Dr. Eamonn Moloney:

I thank the Chairman and the committee for this opportunity to speak them today. I am not a member of any particular interest group in this area. I speak to them as a practising consultant psychiatrist and as a clinical director of one of the largest catchment areas of mental health services in the country. The inpatient base is at Cork University Hospital, CUH, where the approved centre is based, and on the site of that hospital is one of largest maternity hospitals in the country, Cork University Maternity Hospital. That hospital has more than 9,000 deliveries per annum. In CUH, more than 600 people are seen for assessment following suicidal behaviour on an annual basis, and many more present with suicidal ideation.

As clinical director I have overseen the implementation of new legislation in the form of the Mental Health Act 2001 within the service over the past six years, and as clinical director I have an ongoing responsibility to ensure that the appropriate legislative procedures are followed. My comments on the heads of the Bill are from that perspective and primarily relate to the practical application of this proposed legislation. I was also a member of the Mental Health Commission for five years up to April of last year and so I have a particular interest and expertise in this area.

The current operation of the Mental Health Act 2001 leads me to believe that this legislation could be practically implemented but I will suggest some areas where I believe amendments would ensure that a suicidal woman with a crisis pregnancy is managed in the most appropriate, humane and timely manner. I will also describe the relevant proposed care pathway that I believe is the best way this legislation could be implemented.

I will comment on head 2, particularly in relation to the need for the number of medical opinions required, and talk about a proposed pathway. In my opinion the requirement for two psychiatrists and an obstetrician to certify that a woman is eligible for a termination of pregnancy is excessive. Two medical opinions should suffice. One of these opinions in my view should be a general practitioner and the other a consultant psychiatrist.

Although the heads of the Bill state that a general practitioner, GP, should be consulted where practicable, I believe the importance of the general practitioner needs to be recognised in their everyday care of patients. In terms of health strategy in Ireland, the importance of primary care physicians in primary care centres - primary care teams - is acknowledged. GPs have a wide range of experience of dealing with people presenting to them with emotional and psychological difficulties. The importance of the GP is recognised in the explanatory notes by virtue of his or her long-term and in-depth knowledge of the woman as referred to in head 4(2)(a)(1). The GP clearly has a unique perspective on the woman's particular circumstances in relation to, for example, her social supports, relationships, previous pregnancies, any history of sexual assault or abuse, and general family background.

It is likely in any event that the woman will consult her general practitioner in the first instance for confirmation of pregnancy and discussion of the options for what may be a crisis pregnancy. The woman's general practitioner would have experience in carrying out assessment of the woman's mental state, or perhaps more than one assessment, over a period of a few days. He or she may then certify that the patient is acutely suicidal, that there is a real and substantial risk to her life, and that this risk can only be averted by a termination of pregnancy.

A general practitioner is likely to have considerable experience of assessing suicide risk and of making a medical recommendation for detention of persons under the Mental Health Act. This has been referred to previously. Both GPs and consultant psychiatrists are used to dealing with these situations. The GP is well-placed to carry out a similar type of certification process under this proposed legislation. If the GP is satisfied that the appropriate criteria under the Act are met, he or she will inform the executive which will then either confirm an appointment with a psychiatrist that has already been made by the GP or arrange for an assessment by a relevant consultant psychiatrist. That is the first medical opinion.

The second medical opinion should be done by a consultant psychiatrist. This doctor should be drawn from a panel of consultant psychiatrists who are agreeable to operate the enacted legislation. This process is similar to the pathway for hospital admission under the Mental Health Act where a consultant psychiatrist must assess a person brought to an approved centre following appropriate application and medical recommendation. A consultant psychiatrist has a particular expertise in assessing suicide risk so it is appropriate for them to carry out this assessment.

This process of consultation with a GP and referral to a consultant psychiatrist for further assessment reflects the usual and ideal care pathway for all suicidal patients. It is likely to be the least distressing process for the pregnant woman, the most appropriate way of accessing the assessment and care that the woman needs and is a process that is practical, as evidenced by the current operation of the Mental Health Act.

A further medical opinion is not necessary in my view and the explanatory notes for head 2(3) refer to the Mental Health Act 2001 to support the need for only two medical opinions where there is a risk of loss of life from physical illness. The assessment of suicidal intent is one of the core skills of consultant psychiatrists who are carrying out such assessments on a daily basis.

We have heard that there are no data to confirm the accuracy of psychiatrists in predicting suicide but the relative rarity of completed suicide and the inability to determine the number of people saved from death by suicide following appropriate suicide assessment and intervention means that this exact calculation is not possible because the studies cannot be done. They would be unethical and would involve not treating some people who were suicidal, treating another group and then comparing the outcomes or else denying one group of suicidal pregnant women access to an abortion, not denying the other and seeing what happens. These are impractical and unethical studies which will never be done. We have very clear data on self-harm in this country and it is clear that women in this age group are at high risk of self-harm, and self-harm is a single best predictor of subsequent suicide, with one in 100 people, following an episode of self-harm, dying by suicide in the following year.

The fact that we cannot accurately assess this does not mean that suicide risk assessment carried out by a woman's general practitioner and a consultant psychiatrist are inaccurate. In mental health services throughout the world, it is ultimately the consultant psychiatrist who makes the decision about suicide risk. Mental health legislation throughout the world, as in this country, dictates that the consultant psychiatrist decides on whether criteria are met for admission of an individual under the Mental Health Act, and one of those criteria is risk of suicide.

In my view the involvement of an obstetrician in the assessment of risk of death by suicide is not appropriate as it is outside their area of expertise, as others have pointed out.

I do not believe it should be necessary for the consultant psychiatrist to be attached to an institution where such a procedure is carried out as this would unnecessarily restrict access to appropriate and timely assessment, which could be done by a consultant psychiatrist not necessarily attached to that hospital.

Moving on to head 4 - formal medical review procedures, I believe the timescale proposed of up to seven days to convene a committee and up to a further seven days to form an opinion could lead to a potential delay of two weeks following a woman's appeal to a decision being made. This is likely to cause considerable distress, which could be alleviated by shorter timeframes of 72 hours to the convening and 72 hours to a decision being made.

In relation to head 8 - the review in a case of loss of life through self-destruction, again, the requirement that the consultant psychiatrist shall be employed at the appropriate location is in my view unnecessary. Most women at risk of suicide in the early stages of pregnancy would be most likely to be seen by a general adult community psychiatrist or a liaison psychiatrist following self-harm rather than a perinatal psychiatrist employed at an appropriate location. It has already been pointed out that there are very few perinatal psychiatrists. Despite the fact that Cork University Maternity Hospital is one of the largest maternity hospitals, it does not have a perinatal psychiatrist, although emergency care is provided by the liaison psychiatry team based at the hospital. Again, the proposed timeframe is too long and a delay of up to seven days should be shortened to 72 hours.

The decision of the review committee should be by majority decision. This is the case for decisions made by the Mental Health Review Tribunal under the Mental Health Act where three persons on the tribunal decide on whether to revoke or affirm the detention of the person under the Act. A simple majority should be sufficient, and that should also apply under this legislation.

In summary, the certification procedure proposed here ensures that the most appropriate and relevant medical opinions are obtained and that the usual care pathway and referral processes for suicidal women are followed to minimise any unnecessary additional distress to the pregnant woman. This process is similar to the current procedures under the Mental Health Act 2001 and so the practical application of the legislation can be assured.