Professor Patricia Casey:

Deputy Kelleher asked if we know how many women are going to Britain for abortion and might be suicidal. We do not. The British statistics do not record the reason for women having abortions, except in very broad terms such as mental health, physical health and so on. I have seen women who have been to Britain for abortions. They say they did not want to be pregnant but when I ask if they were given any treatment, help or advice they say they were not. That is crucial. We do not know if these women are going to Britain because they are not being given alternatives to abortion. If they are depressed do they see general practitioners or people who can treat them? That is the problem. We do not have any concrete facts on which to base decisions. Is there a potential for self harm and suicide among women who go to Britain? We do not know because we do not have the statistics.

Can we, clinically, differentiate between suicidal ideation, suicide intent, passive death wishes and active death wishes? The answer is, "Yes". We have a difficulty, however, in identifying which individuals, of the people we are seeing, will go on to take their lives. I can know how a patient is, in the here and now, but I cannot tell if a certain lady will, in two months, six months or ten months, have died by suicide because she is now depressed. All the studies suggest that we cannot answer that question. Studies have been conducted on people who are attending psychiatrists. When psychiatrists have been asked to predict which patient would die by suicide we have not been able to do that.

Deputy Ó Caoláin asked if this is rare and whether this is a reason not to legislate. Legislation must always be based on good medicine and on fact. There are many assumptions in these questions that if a woman is suicidal in pregnancy an abortion is the only thing that will help and there is no other alternative. That is a chain that does not necessarily flow. It is a linear chain which assumes that a woman who is suicidal needs an abortion and that the abortion will be helpful. An abortion may harm people and there is no way of knowing. The balance of evidence is that abortion either has a neutral effect or it can have a negative effect in some cases. There are too many unknowns there to suggest that this kind of legislation would be based on anything scientific or evidence-based.

I agree there is no doubt that we are short of perinatal psychiatrists. However, psychiatrists around the country see suicidal people every day. They carry out suicide risk assessments throughout the country, from Kerry to Donegal and from Drogheda over to Galway. These can be done on anyone who is suicidal. We need more perinatal psychiatrists for difficult cases.

Deputy Ó Caoláin referred to the possibility of abuse which I have mentioned in my report. The reason I raised the question whether the suicide ground for abortion would be open to abuse is because it is a valid question. Lots of people are asking it. I am not answering it here but I am giving the committee some information that may assist. I refer to a comment from the British Pregnancy Advisory Service published in its May 2012 edition. It is the biggest provider of abortion services in the UK. The agency stated: "It is not the case that the majority of women seeking abortions under ground C are necessarily at risk of damaging their health if they continue the pregnancy but it is significant that because of the law, women and their doctors have to indicate that this is the case".

These are valid issues to raise when discussing such a serious matter. On the question as to whether legislation will open the flood-gates, it may not open the flood-gates immediately but there will certainly be widespread abortion within a short period of time. I think what will happen is that even though Dr. McCarthy does not believe that people will come near a psychiatrist, what will happen is that GPs, in good faith, will send women who are pregnant to the doctors to be assessed to see if they come within the X criteria. The system will be described as cumbersome and in due course it will be dismantled. I think there will be a gradual opening up - as has happened in every other country. We are no different from any other country in the world. On the question whether women may manipulate, I do not believe that women will manipulate. I believe that in every situation we have to take a complete history and reach our diagnosis based on the totality of the information.

Both Deputy Conway and Professor O'Keane stated that women will not go to maternity hospitals. It is surprising that women who are currently suicidal do not even come to the psychiatric outpatient clinics or to the self-harm services, such as the ones I run. General practitioners send people with suicidal thoughts and suicidal plans to those services for assessment all the time. We are not seeing the women. I recently saw two women who had overdosed and both of them wanted abortions but that was because they were being coerced. However, we are not seeing many of these women at all.