Oireachtas Joint and Select Committees
Wednesday, 8 March 2017
Joint Oireachtas Committee on Health
Women's Reproductive Health: Discussion
I welcome our guests from the office of the UN special rapporteur and the National Women's Council of Ireland. The purpose of this evening's session is to discuss the right of everyone to enjoy the highest attainable standards of physical and mental health. Professor Dainius Pras and Ms Orla O'Connor, director of the National Women's Council of Ireland, are with us today.
I draw the witnesses' attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009 they are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.
Any submissions or opening statements which have been submitted to the committee may be published on the committee's website after this meeting.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.
I invite Professor Dainius Pras to make his opening statement.
Ms Orla O'Connor:
If it is all right with the Chair, I will start by giving the committee the context of Professor Pras's visit to Ireland.
I thank the committee members for the opportunity to come and speak to them today and I wish them a happy International Women's Day. A world congress on women's mental health has been going on for the past three or four days in the RDS in Dublin. It is being jointly hosted by ourselves, Trinity College, Dublin and the International Association of Women's Mental Health. It has been examining women's mental health needs within the context of health and well-being for women.
As part of the congress, we had the pleasure of inviting the UN special rapporteur, Professor Dainius Pras, to Dublin. He addressed the congress this morning at the event for International Women's Day. That is to give the committee a sense of what this is about and also to be clear that this is an unofficial visit by Professor Pras. An official visit by a special rapporteur is when the Government invites him or her to make a report on the State. This is an unofficial visit on the invitation of the National Women's Council of Ireland and Trinity College, Dublin. It does not result in a report but is a way of meeting people in Ireland.
Professor Dainius Pras:
Honourable Chair, members of the parliamentary committee, it is a great pleasure and honour for me to be here and to share my experience while discharging the UN mandate of the special rapporteur on the right to health. This mandate was established by the UN Human Rights Council in 2002. Rapporteurs may also work on other issues as there are more than 40 thematic mandates. My role as special rapporteur is to inform the UN and member states on opportunities, challenges and obstacles to the implementation of the right to physical and mental health. Special rapporteurs carry out this work through thematic reports, country missions and reports, communications procedure and also non-mandated activities such as my participation in the congress.
While discharging my mandate, I use the analytical framework developed by the first special rapporteur on the right to health, Paul Hunt. Many important themes have been developed by my predecessors, Paul Hunt and Anand Grover, for example, the themes of health systems; access to essential medicines; rights to health of vulnerable groups; and social and underlying determinants of health. Both of my predecessors also issued very powerful reports on sexual and reproductive rights and health.
In my thematic reports and country missions since my appointment in 2014, I have been addressing issues that have not been sufficiently addressed and issues that are emerging as new priorities. My reports to date have addressed the right to health in early childhood and adolescence, the right to health and sustainable development goals, SDGs, and the right to health and healthy lifestyles. I am currently finishing my thematic report to the Human Rights Council on the right to mental health.
As the committee members know, all human rights are indivisible and interdependent, and the right to health cannot be exercised effectively without protecting and promoting all other human rights. The congress I have attended in Dublin is a very good attempt to link two important parts of the right to health, namely, the right to sexual and reproductive health and the right to mental health. With regard to sexual and reproductive health and rights, I have elaborated on this in my thematic report on the right to health in adolescence of 2015, and in the statement of UN independent experts last year. One of the conclusions of my report on the right to health in adolescence is that states should adopt comprehensive sexual and reproductive health policies to ensure universal access to sexual and reproductive health care services. My main recommendations were that abortions should not be criminalised; that all adolescents should have access to confidential, adolescent-responsive and non-discriminatory sexual and reproductive health information, services and goods; and that age appropriate, comprehensive and inclusive sexuality education, based on scientific evidence, should be part of the school curriculum.
Last September, on the day of action for access to safe and legal abortion, I joined other independent experts to highlight that the criminalisation of abortion and failure to provide adequate access to services for termination of an unwanted pregnancy are a form of discrimination based on sex. Restrictive legislation which denies access to safe abortion is one of most damaging ways of instrumentalising women’s bodies and a grave violation of women’s human rights. We recommended the good practice found in many countries, which provide women with access to safe abortion services on request during the first trimester of pregnancy. We insisted on international legal requirements that women can access abortion at the very least in cases of risk to their life or health, including mental health, rape, incest and fatal impairment of the foetus during the first trimester and later.
Violations of sexual and reproductive rights, including denial of access to safe and legal termination of pregnancy, remain a worldwide problem. During all country missions I have had, I have been raising the issue of gender-based violence and violations of sexual and reproductive rights. Human rights are interrelated, and so are violations of different human rights. When sexual and reproductive rights are violated, this has a negative impact on physical and mental health. In my current report on mental health, which will be presented in June 2017 to the UN Human Rights Council, I critically assess the current situation in global mental health and psychiatry, including violations of the rights of persons with psychosocial, intellectual and cognitive disabilities. Following numerous consultations in countries across the globe, I have identified major obstacles for the realisation of the right to mental health. These include the medicalisation of mental health and overuse of biomedical interventions; huge power asymmetries in mental health care between service providers and service users; the legacy of coercion and forced treatment in psychiatry and mental health care; inadequate attention to mental health promotion and prevention; reluctance to eliminate violence, including that against women and children, in all ages and all settings; and other factors.
Now, when mental health is included in strategic development goals and Agenda 2030, it is of utmost importance not only to invest more in mental health, but also to invest in a human rights approach in mental health care and to abandon outdated concepts and power asymmetries than hinder progress in global mental health. The main priorities should be to address all human rights in all settings so that poverty, inequality and violence are effectively addressed, to target relationships rather than individuals and their brains, and to develop rights-compliant mental health services with a radical reduction of coercion in psychiatry. There will be a need for states to act as champions in the promotion of such a shift in mental health policies and services.
More information on activities while discharging the right to health mandate can be found atand.
I thank the delegates very much for taking the time to come and see us. I have read a little about Professor Pras recently. I would like him to elaborate on the issue of access to free, safe and legal abortion. His statement refers to access to abortion "at the very least in cases of risk to their life or health, including mental health, rape, incest and fatal impairment of the foetus during the first trimester and later." Has he done any work on or does he have recommendations or thoughts on how one could tick the boxes for women who have been raped? While it might sound easy to allow abortion in a case of rape or incest, I have always asked whether a woman has to go to her police station to report it? Who fills in the form? What man, or woman, for that matter, will tick the box stating the woman deserves an abortion because she ticks the rape or incest box? How is it implementable practically?
In his submission Professor Pras uses the phrase "abandon outdated concepts and power asymmetries". Perhaps he might elaborate on it briefly. Is he saying we over-rely on medications with regard to mental health in general? Is it a funding issue? We have discussed this at some meetings of health committees, although I am not sure about this one. Six months of cognitive behavioural therapy in Ireland costs far more than a dosage of antidepressant tablets lasting six months. Is this what Professor Pras is getting at or am I misinterpreting him? Is he saying we need to change our approach to mental health? Rather than prescribing a tablet for everything, would other methods be as or more effective? Leaving the money element out of it, would there possibly be better outcomes? Perhaps Professor Pras might elaborate on the issue.
I welcome Professor Pras and Ms O'Connor and thank them for their presentations. Given that it is International Women's Day, I wish to ask a few relevant questions.
Reference was made to the right to access terminations, particularly in the first trimester, in the context of rape, incest and fatal foetal abnormalities. This Parliament has established a citzens' assembly to examine the issue of abortion. We have a written constitution that prohibits abortion in this country, except on very limited grounds, namely, where the life of the woman is threatened. Legislation passed through the Parliament in 2013 to support that interpretation of the Constitution. We are now going through a process of considering the issue of abortion. More than likely, the people will be the final decision-makers in this context and there are varying views. The delegates' views on the issue would not be universal. The issue has been very divisive, not only in Ireland but across the globe.
While I believe our current system is not ideal - we have to address it - we take a very casual view of women's health internationally, other than in respect of the issue of abortion. In this regard, one should consider vaccinations and access to proper health care, for example. In many countries, there is a stigma attached to vaccinations which women and their children are not able to obtain. What is the United Nations doing about these broader issues? Professor Pras, as special rapporteur, talks about a right to health. The basic health issues include access to clean water, for example. I wonder at times what the United Nations is doing at international level to push out the boundaries in terms of female health in general, including mental health. Professor Pras highlighted some of the issues. While efforts are made to deal with practices such as female genital mutilation, for example, what is the United Nations doing on a country by country basis to address the issues to which I have drawn attention? I have highlighted the issue of vaccinations and taboos associated with women's reproductive health. Sometimes we do not highlight them enough as nations and internationally. Very often we get caught up in the one issue of reproductive rights and women's health.
Professor Pras talks about mental health and oppression in some countries. In this regard, what research is the United Nations carrying out on basic equality across the globe? Many of us have grave concerns about this issue. While we all respect one another's culture across the globe, issues arise regarding the oppression of women in various states. To tell the truth, my view is that at times the United Nations can be casual about such oppression owing to larger political interpretations, alignments, etc. At times, it has to be above and beyond these and call it as it is.
Professor Dainius Pras:
I thank members for their good questions. On the issue of access to abortion, I have outlined the minimum requirements or standards the United Nation proposes. Personally, I find them confusing. Actually they create new problems. Of course, I would be in favour of the recommendation that we, as experts, have provided in the statement, but I recognises what happens in real life. With regard to having special circumstances, those states that choose to have restrictive laws are recommended to do as outlined, at the least. I agree that almost all of the cases mentioned are such that if we try to imagine how the system would work - there are countries where the type of legislation in question is in place - we note that problems would be created not only for women but also for doctors, for example. They have to decide.
Especially in mental health but also in physical health, medicine is not as exact a science as maybe we would like it to be. Therefore, on the question of what is the criteria to differentiate between the right to health and the right to life, as a medical doctor, I should not agree to be involved in this exercise because it will be always subjective. This is particularly so with mental health, where we do not have any single biological marker. If we take any sample of blood or biopsy, we will never find anything to indicate if it is, let us say, depression or not depression, and if it is a high risk of suicide or a low risk of suicide. To further complicate matters, in the countries which have high rates of suicide, these are not because of severe depressions but rather as a result of a very high number of mild depressions which make this number of suicides high. Most suicides are from mild depressions, not severe depressions, because there are so many mild depressions.
We understand that all these ethical issues are related to prenatal diagnostics of, let us say, chromosomal diseases or abnormal development of the child. This is a huge issue to be discussed. For example, it is a more clear position that we have to inform families and to support any decision. If, in the first trimester, Down's syndrome is diagnosed, we should respect any decision. If they decide to terminate the pregnancy or if they decide to have this child, it is not for us to apply pressure for one side or the other, although this happens. I know some colleagues who would like all these women to terminate pregnancies in such cases and I do not understand why. It is not their business so to say. It is up to families to decide what decision they make.
I agree that these minimal standards create new legal, ethical and other issues for women and for doctors. When travelling in these countries where they do not have these even minimal requirements, I have seen how the thinking of doctors is changing. In one country there was a case of a ten year old girl who was pregnant as a consequence of rape and my formulation was she was forced to pregnancy and motherhood, but the doctors with whom I discussed it could not see any problem. The doctors told me the girl was okay and there was no harm to her physical and mental health. I was thinking the doctors were wrong but who will judge whether I am right or this doctor is right? In that context - maybe it is some survival strategy - it depends on cultural and legal contexts. Doctors are human beings and they adapt. I could share also other stories about this so-called "dual-loyalty" when doctors, as doctors, should think one way but the law suggests to them to think another way. It is a complex situation for doctors.
If I may move to the second question, it is about this interesting situation in global mental health when there is common agreement between experts that there is a global mental health crisis but some experts emphasise a so-called "global burden of mental disorders" and other experts like me emphasise a global burden of obstacles in the realisation of the right to mental health. People have always had mental health conditions. We do not now have some epidemics. It is just that we may collect information better. The problem I see is overuse of biomedical interventions for different reasons. Biological psychiatry promised 30 years ago to solve effectively problems, and maybe even to cure mental health conditions with modern medications, and now there are not so many promises. We see that psychotropic medications may be effective but may be also not effective, and they are overused. For example, to treat mild and moderate depressions, one does not need anti-depressants. Anti-depressants are usually needed for severe depression.
Deputy O'Connell raised a question about therapies. I am presenting the global view. Again, I am here not to assess the Irish situation but to merely inform about global situation. There are many countries, including in eastern Europe, where psychosocial interventions have never been covered. If a woman or a family with child will go to the mental health services, they will always receive medications, whether they are needed or not needed. It is merely that there is a long tradition to biomedicalise mental health and it is still this way. We can find compromise with inexpensive more short-term and not-so-very-sophisticated psychosocial interventions which can be cost-effective and not so expensive. The main point is that we should address more social and structural determinants of health, such as poverty and equality, and violence, instead of medicalising consequences. It often happens that those who are suffering from unbearable conditions in their lives, if they go to mental health services, will be diagnosed as if it is a chemical imbalance. In today's presentation, I allowed myself to use this. I think it is more often a power imbalance than a chemical imbalance. Too often, it is the consequences of different social and environmental determinants, including the fact that many societies tolerate and condone violence against women and against children and then they are surprised why there are so many mental health issues. I do not want say that medications are not needed. I merely want to signal also in this report that sometimes biomedical interventions are overused, not to speak about institutionalisation. In many countries, there are many people enclosed in residential institutions. Under my report to the Human Rights Council, I will merely remind it that psychosocial interventions and public health interventions are not a luxury. They can be very effective. They are not less effective than medications.
A more complex question followed. I mentioned and then Deputy O'Connell mentioned power asymmetries. Power asymmetries means that if, in general medicine, there was agreement globally, in law and ethics, to move from paternalistic relations between doctor and patient to partnership, this has not happened in psychiatry. In psychiatry, the doctor still make decisions for basic elements of life of users of mental health services and when one has such monopoly of power, it is difficult not to misuse this power.
This power asymmetry does not help to empower users of mental health services, and we need to address that. I am looking for states which could be champions. I want to discuss the matter with the leadership of the psychiatric profession and to move to more innovative mental health services, which would reduce this power asymmetry.
I will respond to a question on broader issues of women's health. I agree that there are many equally important issues regarding women's health, including physical health. The UN is doing its best, but I have to remind the committee that I do not represent the UN. We special rapporteurs often like to criticise the UN and the World Health Organization, WHO. We have such a right because we are independent experts and the UN and WHO were perhaps too slow to react to emerging new priorities. The first priority was communicable diseases and the global response to the HIV-AIDS crisis was quite good. Indicators suggest we are now in the middle of the way. This very ambitious sustainable development goal to eliminate AIDS by 2030 is an example of where the human rights approach was really used in practice. I do not know the motives, and perhaps it was out of fear, but many countries moved to effective policies to address HIV-AIDS and reduce discrimination against these people. There are new priorities now, as states are starting to understand, in the form of non-communicable diseases and mental health.
Sustainable development goals, SDGs, signal that these problems are equally important for all countries, including high income countries, while millennium development goals, MDGs, as the committee remembers, were more focused on the developing world. Europe was maybe not so interested in SDGs because major problems have been solved by European countries. All 17 sustainable development goals, including goal 3, to promote health and well-being, are equally important. These include the health of women, demographic shifts where there are huge numbers of children, adolescents and young people in many countries, and also issues of a large population ageing. These shifts should be addressed by countries implementing practical health policies. Some countries are doing this better and some are doing worse. I agree that there are many issues relating to women's health which need to be addressed better to reduce this gap and these gender inequalities which still exist where women in many countries cannot access health care and girls cannot receive education.
This is also related to the next question which Deputy Kelleher raised, about research across the globe. He mentioned oppression from which women in particular suffer because of different political systems, if I understood correctly. I agree and share this concern that the global picture is not very good. Many countries threaten to take more populist decisions and do not pay enough attention to human rights, as it was in 1948, for example, when the Universal Declaration of Human Rights was unanimously approved. Now we need more arguments to convince everyone why we need full respect for all human rights. I see some countries exercise human rights and the right to health care in a selective way when I go to them. Some rights for some people are okay, and some rights for other people could be ignored. This leads to further inequality, social exclusion and I do not imagine that we can reach the agenda for 2030 and its very ambitious sustainable development goals in this way. I agree that there are many issues globally which need to be addressed in a more serious way. I am doing this on behalf of my mandate, which is about a right to health care. Sometimes, some countries remind me that when I go abroad that I may overstep my mandate since the right to health care may not be exercised without other rights. I do not think I do.
The issue of birth control, for example, is something that is possibly not supported in a way that would address some of the problems with large families across the globe. There is huge poverty and poor vaccination programmes for children on top of that resulting in much disability and so on, and the women of these countries are often charged with trying to mind all of that. An observation I would make, and it is not a criticism of Professor Pras, who I hope refers this to the UN, is that it should be more proactive in those areas or as active as it is in other areas.
I wish everyone a very happy International Women's Day. We often talk in this Parliament about the provision of abortion services for women. Some like to think that this is a country where we do not have abortion. Of course we do. Women have abortions every day of the week. They mostly travel to England to do so because they cannot avail of services here. We would be foolish to suggest that we have somehow created a little statelet where abortion is not a reality. It is. Women have abortions every day of the week. The only difference between here and a country where a woman can avail of a full suite of services is that she has to travel.
The UN found that the State had failed to protect one of our citizens, a woman by the name of Amanda Mellet, from cruel, inhuman and degrading treatment. It is a fairly damning indictment of the State, of our health care system and the choices and the options that are available to women, that we could say that our State has failed women to that extent in the very recent past. I would be interested to hear Professor Pras' views on that. Women have abortions, as we said. We know that this happens. They are our sisters, our friends, our aunts and our mothers. We know that it happens.
We have an issue with follow-up care for women. I wonder if Professor Pras might comment on the necessity for women to be able to avail of a full suite of services, including follow-up care where a termination has taken place. We can talk a lot about how we have failed women - and we continue to fail them - but are there examples of best practice?
Professor Pras's presentation refers to universal access to sexual and reproductive health care services, and the need for states to act as champions in the promotion of mental health policies and services. Are there countries that do it better than we do, from which we could learn in order to become the champions, as Professor Pras advocates and as we would all like to be?
It is very timely to get an international perspective on the extent to which the church, specifically the Roman Catholic Church in the case of this country, exerts an influence over the choices available to women.
I welcome Ms Orla O'Connor of the National Women's Council who has worked with me through the community and social pillar for many years. Many issues relate to women, disability and mental health. I am delighted that Professor Pras is here. It is interesting that it was not until 2002 that the UN appointed a rapporteur on the right to health. That may be an echo of some of the comments that have been made already. However, it is important that it is there.
Professor Pras mentioned that the Universal Declaration of Human Rights in 1948 was the first declaration of the UN and came in the wake of awful tragedies across the world. I believe that committee was chaired by Eleanor Roosevelt, the widow of the former American President, who was a man with a disability. I am making a point about culture. It took the international community until 2006 to realise that people with disabilities had human rights, because that was when the UN agreed the Convention on the Rights of Persons with Disabilities. People with disabilities were people in 1948. It makes the point that it is easier to validate the rights of some people in some situations than for others. I am not talking exclusively about people with disabilities but lots of vulnerable folk. It is very difficult to get that mindset and that culture.
In answering a question Professor Pras mentioned it is more often the power imbalance rather than chemical imbalance that is in question. I accept that regarding the mental health area. The culture of things is so ingrained. There are different cultural issues in the western world, the south or different parts of the world with different religious backgrounds etc. The cultural thing is almost like a virus that is nearly impossible to neutralise. That is a major obstacle to dealing with these things.
Professor Pras also mentioned the importance of addressing the social determinants of health, which resonates with me. He took the example of Down's syndrome. Now not just Down's syndrome but a whole range of conditions can be identified before a baby is born. People can carry certain genes and get certain conditions. In some parts of the world because we have this information and knowledge we might now be on the cusp of making judgments based more on economics than on human dignity and protecting people's lives. To make it concrete, if a mother finds out she is carrying a child with Down's syndrome, there can be a lot of pressure. There is no contest here; there is only one thing to do - terminate the pregnancy. That is a cultural thing. It is a push. However, in the state where that woman lives she has to look at the very practical bread-and-butter services and supports that she would need to actually if she is supported enough to get over the cultural issue. Where will the supports be there for that woman and hopefully for those parents to be able to give that baby, that child, a decent worthwhile life? I am not saying it has to be right or whatever. I believe these kinds of social and cultural issues have become a very contested space and will continue to be more so.
The European Commission has declared this year as the European year of focused action to combat violence against women and girls. I know we are talking about a wider canvas here, but let us just keep it to Europe. There are huge issues. Disability and mental health are mixed in with a range of other areas where women and girls are vulnerable. Women as they get older are more vulnerable. Young girls are vulnerable if they are migrants or come from different ethnic groups. There are major issues here on our doorstep. I ask Professor Pras to comment on some of the observations I have made.
The European Parliament, the Commission and the Council Presidency in the Malta joint statement of February of this year have jointly made a strong call for action to member states - we are one of them - to ratify and fully implement the Council of Europe's Istanbul convention on preventing and combatting violence against domestic violence. There is no science to the answer to this. What is Professor Pras's hunch or sense if the vulnerability around violence against women and girls were removed, how significant would that be in aiding the health and well-being of females?
I welcome our guests. They are very welcome as fellow human beings who are lucky enough to be alive. While welcoming Professor Pras, I am disturbed although not surprised by his presentation. He bears a great title of UN special rapporteur on the right to health and he has an important brief. It is vital that the UN succeeds in its mission in the world at so many levels. However, I consider that he is operating on what seems to me a very corrupted understanding of human rights, if on the one hand he can talk so much and no doubt so sincerely about the need to eliminate violence and violence against women in particular without acknowledging that violence against the unborn is what we talk about when he promotes abortion as a right. I think he has a very corrupted understanding about human rights. I do not see how we can talk authentically about human rights unless we include the whole human community.
More than the problem of misunderstanding human rights is the damage Professor Pras does to his ability to get buy-in on so many important issues around the world from so many different states. Let us acknowledge and salute on this International Women's Day the countless women who oppose abortion not for anachronistic, religious or philosophically idiosyncratic reasons as some would have us believe, but because they have an essential idea that human dignity belongs to all and starts with the protection of the most vulnerable, and that there is always a better solution than the taking of an innocent human life.
In his presentation Professor Pras did not mention the baby or the foetus. He does not appear to acknowledge that abortion involves the killing of a child and that is a serious problem given the brief that he holds. He also said some very tendentious things, for example, stating so matter of factly that the criminalisation of abortion leads to a higher number of maternal deaths when he is in a country that, since 1983 as a matter of human rights and constitutional law, has upheld the equal right to life of mothers and their unborn children and has done so in a way that allowed Ireland to be consistently among the countries with the lowest maternal mortality rates in the world. Medics here have become highly skilled at seeking to protect mothers and their unborn children and where necessary medical interventions to save mothers’ lives have always enjoyed top priority. That has been the Irish experience. To be unable to acknowledge another reality, that the non-legality of abortion in Ireland has meant that Ireland has a very significantly lower abortion rate than other countries, taking into account what Deputy O'Reilly has to say about the sad reality that some Irishwomen travel-----
Indeed. Some Irishwomen go to Britain for abortions. I was about to give the figure that Deputy O'Reilly cited, 4,000 to 5,000 a year. One can also count the newer reality of people importing abortion pills and the like. That sad reality, tragic for those women and their babies, leaves Ireland with a situation where approximately one in 20 pregnancies ends in abortion, whereas in our nearest neighbour that rate is four times higher, at one in five. Professor Pras should acknowledge that the Irish law has had a protective effect. In the words of one woman, the time it took to arrange an abortion in England was the time she needed to change her mind.
I do not mind the witness acknowledging, if he were generous enough to do so, that sincere people can differ on this issue. It is clear they do but dogmatism underlies this document, where he does not even acknowledge that this is not an issue like others, that it is an issue that divides sincere people, atheists and religious, people of good will. He does not acknowledge that abortion is a reality around the world and is responsible for millions of deaths. I have asked that today we remember the countless women who oppose abortion because it is contrary to human dignity, and the countless, 50% plus, of unborn women who die as a result of abortion. Will Professor Pras consider the UN Convention on the Rights of the Child, which in its preamble, the bit Professor Pras never quotes, states: "... the child, by reason of his [or her] physical and mental immaturity, needs special safeguards and care, including appropriate legal protection, before as well as after birth." How can we conclude otherwise than that human rights are being corrupted when people in Professor Pras' position never quote that preamble? At most they will offer that the preamble does not contain justiciable rights, which is true, but it has legal force and it is a required part of the interpretation of UN jurisprudence. I see his colleague taking a note on that but I would like to hear that point contradicted. It is legal. It is part of the law. It is the never quoted part.
I note Professor Pras says that he does not speak for the UN and that he is free to criticise it which is very good. Would he agree with me that it might be okay if the UN were to criticise him? I wonder does he speak, for example, for the new Secretary General, António Guterres, who speaks about human dignity with great regularity, and whose voting record as a politician has been to include all, born and unborn. Surely the presence of such an eminent figure at the head of the UN should prompt him to rethink his understanding of human rights or at least to acknowledge that there are different points of view on this issue. Where there is a different point of view, there must surely be greater respect for different member states' rights to make laws reflecting their understanding of human dignity. Would Professor Pras agree that he does a disservice when he links issues such as gender-based violence on which we must all act together, with, as he put it, violations of sexual and reproductive rights, by which I presume he means the denial of legal abortion? He does a great disservice to human rights when he links areas that should be common case with areas that are highly contestable and I would argue noxious because of the danger to life.
Professor Pras mentioned Down's syndrome and spoke of his respect for the decision of people to terminate or to have a child. Is he really doing enough there, given that his brief is health and in other contexts we would all talk about the need to treat disabled members of our community on the same footing as those who do not have a disability? I note with great attention and care what my colleague, Senator Dolan, has had to say and I agree with him. Would Professor Pras agree that laws on abortion at the very least should not discriminate between children who are disabled and able-bodied members of the community? I think it was Lord Shinkwin who unsuccessfully attempted in the House of Lords to change the British abortion laws so that there would be no extra grounds for abortion on grounds of disability. Would Professor Pras agree that if there is a sincere motivation to treat disabled members of our community on the same footing as everybody else and to champion everybody's rights equally that there should be no extra grounds for abortion, based on disability whether serious, life-limiting or more trivial? Is he not being hypocritical if he supports the rights of countries to legislation for abortion on the particular grounds of disability?
In talking about respecting the decision to terminate or to have the child, I note that Professor Pras talks about the goal to eliminate AIDS by 2030. Let me tell him about another 2030 goal, which is the goal of the great and the good in Denmark to be Down's syndrome free by 2030. Is that not the reality that Professor Pras' neutrality masks, whereby the existence of children with Down's syndrome has become increasingly uncommon in the Western world with rates of abortion of children with Down's syndrome at well over 90% in Britain? Has he anything to say to that? As one commentator in Ireland recently said about that Danish aspiration, all will be well and all will be Orwellian. Would Professor Pras agree that is an Orwellian aspiration? It is a goal already achieved in Iceland. He says first trimester abortion is a basic right to which he would aspire. Has he anything to say about the reality of abortion in a country such as Britain where a child with a disability as mild as cleft palate can be aborted because of that disability?
Does the witness have anything to say about the fact that in 2008, according to British statistics, more than 60 children survived a botched abortion and were simply left to die? Does it come under the health brief to have any kind of care for those aborted children or is the witness happy enough for the British to have such a law?
I have a brief comment. The Chairman is very kind to indulge me. Ms O'Connor would be well aware of this but I will say it for the benefit of our visitor. A somewhat distorted picture of the reality of our maternity services was painted there and I can speak with a small degree of confidence as somebody who has used the maternity services in this country and seen my daughter use those maternity services very recently.
The witness is in a country where 20-week anomaly scans are not offered to women. It is something that would be considered very basic. Before we get ourselves into a frenzy of praising the maternity services in this country - the men and women who deliver those services are exemplary - we should realise that this is a country where a 20-week anomaly scan, if one is lucky, might be offered if that woman is in one in six of our maternity units. In truth, this routine screening is not offered to pregnant Irish women. Dr. Louise Kenny from Cork University Maternity Hospital has made it clear that women under the care of maternity services undergo unnecessary procedures because of the failure by the State to provide this scan for women.
That is one example but if I chose to I could take up all the time in this meeting describing exactly what it is like in reality to use the maternity services in this country. It is a fact that one cannot as a matter of routine access a 20-week anomaly scan in this country. I would not want the witness to think he had somehow landed in a sort of maternity paradise, as he has not. The truth is very far from that.
Professor Dainius Pras:
I thank the members for their questions and I will try to match them somehow with answers. I thank Senator Mullen for his frank statement. I have attended many international meetings and participated in discussions like this. Of course we cannot reach agreement today or in the new few days on the main issues but I stand firmly behind universal human rights principles. Among them is a woman's right to control her own body and make decisions about it. I am not here to assess the Irish position and what I have said was not about Ireland but rather the global position. In the 21st century, unsafe abortion is one of the leading causes of maternal mortality and morbidity globally. According to the World Health Organization, WHO, approximately 22 million unsafe abortions take place each year worldwide and an estimated 47,000 women die annually from complications resulting from the unsafe practices for termination of pregnancy.
I will raise the issue of violence against women. Reports on country missions indicate some hypocritical division of violence, with some so-called mild forms of violence tolerated and condoned in the name of culture or patriarchal tradition. We face some regressive tendencies in countries, including some in Europe, as in the name of so-called traditional family values, the rights of women and children are undermined. The role of a woman is reconsidered in such cases, with the idea that a woman should be needed mainly for reproduction and raising children. This is alarming in the 21st century. Deputy O'Reilly spoke on the role of the church. We should respect religion and religious feeling but in secular countries decisions should not be made from a church perspective.
Violence remains one of the major risk factors with regard to mental and physical health. There are many forms of violence, as we know. Against children there is child abuse, against women there is domestic violence and with collective violence we see terrorism, wars and youth violence. All forms of violence must be addressed not with violence, which will escalate a new cycle of violence, but with a good combination of public health and human rights approaches. I will raise the issues in my next report, which will take in bullying and different forms of violence against women and children. Even suicide is considered by the WHO as a form of violence. From a public health perspective, if people do not have enough skills to know themselves in a constructive way, they will regress to destructive or self-destructive behaviour. Suicide is not just an issue of psychiatry and it is a public health issue as well. It is considered a form of self-directed violence.
There are many good recommendations to address violence, including gender-based violence and violence against children. In the world only 53 countries - we know there are almost 200 UN member states - have banned corporal punishment of children. When I travel and ask why it has not been banned, I am told it is very good for discipline and a very healthy measure. The world still has nostalgia for a culture of violence.
I understand the issue raised by Senator Mullen is very sensitive. I understand we need to discuss this but I do not envisage agreement. Perhaps the only agreement is that both sides agree we should have as few abortions as possible.
My notion of the right to choose is that it also implies the right to make a different choice. I may choose to join a trade union but next week I might choose to unjoin. I will give the example of a mother with a baby with Down's syndrome. Hopefully there is a partner but I will not complicate the matter by talking about them at the moment. The availability of services and supports, including soft supports, and the fact that it is culturally okay to have a child with a disability have a bearing on a woman making a choice. How does one make a choice when one does not have a choice? What are the views of the witnesses as to the responsibilities of the State to enable a woman in such a situation to have an equal opportunity to make a choice? In this case she would know that there were supports, whatever her decision, and that if she decided to give birth there would be a decent chance of dignity and a future for her child, and that she would be respected as a mother.
Ms Orla O'Connor:
This is a really important issue for the National Women's Council of Ireland. We have stated very clearly that abortion is not in isolation from all the other things in society, including the inequalities that women experience. I agree that we need it to be easier in this society to have children. There needs to be choice but there also need to be supports and the National Women's Council of Ireland campaigns for affordable child care and other things. Disability is sometimes brought into the discussion disingenuously, and we need to do a lot more on the rights of people with disabilities, including the area of State supports where disabled people need it. However, that does not take away from choice.
This is about the human rights of women, including the right to make choices and rights over our bodies, but that is totally missing from Senator Mullen's contribution. We will never agree but abortion is a reality and women in Ireland choose to have abortions. We have to make a decision about how we support those women and provide the services here because it is happening here.
The position in our country contradicts what Ms O'Connor is saying. In an answer to the Chairman's question, the special rapporteur clarified that the UN has nothing to say to contradict abortion at any stage before birth and that is very revealing. Many Irish people will find that absolutely chilling. I noticed the chairperson of the National Women's Council of Ireland nodding in approval as he conceded that.
We have asked what the UN supports but it is important to realise that we are talking about UN committees, which have been interpreting treaties to which member states have signed up. These committees claim a moral authority and, on the back of that, declare that what they say is the UN's position. In reality, these committees are highly ideological and their new version of human rights, which excludes babies before birth, has no legal standing. This is why I say that what the special rapporteur is doing is so dangerous. He has such a radicalised, perverted concept of human rights that he is undermining the moral authority of the UN in many areas.
Ms O'Connor represents an organisation that is an umbrella body for different women's organisations and gets significant State funding. Perhaps she will tell us how much it gets. She does not speak for many of the women who are members of these organisations and she never acknowledges the differences of opinion they have. In surveys, the figures of those opposed to abortion are slightly higher among women than among men but the National Women's Council never speaks for them or acknowledges their existence. The Constitution acknowledges the equal right to life of the unborn, meaning they are constitutionally protected human beings. Is it not anomalous to get massive State funding to advocate a position that not everyone shares and goes directly against one of our fundamental constitutional rights? Can Ms O'Connor give me any other example of an organisation which is opposed to the constitutional rights of other human beings in this country but which gets significant State support? Can she not concede that, whatever about our difference of opinion, this is at least anomalous? Would she not concede that she should also give voice to the thousands of women who are members of the organisations for which the National Women's Council is an umbrella group but who differ from her in believing that unborn children are human beings and ought not to be killed before birth?
I apologise, but we acceded to their request and they are here because it has been facilitated. The National Women's Council speaks for me on most issues and I do not believe its funding structure is a matter for the Joint Committee on Health.
I note people getting very exercised on the issue of abortion who are never exercised about any other aspect of women's health care. It all comes down to one element for which, with respect to all of the people here and their views, there is an ideological difference between some of us. The fact is, however, women cannot access a 20-week scan. I would love to live in a country where men and women got exercised about the way that we let women down continuously but regrettably, it seems that level of hysteria can only be reached when discussing access to abortion services. These people are not here to answer for the funding structure and it is not the business of this committee to interrogate that.
I will say one sentence which might clarify because Deputy O'Reilly's comment seemed to be directed towards me. Long before Deputy O'Reilly was even heard of and long before her party ever spoke on the subject, I championed the criminalisation of the users of persons in prostitution; it has been one of my issues. Any attempt to suggest that the concern of people who are opposed to abortion for women's health and well-being is partial is deeply ill-founded.
To follow on from my question, I am disturbed to think the UN does not take the rights of an unborn child into account on this issue. The passage of a child from its mother's womb to the outside world is a very short one but it seems to be jumping a huge gap in respect of its rights. We are, and will be, discussing abortion in our Parliament over the next number of months. In fact there is a Bill before the House tomorrow on attempting to decriminalise women who have had an abortion. There was a lot of sympathy in the debate last night on how a woman who had procured an abortion in Ireland could be subject to a 14-year jail sentence and the purpose of the Bill debated last night is to reduce that to a small monetary fine because the Constitution does not allow complete decriminalisation of somebody who procures an abortion. Certainly, the balancing of the right of an unborn child and giving it no balance whatsoever in respect of the mother and the mother having the right to control her own body without consulting the silent foetus seems difficult to conceive, if that is not the wrong word. I find that difficult myself. Does the UN have a difficulty like that?
This is very interesting. We are talking about global concepts with regard to the termination of pregnancies. Even if people agree the concept that a woman is entitled to her reproductive health, there is always a concept in legislation - which one will find in most national parliaments I know of - whereby a term limit is put on a stage at which a termination can take place, after which a termination cannot take place unless it is on health grounds. Is Professor Pras saying the UN has no view on what stage a termination can take place? Are we talking about pre-partum? I seek clarity on this point because it is important. I hope we are talking about two different things. When Professor Pras talks about entitlement to a termination, is that for health or for life, as opposed to a decision which the woman makes?
Ms Orla O'Connor:
To be clear on what the UN expert statement has said, which I think was submitted to members, was:
We recommend the good practice found in many countries which provide women’s access to safe abortion services, on request during the first trimester of pregnancy. We insist on international legal requirements that women can access abortion at the very least in cases of risk to their life or health, including mental health, rape, incest and fatal impairment of the foetus during the first trimester and later.
Surely the UN will not be making the law for this State when hopefully we repeal the eighth amendment and get a chance to have a grown-up discussion in our Parliament about women's access to a full range of health and reproductive rights. Presumably, while the UN might have a view it would be up to each member state, as it were, to have that debate in their parliament and to put that legislation in place. Clearly the UN would not have a role in drafting that legislation or even debating it. The document here states the position up to the first trimester but it is a matter for individual states to legislate as appropriate and put whatever measures are necessary into law.
I have another question before I allow Senator Mullen to come back in. On Senator Dolan's remarks about chromosomal abnormalities, of which Down's syndrome would be the most common, is the UN position that it alone is a legitimate reason to have a termination of pregnancy? Whether on chromosomal abnormalities or other abnormalities, how does the UN judge an abnormality to be sufficient to warrant a termination of pregnancy or does that even come into account? Is it just the decision of the mother regardless of what condition her foetus is in?
Professor Dainius Pras:
I suppose that the Committee on the Rights of Persons with Disabilities would be against such a position because it would regard that as discrimination of persons with disabilities. Again, I think that is up to the parents - up to the mother - to decide.
We should not force people to have a child after we inform them of the results of prenatal diagnostics. The idea behind the prenatal diagnostics is to inform people. If we inform people that the child will be born, for example, with severe disability, my position is that we should respect the decision of the family. Perhaps the Committee on the Rights of Persons with Disabilities, which is a board of independent experts interpreting the Convention on the Rights of Persons with Disabilities, will protect the rights of those with disabilities. The committee is not happy with the tendency of people to choose not to have children with disabilities. We are back to advances in science. This is a most sensitive issue. My background is in working with children with disabilities. I do not know why the world is looking for a cure for autism, for example. For me, autism is a matter of diversity. It is good that we have many children and adults who are autistic, yet science is looking for a cure for autism. This is not about the termination of pregnancy. If many people think it is okay to not have any more people with disabilities, it is a mistake. I do not think I contradict myself when I say that parents have to make the choice but they have to be well informed.
I agree with the rapporteur in so far as he says he is not contradicting himself but I think he is contradicting good sense. I might begin to agree with Deputy O'Reilly as she appeared to be suggesting it is for Ireland to decide its own laws on abortion without regard to what the UN has to say. She did not quite say that but she was going in that direction in her effort to support the special rapporteur. Deputy O'Reilly is heading towards better ground because quite clearly there is no moral coherence coming from the UN. We have just heard from the special rapporteur that, on the one hand, the Committee on the Rights of Persons with Disabilities might oppose - I would like to know if it does - a chromosomal abnormality as a ground for abortion because it is discrimination but he has no problem with it on his committee. Not only that, he says he believes in promoting diversity and does not believe autism should be seen as something to be cured. Yet, at the same time, despite his interest in diversity, he says that somehow disability can be a particular ground where abortion is legal even though it might not be legal otherwise. That is logically incoherent, not to mind morally incoherent.
I will not wear this out for the rest of the evening but the cultural milieu that people live in and the tolerance for one thing or another influences choice. That is one thing. The other thing is when that woman looks around her and sees there are no services or that they are scattered and poor, it is a real influencer of choice. At present, we are dealing in Ireland with women who gave up their children. Did they give them up or did they have no choice? We have to look at choice in the context in which it takes place. Is it really a choice? That brings me back to this difficult issue about the dominant culture. Dare I ask, what is the fashion? Who will knock on that woman's door, say they are there for her and that there is a health service, social service or education service available? Who is there for them? That is part of being able to cleanly exercise choice. That is still something that needs to more strongly come into this discussion. We will not solve it this evening but it is a really important practical element of it.
Before Deputy O'Reilly comes in, it is a very interesting discussion, which I did not anticipate having this afternoon. It has been a very important discussion and perhaps far more informative than a debate in the House where there is no interaction. I think it is important.
It is absolutely welcome. I want to correct Senator Mullen on one point. I thank him not to put words in my mouth because I was fairly clear on what I said and it does not require any interpretation by the Senator or anybody else. When Senator Dolan referred to women giving up their children, was he referring to the mother and baby homes?
I heard that. It is very important to say they did not just have their children taken from them. By all accounts, what is emerging from the mother and baby homes and what some of us might have known for a while is that these women had their human rights violated in the most disgusting way possible. If we want to talk about morals - Senator Mullen mentioned some sort of moral code - we have to take a good, long, hard look at ourselves and how we treated women down through the decades and generations. Senator Mullen made a reference to something he was doing long before I was around. I suspect long before he knew I was around I was campaigning for women's rights. If his ears are deaf to those arguments, he probably did not.
I do not think we have much more time. Some of us have commitments elsewhere. I echo exactly what the Chairman said. This has been a very informative debate. It is good to have some interaction because we sometimes lack that on the floor of the House.
My intervention and comment came from my experience of people with disabilities. We have to have a good, hard, look at ourselves. That is what I am getting at when I talk about the services and supports that are there in order that people can actually exercise choice.
It is one last quick question because it is International Women's Day. There is a problem internationally of gendercide in countries such as China, India, and the Caucasus regions where girls are aborted disproportionately because less value is placed on girls' lives. Does the UN oppose gender as a ground for abortion or is that also the parents' right to decide?
I think everybody in this committee has been called "Dr." at one stage or another by me. I thank the witnesses for coming in and stimulating a very interesting and timely debate on the issues.
As there is no other business, this meeting of the joint committee is adjourned until Wednesday, 22 March. Members of the committee have one week's holidays.