Dr. Jacqueline Montwill:

Deputy Kelleher asked if there had ever been a case of suicide in a crisis pregnancy. That is the difficulty, in that there is no data. What we are probably assuming is that some of the 5,000 women who go abroad are suicidal at the time they make that decision but we do not know if they are suicidal when they have a termination. We do not know, for example, if they bought their airline tickets and then changed their minds. We do not know how many women are suicidal on returning home. We also do not know how many women regret the procedure or would say they have no regrets. We have no data and that is the problem.

Many assumptions have been made. For example, Professor O'Keane described a 20% suicide rate in women of childbearing age, but that does not mean that is in any way related to crisis pregnancy, just because the women are of childbearing age. How can we not say that perhaps some of those women who committed suicide were women who had a suicidal reaction to an abortion? There is no data. A great many assumptions are being made. If members look through the submissions, they will note that many of them have no evidence or references in this respect.

The Deputy's second question was why a psychiatrist would ever prescribe a treatment that is not a treatment. I agree, but the problem is that we do not think we are prescribing this treatment; rather, as was said earlier, we will be certifying eligibility. Let us see if can we certify eligibility and what the eligibility criteria are. There are no such criteria, because if a woman has mental illness or an acute crisis reaction, she will be in a state of crisis and people will recognise that. Even when people have a simple crisis in their lives, they will not be able to think straight. That is okay and can settle down within a day or two. If people are in that state, their capacity will be affected. We have to make, supposedly, in this law, a judgment that the woman still fully understands what is going on, has full capacity, is saying she is suicidal and meets the criteria that suicidality will mean that abortion is indicated when there is no evidence that it is, but we also have to make sure the woman is not so distressed that her judgment is impaired. As we know in our mental health practices as consultant psychiatrists, those patients' judgments are impaired and we never impose any life decisions on those patients at such times. We say to them: "Please wait; you are not in the right frame of mind, and in a day or two, or when the medication takes effect, things will be different." We have no criteria by which to apply a test for this law. It does not exist.

The research that Professor Casey talks about involves the worst cases we can think of - patients who are extremely unwell, in a psychiatric unit, and all, as far as a consultant psychiatrist is concerned, at the highest risk possible for committing suicide. In that situation, in which one would think we would have a very good prediction rate, we do not; we can only predict 3% of suicides. In all our assessment cases we make a full assessment and examine all the pressures surrounding the patient and why he or she is suicidal at this time. For example, we examine what has happened to this woman who is pregnant, what are her supports, whether she had mental illness previously and whether there was a risk of suicide. That is all part of our assessment.

Deputy Ó Caoláin asked for an elaboration on consent. That is the issue. We have three broad groups of women. The first group is women who have severe mental illness, which could include psychosis or depression. The definition of psychosis is that people can have strange ideas that are not true but they resolve with treatment. The second group consists of those with adjustment reactions. One can have a depressive reaction with suicidal ideation. This is in the psychiatric classification of diagnosis, and it settles with treatment. Both of those are classified in terms of mental illness. The third category includes people who are in a life crisis but have no mental illness. It could be rightly assumed that valid consent to an abortion must be given when there is no impairment of judgment and the person has the capacity to make that decision.

Moving on to Deputy Mattie McGrath's question, in terms of the X case judgment, the problem is that there is no study indicating that abortion can ever alleviate a real and substantial risk to the life of the mother. Professor Fergusson's research is incredibly important in this regard. In his hypothesis he examined whether abortion reduces rates of mental health problems in women with unwanted or unintended pregnancies, and for this reason he looked at all the research. When he was contacted he rightly said, with regard to the explicit question of a woman being offered an abortion when she is suicidal, that research had not been done. One could understand why that would happen because no doctor will offer a woman an abortion when she is acutely suicidal. I have grave reservations about colleagues stating that they think the timeframe should be reduced. If one had a woman who was acutely suicidal, one would help her get better so that she had a good capacity to make judgments about what she wanted in her life. That is all we are saying. When somebody is acutely suicidal the particular issue is that the person cannot make judgments and the person is not looking to the future. If somebody is truly suicidal, the person sees no future.