Professor Veronica O'Keane:

My name is Professor Veronica O'Keane and I am a professor of psychiatry in Trinity College Dublin, a consultant psychiatrist for the HSE at the hospital in Tallaght and I run a research programme in perinatal depression. I led a national perinatal psychiatry service in London for five years in the Maudsley Hospital serving all of the UK. I was concurrently head of perinatal psychiatry in King's College Medical School, from where I led a research programme in perinatal depression. I have published extensively in the scientific literature and I have written a book on perinatal psychiatric disorders during pregnancy. I have co-authored the standard clinical assessment tool for perinatal psychiatric disorder and I was an expert for the National Institute for Clinical Excellence, NICE, UK guidelines for the management of perinatal depression in the UK. I have set up two general hospital psychiatric services, with one in Beaumont Hospital and another at Addenbrooke's Hospital in Cambridge. I have researched and published on the topic of suicide assessment.

I am delighted to be here today and to have the privilege of advising our legislators on the heads of the protection of life during pregnancy Bill. The sole purpose of this legislation is to provide law as established in the Supreme Court ruling in the X case; namely, to provide a service for women who, unless they have an abortion, are in danger of dying. A woman's right to this service has been established in Ireland in our law and Constitution. There has been vigorous campaigning against the right for women to have their lives protected during pregnancy established in primary legislation.

Our role, as psychiatrists, is to facilitate the provision of this proposed service for women who express suicidal intent and request an abortion in this context. Women who are suicidal because of an unintended or unwanted pregnancy - I will refer to this as a crisis pregnancy - will be the main users of this service, given the extreme rarity of requests for abortion in women who are mentally ill during pregnancy. Primary care, adult and child psychiatrists, rather than specialist services, should and will be the main service providers. We have been told by the European Court of Human Rights that the service should be "accessible and efficient". To this end, a national panel of those prepared to lawfully engage with this process should be established and an efficient executive should be put in place to efficiently administer requests for termination of pregnancy by Irish citizens. The GP should make the recommendation for an abortion and one psychiatrist should assess the suicidal risk. Details of the practical implementation of these recommendations are contained in my Oireachtas submission. My colleagues have given recommendations, all of which I agree with.

Some legislators may continue to hold and express views about the "suicide" clause. A consistent argument is that "allowing" the suicide clause will remove the only effective barrier to "abortion on demand" and will provide a mechanism for women who want an abortion to get one, even if they are not genuinely suicidal. The argument goes that some psychiatrists will be complicit in this process or may not have the requisite professional skills to be able to predict suicide. Another argument is that abortion is not good for mental health and is not a treatment for suicidal intent.

Underlying all these arguments are deeply problematic assumptions about the credibility of women, the reliability of psychiatry as a medical discipline, the meaning and management of expressed suicidal intent and the concept that doctors or legislators have the power to control women's reproductive autonomy. The proponents of these arguments have caused some confusion, and the arguments require clarification so that head 4 can be implemented and run without unnecessary obstructions.

First, with regard to credibility of women, we do not practise psychiatry by disbelieving patients. A key ethical principle underlying all medical care is the relationship of trust that is taken to exist between a doctor and the patient. We regard all patients whom we see, in the first instance, as being truthful and credible. Second, with regard to the scientific evidence that suicidal ideation is difficult to assess, it has previously been said by people in the College of Psychiatrists of Ireland that we measure suicidal intent using clinically established markers. A crisis pregnancy is an emotionally traumatic experience which is potentially life-changing, and a woman who expresses sudden-onset suicidal intent is at a high risk of killing herself.

We do not require scientific evidence to understand the self-evident truth that young women in crisis kill themselves. Some 20% of deaths among young Irish women are by suicide or self-destruction, that is, in the same age range when women are most likely also to have an abortion. In other words, suicide is a common cause of death and is a recognised public health problem that is part of a national clinical programme in this country. The message that suicidal intent is difficult to assess and manage is untrue and the national office for suicide prevention is holding workshops for caregivers to help ordinary and non-professional individuals identify suicide risk, helping to increase the safety of individuals experiencing suicidal ideation and get further help. The message we want to get to people is that we can efficiently and safely manage suicidal ideation.

The phrase "abortion is not a treatment for suicide" has been iterated and reiterated, as has the contention that there was unanimous agreement among psychiatrists at the Oireachtas hearings in January that this was the case. This is not true. I gave evidence at the Oireachtas hearings in January and I did not give any evidence to support or reject the idea that abortion is a treatment for suicide. This is recorded as a matter of fact and was witnessed by this committee. The reason I would never say this is because a treatment implies that a doctor prescribes or at the very least recommends an intervention. A treatment involves a doctor in a process of active advice, and in the case of abortion, the woman rather than the doctor is requesting the procedure. The psychiatrist would only determine eligibility. Therefore, neither the woman's GP, the assessing psychiatrist nor the obstetrician carrying out the procedure would be advising a patient that she ought to have an abortion. Abortion is not a treatment as the doctor is not involved in giving advice.

There are no treatments for suicide and we manage underlying risks and issues that the individual presents us with. There is no evidence that any treatment prevents suicide. As outlined by Dr. Moloney and Dr. McCarthy earlier, such studies would unethical. There is scientific evidence from epidemiological studies that certain interventions reduce the suicide rate, for example, such interventions would include treating depression or removing access to lethal methods, such as charcoal in eastern countries and domestic gas in the western world. Reducing access to such means of lethality reduced suicide rates. The same is true for abortion. Abortion legislation was introduced in the UK because unsafe and illegal abortion was the leading cause of maternal death in the 12 years prior to the introduction of the 1967 Act. In 1950s Ireland, 10% of Irish women who killed themselves were pregnant.

Studies about whether abortion is bad or not for a woman's mental health have been taken out of context. The studies subject to public debate have all taken place in countries where abortion services are available, and in those cases we are considering women with a choice of continuing with the pregnancy or having an abortion. In scenarios where abortion services are not available, unwanted pregnancy is a leading cause of death, which we know from geographical and historical studies.

As I said previously, this is why we have abortion legislation.

My last point is that Irish women have an abortion service. It does need to be acknowledged that women in Ireland have abortion rights that they exercise as cognisant citizens through their right to travel. This very limited legislation that we are discussing is just a small concession to this reality in that it provides for the right to an abortion within our own health services when a woman is too sick or distressed to travel abroad. The constituency which is opposed to this legislation has spoken about suicide and abortion in abstract, moral terms. This is very regrettable. Irish women have often been portrayed as unreliable, sometimes manipulative and nearly always as passive. We need to acknowledge that it is the law that women who are in such dread about a pregnancy that they want to kill themselves and their foetus have a right to have an abortion in this country. As the Taoiseach said, this legislation is not conferring any new rights for women. This is an established right.