Dr. John Monaghan:

I appreciate the invitation to speak at this gathering. I previously sent in a submission in early January which dealt with two specific matters which I will deal with today. As I was instructed to deal with the heads of the Bill, I have four points to make this evening. The word I am intending to use is "clarity", which seems to be the word of the evening.

Head 2 refers to risk of loss of life from physical illness. My point on this is personal and relates to cancer. Senator Crown may be one of the most eminent oncologists in the country, maybe in the world. I have a personal point to which he may attend. One of the reasons we are here is the judgment of the European Court of Human Rights in the A, B and C cases. One successful plaintiff, C, was a woman who had been treated for cancer. She was, according to the expert report, “unable to obtain clear advice as to the effect of the pregnancy on her health or the effect of medical treatment on the foetus.” If this legislation goes through, as broadly outlined in the heads of the Bill, will a woman such as C be in a better position?

Part of my reason for bringing this up is that the medical risks involved with cancer in pregnancy, which is one of the major threats to a woman’s life that may lead to a need for termination, have changed dramatically over the past few years. A Belgian doctor, Dr. Frédéric Amant, has spoken in Ireland several times on these developments and there are several publications in The Lancet on the matter from last year, which I attached to my submission. While they may be technical in nature, I added them for two reasons. The first is that they describe the changes in the treatments available and the second is that they deal with the problems of treating cancer in pregnancy. The three that are listed are under-treatment because of fear of treating the baby, late diagnosis and the carrying out of terminations of pregnancy when not required.

My end reason for bringing up this subject is that I suggest to the committee that the legislation should mention somewhere that patients with cancer in pregnancy should be referred to a single cancer treatment centre which has acquired expertise in the management of pregnant patients. One of the articles I attached to my submission dealt with the question of leukaemia or blood and bone marrow cancers. The reason I put it in is that it is an extraordinary complex area. As an average obstetrician and gynaecologist, it is beyond my understanding. My basic idea is that patients who are pregnant and have cancer should have access to a specialist oncology centre with surgery and radiotherapy. There should be one such centre in the country which has expertise to offer this particular group of patients.

My second point refers to head 4, which deals with the risk of loss of life from self-destruction. The other reason we are here today is the Supreme Court case of X, which occurred 22 years ago. As an obstetrician, I do not have any first-hand experience of psychiatry. It reflects an enormous change in obstetric practice that an obstetrician is being asked to intervene in a physically healthy pregnancy. While it appears from the legislation that an obstetrician would be involved in the decision-making, he is referred to otherwise possibly as a technician, suggesting that maybe he should be involved so he does not feel like a technician. However, my gut is extremely unhappy with the idea of a mindless terminator for psychiatric reasons. This decision was made 21 years ago. From the hearings that were held in January, I do not believe any case of suicide associated with refusal of termination has ever surfaced. The evidence from my reading of it seems to be extremely poor. Many of the speakers earlier were happy to take the expert advice of a psychiatrist to act if required. I am not certain how a psychiatrist can reach a decision on this matter where to date I do not believe any evidence has been produced.

The psychiatric or suicide risk clause has been brought in in other jurisdictions and has been widely - I would say universally - abused. Last year, The Daily Telegraph did an exposé of the abuse of psychiatric reasons in the UK, with the use of pre-stamped forms. People went to one doctor to get a form stamped, then to another to get it stamped and then got a termination. I can see no reason, despite the safeguards built into this legislation, that culture could not arise in this country in the future. I am extremely concerned as an obstetrician that I would be drawn into a situation in which a termination of pregnancy will be done for psychiatric reasons without very clear evidence that this is to the patient’s benefit. If the baby is going to lose its life in this circumstance, then I would want to be very clear that there is a clinical benefit to the mother. To date, I can see none of that. That is my big issue with the heads of the Bill.

The other matter which I would like to deal with is the question of conscience, which Dr. Mary McCaffrey mentioned as well. I use the term “conscience” rather than “conscientious objection” because the latter implies that this is a problem. Twice in the past few months, as a doctor, I have been told that a doctor should leave his or her conscience outside the room. I would ask the committee to reflect on what it means if a doctor suspends his or her conscience faculties. Conscience is not a religious concept. If one sees somebody beating a child on the street and one continues to do one’s shopping, then there is something wrong with one’s conscience. It is an obvious thing. For example, if I decided to suspend my conscience with a patient on a waiting list and he offered me €300 to go up the list, then that is a very tempting, painless and invisible transaction which I am sure occurs in the political world. The only thing that will stop a practitioner-----