Is there a grey area in determining risk to the mother?

One of the conclusions that stood out in the HSE report into the death of Savita Halappanavar was the statement of an "immediate and urgent requirement for a clear statement of the legal context in which clinical professional judgment can be exercised in the best medical welfare interests of patients".

It begs the question: will there still be a grey area for doctors in working out when there is a real and substantial risk to the mother even with the new abortion legislation published by the Government this week?

Immediate risk
The draft law gives a medical practitioner the power to carry out a termination after deciding in good faith there is an immediate risk of loss to the woman's life from physical illness. The Bill says the pregnancy can be terminated if two doctors jointly certify in good faith that the procedure is the only way to save the woman's life.

However, as Prof Sabaratnam Arulkumaran, the chairman of the review group which investigated Ms Halappanavar's death, said, there is also a need to ensure that not only the life but the health of the mother can be protected in pregnancy. "There are certain conditions a pregnant mother might have which can suddenly escalate – for example in this particular situation from an infection that is very localised but which spreads to the whole body and is sepsis," he said. "With severe sepsis the mortality rate is about 40 per cent, and if she goes into septic shock the mortality rate can be as much as 60 per cent. This can be in a very short period of time which means that [if] intervening is at a later stage it is difficult to bring the patient back to normality and to control."

The obstetrician makes a valid point. Humans are not machines. At the coalface of clinical medicine, events occur that have yet to be described in textbooks. There is no 100 per cent when it comes to how an illness will progress. Nor is there any test in medicine that is guaranteed to be completely accurate.

Exceptions
Taking infection as an example, a particular bug may be regarded as not especially toxic or infectious. But there are always exceptions: a new strain appears; it secretes a nasty toxin; and it begins to infect a group of patients not previously thought to be susceptible to the microbe. Suddenly you have a patient who is rapidly deteriorating and developing complications at an alarming rate.

If this patient is a pregnant woman and the focus of infection is in her womb, will the new legislation help save her life? One would hope so. But can it protect her health and prevent her developing complications that will stay with her for the rest of her life? Almost certainly not.

Despite protocols and guidelines, medicine remains as much art as science. Doctors frequently work in uncertain and grey areas. Managing these effectively is what distinguishes a good clinician from an average one.