Dr. Anthony McCarthy:

I thank members for a number of interesting and thoughtful questions. I will not refer specifically to the child issue because Dr. Maeve Doyle has covered it well and adequately. I note that, again, there are technicalities on which we really must work and while none of them is insuperable, we must work on them. In addition, I will not answer anything further about clinical markers, as that point already has been made.

Yes, suicide is a fact. When people talk about figures, such as one in 500,000 or one in 250,000, it is desperately important to note we actually do not have a clue because these figures are based on the fact that this is a country, the United Kingdom, in which abortion is directly available. I am on that confidential inquiry that considers those maternal deaths to which Dr. John Sheehan has referred but, yes, absolutely, those who commit suicide in the United Kingdom at present nearly always are mentally ill. However, that does not at all account for all the other hundreds of thousands of women who have terminations in England and who may well be mentally distressed and may well have that termination because they are suicidal. Nothing captures that at present and nothing will. Consequently, one must be very cautious about that sort of evidence.

Again, I will not address Deputy Fitzpatrick's questions too much because I believe I covered that issue in my opening statement. I agree that some people have mental illness and it must be treated. In the case of some people, it is mental distress. In the reality of our clinical work, we really are dealing with the complex interaction between stress, distress and mental disorder. If only life were black and white and one could say these ones are mentally ill and should be treated psychiatrically by getting them into hospital and observing them carefully, whereas these ones are in psychosocial distress and should be dismissed. That is not life and every one of you in this room knows that. It is much more complex than that and our jobs and experience are to weigh up these factors. As for the woman who refuses alternatives, we are not naive. If a woman comes to me, having refused all other alternatives, my question will be "Why?". Why is she sitting in front of me if her only option is a termination of pregnancy? Why has she not gone to England? This will be part of the process as we are not fools and it will be a highly complex discussion. The question will be whether she is trying to test the legislation or is it the case she cannot leave the country for some reason. As for the idea that this would be blocked in some way or that she will present in that way, namely, that she refuses everything else and consequently it is up to me, in itself that is a very complex interaction. We are used to dealing with people who put us under all sorts of stress to make decisions. Dr. John Sheehan made reference to people in the emergency department who threaten to kill themselves unless they are given some methadone because their methadone was stolen in the hostel. We are used to being put under pressure. While that might seem like a job that most of you would not like, I love my work. It is really complex but it also is very human. We are aware of the complexities and interactions and are not naive.

A member, whose name I did not get, asked a very good question about multidisciplinary teams. While we work in multidisciplinary teams, there are times when, as psychiatrists, we are the ones who must make that final decision. We have talked a bit about involuntary detention within hospital and it is the consultant's name that goes on that form. Similarly, for someone who has been previously detained, it is the consultant's name that goes on the discharge from hospital form. If that patient appeals against his or her detention in hospital, I as a consultant must go into that room and defend. It is not my multidisciplinary team, just me. Consequently, as psychiatrists we are used to being the individuals who take these decisions. That is our responsibility and duty and is one for which we all are very well trained.

On the viability issue, I agree there are highly complex issues about viability. I think that really is up to our obstetric colleagues to deal with. There are of course complex, painful issues that sometimes must be dealt with. If a woman is six weeks pregnant, my conversation with her will be very different when compared with that with a woman who is 16 weeks or 26 weeks pregnant. We know that. Why does she wish to get rid of that baby? Does she wish to get rid of the baby or does she wish to kill herself? Moreover, if she wants to get rid of that baby, is it because she cannot bear having that baby inside her? Perhaps she has an eating disorder and already has taken three overdoses in the course of that pregnancy because she cannot deal with that real distress. I am sure it is difficult for all of you to understand but I refer to an anorectic who sees herself as totally fat and the issue actually is that she wants the baby out. This is in contrast to someone else who wants that baby killed because it is her father's child or because she actually is in a relationship with a guy who she should have left years ago. When she got pregnant, in that ridiculous way she would do, she kind of imagined that somehow having a baby with him might make him be nice. However, we know that, actually, men are more likely to have affairs during their partner's pregnancy and certainly levels of domestic violence increase during pregnancy. We men do not come out well out of all this. This is a woman who already has been kicked three times in the stomach in pregnancy and who knows now that if she is pregnant, her issue is that if she has this baby, she will never get away from him, because he will be the father of the child and she will be obliged to stay in this country because he will have rights. Consequently, she has a choice, namely, does she kill herself or does she get rid of that baby or perhaps both, but if she has that baby she is stuck. If this conversation takes place at 16 weeks or 22 weeks, yes, we would try to help as much as we can. However, if anyone can say there never will be a woman in this circumstance, he or she really does not understand the messy, horrible nature of life sometimes. I refer to the real mess, the bloody issues that go on. That is the reality which we must deal with and assess, not as cold pre-judgmental black-and-white people but as real professionals who understand mental illness, mental disorder and capacity, but who also understand that, sometimes, it is not black and white and is not easy.

Finally, while talking about bloody issues, let me get back to infanticide, to which I referred the last day I was here. I got a lovely letter from a priest afterwards thanking me for raising this horrible part of Irish history, namely, the history of hundreds of women who committed infanticide every single year in this country during the 19th century and the first 50 years of the 20th century. Wonderful studies have been done on this issue and these were real. The study to which Dr. John Sheehan referred is about infanticide now and not about infanticide then. Infanticide then was not all about mental illness or anything like that. It was about women who found themselves in extremely difficult situations. The treatment of unmarried women, women with unwanted pregnancies in this country is not great, is it? I refer to the Magdalen laundries, industrial schools and psychiatric hospitals. We as a profession played our part in having women in hospitals for many years. For what reason? We colluded with unwanted pregnancies.

The reason I stand here, not just as a perinatal psychiatrist but as a human being and as president of the college is to say that should stop. We must do anything that will protect women in these circumstances. The women will be treated with dignity and respect. If at all possible, the life of their unborn child will also be preserved. That is not only my responsibility under the Constitution and the law but also as a human being and as a father. If a woman goes on to kill herself, her child or children die as well. Such situations happen. They are real and it is our job to prevent that.