Dr. Anthony McCarthy:

I am Dr. Anthony McCarthy, president of the College of Psychiatrists of Ireland and a specialist in perinatal psychiatry at the National Maternity Hospital, Holles Street. I am also the psychiatric assessor for the confidential inquiry into maternal deaths in Ireland.

Our written submission has detailed comments on the heads of Bill and we recommend that close attention is paid to these points. Some practical points will need to be addressed and will require some technical amendments to the Bill. This submission was agreed by the council of the college, the sole organisation recognised by the Medical Council of Ireland as being responsible for the life-long training of all psychiatrists in Ireland. This council is the elected decision making body of the college and we know that among our 864 members there will be a wide range of opinions with regard to the sensitive issue of abortion, reflecting the deep divisions in society in general about this issue. Many of these views will be heard today but the submission is the official college position.

This Bill is about saving women's lives. We recognise that the Bill is restricted only to circumstances where the life of the mother is at risk rather than her mental health. We recommend that any woman who has suicidal ideation in pregnancy must be enabled to readily avail of expert psychiatric assessment, and that assessment must be individual, comprehensive, compassionate and not prejudged. Every maternity unit in this country should have such services, and there is a significant lack in such provision currently, as outlined in our written submission.

As so much will be said and heard today about the risk of suicide in pregnancy, I wish to make some brief overall points as someone who has been working as a specialist perinatal psychiatrist for more than 16 years in a service seeing in excess of 500 women every year. Suicide in pregnancy is real; it is a real risk and it does happen. This is always a tragedy as at least two lives are lost and many others are affected significantly. We must do everything we can to prevent such deaths. Much has been made and will be made about the so-called lack of evidence with regard to abortion and whether it will ever prevent a suicide. I believe there will never be statistical evidence to prove this point one way or other because trying to prove anything statistically for such a rare event is extremely difficult, if not impossible. Only a study involving thousands of women who were expressing suicidal ideation in pregnancy and wanted an abortion, and where half of them had that abortion and the other half did not, for example, if they were prevented from travelling to the UK, could answer this question about statistical evidence. This study will almost certainly never be done, I hope.

As doctors, we must always be aware of research but also be very aware of the limitations of research and of the questions which it cannot answer. In our clinical work, we search always for clinical evidence and not statistical evidence. As doctors, we assess suicidal risk as part of our everyday work and we rely on clinical evidence, our clinical skills and our experience and training in assessing each woman or child individually. There are extra challenges in assessing anyone in emotionally intense situations and where there are potentially serious outcomes, whatever the assessment concludes. Again I stress that we do these sorts of assessments regularly, even if most psychiatrists do not do so in this specific circumstance. Part of suicidal risk assessment always includes assessing the presence or absence of a mental disorder or mental illness and an assessment of the capacity of the individual to make an informed decision. That will be essential here too.

We also always assess for what are called psychosocial stresses, or life stresses. However, some in this debate have tried to present the case that these are somehow mutually exclusive, as if a woman who is at risk of suicide is either mentally ill and hence needs psychiatric treatment or that she just has a psychosocial stress - an unwanted pregnancy - and is then either not really suicidal or her case has nothing to do with psychiatry. Clinical reality and life reality is that frequently there is a complex interaction between major life stresses, mental distress and mental disorder. It is sometimes black and white but most often it is not so. Attempts to present it as such not only does a great disservice to any women who may find themselves in this particular position but also to any person at any time in life who is suffering from major stress, depression or other mental disorder. They too require a comprehensive mental health assessment and treatment, one that does not focus exclusively on the presence or absence of a mental illness but on an holistic assessment and treatment which recognises the individuality of that person.

I will specifically discuss a phrase that is being quoted frequently at the moment that "abortion is never a treatment for suicide". This is true, and abortion is never a treatment for suicide, but neither is counselling, psychotherapy, antidepressants or anything else. There is no treatment for suicide. What society needs to address in general, and what we as psychiatrists have to do specifically, is try to prevent suicide, and this requires looking at the causes of suicide and what can be done to address those causes. The question is not whether abortion treats suicide but is there ever a case where a woman will kill herself because of an unwanted pregnancy, and if so, what can we do to save her life, and would that ever be a termination of pregnancy? This Bill is about legislating for that very small but real possibility.

There are concerns among many psychiatrists that somehow this legislation will result in them being placed in very difficult clinical circumstances. For some this is because of their religious, philosophical or ethical beliefs, and these must be respected. I welcome that those views will be heard today as well. For others, there is a fear of increased workload for their already overstretched services, and doing this with no extra resources. For others it is a fear of being faced with very difficult clinical issues and dilemmas where, for example, a woman may be genuinely highly distressed, such as after rape, and wants a termination but is assessed as not being actively suicidal because she does not want to die. This woman may just want an end to the pregnancy but she will have to be refused an abortion under this legislation. That will be difficult for her and us as clinicians.

These are real concerns and difficulties but they still must be addressed. They cannot simply be ignored or denied by our profession or by society, and will not be by the college.

Many in the profession see this issue as being predominantly a social and political issue, which psychiatrists are now being asked to solve or arbitrate upon, an issue which society as a whole and the Legislature need to address, and are addressing, which is to be congratulated. As psychiatrists, we want to be there to care for and treat women appropriately, professionally and compassionately and not be placed in a position of social policing. However, again at the end of the day, this is about saving women's lives and we as psychiatrists must be prepared to use our professional skills and expertise to assess and treat pregnant women who have suicidal ideation or intent in pregnancy. If, as a result of this legislation, better psychiatric services are put in place so that expert psychiatric assessments and treatments are provided for all pregnant women in Ireland who wish to avail of such services, women and children's lives will be saved.