Never Again

Dr. Peadar O’Grady
Child Psychiatrist and Doctors For Choice spokesperson

There’s an attempt to confine the abortion debate to individual tragic cases. Savita Halapannavar, the X case, and the recent C case, in which the European Court of Human Rights ruled that the human rights of C, who had cancer, had been breached when she was compelled to travel for an abortion – those are the tragedies that we know about. But that’s not the entirety of what abortion is about.
To truly protect the health and the rights of women, you need to have the principle of a woman’s right to choose enshrined within your laws. That greatly simplifies the complex approaches that are currently being taken. The expression ‘a woman’s right to choose’ is what some people call ‘abortion on demand’. When people say they are against abortion on demand, they should be asked what it is they are against. Are they against women deciding what’s best for themselves, as in Savita’s case?

Abortion On Demand
Those who use the the term ‘abortion on demand’ need to be asked what they mean by it. But where is this being asked in the mainstream media? Where is it happening that the notion of ‘abortion on demand’ is being questioned? ‘Abortion on demand’ is not a pro-choice expression; it’s a right-wing, illiberal expression. So the media need to start doing their job, and get to the truth of what politicians actually mean when they say they are opposed to abortion on demand.
The anti-choice side have raised the argument that women don’t die because of the Irish ban on abortion. But that’s because there is no effective ban on abortion, except in a very limited number of cases. They are the cases of women who are not in a position to travel, either because they’re too young; or they can’t get access to money; or they’re too sick, like Savita; or they’re in some way restricted from travelling – for example a trafficked migrant who doesn’t have papers can’t travel outside of the country.
What was startling in the few days after Savita’s death, was where women rang in on the Joe Duffy programme saying that in the same situation, having a miscarriage, they were told things like ‘read between the lines’, ie, go to England. This was told to women who were having a miscarriage. Now, they could travel, while Savita was too sick to travel: that was the only difference. It is crazy that health workers and medical practitioners are being forced to advise, in a coded way, that women in the course of a miscarriage should travel for abortion. They clearly agree that abortion at this stage is the best option for the woman, yet they can’t do it themselves.
What’s become clear in this debate are the dangers inherent in this notion, put forward in the Suprreme Court, of a ‘risk to the life’ as opposed to a ‘risk to the health’ of a woman who is pregnant. The key question is who decides? Women are prevented from deciding. Health workers are constantly pointing out that they’re not in a position to decide when it’s not clear. The distinction between health and life made by the Supreme Court makes no sense in terms of health care. If you have the flu, is it a threat to your health or your life? Generally we think it’s a threat to your health, with a small threat to your life. But in 1919, 50 million people died of the flu. So that year, flu wasn’t just a threat to health.
The question has to be: who takes the risk of deciding? By default it should be the patient who decides, because the patient is the one who experiences the risk. In terms of treatment generally in medicine, the decision about whether or not to avail of treatment is up to the patient. The doctor’s job is to decide on illness status, what the treatment options are, and inform the patient. But the decision is down to the patient. And the only exception we have for that is if the patient is not able to decide; if in some way their mental capacity is affected, and there’s an urgent need to treat them. If it wasn’t urgent you could wait and see if their mental capacity improves, which will give you time to help them to understand or consider, or be convinced of best treatment.
In the case of abortion, the patient is able to decide, plus the situation is urgent, and yet they’re not allowed the decision here in Ireland. That doesn’t apply anywhere else. The point here is that this is not medicine. In Ireland in the case of abortion, the decision of whether you give it or not is not based on medical thinking – and the doctors have said this – it’s based on whether or not it’s considered to be legal. Here the law is intervening in good medical practice.
But what is the excuse for not treating a woman? In what way are women not compos mentis? If you are a patient in Ireland who is denied the decision as to which treatment to take, it is because you either lack mental capacity, or you are a woman who wants an abortion. So what we’re saying, in effect, is that women who want an abortion lack the mental capacity to make that decision. I’d like to know why the doctor has the mental capacity to make the decision, but the woman who’s actually going through the experience doesn’t. And the point is that this view is not medical opinion. That’s not to say that there aren’t doctors who don’t think it; it’s just that it’s not a uniformly medical position. It is a result of your political and religious prejudice as a doctor; it doesn’t come from your medical training.
Outlining the options and allowing the patient to choose – that’s normal medical practice. And abortion as a medical practice is normal throughout Europe – it’s just not normal in Ireland. That’s a legal and religious and political decision, not a medical one. It has very little, if anything, to do with medicine.

Doctors For Choice
There is a huge variety of opinion on what choices a person would personally consider if faced with an unplanned, unwanted, unfeasible or unviable pregnancy, or a pregnancy that poses a mental or physical health risk to the woman. But the decision about whether you are pro or anti-choice is a political decision. The political decision is whether or not you want to force your view, of what you would do in your personal life, onto someone else; and in what circumstances, because the circumstances matter. And many people take the political decision that it’s better to let other people decide their circumstances, and therefore not to restrict abortion in any circumstances. That doesn’t mean they think personally that they would avail of abortion in all those range of circumstances.
Of course for most people, it’s not just a political decision about not forcing your opinion on others, but it’s an understanding that nobody’s too sure what they would do in certain circumstances. For most men, for instance, it’s obvious that the notion of what you would do if you were pregnant is a fairly abstract consideration. Many people can only imagine, for example, if I was raped and became pregnant, what would I do? You can wonder and imagine and hope, about how you would cope with difficult life experiences, but you don’t really know.
And most people take that view – they don’t want to judge what another person should do in circumstances where they’re not even sure what they would do themselves. So there are two elements to this – the uncertainty of what you actually would do, or would want to do, in those circumstances, and secondly, do you want to force that view on somebody else?
This notion that people who take a pro-choice position are ‘all of a sort’ is not true. There are a variety of understandings and viewpoints. What pro-choice people share is the conclusion that it is the safest political and medical position to leave the decision about which option to avail of in the current circumstances to the person who is at risk, ie., to the patient, not the doctor.
Because the recent debate has been triggered by a catastrophe in a medical setting, people keep saying we can’t make decisions on what needs to be done to make the situation safe for women ‘until we know all the details’ of Savita’s case. But we know enough of the details to know these facts: Savita asked, Savita was refused, Savita died. The other thing we know is that the doctors said that their refusal to grant Savita what she asked was influenced by the law. So the law intervened and interfered in the management of Savita’s care.
The way the question about why Savita died is being framed is evading the question about why an abortion was refused, when it would have been an acceptable option in most other countries. That is the real question. And given the dire situation that Savita was in, with no hope of saving the foetus, and that she and her husband repeatedly requested an abortion, the question being asked all over the world is: Why did you refuse her an abortion?
And it’s like the Irish State is saying, we’re not going to answer that question; instead we’re going to reframe the question, and ask instead: would an abortion have saved her life? Well, what if there’s an uncertainty about that? Why didn’t you just do it? Was there a good reason for not doing it? The obstetrician Peter Boylan has clarified that in circumstances where there is not a high degree of certainty that somebody’s life is at risk, we’re balancing a degree of probability. The only way you can be absolutely sure that someone’s situation is fatal, is if they actually die; otherwise you’re always guessing.
The question then becomes, having guessed, and put some kind of estimate on it, who then decides? Because if it’s the woman, we’re a lot less concerned about that. In Savita’s case, she would have had an abortion. She would have been counselled that it was one of the options, she would have chosen it, she would have had it, and we’d never have heard of her, because she would have died tragically despite having an abortion, or she would have not died, having had an abortion, and nobody would know her name.
The relevance is that she asked, she was refused, and she died. And again – a woman’s right to choose answers the medical and the legal demands of the situation. The issue now is whether Ireland is prepared to face up to the questions that actually come from Savita’s case, rather than the ones the State would like to answer.
The Doctors For Choice position is that we encourage people to be conscientious objectors to the failure to provide abortion services. At times it is portrayed that the only ones with conscience are the ones that are ‘pro-life’. But there are responsibilities when you restrict access to abortion – as we can see in Savita’s case – and I don’t think those restrictions are justified.
There is no medical evidence to show that women who are post-abortion are at an increased risk of suicide. On the other hand, there is evidence that suicide is associated with unwanted pregnancies in countries where abortion is not available. If abortion is not available in a country, you’re putting women at risk of suicide. So suicide is relevant. And it’s the way the country voted in the 2002 referendum. The people were asked: will we remove the risk of suicide as a reason for an abortion, and they said no.
Because of the suicide risk, when women have an unwanted pregnancy and they want to avail of abortion, it is irresponsible to ignore that. The counter-accusation from the anti-choice side has been that people who have abortions have been hurt and harmed by it. Which is absolutely incorrect.

Over To The Politicians
People equate being pro-choice with being pro-abortion, and it’s not the same thing. We’re opposed to abortion being imposed on people. And that’s not an abstract situation. If you’re pro-choice, you’ll oppose, for example, the one-child policy in China. We’re as much in favour of women being in a position to choose to have a baby, and not being forced to not have a baby. If someone decides they want to have a baby, they should be facilitated in every way. The anti-choicers have said, ‘Change society, so there’s no pressure on people to have abortions’. But no matter what way society is organised, there will be times when unwanted, unsafe and unviable pregnancies will arise. One of the best ways to reduce abortion is to improve contraception services. And one of the many contradictions of the anti-choice movement is that it’s full of people who are anti-contraception, and even anti-sex education. These same people also frequently express that homosexuality is a form of abomination.
What Doctors For Choice advocate is that a woman should be able to choose abortion services within the full range of reproductive health services, like sex education, contraception and so on. And abortion shouldn’t be privatised. It should be part of the health service. There’s no reason to exclude the ovaries and the uterus from the health service.
Safe and legal abortion as part of a high-quality reproductive health service is what Ireland needs to get us out of this mess, with a woman’s right to choose as the legal principle. Remove the law from medical practice. It needs to be taken out, not put in. I know what they’re going to try to do now – they’re going to try to detail the circumstances in which abortion is legal. And you do not want the law looking over your shoulder to get you as a doctor to make a decision that should properly be made by the patient. No matter how much help you get, doing the wrong thing is doing the wrong thing, and people trying to help you to do the wrong thing is not really help.
The only regulation that abortion really needs, is that it is subject to the same ethical guidelines as are all other medical procedures. That your doctor is properly trained, that he or she carries out procedures conscientiously, that he or she makes sure that the patient is properly informed and has properly consented, which is a huge issue in medicine. Which is partly the issue that’s being ignored here. If we carry out a procedure to which the patient hasn’t properly consented, we’re in a lot of trouble. Yet when they request and consent and we refuse to give them the treatment – that’s deemed okay.
Why would you need to detail guidelines for abortion? We don’t have a section in the ethical guidelines on how to do a hernia or a coronary bypass, or a lung transplant. It doesn’t belong in the ethical guidelines. You only put in detail when you need it. And the point from medicine is very clear: we don’t need specific guidelines for abortion – women need the right to make the decision. That’s what the right to choose is about.
Women should have the right to choose everything. Why is there no women’s right to choose movement for a bypass or a lung transplant? Because they already have that right. So access to abortion currently in Ireland has nothing to do with medical technology or some medical or health-related confusion; it is absolutely a legal restriction on the basis of religious and political prejudice. But that’s not medicine.
There’s been an interesting development in terms of who is dealing with this. In 1983, it was the bishops in that referendum. In 1992, with the X case, it was the judges. And I think finally in 2012 we’ve come to the politicians, who are the last obstacle to introducing a safe approach to the provision of abortion in the health service.

After Savita...

Dr SinÉad Kennedy
Lecturer in NUI Maynooth and feminist author

What we need, as a bare minimum, is emergency legislation to provide legal clarity that would involve legislation for the X case. The start of this can be the bill that Clare Daly TD and the United Left Alliance are introducing this week, the Medical Treatment (Termination of Pregnancy in Case of Risk to Pregnant Woman) No. 2 Bill 2012 (which is being put before the Dáil as this issue of Hot Press goes to print). This bill provides for the right of pregnant women to legally access abortion services in Ireland where doctors say that the pregnancy presents a threat to their lives, including the threat of suicide.
I think every single politician has an obligation to vote in favour of that bill. It is clearly the will of the people. There are two referenda behind this – in both cases voters refused to exclude suicide as grounds for termination. But what we’ve had is 20 years of political inaction and cowardice that has contributed to a legal vacuum in which it’s difficult for doctors to practice medicine adequately.
The anti-choice groups keep insisting that abortion is never necessary to save a woman’s life. This is clearly not the case. In Northern Ireland, where abortion is permissible where a pregnant woman’s life is endangered, we know from statistics released this year, that in 2008-9, 44 terminations were carried out; in 2009-10, 36 terminations; and in 2010-11, 43 terminations were carried out. So clearly there is a medical need to carry out termination where there is a risk to a woman’s life. If you adjust those figures for the population in the Republic, it would mean that somewhere in the region of 100 to 120 terminations to save the life of a woman would be carried out per year in the Republic.
The anti-choice people are trying to get around the facts through semantics, by claiming that there’s a difference between the word ‘abortion’ and ‘necessary medical treatment’. So abortions that we approve of, those that save women’s lives, must not be called abortions. This is not a medical distinction – it’s a theological distinction. Why in Ireland is this sort of fiction being upheld? That abortions we approve of are not called abortions, and abortions that we disapprove of are abortions? It’s a stupid linguistic game, but it’s endangering women’s lives.
Clare Daly’s bill is being seen as piece of interim or emergency legislation, because it doesn’t really address the wider question about the need for abortion in Ireland. It doesn’t address the fact of the 12 women who travel to England for abortion every single day.
Also, by necessity it has to reflect the Supreme Court’s distinction between the risk to life and health of a woman. Which is a very dangerous distinction, because what at one minute can appear to be a risk to your health, can very quickly change into a risk to your life. The fact that the Irish State is prepared to gamble with women’s lives, and indeed, with women’s health, in this regard is scandalous. Because your health can be damaged in ways that can have long-term consequences that damage your life and your well-being. But also, the only way you can be absolutely sure about the distinction between the risk to your life and your health is in the aftermath, when a woman is actually dead.
Ultimately, to deal with the reality of abortion in the way that other European countries deal with it, we will have to vote to repeal Article 40.3.3 of the Constitution, the so-called ‘right to life of the unborn’ amendment that was inserted in 1983, which has led to disaster. Until that is repealed, women will not have justice in Ireland.