Dr. Peadar O'Grady:

Just before answering the questions, I would like to point out that Doctors for Choice made a detailed head by head submission and members can read that at their leisure.

Deputy Kelleher raised the issue of a link between viability and location. There is quite a misunderstanding among many people in terms of where viability fits in with abortion. Many, including myself, argue that 100% of abortions should be completed long before viability becomes an issue. The situations in which abortion is an issue in terms of a viable foetus are extremely rare. It is not like the US has the most developed service one can get and, even there, one third of counties have no access to abortion facilities. We are not the only region that has difficulties with access. One in 1,000 abortions involves an issue of viability and therefore, is a small number, 99.99% of abortions happen without viability being an option.

The issue of whether an obstetrician is required is a clinical decision and in our presentation we are trying to distinguish clearly between doctors assisting legislators in certifying, something Doctors for Choice argue clearly is not required medically. If legislators required that from the point of view of assisting legislation and they are looking for certification as all of the witnesses today have said, this is something we can do. We should do it to assist things to move forward. Must we do it? Not in the scheme of things. In a proper system, we would not need to do it. In general, psychiatrists are not involved in the provision of abortion care. In terms of viability, there is no need to attach to an institution. Where care in a hospital is required, that should be an option recommended by the physician. It does not need to be legislated for. It is already good practice. We know how to distinguish between intervention and certification. The role of GPs is very much that they are the first responders. It does not always happen but we recommend it. They are the people who will start the process of advising a woman or a child about her state of health, including whether she is not pregnant. It is important in dealing with crisis pregnancies well before the issue of viability occurs. The leading reason for delay in abortions in terms of late term is the delay in the diagnosis of pregnancy or of a fatal foetal abnormality and the commencement of non-directive counselling could well be done in general practice as well as the acquisition of informed consent whereby having chosen an option, women in an unwanted pregnancy can choose to go ahead or choose to terminate early with the morning after pill or later through medical abortion, which can take place in a general practice setting. It does not require an obstetric facility to write a prescription and to advise a patient on how to manage medication and engage with follow up care.

With regard to Deputy Ó Caoláin's questions, GP consultation should be optional. It is good that the GP should be consulted even if he or she is not involved in certification. That should not be done without the patient's consent. Heads 2 and 4 should be amalgamated and this was strongly recommended by the Medical Council last Friday. I refer to the order in which it happens. From the point of view of certification, the major restriction we have all pointed out that the major reason for raising the risk of suicide is a restriction on travel. Soon after the Savita Halappanavar case, several women described on radio getting on a plane while actively miscarrying because there was no other option for them. That is the physical case of having to go to Britain while not fit to travel. This came up earlier and we hope such women will not be forced on to a plane while too sick to travel. There may well be cases where women are too distressed to travel and may need to be facilitated to have an abortion in Ireland.

In those cases, non-directive counselling will have happened and informed consent will have happened before the psychiatrist is asked to give their view as to whether eligibility for access to an abortion is met in this case from a mental health point of view. The other case that everybody has mentioned, which is much rarer, is where in the situation of pregnancy a mental health condition arises and the question of whether or not an abortion as an option would be best for the patient. Looking for a mental health input is a much more clinical situation we deal with, and one where Dr. McCarthy said he would be delighted to be asked for his help.

Deputy Caoimhghín Ó Caoláin asked about the GP and the psychiatrist. GPs certify many things such as absence from work. In terms of assessing people for mental health conditions, including suicidality, GPs are the first to respond and psychiatrists are generally quite happy to accept their first-off certification in many instances, and when they need our help they contact us. In regard to certification, I will take more specific questions about my experience. Mainly it had to do with the restriction on travel of children who were in State care where, because of the difference in their parenting arrangements, the decision about travelling with the child to access an abortion in the UK was more uncertain for the carers in those situations than for a parent to make, for example, in the X case. The decision for them was easier or less complex. They were clearly the parents and they took the decision with their child. It is worth mentioning in that case that the child did not become suicidal until after abortion was restricted, not before. I can answer more specific questions about that. Those were difficult. I think they reflected a genuine concern about the capacity to consent by the carers, but also a concern about the risk of suicide in vulnerable young children. If we have a margin of error in that regard - I think we should do - suicidality in children is a very serious concern and a very serious public health concern in Ireland and not one that any of us in any way take lightly.

In regard to accessibility, the key concern is delay regarding the number of doctors requiring unnecessary institutional restrictions, the dangers of conscientious obstruction and, finally, not ensuring a quick enough appeal time. All of these things can lead to delay and, as we are aware from other countries, are often focused on as ways of denying accessibility, which I think would be in breach of the spirit, at least, of the European Court's recommendations.