Dr. Mary McCaffrey:

I thank the Chairman and the committee for the opportunity to contribute to the discussion. Like Dr. Burke, I commend the Government and the legal draftsmen on putting together these legislative proposals under such difficult circumstances. My submission is intended to reflect on how the proposed legislation might impact on the practice of obstetrics in small to medium-sized units, that is, in units with three consultant obstetricians on the staff. There are 12 such units out of the total of 19 in the country, and they deliver approximately one third of all babies. Therefore, they make up a significant number of deliveries. I will not dwell too much on the issue of resources other than to say that, in general, we would tend to be very under-resourced.

There has been a great deal of repetition in the discussion today, so I will address only those heads of the Bill which we consider specific to the practice in our units. I have collaborated with a number of colleagues in clarifying our position in this regard. In regard to head 2, which deals with the risk to life from physical illness, not being a risk of self-destruction, my understanding is that this relates to cases of severe heart disease, cancer or other major medical illnesses. Under the proposed head, one obstetrician and a doctor from the speciality caring for the significant complex medical condition are required to make a decision regarding ongoing management of the pregnancy. We feel that the bulk of these cases, in general, are likely to be managed in tertiary referral hospitals and are not likely to impact on the smaller maternity units.

The only exception is that in Kerry, Letterkenny and Wexford, which have similar units, during the holiday season the most amazing range of patients about whom one knows nothing arrive as visitors to the area. We are very aware that those women require the backup of intensive care in a general hospital and we endeavour, where possible in our units, to transfer them out safely but we are aware that exceptional circumstances occur and medicine is not always black and white. That needs to be reflected to protect us under the legislation.

Regarding head 3, risk of loss of life from physical illness in an emergency situation, sadly, in the course of our work we deal all the time with patients who have severe impending infection, severe pre-eclampsia or haemorrhage. The legislation now protects us in a way that we were not protected before so we welcome it for those cases. The proposed legislation suggests that one doctor would sign out for making decisions with regard to the care of the patient. It is best practice in most situations that two obstetricians would be involved in such decisions and in general that is what happens. Once again, however, we go back to the fact that in a small maternity unit with only three obstetricians there will always be periods in which only one person is on duty at night and weekends. That person has to be protected and his or her clinical judgment has to be taken on face value. In the January submission I suggested that perhaps where someone felt he or she wanted a second opinion and that was not available in-house, consideration should be given to having a panel of experts in the Dublin maternity hospitals who would be available to people who wanted to collaborate with a colleague.

The wording of head 4, risk of loss of life from self-destruction, should be changed. Suicide is a terrible word but that is what it is. The issue that came up with all the people to whom I spoke is that we do not feel, as obstetricians who are not trained in psychiatry, that we have any role in diagnosis of suicidal intent. We accept and understand that the psychiatrist's input is crucial in this instance. We accept and acknowledge that we can make an input to assist the psychiatrist in managing the pregnancy as it proceeds, if that is what is required, but we do not feel that the current batch of obstetricians is adequately trained to diagnose suicidal intent. We are, however, available to support our psychiatry colleagues in that diagnosis. In all of the conditions involved we realise that there will be situations in which potentially viable foetuses will be born and we must endeavour where at all possible to deliver them in units where they have the appropriate neonatal backup and support for the babies that potentially need neonatal care.

It is also important to point out that not all maternity units and psychiatry units are on the same site. A significant number of hospitals in the country have a maternity unit but no psychiatry unit. If an acutely ill woman is admitted to a psychiatry unit, there will be resource issues in terms of providing a team of psychiatrists to look after her if she is in a maternity unit and vice versa. The fact that many psychiatry units are off-site has not been thought about. Equally, many maternity units, as Dr. Burke has pointed out, do not have the backup of intensive care or general hospital facilities.

My point about head 9 does not appear in my written submission because it was only identified by someone during the course of the day. Under head 9:

(4) A person who –(a) having been directed under subhead (2) to attend before the committee without just cause or excuse disobeys the direction,
(b) fails or refuses to send any document or things legally required by the committee under subhead (1) to be sent to it by the person without just cause or excuse,
shall be guilty of an offence and shall be liable on summary conviction to a class C fine (not exceeding €2,500).

I assume that nobody will put herself or himself forward to be on a committee unless she or he truly wishes to be there and is a volunteer. Medical and staffing circumstances may overtake committee members in a hospital so that they cannot attend a committee meeting. There was a suggestion that maybe there was a bit of carrot and stick about this provision, with more stick than carrot and that it would be hard to recruit volunteers if they felt they were going to be fined and criminalised. There should maybe be a little reflection on that point.

For a significant number of colleagues with whom I have discussed head 12, conscientious objection, this is a really significant area. There are many obstetricians in the country who have conscientious objections to being involved in providing termination of pregnancy. This must be respected. Under Medical Council guidelines, they are entitled to have conscientious objections. The important point is that the public will know that where the life of the mother is at risk and where medical care is needed appropriately, the care of the mother and her baby will always be paramount for every doctor and that if a doctor has a conscientious objection, he or she will have the facility to provide access to another colleague in a timely manner. That is very important.

Over the past couple of months there has been some suggestion in the media and elsewhere that doctors should have to declare their moral and ethical objections to being involved in termination of pregnancy prior to taking up employment. This has caused fear for a number of colleagues, not those of us currently employed because we have our jobs but people in the future might feel that they would be disadvantaged or discriminated against at interview by an employer who feels that a certain doctor is not going to do terminations but one who will do them is needed on the staff. This has to be taken very seriously because under subsection (3) of head 12, "No institution, organisation or third party shall refuse to provide a lawful termination of pregnancy to a woman on grounds of conscientious objection". If there is a hospital management structure that for whatever reason feels all of its doctors must provide terminations, no doctor should fear that if he or she applies for a job there and has a particular ethical point of view, he or she will be discriminated against in getting a job. That is very important. A few people would like to know who is the "third party" referred to in that subsection because that was not clear to us.

There are some other issues that I feel are worth mentioning that I did not see highlighted in the heads of the Bill but maybe I missed them. One is the issue of resources to allow medical staff to carry out these duties safely under the legislation. I am not here to represent the psychiatry profession but they would say that they struggle under the current resources to deal with the mental health tribunals and that imposing an added burden on them would be significant. We also have to acknowledge that the majority of obstetricians practising in this country today do not carry out terminations of pregnancy and probably have not done in the past. They will need to have training for that so that they can safely provide care for their patients and do not work outside the scope of their practice. Many people feel that termination of pregnancy is a procedure that is totally and utterly safe but we know from the confidential inquiries in the UK that there can be morbidity and mortality for women after the procedure. Therefore, it is crucial that if we introduce a medical procedure in this country that people are appropriately trained and feel that they can work well within their scope of practice. Another issue that I may have missed arises if the person is under the age of consent. Are there extra legal procedures and requirements that we would need to incorporate into legislation?

Finally, if legislation is enacted there will need to be a period when hospitals and the regulatory bodies can put care plans in place to ensure safe practice so that the legislation is not passed one week and people are expected the following week to provide a level of medical care that has not been communicated to and discussed with those on the ground.