treat women appropriatel, professionalland compassionatel and not be placed in a position of social policing. However, again at theend of the da, this is abot saving womens lives and we as pschiatrists mst be prepared tose or professional skills and expertise to assess and treat pregnant women who have sicidalideation or intent in pregnanc. If, as a reslt of this legislation, better pschiatric services are

pt in place so that expert pschiatric assessments and treatments are provided for all pregnantwomen in Ireland who wish to avail of sch services, women and childrens lives will be saved.

Dr. Joanne Fenton: I am Dr. Joanne Fenton, consltant adlt pschiatrist and a specialistperinatal pschiatrist in the Coombe Women and Infants universit Hospital. In m role as aperinatal pschiatrist I have treated women attending the Coombe hospital over the past tenyears. These women have had a wide variety of problems and difculties including illnessesranging from severe and endring mental illness like schizophrenia to those with less severeillness like anxiet or depression, bt which ma case eqal levels of distress.

Sicide is a real risk in individals who have mental illness and has a devastating impact

on all those involved with the woman. As pschiatrists, and in particlar in m role as a peri-natal pschiatrist, we are trained to assess women who express sicidal ideation or intent. Itis m role to provide non-jdgmental, compassionate care and treatment to these women. The


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women who present with sicidal intent are in a great deal of distress and it is or aim to treatthese women respectfll.

In m ears in the Coombe hospital I have seen man women who have had a terminationof pregnanc. Each woman has had a different experience and the effect has been different for

each. I have never seen a woman where termination of her pregnanc was the treatment for hermental illness nor do I believe that a termination of pregnanc is a treatment for mental illness.However, that said, I cannot sa that there will never be a sitation where a woman is in sch astate of distress and trmoil that for her, termination of pregnanc is a life-saving option.

The crrent legislation is ver restrictive and man women will contine to travel abroad toseek terminations. There are a nmber of points which m colleages and I will address frtherand are otlined in or written college sbmission. These inclde the nder-18 age grop andthose who lack capacit. I believe that two pschiatrists, as otlined in the heads of Bill, sholdassess a woman who is sicidal and pregnant and be in agreement abot their assessments, btshold not have to see the patient at the same time. I believe that the obstetrician shold assess

the woman from an obstetric point of view bt not be expected to assess sicidalit, which isbeond his or her area of expertise. I believe that the timing between initial referral and assess-ment and the timing for appeal shold be shortened as women in this sitation are freqentldistressed and a lengthening of time can case a frther deterioration in their mental health.

Man pschiatrists do not wish to partake in the assessments of these women for man rea-sons and their concerns mst be respected. In m role as a perinatal pschiatrist I believe it ism responsibilit to contine to assess pregnant women in distress and aim to provide the bestand most compassionate care to them.

Dr. Maeve Doyle: I am Dr. Maeve Dole, consltant child and adolescent pschiatrist and

chair of the child and adolescent faclt of the College of Pschiatrists of Ireland. I welcomethe invitation from the Joint Committee on Health and Children to make a sbmission on spe-cic issues with regard to children, particularly because the X case involved a 14 year old girl,a child, who had been raped and soght a termination becase she said that she was sicidal.The written sbmission, which was sent b the college, incldes a nmber of ke and detailed

points abot the care of children in circmstances where the ma be pregnant and reqest anabortion and how the proposed heads of Bill mst be amended to address these. M openingstatement smmarises some of these ke isses.

On the denition of a child, the heads of Bill do not dene the word child. This is veryimportant as in cases involving children there are very specic and complex issues regardingtheir care which mst be addressed. On consent, nder the Children Act 2001, and other legis-lation, a child is someone nder the age of 18 ears nless married. A person over the age of 16ears can give consent to srgical, medical or dental treatment and it is not necessar to obtainconsent from parents and gardians. For pschiatric assessment the law has been interpretedas meaning that ntil the age of 18, children are still not in a position to legall consent to a

pschiatric assessment and, as sch, reqire consent from their gardians. For children in thecare of the HSE the isse of consent is even more complex. I make these points to highlight theneed for these issues to be considered by those drafting the nal Bill.

The issue of condentiality is also quite complex. Generally, when young people are rst

seen b a child and adolescent pschiatrist the are informed that what the sa will remaincondential unless the information disclosed constitutes a risk to themselves or to others. Thisma well reslt in the ong people censoring what the sa. This is particlarl tre in the area


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of sexal activit. The age of consent to sexal intercorse remains at 17 ears. In man cases,however, parents of 17 ear olds expect to be informed if their 17 ear old child is sexallactive, so isses regarding a possible abortion will reqire expert, experienced and sensitivehandling and clarit for the child, famil and professionals involved.

While there are no gures available, the occurrence of pregnancy within a population at-tending a child and adolescent mental health service is rare. For a pregnant ong person toattend sch a service, the consent mst come from her parents. In addition, if the ong personis nder the age of 17, the professional will have to report to the HSE and the Garda. The likeli-hood of parents of pregnant girls seeking advice from a child and adolescent pschiatrist as towhether or not to proceed with a termination of pregnanc is, therefore, ver low.

What ma happen is that in the case of a ong girl who is in the care of the HSE, becomespregnant and indicates a wish to have a termination of pregnanc on gronds of sicidalit, theHSE, acting in loco parentis, ma well seek the advice of a child and adolescent pschiatrist inmaking that decision. This is probabl the main grop of pregnant teenage girls for whom the

proposed legislation will, in effect, appl.

I hope that the foregoing will draw attention to some of the difculties which would needto be overcome in an legislation involving ong women, children in the ees of the law, who

present with sicidalit in the context of pregnanc.

Dr. Anne Jeffers: I am Dr. Anne Jeffers. I am the director of external affairs and polic atthe College of Pschiatrists of Ireland. I am also a general adlt pschiatrist. I work with adlts

between the ages of 18 and 65 and I work in a commnit based service in east Galwa. In anadeqatel resorced mental health service, general adlt pschiatrists work with a mltidisci-

plinar team made p of nrses, social workers, pschologists and occpational therapists. We

receive referrals from general practitioners or the emergenc departments of general hospitals.I will describe the isses as I see them in this legislation as the are likel to be seen b a gen-eral adult psychiatrist. When a woman nds that she has a crisis pregnancy and feels suicidal,she ma follow a nmber of choices. She ma decide to have a termination and ma travel ot-side the State to have that. She ma visit her GP who will complete a fll assessment, incldingan assessment of her mental state and the risk of sicide. The GP will offer her conselling andma advise that she seek the advice of a crisis pregnanc conselling service. If he or she hasconcerns that the woman is at risk of sicide and reqires a specialist pschiatric assessment,he or she will refer her to a general adlt pschiatrist. The woman ma alternativel presentdirectl to an accident and emergenc department, especiall if she has attempted sicide or has

self-harmed. In this case, she will be assessed b a liaison pschiatrist where one exists or bereferred to the general adlt pschiatrist in the area. Onl in Dblin will there be the option ofa referral to a perinatal pschiatrist.

A pschiatric assessment involves a private one-to-one consltation where the woman hasan opportunity to describe her distress. The psychiatrist identies the issues contributing tothe sicidal risk. These isses inclde an smptoms of mental illness and the pschosocialstresses affecting the woman. Each womans presentation and circmstance is niqe and the

pschiatrist will provide a comprehensive and non-jdgmental assessment. A pschiatric as-sessment is therapetic in itself where a woman is given an opportnit to discss her concernsand stress in a condential setting and a safe and supportive environment. For many women,

the otcome of this assessment will redce her fears and she ma decide to contine with thepregnanc. Where the woman and the assessing pschiatrist and team believe the terminationof the pregnanc is the onl wa to avert self-destrction, a second opinion wold be reqested.


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Ideall, a pschiatric social worker or other ke team member wold also be involved in thisassessment and in the provision of ongoing spport for the woman. It is important to be awarethat not all teams have social workers. It is anticipated that in all except rare cases, the ps-chiatrist will recommend interventions other than termination of the pregnanc. The legisla-tion is extremel restrictive and it will not appl to the majorit of women. In these cases, the

pschiatrist will ensre the woman has access to non-directive conselling arond the options,and these options inclde adoption, parenting or information abot travelling otside the Statefor termination.

As pschiatrists, we are sed to working within a legal framework in sing the MentalHealth Acts. We are sed to the importance of wording within the law. Head 4 of this legisla-tion clearl states that it wold not be an offence to terminate the pregnanc onl if the pschia-trists jointl certif in good faith that there is a real and sbstantial risk of loss of the pregnantwomans life b wa of self-destrction and, in their reasonable opinion, that this risk can beaverted only by that medical procedure. Reasonable opinion is dened to mean an opinionformed in good faith which has regard to the need to preserve nborn life where practicable.The emphasis is on the risk onl being averted b termination and the regard to the need to pre-serve nborn life. This wording will restrict the se of this legislation to extremel rare cases.

Dr. John Sheehan: I thank the committee for the opportnit to contribte. I am a perinatalpschiatrist working in the Rotnda Hospital in Dblin. A perinatal pschiatrist is a pschiatristbased in a maternit hospital and he or she treats women in pregnanc or, for example, follow-ing deliver. I also work as a liaison pschiatrist in the Mater Hospital, Dblin, which has oneof the bsiest accident and emergenc departments in Ireland. Last ear, we had the highestnmber of treated episodes of attempted sicide in the State, and part of m work is assessingand treating people who present with attempted sicide. I therefore work both in a perinatal

setting and in an accident and emergenc department setting.I will conne my comments to the aspect of the Bill that is pertinent to psychiatry, namely

head 4, which is concerned with the risk of loss of life from self-destrction. It has major impli-cations for pschiatrists. First, there is a fndamental difference in the management of medicaland pschiatric emergencies in obstetrics. In obstetrics, medical emergencies and pschiatricemergencies reqire different interventions. In a medical emergenc, speed deliver of the

bab is reqired while, in a pschiatric emergenc, speed deliver of the bab is contraindi-cated. It is exactl the opposite of that reqired in a medical emergenc. In a pschiatric emer-genc sch as when a patent is depressed and has sicidal intent, the patient ma have impairedcapacit and shold be advised not to make irrevocable decisions. The patient probabl cannot

give informed consent. Those of s who see people with sicidal intent often see people whofeel overwhelmed, nspported 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 ofthem except ending his or her life. Sch a patient needs professional help, not an rgent termi-nation of pregnanc.

Second, pschiatrists are doctors, not jdges. If head 4 is enacted, pschiatrists will beasked to determine if there is a real and sbstantial risk to the life of the mother in order thatshe ma procre a termination of pregnanc. This is a role in which Irish pschiatrists have not

been involved to date. Man will not see this as their role as medical practitioners. The rolecold be constred as making pschiatrists the gatekeepers to abortion. Pschiatric practicerelates to assessment and treatment of patients, not assessment and adjdication. Pschiatristsare not jdges.


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M third point relates to the women who crrentl travel abroad for terminations. In thesbmission to the committee earlier this ear, the three Irish perinatal pschiatrists - Dr. Mc-Carth, Dr. Fenton and mself - stated that with more than 40 ears of combined clinical expe-rience, we had not seen a single case where termination of pregnanc was the treatment for amental disorder. If head 4 is enacted, however, it may well change the patient prole currently

seen b Irish pschiatrists. It is likel that women will be referred from that poplation whocrrentl travel for abortion. The extent of mental health problems and sicidal ideation amongthat poplation is nknown and, hence, the tilisation of the proposed legislation b that pop-lation is nknown.

Forth, it is impossible for pschiatrists to predict the ftre. The explanator notes forhead 4 state, It is not necessary for medical practitioners to be of the opinion that the risk tothe womans life is inevitable or immediate. The risk of a woman ding b sicide in preg-nanc is between one in 250,000 and one in 500,000 live births. The risk is exceedingl small.In practice, therefore, it wold be impossible for an pschiatrist to accratel predict whichwoman will die b sicide in pregnanc. Being nable to predict who will die b sicide is,therefore, likely to lead to multiple false positives. Psychiatrists are trained to assess and

provide evidence-based treatments not to predict the ftre.

My nal point relates to the potential adverse effects on the womans mental health due tolate abortion. There is no time limit set in the heads. That is, termination cold, theoreticall,occr p to a ver late stage of pregnanc. Late abortion cold potentiall have a ver deleteri-os effect on the womans mental health.

Chairman: I thank Dr. Sheehan. We are now moving into Members time which is 70 min-tes. I remind Members qestions are on the heads of the Bill. In the context of the langagewe se and the wa we behave in the Chamber, if we cold be tolerant and respectfl towardseach other it would be appreciated and, perhaps, remarks could be conned to the heads of theBill.

Deputy Billy Kelleher: I welcome the witnesses. On head 4, how do the witnesses seethe role of the panel in terms of a womans crisis pregnanc? She ma or ma not visit her GPor may present at an accident and emergency unit. Her rst port of contact, probably, will bethrogh a pschiatrist if she is to go forward for assessment nder the panel process. Therewold be a pschiatrist who wold assess the woman in distress. If she felt that the onl optionavailable to her was a termination there wold be a second assessment b another pschiatristand an obstetrician. What I am tring to nderstand is whether the witnesses believe it shold

be jst an assessment process or an assessment with care? In other words, when a woman pres-ents to a pschiatrist I presme it is not a jst a box-ticking exercise. I assme the wold lookat all avenes to see what spports this particlar woman in crisis pregnanc needs, as opposedto jst assessment, and moving her on to somewhere else. Man people are ver concernedabot this particlar area. I wold like clarit on where the witnesses see a role not necessarilon the adjdication bt on the conselling, assistance and spport.

There is another area I wish to qestion. Dr. John Sheehan points ot that ever ear annknown nmber of women go abroad in crisis pregnanc for a termination. We do not knowthe exact nmber who are in deep crisis mentall and pschologicall. He said there cold bean increase in the prole of people who will present under this legislation. One could argue it

is a good thing that women wold now tr to seek spport, assistance and conselling when incrisis pregnanc as opposed to jst making the fatefl decision of getting on an aeroplane andgoing to Britain withot an spports or services arond them. Perhaps he wold elaborate on


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that particlar isse?

The other isse is that if legislation is passed, it will need resorcing, particlarl if there isan increase in presentations b women who ma be sicidal or with sicidal intent or sicidalideation. One ma arge that is a good thing becase the wold be making contact with the

health services bt do we have the resorces in terms of pschiatrist assessment, spports andconselling if there is an increase in the nmber of women seeking assistance or a determina-tion on their mental stats?

Deputy Caoimhghn Caolin: I join with the Chairman in welcoming each of orguests this morning. I wish to put a question specically to Dr. McCarthy. In relation to theve obligations of the State as set out in the expert group report two of them are referred to asfollows: to establish criteria or procedres in legislation or otherwise for measring or deter-mining the risk to her life, and the other, to provide precision as to the criteria b which a doctoris to assess that risk. Does Dr. McCarthy believe that the draft legislation before us fulls bothof those two criteria from his professional perspective? For the panel, there is a reqirement

for three professional opinions, somebod from obstetrics and two pschiatrists. I wold liketo ask for or individal opinion. We wold like to know, whether, in the witnesses respec-tive opinions, this nmber is too high? Does the reqirement of nanimit of all three medical

professionals render it difcult or, perhaps, even unworkable in practice and place an unduebrden on the woman? In relation to their respective experiences - and the have indicatedthey reect both City of Dublin and outside the City of Dublin experiences - will the issue ofconscientios objection have an impact on the nmbers available, those in practice associatedwith the respective 19 indicated-for-approval sites? Man pschiatrists are not actall associ-ated with an of these et one mst be in terms of the wa the draft legislation is presented. Doyou see difculties presenting there? In your own opinion, who should lead the process? It is

not clear in the legislation whether it shold be an obstetrician or two pschiatrists. One woldexpect it wold be one, at least, of the two pschiatrists and that person wold be attached tothe individal site.

In regard to the appeals process becase it is particlar to head 4 on sicidalit, is the time-frame reasonable and workable? Before the Chair plls me p, as we have onl three mintesto ask qestions and elicit as mch information as possible, I wish to ask Dr. Maeve Dole, inher role as child and adolescent pschiatrist, if the Bill deals adeqatel or at all with consen-tive and minor adlts or adlts withot capacit - that ma or ma not be nder her particlarexpertise bt perhaps she wold like to offer her opinion. That is ver important. She is onlone of two voices coming from a child and adolescent view over the corse of todas hearings.

I wold like to know each of or respective opinions.

Deputy Mattie McGrath: I too welcome or gests and thank them for their attendance.Part one of the test for abortion on suicide grounds, as per the X case, is that as a matter of prob-abilit there mst be a real threat posed to the life of the mother b wa of self-destrction. Can

pschiatrists jdge, as a matter of probabilit, whether someone will commit sicide? Can thepoint to an pblished research spporting their answer and their views? Wold the contendthat this part of the X case test is generally unachievable from a psychiatric perspective? The Xcase jdgment stated that abortion cold be the onl wa of treating sicidal ideation. Is there

pschiatric evidence for what that jdgment prespposed, namel, that abortion can be a formof nnecessar mental health treatment?

In paragraph for of his sbmission, Dr. John Sheehan said that in a pschiatric emergenc,speed deliver of the bab is contraindicated as it is likel that the patient has an impaired


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capacit and shold be advised not to make irrevocable decisions in sch a state. This is par-ticlarl relevant in cases where a person ma have developed a transient and negative pes-simism, hopelessness or despair which, with treatment, is generall resolved, as stated earlier.In light of this, what does he make of the calls to drasticall shorten the processes for decidingon whether a termination in sch circmstances in permissible and shold sch processes be

strengthened rather than shortened?

Chairman: I thank the Dept. Does Dr. McCarth wish to start? I will take qestions ingrops of three.

Dr. Anthony McCarthy: I thank Dept Kelleher for his qestions. He raised the isse ofthe nmber of women who ma go abroad bt who now might come here and mabe that is agood thing. It is qite extraordinar sometimes that those who are most opposed to an legisla-tion here, almost totall disregard the fact that, es, of the thosands who go abroad, most, nodobt, have no mental illness or anthing of the sort. uneqivocall, within that grop thereare women who cold do with expert pschiatric care that might well redce their mental health

difculties. These women could be psychotic, have voices in their head telling them to kill thebab. It might be the worst the have ever done. We have seen some women who have sfferedafter abortions becase the regretted them, and mabe if the had had a pschiatric assessmentand treatment, those women wold not have gone abroad and wold have been treated here andthe and their children wold now be alive toda. We completel disregard these women.

On those who are worried abot and want to protect the nborn, we are completel ignoringthis realit that there are women going abroad now. We want to pretend that the are not orisse, that if the go abroad and have an abortion that is jst not or isse, and we onl wantto address those who are here now and who want to present in this tin little narrow window.

This is a personal view rather than a professional view. I think it is a sign of or nationalability sometimes just to ignore difcult questions and say let them go to England, Northern Ire-land, Norwa or wherever the go now to have their terminations or, increasingl, let them taketheir medication that the b over the Internet and take it in their hotel rooms here or in theirhomes, and abort their babies here, as women over centries have done. I have seen women,now in their 80s, who have talked abot sticking knitting needles in themselves before abortionwas available in England. There is a terrible Irish social histor of the treatment of women in

pregnanc who are in distress and if some of those women, who now go and mabe will regretit afterwards, cold have professional care and spport here, no dobt some of those womencold well be treated, some of those women cold well be helped and some of their children

might be alive toda, and that wold be a ver good thing.With regards to the panels, the workings of the panels will be difcult. They must be organ-

ised. The reality is that the rst psychiatrist will have to see the woman. If that psychiatrist,after that evalation, comes to the conclsion that a termination wold be important here - thisis a ver rare grop becase I re-emphasise, looking at the procedre here of seeing three dif-ferent people, the vast majorit of women will contine to go to England or take their medica-tion or whatever it is as the are not going to come near s - he or she will then ask a second

pschiatrist for a second opinion. I note Dept Caolin asked the same qestion - do Ithink that is reasonable? In the crrent social sitation in which we live in Ireland, bt also asit is reasonable clinical practice, in difcult situations like this it is very reasonable to ask for a

second opinion, as long as the obstetrician is not also being asked to assess her sicidalit wabeond his or her level of competence. Some of the comments from some of the obstetricianson Frida last jst showed a complete failre of nderstanding of mental illness and mental


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distress and the realit of the sort of women with whom we deal in or clinics. That will haveto be dealt with.

We need an increase in resorces. Between Dr. Sheehan, Dr. Fenton and mself, if oneadded all of or sessions together, that is not one consltant post in this contr. All of s are

part-time. There needs to be a huge increase in resources. That is why I nished my openingstatement saing that if the reslt of this is better resorces in hospitals for women, that woldbe a reall good thing.

To address Deputy Caolins specic question on precision, some of the questions thatDr. Sheehan raised abot pschiatrists not being jdges and Dept Mattie McGraths qes-tion abot probabilit, trthfll, we mst make probable decisions ever da of the week.When somebod comes in to me - not one pschiatrist the committee will hear toda will not

be reglarl in a sitation in an emergenc department or in an inpatient pschiatric ward orwherever saying: On probability, I will let this person go home because my clinical judgmentis this person will not kill themselves. I make that decision ever da of the week. Eqall,

there is not one pschiatrist who will talk here toda, whether for or against this legislation,who has not written on a Mental Health Act form ofcially I am certifying this person into a

pschiatric hospital toda against their will on the basis of a risk to their life., becase we aremaking clinical jdgments here that there is a sicidal risk. If an pschiatrist standing p heretoday says we cannot make these predictions, ask that psychiatrist, Have you ever written ona mental health form saying, On the balance of probability, this person needs to be admittedinto hospital against their will, and sometimes treated against their will, becase m view is thatthey have a signicant suicidal risk.. That is what we do in our work all of the time and it willnot be an different here.

With regards to the isse of nanimit, it is important the pschiatrists are nanimos. Ofcorse, the can be nanimos. Most likel, or nanimos view will be that a terminationhere is not likel to help. That is likel to be or view becase of the tin little grop we will

be seeing to whom it would apply. I have total condence that in the vast majority of casespsychiatrists will be able to agree, Probably, No., because of the restrictiveness of this legisla-tion, but sometimes, Yes.

We pointed out in our submissions real practical difculties because of conscientious objec-tors - I fll spport conscientios objectors - abot the heads of the Bill as there cold be one,for example, Dr. Sheehan, working in the Rotnda on his own. If he does not agree or I do notagree in m hospital, there mst be a panel of persons otside and that mst be looked at in the

heads of the Bill.On appeals being too long, I am ver concerned abot the appeals process being so long,

particlarl becase a small nmber of these women ma be ver mentall ill. A woman mabe ver nhapp that we have trned her down, and for two weeks she ma have a mental ill-ness ntreated. People are worried abot what the appeals process will lead to and sggeststretching it ot so that no woman will have an abortion who might regret having an abortion.I am worried that if we stretch it ot for too long women who need pschiatric treatment will

be missed. That is ver important. The committee shold think of the increased risk becaseof that. That is the sometimes horrible realit for those of s who have dealt with patients whohave gone on to kill themselves.

Dr. Joanne Fenton: In reference to Dept Kellehers qestions, with regard to the paneland assessment, the pschiatrist is there to evalate, to assess and to refer for treatment and it


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will not be a tick the box exercise. That is or role as doctors - to care for the individal and tomake the accrate assessment.

With regard to the women travelling abroad for a termination, we know that there are manwho attend. We do not know the specics of each woman and what her circumstances are, but

certainl there wold be a nmber of women who are most vlnerable and have mental healthisses. We cannot ignore that grop and we need to be able to provide for them here. We needto be able to care for those women.

With regards to resorcing, as has been stated, there are onl the three perinatal pschiatristsin Dblin. There are no other perinatal pschiatrists in the rest of the contr. Pschiatric careservices need to be available for all pregnant women who are attending maternit hospitals.That is essential.

With regards to Dept Caolins qestions, I think that there will be an agreement be-tween the pschiatrists and the obstetrician becase we are there to care for the individal. We

want the best available care for her. It is not abot s arging with each other bt providing carefor this woman. I am fairly condent that there will be agreement.

With regards to the timeframe, it shold be shortened. The longer that we leave a women indistress, the greater her risk of sicide.

On the last qestion, we are trained as pschiatrists over man ears to do risk assessmentsand to care for and evalate women. That is what we are trained to do. We cannot predict theftre bt we are there to give the best available care to these women. That is essential.

Dr. Maeve Doyle: On Dept Kellehers statement that 4,000 women go to the unitedKingdom for an abortion, what is quite worrying is that there are no gures at all for children.I am being accsed of being a broken record abot children, bt I will contine to be so.

Senator Jillian van Turnhout: Keep going.

Dr. Maeve Doyle: What we are most likel to see is the most vlnerable grop presentingagain. These are children in the fll care of the HSE. The will be sbjected to the process hereand I do not think it has been thoght throgh adeqatel.

In terms of resorces, obviosl child pschiatr is a onger specialit. There are approxi-matel 90 consltants in the contr and approximatel 70 mltidisciplinar teams. There aresupposed to be approximately 100 teams. There are ve approved centres - that has been ref-

erenced in the docment - and onl 60 beds there. Most of the child pschiatrists are workingin the commnit in catchment area services. Therefore the stiplation in the heads of the Billthat a pschiatrist needs to be attached to an approved centre will not happen and those whoare attached to approved centres are not attached to maternit nits either. Those are two ver

practical points that will make this extremely difcult to work on.

The issue of consent, which Deputy Caolin brought up, will be very difcult for thelegislators. If a child is placed in care volntaril b the parents and is sicidal, pregnant andseeking a soltion nder this legislation, the HSE and gardians mst give consent. What hap-

pens if the gardians disagree?

Head 4, sbsection 4 states that the woman can alwas decide whether to proceed with anprocedre. That is not elaborated on in the case of a child. How will children presenting with


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acute psychosis or signicant intellectual disability be able to decide whether to proceed? Ourinterpretation of the Non-Fatal Offences Against the Person Act is that a child ma not refsetreatment as she is not viewed as having the capacit to refse. Therefore, if a panel decidesthat a child can go ahead, the child may nd herself undergoing a procedure that is potentiallylife-threatening withot the capacit to refse.

There is an appeals process for a woman. It is nclear who can appeal on behalf on a minor.While there is a review procedre, shold a panel disagree among themselves on a corse ofaction, there is no eqivalent mechanism for dispting gardians. In respect of the nanimitof the panel, if the isse is sicidalit, one wold expect it wold be the pschiatrists view thatwold be taken primaril. We wold certainl not be able to advise the obstetricians on whenit is appropriate for them to carr ot their procedres.

Dr. Anne Jeffers: Dept Kelleher spoke abot the role of the panels. We stated in orsbmission that we feel nothing in this legislation shold sbvert the sal pathwa to care.We would expect that a woman who nds she has a crisis pregnancy would go to crisis preg-

nanc conselling services bt that we wold see anbod who needs inpt from a specialistpschiatric service. We sggested in or sbmission that if it is a case in which, perhaps deto conscientios objection, there is no pschiatrist to see the woman, she wold be referred toa panel set p b the HSE.

In respect of women who travel, it is very clear, and we have the gures to show, that atleast 4,000 Irish women are having abortions in the uK ever ear. We presme the vast ma-

jorit of these women are mentall and phsicall ver health. The have nothing to do withpschiatr and pschiatrists have nothing to do with them. M concern is for the vlnerablewomen who ma have a crisis and ma travel for an abortion and it ma not be the right thingfor them. We do not have a cltre or environment in Ireland in which the woman feels she candiscss that and talk openl abot it. The other woman is the one who travels for an abortionand believes that the onl alternative to that abortion wold be to kill herself. We need to askwhat kind of a State we are that we wold allow a woman to travel in that state. If this legisla-tion can do something abot that, it is to be welcomed.

M colleages mentioned resorces. For commnit mental health teams and particlarlsocial workers, ever commnit mental health team in the contr shold have the fll mlti-disciplinar team.

In respect of the reqirement for three doctors, we generall feel as pschiatrists that we arethe ones with the expertise in managing sicide risk. There has been mch talk abot predictingsicide risk, bt when anbod who is sicidal comes to s, it is or job to assess what is goingon for them. What are the factors and what is happening that leads them to believe that killingthemselves wold be a thing to do? We engage with them - not jst the pschiatrist bt evermember of the team - in nding a way to ensure we can keep that person safe. That is what wedo as pschiatrists. We do it ever da and we know how to do that well.

In respect of the timeframe, the decision shold never be rshed, bt a pschiatric assess-ment does not need to take das. For man of these women we wold be talking abot two orthree hors for the assessment, bt one can do a second or third one within a few das, so theimportant thing is that the woman is not left in distress.

In respect of the degree to which we can predict the risk of sicide, as I have emphasised,what is most important is that anbod who is sicidal feels able to access the service and talk


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openl abot their concerns and fears. I think I have covered most things.

Dr. John Sheehan: To repl to Dept Kellehers point abot the extensive mental healthproblems of women travelling and whether some of those women present for help, it woldclearly be a very good thing if that happened. One difculty we have is that we may have a rea-

sonable idea of the nmbers of women who travel for terminations bt we have no data on theextent of mental health problems in that grop. We have no data on how man of those womenare sicidal, so when people make comments abot this grop, the are entirel speclative

becase we have no data. Wold anthing that encorages women who travel for terminationsto come for help be a good thing? Of corse it wold. One onl has to look at people schas Bressie on the television last weekend or Alan Qinlan, the Lions and Ireland rgb plaer,talking abot mental health isses and redcing stigma. Anthing we can do to help peoplecome forward and seek appropriate help is clearl a ver good thing. If that happened, I wold

be delighted to see it.

Deputy Caolin raised the difcult question of the numbers - whether there should be two

pschiatrists and an obstetrician, and the nmber of specialists that is reqired. The core of thisqestion is whether anbod has the capacit to identif that one woman in 250,000 who willgo on to commit sicide. Whether it is one, two or three doctors, the nmber does not improveones abilit to identif that woman in 250,000 to 500,000 becase it is impossible to predictwith any accuracy when one is looking at statistics as signicant as that. The number issue isa difcult one because one is in an area of trying to predict something that is extremely rare.

It must also be said that when we look at the information from the condential inquiries andthe forensic examination of the case histories of women who died b sicide in pregnanc, wesee that the ver small nmber of women who die are women with major mental illness sch asschizophrenia or bipolar disorder or with alcohol dependence or serios drg problems. This isthe grop we are dealing with. When one looks at pschiatric involvement, often the pschia-trist is looking at specic risk factors. As Dr. McCarthy mentioned earlier, when we see peoplewith a mental disorder who are deemed to be an immediate risk to themselves or others, thecrrent pschiatric practice is to detain that person is hospital. That, of corse, is completel atvariance with what is proposed in the heads becase the propose that someone who is deemedto have sicidal intent is able to make a decision abot having a termination of pregnanc. Itis completel at odds with what one wold call standard good practice in pschiatr. DeptMcGraths point tied in with the qestion of probabilit which I covered. In the case of prob-abilit, doctors assess risk all the time; I do it ever da at work. We assess risk in order toredce risk, to care for the person and to intervene - inclding even in certain sitations as I

mentioned - detaining the person in hospital. That is different from what we are being asked todo and what pschiatrists are being asked to do in this Bill. It is also complicated b the factthat with regard to evidence-based practice there is no evidence base to show that terminationof pregnanc prevents sicide. There is no data available.

The qestion comes p too abot whether to shorten or lengthen the dration of the assess-ments. I do not think that the time is the central factor of importance. The womans mentalstate is the central factor. As I mentioned at the start of m sbmission, a person ma be ex-tremel distressed, agitated, perhaps feeling abandoned and hopeless. We see people almostever week in the emergenc department who ma have been bllied at work or there is a crisisat work; they have self-harmed and they come to the emergency department. They then say, Iam resigning. We say to them: Dont make any decision now. Wait. Such people need timeot and spport. The need to consider carefll all their options and then, with the level of


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distress redced, the can decide whether to resign or whatever. There seems to be this notionthat becase a person is expressing sicidal intent that the response has to be a rapid terminationof pregnancy. That ies in the face of what we do at work every day of the week. It is exactlythe opposite of what is regarded as good practice.

Senator Jillian van Turnhout: I thank all the experts for their ver compelling contrib-tions. I have specic questions about head 4 of the Bill. I refer to the submission from theCollege of Psychiatrists of Ireland which proposes that the term absence of clinical markersis incorrect. This has alread been referred to this morning. The talked abot the absence of

biological markers bt that there are clinical signs and smptoms. Given the debate and thediscssion on Frida, it wold be sefl and informative if the expert witnesses cold elaborateon the reason the propose that this wold be deleted from the legislation.

Dr. Doyle raised the issue of the denition of child in the legislation. I say to Dr. Doylenot to be afraid to be a broken record on this issue. It is startling that child is not denedin the legislation. I am very mindful that we are talking about the X case. Dr. McCarthy said

in his statement that, Suicide in Pregnancy is real, a real risk, it does happen. That is a factwhich needs to be clearl stated. He referred to the isse of consent, in particlar, with regardto children. It is often the case that consent is regarded as one-wa, that a person consents to amedical procedre. However, a person can eqall refse to give consent for a procedre. Weneed to be very mindful of the use of the word, consent with regard to the child. I am think-ing in particlar of children in care. If I am correct in reading between the lines, other childrenma have choices becase their parents ma choose to travel with those children bt a child incare will not have that choice. What if the parents do not agree to that? What if that child is incare becase of parental abse, et the parents ma interfere in the choice made b their child?This is an extreme sitation which ma onl arise in one case, bt that is still a child in the care

of the State.In the view of the experts, should the legislation include a specic provision with regard to

children in the care of the State? I am concerned that sch a child cold be almost smotheredin the process b the nmber of people who ma become involved. This wold add to the dif-culty for a child with suicidal ideation or intent.

Deputy Peter Fitzpatrick: I welcome the expert witnesses. If a patient is sicidal andsffering from mental illness, will she be legall competent to give permission for an abortionin accordance with head 4 of the Bill? Where a patient is sicidal, wold the provision of fll-time care, which includes close observation, reduce the risk of self-destruction to a signicantly

low level? If a patient has stated sicidal intent bt is not sffering from mental illness, whichcriteria will be sed b pschiatrists to decide that a real and sbstantial risk of sicide exists?If a patient is sicidal bt not sffering from mental illness, what pschiatric and medical treat-ment can be provided?

Deputy Denis Naughten: Following from Dept Fitzpatricks last qestion, what hap-pens in a sitation where someone has refsed alternative interventions? How wold this sit-ation be dealt with b pschiatrists? The College of Pschiatr of Irelands sbmission is verclear that suicidal assessment should be left to the psychiatric profession. How does this t intothe sstem of mlti-disciplinar medical teams?

How does it stand with regard to the tests that mst be inclded in the pschiatric assess-ment regarding the need to preserve the life of the nborn? What are the particlar skills ofpschiatrists in making that assessment if the are doing so on their own? The witnesses have


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stated that obstetricians shold not be involved in this part of the decision, et in the sbmissionit is stated that child pschologists shold deal with children bt that perinatal pschologistsshold not necessaril deal with adlts. I ask the witnesses to elaborate on that point. Thereseems to be contradictions in the presentations.

What happens if the risk of sicide is as a reslt of non-fatal bt serios life-limiting foetalabnormalities? I am trying to nd out the differentiation between early delivery and inductionprior to viabilit. In the case of a patient with a medical illness, the obstetricians endeavor tocontine the pregnanc in so far as it is possible bt in some cases where the woman wishes tohave a termination - please correct me if I am mistaken - I presme it is important that indc-tion wold take place prior to viabilit. How do doctors deal with sch a sitation if the woman

presents late with a non-fatal serios foetal abnormalit which is ver close to that 22-weekthreshold of viabilit?

Dr. John Sheehan made the point that the procedre in the legislation contradicts good prac-tice in pschiatr. I ask him to elaborate. I ask him to give his views on the fact that with regard

to infanticide, women who have recentl delivered are treated differentl from anone else insociet who ma be accsed of mrder.

Dr. John Sheehan: I will begin with the rst question on the absence of a clinical markerin head 4. There is no specic clinical marker to assess suicidal risk. A risk assessment willinclde whether a person has a crrent mental disorder, sch as depression or a depressive ill-ness. It will also examine alcohol or drug use and then it will look specically at a whole rangeof risk factors. We also take other factors into consideration sch as gender becase sicide isfor times more common in men than in women; the peak in sicide depending on age with a

peak in ong men and in older people. There is a range of factors to be taken into consider-ation. However, there is not a scientic formula. There are different scales, for example, these of what is called a hopelessness scale. These scales are helpfl. However, I think all wecould actually say it that these are helpful as opposed to being denitive. Therefore, there is nota denitive clinical marker in that regard.

The second qestion raises an interesting isse concerning a person who is sicidal andhas a mental illness. The bread and btter of pschiatr is seeing people with mental illness ormental disorder who, for example, ma be sicidal. Good standard medical practice comes into

pla there - that is, everthing from evidence-based treatment, sch as cognitive therapies, dahospital care and admission to hospital. There is a wide range and medication ma be sed. Inthose sitations, dealing with a person who is sicidal with mental illness, the principles are to

target the mental illness and keeping the person safe.It gets more difcult when a person does not have a mental illness. Anybody who works

in an emergenc department, particlarl in the inner cit, reglarl sees homeless individalswho essentiall want a bed for the night. The will come in and sa the are sicidal and I needto be admitted. When one delves down to what is going on, the need a bed for the night andthat is what the are looking for. The know that b asking the qestion in that wa, that is howthe can access a bed. It becomes mch more complex when one is dealing with isses that donot relate to mental illness or mental disorder as sch.

The liaison pschiatr faclt, of which I am a member, represents doctors who largel

work in emergenc departments and see people who have attempted sicide. The wold qes-tion the validit of an assessment of an individal who does not have a mental illness bt who,for example, is requesting or demanding something. It can be quite difcult to be certain and


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accrate in an assessment when a person does not have a mental illness or mental disorder.

I also wish to allde to some other points. If a pschiatric assessment is done b a ps-chiatrist or a member of a mlti-disciplinar team, in certain services members of the mlti-disciplinar team have condcted assessments of people presenting after self harm. Nationall,

it tends to be a pschiatric assessment bt there are services that have involved people from themlti-disciplinar team concerning people who have done self harm.

We warml welcome the clinical care pathwa programme which is coming down thetracks. It will involve having specialist nrses doing assessments of people post-self harm. Wewelcome that bt it is not a pschiatrist doing the assessment there.

Finall, I will deal with the isse of infanticide, which is extremel rare. Resnick dividedinfanticide into two tpes: earl and late. Earl infanticide was where a mother killed her little

bab within 24 hors after deliver. In that sitation, the woman was often sall ver ong,completel nspported and immatre. She felt she had no other option bt to do what she did,

bt certainl did not have a mental illness.Infanticide that occrs later is related to major pschiatric illness and sall what we call

pschosis. This is ver rare and clearl ver tragic when it happens. That is the isse concern-ing infanticide.

Dr. Anne Jeffers: To start with, we wold see it as a qestion on the absence of biologi-cal markers, rather than clinical markers. I do not think people will be asking obstetricians toexplain how they do their job. It is really difcult for me to distil down the amount of trainingand expertise I have, the 30 ears experience and working with mlti-disciplinar teams, to trto adeqatel get across the expertise of a pschiatrist in assessing sicide.

I will give an example of somebod who might come to s in this sitation, Often, it is aong woman who ma herself have had experience of extreme abse in her childhood, mahave been raised in care, ma alread have had children taken into care, and ma be comingto s with the prospect of going throgh another pregnanc when she fears that the child ma

be taken into care also. These are women who, becase of their circmstances, have not beenable to bild p the normal social spports that the rest of s rel on to get b. The come to a

pschiatrist and a mlti-disciplinar team. A social worker will meet with them and a pscholo-gist will be involved. Between s all, we will be offering spport to this woman. We are not

jst talking abot a once-off assessment, we are talking abot ongoing care and spport. Theimportant thing is that we identif where the hopelessness is coming from, identif what the

isses are and what we can do abot them. That might describe how we, as pschiatrists, assessclinical risk.

I was interested in Senator van Trnhots statement that we ma onl be speaking abotone case of somebod who is in care or a child in care. A lot of the women we see in thesestressfl sitations wold themselves have been in care and often have children in care.

Senator Jillian van Turnhout: Oka.

Dr. Anne Jeffers: On the isse of whether somebod who is sicidal can give consent, onceagain it is abot working collaborativle. That is what we do in pschiatr - we work closel

with the individal who comes to s with the problem and we ensre that, as regards decisionsthat are reached, the person is capable of making that decision. It is ver clear in the Bill thatthe person has to, althogh the have not addressed the isses where the person does not have


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the capacit. We will certainl be working with the person who has the capacit.

If they do not suffer from a mental illness, this is a difcult area. The whole issue of whatwe do if somebod comes to s and we think there might be another intervention other than atermination, et the are ver determined that a termination is the onl answer. The Mental

Health Act wold not be applicable in this case. There ma be cases bt it is hard to describe.I think we wold have to tr to nderstand wh the person was relctant to take on an of thetreatments we are sggesting. That goes back to their childhood experience and their pscho-logical make-p. There are sall reasons wh people cannot avail of treatments that we ma

be offering. That is what we do in or da-to-da practice, bt there ma be cases where wehave to say to women, This law doesnt apply to you. They have autonomy and have to maketheir own decisions. In practice, that is not going to be a decision that is made b one pschia-trist - it is part of the team approach.

The qestion was raised concerning how one handles a sitation where somebod will notaccept treatment. The isses of earl indction and infanticide were also raised. I will leave

these matters to the perinatal pschiatrist.

Dr. Maeve Doyle: I was ver pleased with Senator van Trnhots contribtion. It washeartening to acknowledge that we are here becase of the predicament a child fond herself in.

I will talk a little bit abot child pschiatr. We work in a mlti-disciplinar wa and childpschiatr was probabl invented in a mlti-disciplinar wa. That is becase we consider thechildren as part of a sstem with famil, school and the wider environment. As child pschia-trists we assess for the presence and absence of pschiatric disorder. We are well sed to work-ing with or colleages and tend to devise protocols where we look at deliberate self harm andsicidal ideation, bt we alwas have access to the pschiatrist to determine whether there is an

actual mental illness. I think Senator van Turnhouts question on whether specic elaborationswith regard to children and adolescents ma be needed is a good one becase the complexitiesof the sitation with regard to consent, refsal, capacit and so on are not ver well nderstood.I will give members a short example with regard to the admission of ong people to inpatientnits for mental health assessment and treatment. The childs gardians can sign the admis-sion form on behalf of the child, assming the relevant gardians are happ to so do. In theabsence of that consent and if a determination has been made that a child reqires admission toan inpatient nit either for assessment or treatment, then recorse is made to the Mental HealthAct 2001. In addition, if a child is in the care of the HSE and admission is soght, the practice,

based on legal advice, is that the protection of the Mental Health Act is soght. In cases in

which a child is 16 or 17 ears old and explicitl states he or she does not wish to be admitted,while his or her gardians are keen that he or she be admitted, it has been deemed prdent toseek the protection of the Mental Health Act in case a sitation arises in which the treating teamma be obliged to phsicall administer medication against the will of the ong person. Theoverriding principle in all of this is that the welfare of the child is paramont. However, it is theappropriate adlts who determine what is, in fact, in a childs best interest and perhaps some-thing sch as a gardian ad litem might help in this procedre. I reall wish to highlight that itis not that the legislation is unworkable - we will work with it- but we need to ag, in particularfor children and adolescents, the additional laers that mst be considered.

Dr. Joanne Fenton: I will address some of the questions from Deputy Fitzpatrick, the rst

of which pertains to an absence of clinical markers. As Dr. Jeffers mentioned earlier, we aretrained to carr ot risk assessments and to look after carefll and treat the women. It takesman ears to do this bt we are ver competent in making those assessments. In the case of


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a woman who presents for an assessment stating she wants to have a termination and who ispschotic, it wold be or role to treat that pschosis, rather than making the jdgment to havea termination. Conseqentl, it is within the capacit. In addition, we wold make that decisionalong with the obstetricians. We wold make or pschiatric assessment and then wold speakwith the obstetricians, so we wold work as a mltidisciplinar team.

Dr. Anthony McCarthy: I thank members for a nmber of interesting and thoghtfl qes-tions. I will not refer specically to the child issue because Dr. Maeve Doyle has covered itwell and adeqatel. I note that, again, there are technicalities on which we reall mst workand while none of them is insperable, we mst work on them. In addition, I will not answeranthing frther abot clinical markers, as that point alread has been made.

Yes, suicide is a fact. When people talk about gures, such as one in 500,000 or one in250,000, it is desperately important to note we actually do not have a clue because these guresare based on the fact that this is a contr, the united Kingdom, in which abortion is directlavailable. I am on that condential inquiry that considers those maternal deaths to which Dr.

John Sheehan has referred bt, es, absoltel, those who commit sicide in the united King-dom at present nearl alwas are mentall ill. However, that does not at all accont for all theother hndreds of thosands of women who have terminations in England and who ma well

be mentall distressed and ma well have that termination becase the are sicidal. Nothingcaptres that at present and nothing will. Conseqentl, one mst be ver catios abot thatsort of evidence.

Again, I will not address Dept Fitzpatricks qestions too mch becase I believe I cov-ered that isse in m opening statement. I agree that some people have mental illness and itmst be treated. In the case of some people, it is mental distress. In the realit of or clinicalwork, we reall are dealing with the complex interaction between stress, distress and mentaldisorder. If onl life were black and white and one cold sa these ones are mentall ill andshold be treated pschiatricall b getting them into hospital and observing them carefll,whereas these ones are in pschosocial distress and shold be dismissed. That is not life andever one of o in this room knows that. It is mch more complex than that and or jobs andexperience are to weigh p these factors. As for the woman who refses alternatives, we arenot naive. If a woman comes to me, having refsed all other alternatives, m qestion will beWhy?. Why is she sitting in front of me if her only option is a termination of pregnancy?Wh has she not gone to England? This will be part of the process as we are not fools andit will be a highl complex discssion. The qestion will be whether she is tring to test thelegislation or is it the case she cannot leave the contr for some reason. As for the idea that

this wold be blocked in some wa or that she will present in that wa, namel, that she refseseverthing else and conseqentl it is p to me, in itself that is a ver complex interaction. Weare sed to dealing with people who pt s nder all sorts of stress to make decisions. Dr. JohnSheehan made reference to people in the emergenc department who threaten to kill themselvesnless the are given some methadone becase their methadone was stolen in the hostel. Weare sed to being pt nder pressre. While that might seem like a job that most of o woldnot like, I love m work. It is reall complex bt it also is ver hman. We are aware of thecomplexities and interactions and are not naive.

A member, whose name I did not get, asked a ver good qestion abot mltidisciplinarteams. While we work in mltidisciplinar teams, there are times when, as pschiatrists, we arethe ones who must make that nal decision. We have talked a bit about involuntary detentionwithin hospital and it is the consltants name that goes on that form. Similarl, for someone


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who has been previosl detained, it is the consltants name that goes on the discharge fromhospital form. If that patient appeals against his or her detention in hospital, I as a consltantmst go into that room and defend. It is not m mltidisciplinar team, jst me. Conseqentl,as pschiatrists we are sed to being the individals who take these decisions. That is or re-sponsibilit and dt and is one for which we all are ver well trained.

On the viabilit isse, I agree there are highl complex isses abot viabilit. I think thatreall is p to or obstetric colleages to deal with. There are of corse complex, painfl issesthat sometimes mst be dealt with. If a woman is six weeks pregnant, m conversation withher will be ver different when compared with that with a woman who is 16 weeks or 26 weeks

pregnant. We know that. Wh does she wish to get rid of that bab? Does she wish to get ridof the bab or does she wish to kill herself? Moreover, if she wants to get rid of that bab, is it

becase she cannot bear having that bab inside her? Perhaps she has an eating disorder andalread has taken three overdoses in the corse of that pregnanc becase she cannot deal withthat real distress. I am sure it is difcult for all of you to understand but I refer to an anorecticwho sees herself as totall fat and the isse actall is that she wants the bab ot. This is incontrast to someone else who wants that bab killed becase it is her fathers child or becaseshe actall is in a relationship with a g who she shold have left ears ago. When she got

pregnant, in that ridiclos wa she wold do, she kind of imagined that somehow having abab with him might make him be nice. However, we know that, actall, men are more likelto have affairs dring their partners pregnanc and certainl levels of domestic violence in-crease dring pregnanc. We men do not come ot well ot of all this. This is a woman whoalread has been kicked three times in the stomach in pregnanc and who knows now that ifshe is pregnant, her isse is that if she has this bab, she will never get awa from him, becasehe will be the father of the child and she will be obliged to sta in this contr becase he willhave rights. Conseqentl, she has a choice, namel, does she kill herself or does she get rid of

that bab or perhaps both, bt if she has that bab she is stck. If this conversation takes placeat 16 weeks or 22 weeks, es, we wold tr to help as mch as we can. However, if anonecan sa there never will be a woman in this circmstance, he or she reall does not nderstandthe mess, horrible natre of life sometimes. I refer to the real mess, the blood isses that goon. That is the realit which we mst deal with and assess, not as cold pre-jdgmental black-and-white people bt as real professionals who nderstand mental illness, mental disorder andcapacit, bt who also nderstand that, sometimes, it is not black and white and is not eas.

Finall, while talking abot blood isses, let me get back to infanticide, to which I referredthe last da I was here. I got a lovel letter from a priest afterwards thanking me for raisingthis horrible part of Irish histor, namel, the histor of hndreds of women who committedinfanticide every single year in this country during the 19th century and the rst 50 years of the20th centr. Wonderfl stdies have been done on this isse and these were real. The stdto which Dr. John Sheehan referred is abot infanticide now and not abot infanticide then.Infanticide then was not all abot mental illness or anthing like that. It was abot womenwho found themselves in extremely difcult situations. The treatment of unmarried women,women with nwanted pregnancies in this contr is not great, is it? I refer to the Magdalenlandries, indstrial schools and pschiatric hospitals. We as a profession plaed or part inhaving women in hospitals for man ears. For what reason? We collded with nwanted

pregnancies. The reason I stand here, not jst as a perinatal pschiatrist bt as a hman beingand as president of the college is to sa that shold stop. We mst do anthing that will protect

women in these circmstances. The women will be treated with dignit and respect. If at allpossible, the life of their nborn child will also be preserved. That is not onl m responsibilitnder the Constittion and the law bt also as a hman being and as a father. If a woman goes


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on to kill herself, her child or children die as well. Sch sitations happen. The are real andit is or job to prevent that.

Chairman: We have 23 mintes remaining in the session. I apologise to members, as noteverone will get to contribte in this session. Six members have indicated to speak. The

next three to speak will be Senators Ivana Bacik and Colm Brke and Dept Mar MitchellOConnor.

Senator Ivana Bacik: I thank the witnesses for their compelling evidence and for clarif-ing a nmber of important points for s. First, that pschiatrists have the experience and exper-tise to assess sicide risk, that it is something the all do rotinel and that in particlar the aresed to operating within the stattor framework of the Mental Health Act and of adjdicatingon detaining people against their will on the basis of their clinical assessment. That is verhelpfl to s in the context of some of the comments we heard on Frida. It is also helpfl tohear from them that abortion is not a treatment for mental illness bt rather it ma in rare cases

be reqired in order to avert the risk of sicide. That is the langage of the Spreme Cort and

of the heads of the Bill. That is helpfl as that is what we need to work within.

Pschiatrists have also pointed ot the highl restrictive natre of the legislation, and as areslt the realit that for the majorit of women who travel the 4,000 women - ever earfor abortion will contine to do so and will not avail of the highl restrictive procedres in thiscontr. Dr. Dole pt it extremel clearl that the majorit of the ver small nmber of wom-en or girls who will avail of the measre will be those in the care of the HSE who are nable totravel otherwise. The comments on the amendments on children are ver important.

I wish to ask a couple of specic questions on other points about amendments. In head 4there are currently two specic restrictions on psychiatrists requiring that both of the psychia-

trists will be emploed at a centre registered b the Mental Health Commission and that onewold be attached to an instittion where a procedre is carried ot, in other words, a maternitnit. Concern was expressed on Frida that this was too restrictive, as there wold be too smalla pool of pschiatrists from which to choose. Cold the witnesses comment on the point andwhether we should broaden the denition?

As a criminal lawyer I am extremely concerned about the denition of the criminal offenceinvolved in a head that has not et been referred to toda, head 19, in particlar the criminalisa-tion of women. Some of the witnesses have pointed ot the realit that man ong womenin particlar are availing of abortion pills over the Internet reslting in self-indced abortionin this jrisdiction. under the crrent wording the wold be sbject to criminalisation and a14-ear penalt. As pschiatrists, do the witnesses believe that wold have a chilling effect onwomen seeking help in after care?

My nal question is for Dr. Sheehan. I apologise if I misunderstood him, but is he suggest-ing that a girl like X who is suicidal because of her pregnancy and has been denied an abortionwold never commit sicide? How wold one care for a ong woman or girl in that sitationwho wants to kill herself becase she is denied abortion. She is ver clear abot that. Does hesggest she wold be detained involntaril for the dration of her pregnanc? That is a seriossggestion. I apologise in advance if I misnderstood his meaning.

Senator Colm Burke: I thank all of the contribtors this morning. The sbmission onthe role of pschiatrists in making the decision is in line with the Medical Concils proposedamendment nder head 4, which was presented to s on Frida, namel, that the pschiatrists


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wold sign off on the pschiatric isse and then there wold be consltation with the obstetri-cians. Do pschiatrists feel that GPs shold have a more involved role in the decision-making

process or are the happ with the Medical Concils proposal to deal with the isse?

The second isse relates to pregnant adlts nder pschiatric care at present. How is the

isse of consent crrentl dealt with if, for argments sake a decision is taken that a personneeds a caesarean section? Does crrent legislation allow medical practitioners to take a deci-sion withot referral to a jdicial process?

The third isse is one abot which I have serios concern. It relates to expectant mothersaged under 18 or under 16. What clarication needs to be provided in the heads of the Bill todeal with the isse? What protection mst be provided for the expectant mother, the parents andthe doctors dealing with such cases? What clarication would the witnesses suggest is requirednder the section?

Deputy Mary Mitchell OConnor: I thank Dr. Maeve Dole ver mch for raising serios

issues around the legislation. We must examine specically what she has raised today. I thankthose witnesses who mentioned compassion. As a woman and a mother I reall appreciate that.

Dr. McCarth stated that all assessments mst be individal, comprehensive, compassionateand not prejdged. He stated that he is the president of the College of Pschiatrists of Irelandand a specialist in perinatal pschiatr. Does he foresee that some women will be prejdged bhis profession if the Bill goes ahead?

It has been stated that there are 864 members in the College of Pschiatrists of Ireland. Arecent srve was completed b approximatel 130 members. I wonder wh the other ap-

proximatel 600 pschiatrists did not answer the srve. Was the srve widespread? In m

ignorance I thoght there were onl approximatel 130 pschiatrists in total.Chairman: Cold Dept Mitchell OConnor please address the Bill?

Deputy Mary Mitchell OConnor: This is relevant becase we received information onthe srve b e-mail.

Dr. McCarth asked a qestion which I wold like to echo on whether pschiatrists haveever signed a form for involntar detention of a patient de to the risk of them being a dangerto themselves? Cold the ever foresee that the might have to do that for a pregnant woman?I will leave it at that. Perhaps the Chairman will allow me to speak again if necessar.

Chairman: We will not have time bt if I can I will. Three other members have indicatedand I will take them now if that is okay. I accept it is difcult on the witnesses but I wish to befair to members who have been present all morning. I call Senator John Crown, Dept Cath-erine Brne and Senator Jim Walsh.

Senator John Crown: In formlating the decision as to whether sicidalit will be in theBill, the ve witnesses have the same rights as any ve citizens of our country in a popularreferendm. The decision has been made b the Spreme Cort, which according to Article34.4.6 of the Constittion states that the decision of the Spreme Cort shall in all cases benal and denitive. That can be challenged by the people in popular referendum. That has

happened twice. On the rst occasion when it was asked clearly and unambiguously it was de-feated b a margin of 2:1. There reall is no constittional mechanism for s in this Chamberto decide that we are not going to include suicidality or that we are going to specically exclude


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sicidalit from a Bill which allows abortion to save the life of the mother.

What we need the witnesses to do, which the are doing ver well, is to inform s abotsome of the relevant practical isses. The realit is pschiatrists do not change the Constittion

bt the determine pschiatric practice and the pschiatric evidence base. Therefore, when

constittionall mandated pschiatrists at some hpothetical I believe it ma never happen occasion in the ftre are confronted with a pregnant woman who is sicidal and are askedto make an adjdication within the rles of the law which we will be asked to pass sometimedring 2013, it is their job to formlate the evidence base which best informs the pschiatristswho will be in that position. In trth, what the have told s toda is ver sefl.

I have a few specic questions to ask. One is to my very old and dear friend and colleague,John Sheehan. If we believe that there will be a net transfer of women who are now going tothe uK for abortions to this contr - in the event that this new regime occrs - we have to askwhy. It will happen for one of two reasons. The rst reason is that they are legitimately goingto the uK becase the are sicidal to seek a legal abortion which the believe might not be

freel and legall available in this contr. The other alternative is that the are not going tothe uK becase the are sicidal bt will tr to game or sstem. To game or sstem thewill need to do it with the free, volntar, informed collsion of two pschiatrists. There isno other wa rond this and some of or witnesses in Janar were ting themselves in knotsabout this, saying oodgates will open but women will not lie. They never explained what themechanism wold be. We will have informed pschiatrists who have the evidence, which tellsthem a woman is or is not sicidal.

I am a little confsed b one thing. In the corse of m job I mst freqentl take historiesfrom people who are ver distressed. Sometimes the sa the often think of ending it. That isa red ag to me and I must refer them to a psychiatrist who is more skilled than I am in assessingthe likelihood that sicide will nor will not occr. I am hearing this morning that pschiatristscannot do that and I am trobled b that. I feel ver vlnerable when I do not send someone toa pschiatrist in case some traged happens. As an oncologist who has had a patient commitsicide, I need to know we have the back-p of pschiatrists on this.

Deputy Catherine Byrne: This morning I looked at the logo for the College of Pschia-trists of Ireland - wisdom, learning and compassion - and those are what this Bill is abot. Wemst have the wisdom to make the right decisions, the learning skills to listen to witnesses andabove all, we mst all have compassion. unfortnatel this is not abot the lovel, beatifl4,000 women who go to England ever ear. It is not abot them. I agree abot the length of

time for the appeals.Have an of the witnesses in their profession, becase of the increase of illegal drg taking

b ong women, particlarl in Dblin, an evidence that more ong women who are preg-nant with mental illness are contacting their practices? Is that leading to people wanting to endtheir pregnancies?

Senator Jim Walsh: Capacit to consent is an isse. Cold we get some idea if what thisentails? M nderstanding is that where a major decision is being made b someone who has amental illness, not to talk abot being sicidal, it does not stand p in law and he or she wold bediscoraged from doing it. Abortion is an irrevocable decision which wold be recommended.

On a point made about the X case, would the witnesses comment on the progress in psychi-atric medical evidence in the last 21 years since the X case? We know the Supreme Court and


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the High Cort got no pschiatric evidence at that stage.

When the obstetricians were in on Frida, the were ver strong on doctors being ethicallobliged to act on medical evidence. The institte chairman emphasised this in his report tous. Above all, they maintain do no harm and the two patient model was something they es-

posed. The witnesses toda all agree abortion is absoltel no

Documents

Second Day of Hearings