Dr. Matthew Sadlier:

I thank the Chairman, Deputies and Senators. On behalf of the Irish Medical Organisation, which represents more than 5,000 doctors of all craft groups and specialties in the country, I thank the committee for inviting us to address it today. I know that everyone here agrees that the matters before this committee are of enormous importance and sensitivity for people throughout the country and deal with issues on which people have very strong, and often very opposing, views.

Within the Irish Medical Organisation, we have debated the issue of abortion on a number of occasions, and when we have done so, we have found that the diversity of opinion that is found in the wider community is reflected among our own members. Our official position on this dates back 20 years to 1993 and states that the Irish Medical Organisation endorses the principle of respect for all human life, both born and unborn, and that it rejects abortion. More recently, at our recent annual general meeting in April, the issue was debated in a number of motions, but our policy did not change.

However, the Irish Medical Organisation accepts that whatever our policy position might be, our members operate within a legal framework. Therefore, without turning our backs on the formal policy position we have adopted, we have an obligation to engage in the debate about the legal framework that is being established. We understand that it is the role of the people through referenda and Deputies and Senators through the Oireachtas to frame the laws under which this country operates. Furthermore, we accept that the Government is now moving to introduce a legislative framework on this issue.

In that context we have a number of general concerns regarding the legislation: that the patient's health and welfare is of paramount importance; the legislation must provide adequate clarity and protection to health care professionals who must operate under it; the legislation must be practical and realistic for application in a hospital and health care environment; the legislation must be sufficiently resourced; where issues of morals are concerned, such as in abortion, the laws must provide adequate flexibility to ensure that an individual can abstain from engaging in an activity which he or she may deem, in conscience, to be immoral without jeopardising the right of the relevant patients to all the facilities and treatments for which the law provides.

I will give a brief summary of our issues in respect of each head of the Bill. In head 1, we believe the term "reasonable opinion" should be replaced by the term "opinion" and the term "unborn" replaced by the more medical term "foetus". In head 2, the opinion of two medical practitioners is required to certify jointly that there is a real and substantial risk to the life of the mother and where the risk can only be averted by the termination of the pregnancy. Where a pregnant woman presents with a physical condition that poses a real and substantial risk to her life, clear clinical guidelines are required in order to identify, monitor and treat such patients. While such cases are rare, public obstetric units must be appropriately resourced to ensure that patients are adequately cared for according to clinical guidelines and that no delay to life saving procedures arises due to under-resourcing. A system should be in place to allow medical practitioners to declare a conscientious objection and protocols must be in place to deal with situations of conscientious objection as they arise.

Medical practitioners who have no conscientious objection must receive appropriate training either during postgraduate training or as part of compulsory CPD programmes organised and resourced by the State. The health and welfare of the patient is paramount and therefore women must be provided with appropriate follow-on care, both physical and psychological, following any termination.

Head 3 deals with the risk of loss of life from physical illness in a medical emergency. Again, such cases are likely to be rare and clear clinical guidelines must be in place. Patients must be attended by a practitioner that has no conscientious objection and is appropriately trained to perform such procedures. Patient consent must be obtained where possible - we will deal with the issue of consent later in our submission. Women must be provided with appropriate follow-on care, both physical and psychological.

Head 4 refers to the risk of loss of life from self-destruction. Under that head the opinion of three medical practitioners - one obstetrician-gynaecologist and two psychiatrists - is required to certify jointly that there is a real and substantial risk to the life of the mother and where the risk can only be averted by the termination of the pregnancy. Imposing a requirement for three doctors may cause unnecessary delay and is in excess of the maximum of two doctors recommended by the expert group. It also adds an extra burden of resources an already stretched services.

Obstetricians should not be required to certify risk of loss of the pregnant woman's life by way of self destruction. This should be done by two psychiatrists in consultation with the woman's general practitioner. The Bill requires the psychiatrists to be employed in an institution registered with the Mental Health Commission. We believe this is an unnecessary specification. Specialists are required to be registered with the Medical Council and this should be the only stipulation. Such cases again are likely to be rare and, again, clear clinical guidelines must be put in place. Patients must be attended by specialists who have declared no conscientious objection. As it stands, mental health services throughout the country are significantly under-resourced. Adequate resources must be provided to ensure that patients at imminent risk of suicide receive appropriate psychiatric care. Additional resources must be provided to ensure that there is no drop off in existing services as clinicians are tending reviews specified under this Bill.

Regarding head 5, medical opinion to be in the form and manner prescribed by the Minister, we believe the medical opinion should be given in the form and manner prescribed through clinical guidelines established by the relevant professional colleges, not by the Minister.

The issue of mental capacity is relevant to the Bill in a number of areas. Given the importance of this legislation and that decisions may be contentious, it is important that the legislation removes the potential for ambiguity and gives a clear definition of the criteria for determining capacity to make a medical decision. It is quite possible that in many of the cases that will occur the woman will lack capacity temporarily either due to a mental health problem or physical illness. The legislation should also clearly state what should be done in cases where a woman is found not to have the capacity to make a medical decision. Also, the legislation should define at what age a woman has the legal capacity to ask for a termination as there is ambiguity regarding the Non-Fatal Offences Against the Person Act 1997, which defines the age to give consent for medical treatment at 16 years, and the Mental Health Act 2001, which defines the age of medical consent in mental health issues at 18 years.

Head 6 deals with formal medical review panels. Under this head the HSE is to establish and maintain a panel of medical practitioners for the purpose of review. Practitioners who declare a conscientious objection must be excluded from such panels.

Regarding head 7 and head 8, the establishment and convening of a review committee and the review procedures combined may take up to 14 days. This is an unacceptable delay. During this time there is a risk that the patient's health could deteriorate significantly. Resources must be put in place to ensure that patients are adequately cared for and receive appropriate support during the period of the review. The opinion of the review committee should be made in accordance with appropriate clinical guidelines.

Head 11 and head 12 detail that the reviews and medical procedures permitted and carried out under this Bill are to be notified to the Minister. This seems unnecessarily prescriptive. The HIPE, hospital in-patient enquiry, data currently records the numbers and types of procedures carried out in acute hospitals and the Medical Council is the body authorised to investigate complaints relating to the performance of individual medical practitioners. Patient confidentiality must be guaranteed and patient anonymity is welcomed in the heads of the Bill. There must be no possibility of identification of the women in respect of whom the termination was carried out. To protect both the patients and the medical practitioners involved and to avoid sensationalist media reporting of such procedures, the names of medical practitioners involved should not be publicised.

Finally, head 12 deals with conscientious objection. Recent debate at the IMO's annual general meeting shows that there are a number of physicians who object strongly to the termination of pregnancy on moral and ethical grounds and the IMO welcomes the provision for conscientious objection under head 12. However, patients who present with life threatening illness must be reassured that they will receive adequate care and the necessary termination to protect maternal life. Clear protocols must be in place to ensure appropriate and timely referral of patients to other colleagues in the case of conscientious objection.