Dr. Peadar O'Grady:

I am very grateful to be able to make an opening statement to the committee. I am giving a statement on behalf of Doctors for Choice Ireland. I have had experience as a consultant child psychiatrist for the past 20 years but also some specific experience of certifying children and young adults under the terms of the Supreme Court judgment in terms of their eligibility to access an abortion, not something of which there is much experience. I understand Dr. Maeve Doyle referred to this earlier in terms of the types of women or children who might end up being dealt with under the legislation, as proposed.

According to the World Health Organization's 2012 document, Safe abortion, "In nearly all developed countries, safe abortions are legally available upon request or under broad social and economic grounds, and services are generally easily accessible and available". This largely applies to the services Irish women avail of in the United Kingdom every year. In Ireland the proposed legislation to deal with access to abortion services arose from the Supreme Court's judgment in 1992 that a 14 year old child had a constitutional right to have an abortion in Ireland because of the risk of suicide. Doctors for Choice Ireland welcomes any improvement in the care of women and children who choose to have an abortion. However, we believe reassurance is needed that the Bill will in practice provide for an effective and accessible procedure in a situation similar to that of the 14 year old child in the X case. The risk of suicide in the X case arose in a situation where a pregnant child had become suicidal when she was unable to travel, having decided to have an abortion while pregnant as the result of rape by an adult neighbour.

The opinion of many psychiatrists and other doctors internationally is that the risk of suicide is increased by having access to abortion restricted. While I am not going to go into the detail of how that came about, the internationally renowned psychiatrist Professor Robert Kendell summed this up well in 1991 in his review in the British Medical Journal. The title of the paper is, "Suicide in pregnancy ... much rarer now: thanks to contraception, legal abortion and less punitive attitudes", reminding us of the issue of stigma involved in suicide in pregnancy.

In Ireland restricted access to abortion services is most likely to arise as a result of an inability to travel, a point made well this morning by Dr. Anthony McCarthy, president of the College of Psychiatrists of Ireland. This means that women who are too sick, young, poor or disabled to travel are at particularly high risk. Women who are migrants or whose pregnancy involves a fatal foetal abnormality or which arose as a result of rape or child sexual abuse also experience difficulty in accessing abortions through impairment of their ability to travel. Children are not specifically mentioned in the legislation, even though they are more likely to experience difficulties in their ability to travel for an abortion and to be at increased risk of suicide as a result. The costs of travel for an abortion are higher for children as they usually require a parent or guardian to travel with them because of their greater requirement for practical and emotional support.

Our concerns about the legislation come under three headings: delays in accessing abortion which might occur, the exclusion of certain categories from access to abortion and criminalisation of women and health workers who take part in abortions which do not meet the guidelines laid down.

As for delays, Doctors for Choice Ireland is particularly concerned that the Bill contains elements that will cause unnecessary delay in accessing abortion services, causing an unnecessary prolonging of an emergency level of risk and requiring more complicated procedures because of that delay, for example, surgical instead of medical abortions. In Britain most abortions are medical abortions. They do not involve a surgical procedure and do not, in fact, involve an obstetrician, which is a notable point.

In the case of eligibility for abortion on the basis of a risk of suicide, imposing a requirement for three doctors will cause unnecessary delay and, including the general practitioner, we may be talking about four doctors. There is no medical basis for differentiating between a medical emergency and a psychiatric emergency, as the Bill does, a point alluded to by Professor Murphy of the Medical Council on Friday. All psychiatric emergencies are medical emergencies. Only one psychiatrist or GP is required to certify eligibility for an abortion. It is clearly the view of Doctors for Choice Ireland that one does not need any doctor to certify eligibility for an abortion as a necessity, but, if one wants to, only one is required. Obstetricians should not certify eligibility in cases of suicide risk.

This should be done either by a GP or a psychiatrist, and by that I specifically mean giving advice about eligibility on the basis of suicide risk, not his or her potential involvement in an abortion procedure, a point of practice in which the psychiatrist is not usually involved. If this legislation is enacted, it is likely that women and children will already have had non-directive counselling and will have given informed consent before seeking an opinion on eligibility of the grounds of a risk of suicide.

The Bill requires the psychiatrist certifying eligibility to be employed in an institution registered with the Mental Health Commission, which is another point regarding a delay. Most consultant child psychiatrists are not employed in this way. This is an unnecessary requirement. Specialists are required to be registered with the Medical Council and this should be the only stipulation. Specialists should not be required to be attached to any specific institution. Most abortions in developed health services are medical abortions and do not need any hospital facilities necessarily. The term "reasonable opinion" should be replaced by the term "opinion" and the term "unborn" should be replaced by medical term "foetus".

Regarding exclusions, women and children in situations of rape, child sexual abuse and fatal foetal anomalies will, unfortunately, have to wait for further legislation to allow for the option of abortion in those cases, as this Bill does not provide for this, and this is a serious limitation of it.

I take on board the advice of the Chairman, Deputy Buttimer, about keeping our language temperate and moderate but Doctors for Choice are at pains to point out that a 14-year criminal sentence is not a moderate or temperate element of the legislation. With regard to that, the inclusion of a criminal sanction of up to 14 years against women or doctors will hamper good practice and increase the risk of suicide in vulnerable patients through stigma and its emotional consequences - fear and distress. Fear of prosecution, a noted chilling factor, can only cause further delays in access. The notion that women who are forced to travel for an abortion in a situation of fatal foetal anomaly, for example, are carrying out the equivalent of a gravely serious crime worthy of 14 years in prison is particularly offensive. The prospect of prosecuting children and or their parents or those carrying out a home abortion with medication bought on the Internet is also very concerning. The overwhelming support in 1992 for the constitutional right to travel for an abortion confirmed that Irish people do not consider abortion a grave crime, as did the lack of any prosecutions before then for abortions procured abroad. To our knowledge criminal sanction has not been seriously advocated by any party to the debate thus far on access to abortion services. As criminal sanction is thus dangerous, offensive and manifestly absurd, it should be removed from the Bill.

As there is a gross lack of expertise in Ireland, which I think the medical profession in Ireland is well ready to admit - we do not have abortion services located in Ireland, although we have abortion services for Irish women but they just happen to be located largely in Britain but also, in so far as we know, the Netherlands and perhaps Spain; we are not so sure where people access them because we do not count that, research it or follow it up - we humbly submit that the Oireachtas Joint Committee on Health and Children should take advice from a relevant health care agency that has experience in providing an abortion service. The British Pregnancy Advisory Service, for example, provides the majority of abortions availed of by women from Ireland every year and that service has already offered its assistance to the committee.