Dr. Tony Holohan:

I am pleased to be here on behalf of the Department to contribute to the hearings on the general scheme of the protection of life during pregnancy Bill. The Minister has already provided the background and a detailed presentation on the heads of the Bill. I will begin by setting out the principles which underpin the legislation and commenting on matters of professional medical practice which arise in the context of these heads. These guiding principles are derived from the work of the expert group chaired by Mr. Justice Sean Ryan of which I was a member. It is important the committee understands these and how they guided the drafting of the heads.

The first principle behind the general scheme is that it should provide legal clarity by way of legislation and regulations on the circumstances in which a termination of pregnancy is permissible, which is where there is a real and substantial risk to the life, as opposed to the health, of a woman. The aim of the general scheme is to bring clarity to the existing situation. As the Minister has already alluded to in his presentation, the scheme does not confer any new substantive rights to termination of pregnancy. Rather, it provides for rights which already exist, within constitutional provisions and the Supreme Court judgment in the X case. Its purpose is to confer procedural rights on a woman who believes she has a life-threatening condition, or whom others believe on her behalf she has a life-threatening condition, so she can have certainty as to whether she requires this intervention.

The second principle underpinning the legislation is that the State will uphold the right to life of the unborn as far as practicable, as per the constitutional obligations in Article 40.3.3°. This means that where a woman has a pregnancy which places her life at risk and her foetus is or may be viable, she may have a right to have the pregnancy brought to an end but not a right to deliberately end the life of the foetus.

The third principle is that termination of a pregnancy must be necessary to save the woman's life. In these circumstances, termination of pregnancy will always be considered a medical intervention which operates within all the existing arrangements that pertain to other medical services and interventions, and standard medical practice should be adhered to as much as possible in its delivery.

I should note, however, that certain additional requirements are considered appropriate due to the fundamental constitutional rights at stake here, namely, the right to life of the pregnant woman and the right to life of her unborn child. The requirements provided for in the legislation include a process for assessment, a process which sets out the number of doctors required for this assessment, the process of certification, the locations where terminations might take place, a formal medical review process, and a notification system.

The requirements provided for in the legislation include a process for assessment, which sets out the number of doctors required for that assessment, the process of certification, the locations where terminations might take place, a formal medical review process and a notification system. We have heard those details outlined by the Minister.

The fourth principle deals with the issue of suicide and states that, given the more subjective process and recognised clinical challenges involved in the evaluation of suicidal ideation, the legislation should reflect this in the checks and balances that it provides for.

The fifth principle deals with the issue of consent which is enshrined in current ethical standards for doctors, set out by the Medical Council under the Medical Practitioners Act. This principle provides that it is always a matter for the patient to decide if she wishes to proceed with a termination of pregnancy following a decision that it is the only intervention which might save her life.

The sixth principle provides that there must be an ability to monitor the impact and operation of the legislation, so therefore it provides for a mandatory monitoring and reporting system. It specifies that, in order to ensure that the general constitutional prohibition on abortion is maintained, the State will regulate and monitor the exercise of a woman's right to lawful termination of pregnancy as stipulated by the Supreme Court judgment in the X case.

I would now like to expand briefly on the issue raised in principle 3, which I have spoken about, regarding adhering to standard medical practice. To reiterate that principle, where termination of a pregnancy is necessary to save the woman's life, the procedure is to be considered a medical intervention and standard medical practice should be adhered to as much as possible in its delivery. The general scheme has put this principle into practice by ensuring that, as far as possible, the processes it sets out for assessing the risk of loss of life do not go beyond what would normally occur in clinical practice. For example, in terms of setting out the assessment process, the general scheme provides for more than one medical practitioner to be involved. This reflects the fact that it increasingly the case that doctors do not act alone in assessing and managing patients where the complexity is of a similar order to that of a pregnant woman who has a real and substantial risk to her life.

Evidence-based practice in many disciplines provides more and more that doctors work as part of a team or consult with colleagues as a matter of course. Emergency situations are the exception here, of course, and these are considered separately - as we have heard from the Minister - by the general scheme, with different requirements set out where the risk of loss of life, for physical health reasons, is immediate or imminent. In addition, the general scheme does not preclude patients from seeking a second or subsequent opinion in relation to any or all members of their treating team, as per standard practice. This is a routine feature of medical practice enshrined within Medical Council guidelines.

Although the general scheme sets out the process to follow in assessing whether a termination of pregnancy is required, I must note that it is silent on how the certification might come about. This was deemed appropriate since clinical scenarios where the X case criteria might apply are bound to be complex and certainly unpredictable, and therefore attempting to predict and set out specific clinical referral pathways in legislation would be unsafe and unsound. Therefore, the general scheme expects and indeed necessitates that standard medical practice would apply as in all other medical practice.

I am the Chief Medical Officer and I have confidence in the medical profession in this country. I believe in the integrity and professionalism of our doctors. We have a highly trained and motivated set of doctors working in this country. They have a track record of high quality, patient-centred care which puts patients first. While none of us is blind to the fact that by today's standards of service, we would not necessarily deem the practices and behaviours of the past - or some of them - as appropriate, I think it is absolutely fair to say that our doctors and our medical colleges have shown a consistent commitment to the public interest in the work they do. For many years they have relied on voluntary altruistic endeavour in the training of the next generation and in the pursuit of research knowledge and understanding, which is the bedrock of evolving evidence-based care. They are showing leadership in every aspect of all major health reforms that are under way, at a scale and pace that would simply be impossible without their active engagement. This is true of doctors right across the spectrum, whether they are GPs, obstetricians, psychiatrists or any other speciality. It is my hope and expectation that the doctors who will give evidence to this committee in the coming days will do so in a manner that reflects their duty of professionalism and respect for one another as colleagues, and that remembers their responsibility to ensuring that this committee and the wider public are informed through evidence and science.

It is perfectly rational and reasonable that society would seek to place limits and boundaries upon certain services provided by doctors where there is a public interest to do so, and to provide clear oversight and accountability arrangements for doctors in the delivery of these services. That is precisely what these heads seek to do, while recognising and respecting the latitude there must be for medical practitioners to carry out their duties in the interests of their patients with clarity and certainty about the legal framework within which they must operate. It is vitally important, therefore, that guidance is developed for doctors on the appropriate operation of this legislation. That is best done by the doctors themselves through the professional colleges and the Medical Council, all of whom have a strong track record in this regard. The Department and my office have a strong and very good working relationship with the colleges and professional bodies. I plan to work with them in preparing guidance to their members on the operation of this Bill. I will be meeting with them in the near future to commence this process.

In conclusion, I wish to thank the Chairman and his fellow committee members for the opportunity to address them today. I would like to wish them well with their work and look forward to the committee's report. I am at the committee's disposal for any questions or clarifications that members may wish to raise.