Dr. Sam Coulter-Smith:

My name is Dr. Sam Coulter-Smith. I am master of the Rotunda Hospital in Dublin. My submission to the committee today is based on my views and the views of my consultant colleagues at the Rotunda Hospital following consideration of the draft heads of the Bill. I thank the Chairman and members of the Joint Committee on Health and Children for giving me the opportunity to present these views on this important draft legislation.

I will start by making some general comments. I acknowledge the work that was done on this extremely difficult and contentious document and I commend those who drafted the text for avoiding the word "abortion" in the terminology. This is a positive move and ensures that those women who have to have a pregnancy terminated in an emergency situation are not stigmatised in any way and this should be welcomed.

In terms of where a termination of pregnancy can occur, there are two factors that need to be considered. I welcome the fact that the legislation provides for termination of pregnancy in an emergency situation in any of the 19 maternity units in the country. However, there are occasions when it may be necessary to terminate a pregnancy outside these institutions, for example, in Mount Carmel Hospital, which is a private, non-HSE institution delivering maternity care.

In addition, in each of the big maternity hospitals in Dublin there is no provision for intensive care. Therefore, our sickest patients from these units, some of whom will have been transferred from other units around the country for care, will be looked after in intensive care units in hospitals such as the Mater Misericordiae University Hospital, St. Vincent's University Hospital, St. James's Hospital and others. There may be occasions, therefore, when it is necessary to provide this type of emergency care, which is provided for within this legislation, to patients in these intensive care units, which are currently outside the draft legislation.

I will turn my attention now to the clinical scenarios that the heads of the Bill cover. The document broadly covers three clinical scenarios. First, when a woman's life is acutely at risk in an emergency situation due to a complication of pregnancy. Second, when the acuity of the situation may be less urgent but the severity of the situation relates to a co-morbidity such as cancer, significant heart disease or other illness. The third clinical scenario is where there is imminent risk of death from suicide or self-destruction.

In respect of the first two scenarios, the heads of the Bill provide clarity and appropriate protection for those giving care to pregnant women. This, in turn, should provide clarity and reassurance for all professionals, including medical, midwifery and nursing professionals, that their actions in giving best care to the mother are covered under the law. It should also provide reassurance for women and their families that the medical profession can act in their best interests during difficult, life-threatening situations, and this is to be welcomed. It is also important to note that there is no gestational limit applied to either of the first two scenarios and this, in my view, is appropriate. It is also important to note, and it is confirmed and reiterated in several areas within the draft document, that doctors must have regard to the protection and preservation of the unborn human life where practicable. This should provide appropriate reassurance for patients and their families in very difficult and distressing situations.

In respect of the first scenario where a woman's life is at risk in an acute emergency situation, it is now acceptable for one obstetrician to decide whether a termination of pregnancy is required to save a woman's life. It is good practice for an obstetrician in this situation to seek a second opinion from a colleague if it is possible to do so. However, in these difficult situations there will often be other consultants involved, such as a haematologist in the case of haemorrhage or a microbiologist in the case of infection. It is also likely that a consultant anaesthetist will be available and it would be appropriate for the consultant obstetrician to seek advice and to discuss the decision-making process with these colleagues.

In respect of loss of life from self-destruction there are a number of issues that need to be raised. First, this is an extraordinarily rare situation with the incidence of suicide in pregnancy of the order of one in 500,000 pregnancies as per United Kingdom figures. Second, our psychiatric colleagues tell us that there is currently no available evidence to show that termination of pregnancy is a treatment for suicidal ideation or intent and, as obstetricians, we are required to provide and practice evidence-based treatment.