Dr. Jacqueline Montwill:

Chairman, members of the joint committee, ladies and gentlemen, I welcome the opportunity to address you on this important issue. My understanding of this law is that it is to reassure the Irish people that no pregnant woman will be denied life-saving treatment because of her pregnancy. In my opinion, we do not need this law in psychiatry. We already have full clarity in terms of our assessment and treatment for patients. There will be no situation where the welfare of the foetus will eclipse the welfare of the woman.

Head 4 of the Bill is seriously flawed for three reasons. First, the treatment it proposes is not a treatment. Second, the treatment it proposes is never the only treatment. Third, if truly suicidal with mental illness the patient may not be able to give a valid consent. We have already heard that abortion is not an evidenced-based treatment for suicidality. Unfortunately, this Government is proceeding as if it is. There is no evidence to support the view that the abortion has any mental health benefits. There is evidence to support the view that in some women, abortion may be associated with small to moderate increases in risks of mental health problems, including suicidality. There is an ethical problem in offering a procedure as a life-saving treatment to a suicidal woman where that very intervention also poses suicidality as an outcome.

It is incorrect to say that abortion could ever be the only treatment for suicidal ideation. Suicidality is multifactorial. It is important the people of Ireland understand this. Our treatment packages take this into account. We work in multidisciplinary teams because we believe that the skills of each member of our team are essential for the proper and full assessment and treatment of our patients. Best practice treatment for mental illness is and always will be appropriate full assessment, psychological support and intervention and medication, if needed. It must be remembered that we have social workers, occupational therapists and psychiatric nurses who work with people in their homes and communities. We will work with patients in the community for as long as needed following discharge from hospital. The proper care of a suicidal pregnant woman would entail proper assessment, support and treatment throughout her pregnancy, delivery and postpartum. Longer term intervention may be required, depending on the circumstances. The point is that the woman will not be abandoned.

We are very aware that mental health intervention must include the assessment of all the stresses in the patient's life at the time in question. These stresses can include relationship difficulties, poverty, unemployment or lack of occupation during the day, accommodation issues, difficult current or past family dynamics and lack of other supportive relationships. These also are an indicator of very poor outcome post-abortion. It is within this holistic view that the treatment package for a suicidal pregnant woman would be appropriately assessed and delivered. Therefore, it is illogical to say that the only treatment for suicidal intent during pregnancy could be an abortion.

Valid consent to an abortion may not be possible while a patient is acutely suicidal due to mental illness or distress. This is important. It is important to note that a psychiatric emergency or crisis is fundamentally different to any other medical or surgical emergency. This is because of the nature of the disorder. In a true psychiatric emergency, the patient's judgment is frequently impaired. Our role at that time is to administer the most appropriate psychiatric treatment and support. It would be highly inappropriate and unethical to impose an irrevocable intervention at that time when the patient may not have sufficient mental capacity to give a valid consent to that intervention. We would in such circumstances be failing our patients. The patient's right to bodily integrity is paramount. It is my view that if a termination were prescribed and given at the time when a patient is in crisis, has an acute crisis adjustment reaction or is mentally ill, the patient would be in a strong position to accuse the treating team of failure in their duty of care. It could be rightly claimed that we as psychiatrists failed in our duty to adequately protect the patient during a period of mental illness. It should not be forgotten that mental illness responds to treatment. Acute crises respond to treatment. They settle down, often in a short period. Any impairment of judgment in these situations will resolve with treatment.

With this law, the focus will be directed away from a full and proper assessment of the patient towards an assessment for a direct abortion. As treating psychiatrists we do not assess suicidality for any reason other than to prescribe the appropriate psychiatric treatment. Society should do the same. Society should validate rather than normalise an expression of extreme psychological distress. Mental illness is just as important as physical illness. Perhaps even more so. It affects a person's thinking, the ability to relate and relationships and the ability to function. It is exceptionally important to state that the proper response to stated suicidal intent should always be the appropriate evidenced based clinical treatment. That is what we do when we assess patients who threaten suicide. Direct abortion is not a clinical treatment. It is a social solution. This law will do damage way beyond the boundaries of simply legislating for a medical treatment that is without the foundation of medical evidence and good clinical practice.

It will directly target and profoundly damage the very nature of the doctor-patient relationship. The interaction for a woman who is suicidal and pregnant will change from therapy to judgment and an adjudication interview for abortion. This will put her in an impossible situation, with outside demands impacting on her treatment and taking her out of the proper therapeutic alliance with her psychiatrist and treatment team.

For patients with mental illness, there is no evidence that abortion is a treatment for suicidal intent or threats. There is no situation in which it could be the only treatment indicated and the issue of valid consent to an abortion for someone who is truly suicidal due to mental illness poses serious ethical concerns. We have heard that the incidence of suicide in pregnancy is extremely rare and some people believe this law is going to relate to those patients. I do not believe that is true. In my opinion, the patients who will avail of terminations of pregnancy through this law are most likely to be those we discussed in earlier sessions, who have no mental illness but do not wish to be pregnant. What difficulties will this pose? Unfortunately, we cannot tell who is going to commit suicide. A study of patients in an acute psychiatric ward found that out of 100 patients who were seriously psychiatrically unwell and who psychiatrists thought would commit suicide, only three did so. We have no way of predicting who will commit suicide but in our assessments we treat everybody as if they will and we provide the appropriate treatment package for each patient on an individual basis.