John Crown (Independent) | Oireachtas source

Oncology was the area of medicine which in many ways was one of the pioneering disciplines for evidence-based medicine. It was a relatively new field and only came to existence in a meaningful way in the 1960s and 1970s in an era when doctors engaged in other specialties had certain proprietorial rights over the treatment of cancer and, as a result, it had an interesting and somewhat controversial internecine baptism of fire but there is now a great established record of all the different disciplines co-operating together in cancer care. It gave us a major focus on evidence because we often had to persuade our colleagues that things they had been doing for 40 or 50 years did not have a sound scientific basis and when we had new ideas, we had to persuade them that they needed to change their ideas in light of evolving data.

Our own ideas have changed and there are things I do now that I would not have done one year ago. There are things I do not do now that I would have done two years ago. Evidence-based medicine is an extraordinarily complex field. It involves careful synthesis of raw data and primary data sources, examining meta analysis where different trials are lumped together as if they are one big trial and listening in some areas to the opinions of experts who have studied the field in great detail and have come to a consensus. In some cases, it goes as far as resting with properly constituted independent committees of doctors run by professional societies, medical schools or various consortia to examine the data and come to the conclusion of what is evidence-based medicine.

One group that does not define evidence-based medicine is politicians. The Oireachtas does not define it. The role of the Oireachtas in evidence-based medicine is to make sure there is appropriate policing, oversight and regulation of the profession and to make sure statutory procedures are in place whereby if the evidence as determined by the experts is not being followed and is being sufficiently departed from that it represents a threat to the health or life of patients, appropriate measures and sanctions will be taken. That is the role of a parliament in evidence-based medicine.

The notion that we are debating a treatment for a particular clinical scenario is not relevant and it is hubris in the face of medicine, biology and the laws of nature to think we have all the answers now about what might be the right way to treat something not only in five years time but in five weeks time because every decision we make now can be made obsolete by the next prospective randomised trial. That is why the apparently interminable arguments put up by Members in both Houses about what constitutes evidence-based medicine are irrelevant. I have been careful not to say too much about the tragedy of Savita Halappanavar and her family. There were complex reasons and it was not as simple as saying a different law would have saved her life and so on. Parenthetically, the fact that she was going through pregnancy complications in the jurisdiction in the western world that has the lowest percentage of consultant obstetricians per head of population was not coincidental given the degree of senior, top level care available to her throughout her entire illness. We need to take that away from the case.

There was prima facie evidence that the care for this lady departed from an evidence basis because of concerns about an ambiguous legal situation. Every senior obstetrician to whom I have spoken said it was likely that they would have seriously considered terminating the pregnancy on the Monday before this poor lady's death once she had an inevitable miscarriage. She had a pregnancy that could not survive. Her waters had broken and her cervix had dilated. Sadly, this pregnancy and the precious baby this young couple were so looking forward to was lost but, because of ambiguity about the law, evidence-based medicine was not practised or considered. Instead, there was an undue concern about the possibility that the practise of evidence-based medicine might be in direct conflict with the legal position in the State. Colleagues can be anti-abortion and anti-the suicide clause if they wish. They can provide a definition of equality of person and of when life begins and they may believe it begins at the moment of conception. That is fine and it is a valid position for them to have but they should please not preach to doctors about evidence-based medicine because they are without competence.

Maternal mortality is an extremely rare event. In all my years of practice, I have never been involved a case of maternal mortality. I am not directly involved in obstetrics but I have worked in the hospital environment and milieu. Any maternal death is a tragedy. If this House could today pass a law that would prevent one maternal death occurring in 13 years time, we would do it. Can anybody say on the basis of the way the evidence base changes week to week, month to month and year to year that we will not be in a position in a few years where a woman may be suicidal and given whichever psychiatric illness she suffers from, she has a particular fervent psychosis driven desire to end her life because she is pregnant? We have heard individual stories of what psychotic behaviour can make people believe is growing inside them and how they should handle that. I have heard stories of people attempting self-mutilation in an attempt to end a pregnancy that they felt was an alien presence within them.

We will not set a new standard in evidence-based medicine and we will not mandate abortion for women who say they are pregnant and suicidal. The legislation addresses the rare case where that might arise. This is not a willy nilly procedure that will happen in a fly-by-night back street abortion clinic where three doctors are flown in to give an appropriately convenient interpretation of the legal position. We are talking about a scenario that will occur in mainstream hospitals with senior registered consultants making a calm, light of day decision.

One of the most upsetting aspects of the debate is to listen to non-doctor after non-doctor saying psychiatrists cannot assess whether somebody is suicidal. On a monthly basis, I send one of my cancer patients to a psychiatrist because they say something casually such as "Sometimes I wonder if it is worth going on". When they say that, I think that I am not good at deciding whether they are a suicide risk but there are people who are better at that than me and, therefore, I refer them. That is what happens and it is nonsense for any Member to say psychiatrists are not competent to assess suicide risk. They cannot assess it 100% accurately any more than I can assess a cancer diagnosis 100% accurately or a cardiologist can assess a heart attack 100% accurately. Medicine is not like that. We are not a system of perfect tubes and squares; we are full of all kinds of strange curly bits and unexpected results and consequences occur with our actions.

While I have been critical of those from the legal, educational and real estate professions who have become expert in medicine, I must assume the same crime and become temporarily expert in law because it annoys me intensely. I am well used to hearing people criticise à la carte Catholics but we have an entire Chamber full of à la carte constitutionalists. With regard to Article 34.4.6°, Members say the decision of the Supreme Court was flawed in the X case and, therefore, they will not be led by it.

Article 34.4.6° states: "The decision of the Supreme Court shall in all cases be final and conclusive." It does not include the phrase, "except if you think it is flawed". What is in the Constitution is simple and the Supreme Court has decided on this. To make it even easier, the people have spoken twice.

In a colossal departure from the evidence base of the history of the constitutional argument, former Taoisigh, former Directors of Public Prosecutions, constitutional lawyers, former Ministers go on and on about the deficiencies of the X case, but never once mention the 12th amendment of the Constitution. This is extraordinary. This was the least close referendum in the history of referenda, with a 65% to 35% vote in which people said suicide should not be excluded. What could be clearer? There was no other question put in the referendum. It was not lumped together, like the 25th amendment, with all kinds of questions about incubators and zygotes and fertility clinics. It was simple and the people said "No".

I am tabling a series of amendments to deal with aspects of this legislation which I believe are brutal, such as the 14-year sentence which could be applied to a young girl who had an abortion or to her sister if she wrote away to get abortion pills online or which might stop the young girl from getting medical attention or which might incentivise her doctor to break the bounds of doctor-patient confidentiality in prosecutorial zeal against an illegal abortionist. I support the Bill and will table amendments. I thank the Minister for his time and am glad a female Senator has finally joined us in the House, as it was singularly inappropriate that over the past hour of the debate we had 11 male Senators in the House and no female present.